Refractory Peptic Ulcer Disease Research Articles

The Occurrence of a Thyroid Storm in a Patient with Recurrent Refractory Peptic Ulcer: A Case Report

A thyroid storm is a rare complication of hyperthyroidism. Although a thyroid storm rarely presents with symptoms similar to those of an acute abdomen, and in cases where emergency surgery is needed, the thyroid function test is not performed routinely. In this study, we report a case in which hyperthyroidism was diagnosed after surgery in a patient with recurrent refractory peptic ulcer disease. Although peptic ulcer disease and hyperthyroidism rarely coexist, when the patient's initial condition was reviewed in the Emergency Department, the findings were reasonable for panperitonitis due to peptic ulcer perforation, which is considered as a condition suitable for a thyroid storm. This isolated case indicates a logical leap in the correlation between peptic ulcer and thyroid storm. In recurrent refractory peptic ulcer disease, the thyroid function test may be helpful as a routine laboratory test before emergency surgery.

S2216 A Knot in My Stomach: A Rare Cause of a Malfunctioning PEG-J Tube

Introduction: Gastrostomy and jejunostomy tubes are placed to provide long term nutrition. Tube malfunctioning is not uncommon and usually due to coiling, occlusion, and malpositioning. We report a rare case of percutaneous endoscopic gastrostomy with jejunal extension (PEG-J) tube malfunction due to a knot formation. Case Description/Methods: A 45 year old female with history of traumatic brain injury with resultant tracheostomy and PEG-J tube, presented from a nursing home for PEG-J tube malfunction. The PEG-J tube was noted to be torn externally with an inability to administer feeds or medications. An abdominal CT scan revealed a percutaneous G-J tube with the balloon inflated within the gastric body, a portion of the tube coiled within the duodenum, but the distal end in the proximal jejunum. Bedside removal of the tube was unsuccessful due to significant resistance. She then underwent upper endoscopy which revealed an intact gastrostomy with the internal balloon properly inflated in the gastric body. The jejunal extension was found to have a knot in the tube in the gastric portion with the remainder of the tube extending into the duodenum. The distal end of the PEG-J was grasped with a snare, cut externally, and the knotted portion was withdrawn with the scope. A replacement PEG was then placed via the gastrostomy. The patient was subsequently discharged without further complication. Discussion: Enteral feeding tubes provide nutrition in patients who are unable to tolerate oral diet. This can be achieved with feeds administered into the stomach, or into the small bowel via gastrostomy with a longer tube, or via direct access into the small bowel. Jejunal feeding is preferred in patients with gastric bypass, gastroparesis, gastric outlet obstruction or refractory peptic ulcer disease. Complications of PEG-J tubes include coiling, kinking, malpositioning, and occlusion. There are six previously reported cases of knotted PEG-J tubes causing tube malfunction. A proposed mechanism is that the longer tube inserted distally into the GI tract is prone to coiling during peristalsis, which can lead to knot formation. Knotting of a PEG-J tube is a rare complication that may not be apparent on imaging as in this patient. It is important to consider this complication when deciding on the method of enteral feeding. It should also be considered in the differential diagnosis in a case of a malfunctioning PEG-J tube, especially if the tube cannot be removed bedside due to increased resistance to removal.Figure 1.: Knotted PEG-J.

S0592 In-Hospital Outcomes of Transcatheter Arterial Embolization vs Surgical Control of Refractory Bleeding Peptic Ulcer Disease: A Propensity Score-Matched Analysis

S0592 In-Hospital Outcomes of Transcatheter Arterial Embolization vs Surgical Control of Refractory Bleeding Peptic Ulcer Disease: A Propensity Score-Matched Analysis

Refractory Peptic Ulcer Disease

The eradication of Helicobacter pylori and the widespread use of effective antisecretory therapies, including proton pump inhibitors, have improved the management of peptic ulcer disease. However, in some patients, peptic ulcer disease is refractory to 8 to 12 weeks of standard antisecretory drug treatment. For refractory peptic ulcer disease, further evaluation of the risk factors and causes of refractory peptic ulcer disease, including patient risk factors and noncompliance (smoking, nonsteroidal anti-inflammatory drug use, and noncompliance with medical treatment), persistent H. pylori infection, and non-H. pylori-related factors (giant ulcer, gastrinoma, