Duodenal Ulcer Recurrence Research Articles

Recurrent Duodenal Ulceration—More Than Simple Peptic Ulcer Disease?

Recurrent Duodenal Ulceration—More Than Simple Peptic Ulcer Disease?

Bleeding due to successive duodenal and rectal ulcers in an 81-year-old patient with severe COVID-19: a case report

BackgroundIn the early stages of the coronavirus disease 2019 (COVID-19) outbreak, the most widely recognised symptoms of the disease were fever, cough, shortness of breath, myalgia, and fatigue. However, in addition to these symptoms, COVID-19 can cause systemic symptoms outside the lungs. Older patients with severe COVID-19 often require admission to the intensive care unit (ICU). Acute rectal ulcer bleeding, characterised by painless, profuse haematochezia, caused by solitary or multiple rectal ulcers, is one of the main causes of severe haematochezia in patients with COVID-19 in the ICU. However, recurrent duodenal ulcer bleeding followed by rectal ulcer bleeding has not previously been reported in older patients during ICU treatment for severe COVID-19.Cases presentationHerein, we report the case of an 81-year-old woman admitted to the emergency department due to severe COVID-19 and transferred to the ICU 2 days later for treatment. During treatment in the ICU, the patient developed recurrent duodenal ulcer bleeding and underwent endoscopic electrocoagulation haemostasis and gastroduodenal artery embolisation. However, the night after the final haemostatic operation, due to rectal ulcer bleeding, the patient discharged bloody stools intermittently, which was effectively controlled using endoscopic electrocoagulation, topical medication, blood transfusion, and haemostatic drugs.ConclusionsTo the best of our knowledge, this is the first report of duodenal ulcer bleeding followed by rectal ulcer bleeding in an older patient with severe COVID-19 infection. This report creates awareness for clinicians about the multiple and complex gastrointestinal symptoms that may occur during COVID-19 treatment.

Black Esophagus and Recurrence of Duodenal Ulcers: Two Signs of the Same Pathogenic Pathway? A Case Report

Black esophagus or acute esophageal necrosis is characterized by circumferential black discoloration of the distal esophageal mucosa. It is a rare condition with a multifactorial pathogenesis, and its most common clinical presentation is acute upper gastrointestinal bleeding. It usually affects elderly patients with multiple comorbidities and is associated with a high mortality rate. This is a case report of a 90-year-old man with multiple comorbidities, including diabetes mellitus, atrial fibrillation with complete atrioventricular block, and a history of ischemic stroke, who presented to the emergency department for a syncopal episode followed by coffee ground emesis. Thoraco-abdominal computer tomography showed thickening of the distal esophagus and ruled out major complications such as perforation. The following esophagogastroduodenoscopy showed black circumferential necrosis of the mid and distal esophagus. Multiple irregular ulcers with black necrotic areas were also present in the bulb and second duodenal portion. During the hospitalization, the patient was treated with PPI, NPO nutrition, and broad-spectrum antibiotics with benefits. Two months later, the patient returned to the emergency department due to a new episode of hematemesis with endoscopic evidence of esophageal stricture without necrosis and recurrence of duodenal ulcers. After a few days, the patient died due to worsening of the underlying comorbidities. A black esophagus is associated with duodenal ulcers, which may recur and are possibly due to a common ischemic origin. In this case report, we explore the potential link between black esophagus and duodenal ulcers, discussing the underlying mechanisms and relevant literature supporting this association.

Long-term safety and effectiveness of vonoprazan for prevention of gastric and duodenal ulcer recurrence in patients on nonsteroidal anti-inflammatory drugs in Japan: a 12-month post-marketing surveillance study

ABSTRACT Background This study assessed the safety and effectiveness of vonoprazan for prevention of duodenal and gastric ulcer recurrence in patients on long-term nonsteroidal anti-inflammatory drugs (NSAIDs) in routine clinical practice. Research design and methods This 12-month, prospective, observational study (145 sites, Japan, September 2016–April 2020) analyzed patients with a history of gastric or duodenal ulcer who started once-daily vonoprazan and were receiving NSAIDs for pain. The primary outcome was the incidence of adverse drug reactions (ADRs). Results Most patients (86.7% [1099/1268]) received vonoprazan for at least 6 months. Most patients (98.6% [1250/1268]) received the 10-mg dose of vonoprazan, 38.3% (486/1268) received cyclooxygenase-2 inhibitors, and 61.7% (782/1268) received other NSAIDs. The overall incidence of ADRs was 0.71% (9/1268). Most commonly reported ADRs were gastrointestinal (0.32%), nervous system (0.16%), and hepatobiliary system (0.16%) disorders. The overall incidence of gastric or duodenal ulcer recurrence was 1.04% (95% CI 0.56–1.78). Conclusions No new safety concerns were reported for vonoprazan for prevention of secondary ulcer or bleeding in patients receiving long-term NSAIDs. Vonoprazan was effective for preventing NSAID-related peptic ulcer recurrence in this real-world study. Trial registration ClinicalTrials.gov: NCT03214198; Japan Pharmaceutical Information Center Clinical Trials Information: JapicCTI-163436.

S1482 Anomaly of the Common Bile Duct, More Than Just About Biliary Drainage

Introduction: The drainage of biliary drain into the duodenal bulb is a rare anatomic abnormality accounting for 0.1%-2.72% cases of all anomalous biliary drains. The common bile duct (CBD) can be seen draining into the stomach, pyloric canal, or the other parts of duodenum. We present a rare case of CBD draining into the duodenal bulb. Case Description/Methods: A 36-year-old female with a history of cholecystectomy presented with fever, right upper quadrant abdominal colic and vomiting for two days. Laboratory data revealed ALT 1180 U/l, AST 1606 U/l, total bilirubin 2.5 mg/dl, ALP 216 U/l and serum lactate 3.1 mg/dl. CT of the abdomen and pelvis demonstrated severe intrahepatic and CBD dilatation to 1.5 cm. She was started on piperacillin-tazobactam for suspected ascending cholangitis. ERCP was unsuccessful as the duodenoscope could not be passed beyond the pylorus, likely due to inflammation. An internal-external biliary drain was performed for biliary decompression. She was transferred to our institution for further management. An upper endoscopy with endoscopic ultrasound revealed a duodenal bulb insertion side of the biliary drain (Fig. 1A). There was no discernible papilla where the drain entered the duodenal bulb nor at the second portion of the duodenum. There was dilation in the CBD which measured up to 7 mm (Figure 1B & 1C). A cholangiogram demonstrated biliary configuration with a distal CBD stricture with contrast drainage to the duodenal lumen, arguing against a choledochoduodenal fistula (Figure 1D). Discussion: The pathogenesis although not completely understood is believed to result from early subdivision of the hepatic diverticulum into pars hepatica and pars cystica (Boyden’s theory). The presentations vary from asymptomatic finding to gallstones, cholangitis, pancreatitis, recurrent duodenal ulcers, and can also lead to cholangiocarcinoma. This results from biliary stasis, reflux of duodenal contents into the CBD and subsequent chronic inflammation. Diagnosis is largely based on imaging modalities with ERCP being the gold standard. Older case reports recommend surgical management, while newer reports corroborate successful management with endoscopic therapies. This rare condition should be considered in patients with recurrent duodenal ulcers; recurrent cholangitis; biliary obstruction without definite obstructing stone; or duodenal deformity.Figure 1.: Anomalous CBD drain into duodenal bulb (A, Endoscopic view of the duodenal bulb demonstrating the biliary drain insertion site; B, 7 mm dilation in the common bile duct with hypoechogenicity surrounding the drain; C, 7 mm dilation in the common bile duct with hypoechogenicity surrounding the drain; D, Cholangiogram revealing a distal common bile duct stricture with contrast drainage into the duodenal lumen).

DOING THE RIGHT THING CAN HARM: DIFFUSE ALVEOLAR HEMORRHAGE SECONDARY TO HYDRALAZINE USE

SESSION TITLE: Fellows Pulmonary Manifestations of Systemic Disease Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Hydralazine-induced vasculitis results from anti-MPO antibody formation and fibrinoid necrosis, leading to disruption of alveolar basement membrane with resultant hemorrhage.1 Rarely does this vasculitis cause diffuse alveolar hemorrhage (DAH).1 Presented is a case where long-term compliance with hydralazine led to the fatal outcome of DAH. CASE PRESENTATION: A 59 year old male with history of HFpEF, HTN, DM, CKD 4 presented with hemoptysis. He was recently admitted for dyspnea and abdominal pain and was discharged the day prior. He had taken hydralazine 100mg BID for 10 years and hydralazine-induced vasculitis was diagnosed at that time with renal biopsy showing pauci-immune glomerulonephritis. On physical exam, a copious amount of blood was present in the mouth. The patient was intubated and admitted to ICU. Bronchoscopy revealed DAH diagnosed by progressively bloodier bronchial alveolar lavages. Treatment consisted of high dose steroids, plasmapheresis, and rituximab with little improvement. The patient continued to have hemoptysis and episodes of oxygen desaturation requiring multiple bronchoscopies to retrieve blood clots and mucous plugs. Lab studies revealed an ANA with a 1:640 titer, anti-MPO antibody greater than 800 unit/mg, and a positive dsDNA with a 1:20 titer. CT thorax demonstrated diffuse bilateral ground-glass opacities. Cyclophosphamide was started due to severe disease resistance to the previously described treatments. The patient initially had good improvement with cyclophosphamide, however, his ICU course was later complicated by profound neutropenia leading to septic shock with multi-organ failure due invasive aspergillosis and recurrent duodenal ulcer bleeding. On hospital day 25, the patient passed away due to these complications. DISCUSSION: Hydralazine-induced vasculitis is a rare entity, occurring in 10 cases per million.2 Majority of cases occur in African-American females around age 70.2 It commonly presents with fever, rash, and joint pain. Renal failure may occur, but pulmonary complications are extremely rare.3 Our case is amongst only a few cases reported of alveolar hemorrhage attributed to hydralazine. Some patients studied achieved remission, with severe cases amenable to rituximab.2 Our patient had multiple rituximab treatments, along with plasmapheresis, steroids, and cyclophosphamide, but progressed to multi-organ failure and eventual death. CONCLUSIONS: Even with proper treatment, patients may progress to ARDS, as seen in our patient. Early diagnosis is imperative to prevent fatal complications. By sharing our case, we hope to increase awareness and prompt further research into a rare but serious complication of a commonly used drug, as fatality rates have increased despite management with current guidelines. Reference #1: Aeddula NR, Pathireddy S, Ansari A, et al. Hydralazine-associated antineutrophil cytoplasmic antibody vasculitis with pulmonary–renal syndrome. Case Reports 2018;2018:bcr-2018-227161. Reference #2: Timlin H, Liebowitz JE, Jaggi K, Geetha D. Outcomes of hydralazine induced renal vasculitis. Eur J Rheumatol. 2018;5(1):5–8. https://doi.org/10.5152/eurjrheum.2017.17075 Reference #3: Thakur, K. et al. “Hydralazine Induced Vasculitis Manifesting in Alveolar Hemorrhage” Crit Care Med. 2014; vol. 42, https://doi.org/10.1097/01.ccm.0000458649.47284.46. DISCLOSURES: No relevant relationships by Fatima Anjum, source=Web Response No relevant relationships by Alex Diaz, source=Web Response No relevant relationships by Aamna Hassan, source=Web Response No relevant relationships by Javed Iqbal, source=Web Response No relevant relationships by James Kang, source=Web Response No relevant relationships by Hyfaa Mashaal, source=Web Response No relevant relationships by Rezwan Munshi, source=Web Response No relevant relationships by José Russe-Russe, source=Web Response

2129 Lumen-Apposing Metal Stent for Benign Gastric Outlet Obstruction!

INTRODUCTION: Lumen-apposing metal stent (LAMS) placement via endoscopic ultrasound (EUS)-guided gastroenterostomy has recently emerged as a promising technique for the management of malignant gastric outlet obstruction (GOO). This is safe, effective and technically feasible if performed by trained advanced endoscopists. Despite that LAMS use in malignant GOO is well defined, it is rarely performed for benign etiologies of GOO and only 4 cases have been reported in the literature. We report the case of a patient with GOO secondary to benign duodenal stricture that was successfully managed by LAMS placement. CASE DESCRIPTION/METHODS: A 60-year-old man with history of recurrent duodenal ulcers presented for vomiting and food intolerance for few days. Two years ago he had a GOO secondary to his ulcer disease and was managed by surgical gastrojejunostomy (GJ). A subsequent marginal ulcer perforation required resection of the GJ with small bowel anastomosis and insertion of a GJ tube. Upon presentation, physical examination was notable for epigastric tenderness with no rebound or rigidity. Contrast computed tomography (CT) scan of the abdomen showed a markedly distended stomach and proximal duodenum with focal narrowing near the pancreatic head (Figure 1). Enteric contrast reached the rectum indicating the absence of complete obstruction. Upper endoscopy showed retained solid material in stomach and an almost completely occluded “pin hole” duodenal lumen that could not be traversed with the endoscope. A wire-guided through the scope dilation with a balloon was performed in conjunction with fluoroscopy but was unsuccessful (Figure 2) so a 10 mm × 15 mm EUS-guided LAMS was successfully deployed. Patient’s symptoms resolved and he was able to tolerate diet. DISCUSSION: GOO usually occurs secondary to malignancy-related mass effect or luminal invasion. Less commonly GOO can be attributed to benign etiologies namely ulcers, caustic ingestion and inflammation. Often managed by endoscopic balloon dilation, benign strictures can recur. Other less favored options include self-expandable metal stents which use is limited by a high rate of migration and failure and surgical approach which provides definitive treatment but is associated with a high risk of mortality and morbidity. LAMS is a novel and appealing less invasive approach proven to be a safe alternative allowing early restoration of enteral luminal access with good short term success and satisfying safety profile. Further studies and long term follow up are recommended.

Retrospective analysis of cases with an ectopic opening of the common bile duct into duodenal bulb.

Ectopic opening of the common bile duct (EOCBD) is a very rare entity. It has been reported in the 3rd or 4th portion of the duodenum, pyloric canal, duodenal bulb, and the stomach. The aim of this study was to evaluate the clinical characteristics, laboratory values and imaging studies of patients with EOCBD into the duodenal bulb retrospectively. The files of patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) between January 2003 and November 2015 were reviewed. The demographic data, presentations, abdominal ultrasonography, computed tomography (CT), magnetic resonance cholangiopancreatography (MRCP), and ERCP findings of patients with EOCBD into the duodenal bulb were evaluated retrospectively. Ectopic openings of the CBD into the duodenal bulb were found in 20 out of 3,270 patients who had undergone ERCP. Twenty patients (15 males and 5 females) with a median age of 59 (40-88) years were included in the study. Ectopic opening of the CBD into the duodenal bulb were found in 20 patients (0.61%). Laboratory test abnormalities included: hyperbilirubinemia in 20 (100%) patients, leukocytosis in 14 (70%) patients, an elevated serum alkaline phosphatase and gamma-glutamyl transferase level in 20 (100%) patients. Indications for ERCP were CBD dilatation and extrahepatic cholestasis (n = 20), cholangitis (n = 12), only choledocholithiasis (n = 7), and acute pancreatitis (n = 2). In patients with recurrent duodenal ulcers and/or apical stricture with accompanying CBD dilatation, extrahepatic cholestasis and cholangitis, EOCBD into the duodenal bulb should be considered.

Potent Potassium-competitive Acid Blockers: A New Era for the Treatment of Acid-related Diseases.

Conventional proton pump inhibitors (PPIs) are used as a first-line therapy to treat acid-related diseases worldwide. However, they have a number of limitations including slow onset of action, influence by cytochrome P450 polymorphisms, unsatisfactory effects at night, and instability in acidic conditions. Alternative formulations of conventional PPIs have been developed to overcome these problems; however, these drugs have only introduced small advantages for controlling acid secretion compared to conventional PPIs. Potassium-competitive acid blockers (P-CABs) were developed and have beneficial effects including rapid, long-lasting, and reversible inhibition of the gastric hydrogen potassium ATPase, the proton pump of the stomach. Vonoprazan was recently innovated as a novel, orally active P-CAB. It is currently indicated for the treatment of gastric and duodenal ulcers, reflux esophagitis, and prevention of low-dose aspirin- or nonsteroidal anti-inflammatory drug-related gastric and duodenal ulcer recurrence in Japan. Vonoprazan does not require enteric coating as it is acid-stable, and it can be taken without food because it is quickly absorbed. Vonoprazan accumulates in parietal cells under both acidic and neutral conditions. It does not require an acidic environment for activation, has long-term stability at the site of action, and has satisfactory safety and tolerability. Thus, vonoprazan may address the unmet medical need for the treatment of acid-related diseases.

A Rare Complication of Recurrent Duodenal Ulcer

Question: A 92-year-old man presented to our emergency department owing to black stool passage for 3 days with general fatigue. He had history of bilateral renal cysts and duodenal bulb ulcer bleeding post suture ligation 6 months ago. On examination, his conjunctiva were pale and his abdomen was soft without tenderness. Digital rectal examination revealed tarry stool. Laboratory data exhibited anemia (hemoglobin, 6.9 g/dL). Esophagogastroduodenoscopy revealed a 2.5-cm bleeding ulcer at the distal bulb and one 1-cm outpunching area at the proximal second portion of the duodenum with internal debris (Figure A, B). Computed tomography (CT) of the abdomen (Figure C) and further upper gastrointestinal series were performed (Figure D, E). What is the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. A CT of the abdomen revealed a 5.4-cm right renal cystic lesion with internal food material and gas pockets that is connected to the second portion of the duodenum (Figure C, arrow). Further upper gastrointestinal series disclosed a focal out-pouching with contrast accumulation arising from the second portion of duodenum and pointing posteriorly (Figure D, E), compatible with a duodenal-renal fistula as diagnosed in CT study. The inflammatory response to a penetrating peptic ulcer can lead to the formation of a fistula between the duodenum and any structure nearby. Fistulae to the biliary tract and colon has been described more commonly. Duodenal-renal fistulae owing to peptic ulcer disease is very rare and unique. The patient was transferred to general surgeon and he was discharged eventfully 34 days later under conservative treatment.

Point-of-care Helicobacter pylori testing: primary care technology update.

#### Clinical Question In adults attending primary care with upper gastrointestinal symptoms, what is the accuracy and utility of point-of-care testing to detect Helicobacter pylori infection? Helicobacter pylori (HP) infection causes approximately 5% of uninvestigated dyspepsia and a 20% lifetime risk of peptic ulcer disease.1 HP is a grade 1 carcinogen: 5.2% of cancers globally are attributable to HP infection.2 HP eradication results in: reduced gastric cancer incidence; prevention of recurrent duodenal (number needed to treat [NNT] = 2) and stomach (NNT = 3) ulceration; and resolution of dyspepsia (NNT = 13).3 Non-invasive Helicobacter pylori diagnostic tests are available for point-of-care (POC) use in primary care and include IgG serology, 13C-urea breath test (UBT), and monoclonal stool antigen. Only UBT is sufficiently accurate to confirm current infection or eradication.4 HP IgG serology cannot differentiate current from past infection. Rapid qualitative stool antigen testing currently lacks diagnostic accuracy. Isotope ratio mass spectrometry (IRMS) is the most commonly used 13C-UBT method in the UK. However, the sampling procedure involves many opportunities for test incompletion: collection of the test from the pharmacy; returning for a subsequent extended appointment; sending the test to the laboratory; and awaiting results. In comparison, non-dispersive isotope selective infrared spectroscopy (NDIRS) has potential as a POC device: it can be used by non-specialist staff outside the laboratory setting, it …

MID-TERM OUTCOME OF PERFORATED DUODENAL ULCER REPAIR USING SINGLE-PORT LAPAROSCOPIC SURGERY

Background: Single-port laparoscopic surgery (SPLS) is increasingly used in surgery and in the treatment of perforated duodenal ulcer. The aim of this study was to evaluate mid-term outcome of perforated duodenal ulcer repair using SPLS. Methods: A prospective study on 72 consecutive patients diagnosed with perforated duodenal ulcer and treated with SPLS at Hue University Hospital and Hue Central Hospital from January 2012 to Mars 2016. Results: The mean age was 48.8 ± 14.0 (17 - 79) years. Male/female ratio was 17.0. Four patients (5.6%) with history of abdominal surgery were successfully treated by pure SPLS. Patients were classified as ASA 1, ASA 2 and ASA 3 in 86.1%, 12.5%, and 1.4% of cases, respectively. Using Boey scoring system, there were 86.1% and 12.5% of cases classified as Boey 0 and Boey 1 while there were no Boey 2 and 3 cases. The average size of perforation was 4.1 ± 2.6 (1.5-22) mm. The perforation was situated on the anterior duodenal wall in 98.6% of cases and on the posterior duodenal wall in 1.4% of cases. There was one case (1.4%) in which one additional trocar was required. Conversion to open surgery was necessary in one patient (1.4%) in which the perforation was situated on the posterior duodenal wall. Average length of hospital stay was 5.7 ± 1.2 (4-12) days. Post-operative complications rate was 2.8%. There was no leakage from the repair site, no port-site hernia and no post-operative mortality. At 2-month follow-up visit, patients were classified as Visick 1 in 95.1% of cases and Visick 2 in 4.9% of cases and the duodenal ulcer was completely healed on gastroduodenoscopy in 86.7% of cases. At 12-month follow-up, patients were classified as Visick 1 in 93.5% of cases and Visick 2 in 4.3% of cases. There was one case (2.2%)diagnosed with recurrent duodenal ulcer perforation at 5 months after the repair of the first perforation. On gastroduodenoscopy, recurrent duodenal ulcer was seen in 8.9% of cases. Conclusions: SPLS is a safe method for the treatment of perforated duodenal ulcer. Conversion rate was 1.4%. Recurrent duodenal ulcer rate was 8,9% and recurrent duodenal ulcer perforation rate was 2.2% after 12-month follow-up. Key words: perforated duodenal ulcer, single port laparoscopic repair, single port laparoscopy

Eradication therapy for peptic ulcer disease in Helicobacter pylori-positive people.

Peptic ulcer disease is the cause of dyspepsia in about 10% of people. Ninety-five percent of duodenal and 70% of gastric ulcers are associated with Helicobacter pylori. Eradication of H. pylori reduces the relapse rate of ulcers but the magnitude of this effect is uncertain. This is an update of Ford AC, Delaney B, Forman D, Moayyedi P. Eradication therapy for peptic ulcer disease in Helicobacter pylori-positive patients. Cochrane Database of Systematic Reviews 2006, Issue 2. Art. No.: CD003840. DOI: 10.1002/14651858.CD003840.pub4. To assess the proportion of peptic ulcers healed and the proportion of participants who remained free from relapse with eradication therapy against placebo or other pharmacological therapies in H. pylori-positive people.To assess the proportion of participants that achieved complete relief of symptoms and improvement in quality of life scores.To compare the incidence of adverse effects/drop-outs (total number for each drug) associated with the different treatments.To assess the proportion of participants in whom successful eradication was achieved. In this update, we identified trials by searching the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE (1950 to March 2016) and Ovid EMBASE (1980 to March 2016). To identify further relevant trials, we handsearched reference lists from trials selected by electronic searching, and published abstracts from conference proceedings from the United European Gastroenterology Week (published in Gut) and Digestive Disease Week (published in Gastroenterology). The search was last updated in March 2016. We contacted members of Cochrane Upper GI and Pancreatic Diseases,and experts in the field and asked them to provide details of outstanding clinical trials and any relevant unpublished materials. We analysed randomised controlled trials of short- and long-term treatment of peptic ulcer disease in H. pylori-positive adults. Participants received at least one week of H. pylori eradication compared with ulcer healing drug, placebo or no treatment. Trials were included if they reported assessment from two weeks onwards. We collected data on ulcer healing, recurrence, relief of symptoms and adverse effects. We calculated the risk ratio (RR) with 95% confidence intervals (CI) using both fixed-effect and random-effects models with Review Manager software (RevMan 5.3) based on intention-to-treat analysis as far as possible. A total of 55 trials were included for one or more outcomes for this review.In duodenal ulcer healing, eradication therapy was superior to ulcer healing drug (UHD) (34 trials, 3910 participants, RR of ulcer persisting = 0.66, 95% confidence interval (CI) 0.58 to 0.76; 381/2286 (adjusted proportion: 12.4%) in eradication therapy plus UHD versus 304/1624 (18.7%) in UHD; low quality evidence) and no treatment (two trials, 207 participants, RR 0.37, 95% CI 0.26 to 0.53; 30/125 (adjusted proportion: 21.7%) in eradication therapy versus 48/82 (58.5%) in no treatment; low quality evidence).In gastric ulcer healing, the differences were imprecise between eradication therapy and UHD (15 trials, 1974 participants, RR 1.23, 95% CI 0.90 to 1.68; 220/1192 (adjusted proportion: 16.0%) in eradication therapy plus UHD versus 102/782 (13.0%) in UHD; very low quality evidence). In preventing duodenal ulcer recurrence the differences were imprecise between maintenance therapy with H.pylori eradication therapy and maintenance therapy with UHD (four trials, 319 participants, RR of ulcer recurring 0.73; 95% CI 0.42 to 1.25; 19/159 (adjusted proportion: 11.9%) in eradication therapy versus 26/160 (16.3%) in UHD; very low quality evidence), but eradication therapy was superior to no treatment (27 trials 2509 participants, RR 0.20, 95% CI 0.15 to 0.26; 215/1501 (adjusted proportion: 12.9%) in eradication therapy versus 649/1008 (64.4%) in no treatment; very low quality evidence).In preventing gastric ulcer recurrence, eradication therapy was superior to no treatment (12 trials, 1476 participants, RR 0.31, 95% CI 0.22 to 0.45; 116/697 (adjusted proportion: 16.3%) in eradication therapy versus 356/679 (52.4%) in no treatment; very low quality evidence). None of the trials reported proportion of people with gastric ulcer not healed after initial therapy between H.pylori eradication therapy and no active treatment or the proportion of people with recurrent gastric ulcer or peptic ulcers during maintenance therapy between H.pylori eradication therapy and ulcer healing drug therapy. Adding a one to two-week course of H. pylori eradication therapy is an effective treatment for people with H. pylori-positive duodenal ulcer when compared to ulcer healing drugs alone and no treatment. H. pylori eradication therapy is also effective in preventing recurrence of duodenal and gastric ulcer compared to no treatment. There is currently no evidence that H. pylori eradication therapy is an effective treatment in people with gastric ulcer or that it is effective in preventing recurrence of duodenal ulcer compared to ulcer healing drug. However, confidence intervals were wide and significant benefits or harms of H. pylori eradication therapy in acute ulcer healing of gastric ulcers compared to no treatment, and in preventing recurrence of duodenal ulcers compared to ulcer healing drugs cannot be ruled out.

Vonoprazan: first global approval.

Vonoprazan (Takecab(®)) is an orally bioavailable potassium-competitive acid blocker (P-CAB) being developed by Takeda for the treatment and prevention of acid-related diseases. The drug is approved in Japan for the treatment of acid-related diseases, including erosive oesophagitis, gastric ulcer, duodenal ulcer, peptic ulcer, gastro-oesophageal reflux, reflux oesophagitis and Helicobacter pylori eradication. Phase III development is underway for the prevention of recurrence of duodenal and gastric ulcer in patients receiving aspirin or NSAID therapy. Phase I development was conducted in the UK for gastro-oesophageal reflux; however, no further development has been reported. This article summarizes the milestones in the development of vonoprazan leading to this first approval for acid-related diseases.

Diagnosis and treatment of ectopic opening of the common bile duct in the duodenal bulb

Objective To investigate the diagnosis and treatment of ectopic opening of the common bile duct in the duodenal bulb. Methods The clinical data of 3 patients who were admitted to the Binzhou People's Hospital and 9 patients who were admitted to the Tianjin People's Hospital from January 2006 to December 2013 with ectopic opening of the common bile duct in the duodenal bulb were retrospectively analyzed. Seven patients had choledocholithiasis and 5 had stenosis at the end of common bile duct. The medical histories and clinical features in patients were analyzed and routine blood test and serum liver function test were done. All the patients received the endoscopic retrograde cholangiopancreatography (ERCP) examination and were cured. All the patients were followed up via outpatient examination and telephone interview up to August 2014. Results Six patients had histories of cholangitis recurrence and 2 had histories of duodenal ulcer recurrence. All the patients had pain in the right hypochondriac region of the abdomen. Seven patients had fever, chills, skin yellowing sclera and tenderness in the right hypochondriac region of the abdomen. The levels of alkaline phosphatase (ALP) and glutamyl-transpeptidase (GGT) in 11 patients, the levels of TBil and DBil in 8 patients and the count of WBC in 7 patients were increased. (1) The results of ERCP showed as follows: there was no papillar opening at the second and third segment of duodenum. The crack-like opening located at the duodenal post-bulb with rough and erosive mucosal surfaces and intermittent outflow of bile. Duodenal ulcer was detected in 5 patients and duodenal bulb metamorphosis in 3 patients. All the 12 patients received successfully intubations. (2) The results of retrograde cholangiography showed as follows: the end of common bile duct of 12 patients was taper and sickle-shaped. Intra-and extrahepatic bile duct dilation was detected in 10 patients, choledocholithiasis in 7 patients and clear findings for the pancreatic duct in 5 patients. Among the 12 patients, 8 received balloon dilation (5 with stenosis at the end of common bile duct , 3 with choledocholithiasis) , 3 received laparoscopic common bile duct exploration (LCBDE) combined with cholangioenterostomy due to diameter of stone more than 1. 5 cm and ectopic opening stenosis of the common bile duct in the duodenal bulb. One patient was treated by percutaneous transhepatic cholangiography (PTC) lithotomy of common bile duct after unsuccessful ERCP without bleeding and pancreatitis-related complications. The symptoms of cholangitis in 3 patients were alleviated after balloon dilation, 2 patients had recurrence of cholangitis and were cured by Roux-en-Y cholangioenterostomy. The mean open surgery time and mean duration of postoperative hospital stay in 5 patients were 85 minutes (range, 60-150 minutes) and 10 days (range, 8-14 days) , respectively. All the 12 patients were followed up with a median time of 38 months (range, 8-90 months) . During the follow-up, 10 patients survived well without recurrence of cholangitis and cholelithiasis. Two patients had recurrence of cholangitis at postoperative month 2 and month 14, including 1 patient with the recurrence of common bile duct sand-like stones, and they were readmitted to hospital and treated by Roux-en-Y cholangioenterostomy without recurrence by follow-up. Conclusions The clinical symptoms of ectopic opening of the common bile duct in the duodenal bulb included recurrence of cholangitis, duodenal ulcer history, pain in the right hypochondriac region of the abdomen, skin yellowing sclera, abnormal liver function, crack-like openings in the duodenal bulb by ERCP examination with outflow of bile, cholangiography-guided taper and sickle-shaped end of common bile duct. The treatment should be aimed at the concomitant diseases. Key words: Common bile duct ectopic opening; Duodenal bulb; Diagnosis; Therapy

Ectopic Opening of the Common Bile Duct into the Duodenal Bulb Accompanied with Cholangitis and Gallbladder Cancer: A Report of Two Cases.

An ectopic opening of the common bile duct (CBD) into the duodenal bulb is a very rare congenital anomaly of the biliary system, which may cause recurrent duodenal ulcer or biliary diseases such as choledocholithiasis and cholangitis. Endoscopic retrograde cholangiopancreatography (ERCP) plays a major role in the diagnosis of this anomaly. We report two such cases: one in a 61-year-old man and the other in a 57-year-old man. In the first case, this anomaly caused acute cholangitis with multiple CBD stones, which were successfully treated by ERCP. In the second case, abdominal computed tomography showed pneumobilia, which was further evaluated using ERCP. Besides, this patient was diagnosed with an ectopic opening of the CBD associated with gallbladder cancer. We report these unusual cases and review the relevant medical literature.

Association of cytokine gene polymorphisms in peptic ulcer development in the Bashkortostan Republic

Peptic ulcer disease (PUD) is a chronic disease based on recurrent gastric or duodenal ulcers. Association analysis of common polymorphisms of the cytokines genes IL1B (rs1143634), IL1RN (rs71941886), IL8 (rs4073), IL10 (rs1800872), and TNFA (rs1800629) was conducted in 254 patients with gastric ulcer or duodenal ulcer and in 277 unrelated healthy individuals from the Bashkortostan Republic. Associations of the rs1143634C allele and the C/C genotype of the IL1B gene with PUD in ethnic Bashkirs have been revealed. The frequency of the rs4073A/A genotype of the IL8 gene was significantly higher in the control group as compared to patients infected with H. pylori. Our results confirm the significant role of rs1143634 of the IL1B gene in PUD development.

A Rare Case of Helicobacter pylori Mix Infections and Recurrence of Duodenal Ulcers

Introduction: Since Helicobacter pylori (H. pylori) infection is a major cause of gastroduodenal ulcers, it is normal to expect successful eradication drastically reduces ulcer recurrence. Case Presentation: We present a case of a 45-year-old woman with no history duodenal ulcer in her family who was referred to the hospital with epigastric pain. A gastroduodenoscopy was then performed, and revealed two active duodenal ulcers, both measuring 10 mm in size. She was prescribed with 14 days H. pylori standard therapy, but no confirmation test concerning bacterial clearance was performed. Ten months later, she was admitted to the hospital again and complained about intense epigastric pain and vomiting. Gastroscopic findings showed a new 11 mm duodenal ulcer. However, because of positive rapid urease test (RUT), further microbiological analysis was prescribed. Strikingly, H. pylori mix infections was observed. With prescription of second-line therapy against H. pylori, after 4 weeks, positive 13C-urea breath test became negative and her duodenal ulcer was also completely cured. Conclusion: Our cases strongly suggest that frequency of H. pylori mix infections is not only considerable but also it can drastically affect the final outcome of clinical manifestations such as duodenal ulcer. Conclusively, current report insists that gastroenterologists should pay more attention to the possibility of presence of H. pylori mix infections in the management of patients with duodenal ulcers. Additionally, after an initial antibacterial treatment, an obligatory follow up system is recommended.

Case of primary hepatic gastrinoma: Diagnostic usefulness of the selective arterial calcium injection test.

Gastrinomas mainly occur in the duodenum and pancreas. Primary hepatic gastrinoma is rare and difficult to diagnose because the liver is a frequent site of metastatic gastrinomas. Clinical factors were assessed in a 28-year-old man with diarrhea and heartburn who was hospitalized for recurrent duodenal ulcers. Abdominal ultrasound, endoscopic ultrasound and computed tomography (CT) could not detect a tumor in the duodenum or pancreas. His gastrin level was 846 pg/mL and magnetic resonance imaging showed a mass 12 mm in diameter in the right robe of the liver. A selective intra-arterial calcium injection (SACI) test and 68-gallium edotreotide positron emission tomography CT (Ga-DOTATOC PET-CT) were therefore performed. Calcium gluconate injection into the proper hepatic artery resulted in a marked increase in serum gastrin concentration in the right hepatic vein, with Ga-DOTATOC PET-CT showing uptake only by the liver mass. Following a diagnosis of primary hepatic gastrinoma, the tumor was resected. A histopathological examination indicated gastrinoma. Six months postoperatively, he has no symptoms, is not taking proton-pump inhibitors and his gastrin level remains within the normal range. The SACI test and the clinical course of this patient strongly suggest that the tumor was a primary hepatic gastrinoma. The SACI test is helpful in the diagnosis of primary hepatic gastrinoma.

Evaluating the effectiveness of endoscopic treatment of gastroduodenal bleeding in children

Introduction: One of the current problems of emergency abdominal child surgery are gastric (GU) and duodenal ulcer (DU). Thus, domestic and foreign researchers have noted that the prevalence of peptic ulcer disease in the pediatric population in recent years has nearly doubled. GU and duodenal ulcer occurs with frequency 1,6-2,7 cases per 1000 children and is 7-12 % of diseases of the gastrointestinal tract in children. Along with the growing incidence of this disease, there is a tendency of the number of complications increase.One of the major complications that pose a threat to a child's life is gastroduodenal bleeding. InUkraine, the rate for the last five years has increased by 14% and in the structure of hemorrhagic complications of diseases of the gastrointestinal tract up to 60 % .Despite the fact that endoscopic hemostasis is considered the "gold standard" treatment of gastroduodenal ulcer bleeding, their effectiveness in the primary use and application in cases of relapse in childhood actively discussed.Insufficient number of pediatric surgeons work on the effectiveness of the treatment of these complications with the use of modern minimally invasive technologies is largely determined by the relevance and purpose of the present study.Research objective. To analyze the efficacy of endoscopic treatment of bleeding and recurrence of gastric and duodenal ulcers in children.Material and research methods. Results of the treatment of 57children with acute bleeding from gastric and duodenal ulcers in age from 2 to 16 years who were treated in the surgical departments of pediatric surgery clinics Dnepropetrovsk State Medical Academy and Zaporozhye State Medical University were presented. 38 (67 %) were girls, 19 (33 %) - boys.All patients were admitted to the intensive care unit and undergone clinical, laboratory examinations, complex etiopathogenetic treatment (infusion, hemostatic, substitution, antisecretory therapy) and fibrogastroduodenoscopy (EGD) for diagnostic and therapeutic purposes. Activity of the bleeding was defined with scale by Forrest (Forrest-Rosch W., 1986) during endoscopy exam. Endoscopic electrocoagulation monoelektrod using fiberoptic gastroduodenoscopy «Olympus» UES 10 was done. Injection of 0.18% solution of adrenaline with endoscopic injection needle 5Ch in different volumes through the working channel of the endoscope and therapy in combination with electrocautery was done. Treatment effectiveness monitoring was based on clinical, laboratory data and endoscopic studies.Results of research. The study found that duodenal ulcer bleeding substantially prevailed and was found in 44 children, whereas bleeding from gastric ulcer were found in 13 patients. Thus at 52 (91 %) there was no history information of the diagnosed ulcer. Chronic abdominal pain with PUD previously was recorded only in 9% of cases.Bleeding duration up to 6 hours before admission was detected in 39% of children, between 6 and 24 hours – in 45% and more than 24 hours – in 16% of patients. During EGD macroscopic acute ulcers appearance was detected in the majority (86 %) of children, 32% of them in the last month had mentioned nonsteroidal anti-inflammatory drugs intake and 41% of patients noted aggressive and soft products intake. Ulcers size ranged approximately 5-7 mm. Contamination of Helicobacter pylori serological test according to the level of IgG antibodies was detected in 89.8% of children. Variations in the levels of pepsinogen and serum gastrin in 98 % of children do not cross the boundaries of age-reference values. The clinical picture was characterized by vomiting blood 15% of patients, vomiting "coffee grounds" was detected in 72 % of children, melena was observed in 61% of cases.Primary hemostasis using endoscopic electrocautery combinations and epinephrine injection solution was effective in 48 (84 %) children. 9 patients that undergone only electrocoagulation treatment on the 2nd day were diagnosed rebleeding, which required re-EGD using a combined endoscopic hemostasis. According to the results of clinical laboratory and endoscopic control full bleeding stop was observed during the first 2 days of children stay in hospital.Conclusions .1. Study improved predominance of duodenal ulcer bleeding in children.2. History of alcohol and/or nonsteroidal anti-inflammatory drugs intake increases the risk of acute gastric or duodenum ulcers complicated by bleeding.3. Use of surgery endoscopic hemostasis using combined coagulation- injection method on the background of the hemostatic and parenteral antisecretory therapy for primary and preventive stop ulcer bleeding ensures maximum efficiency of complex treatment in the practice.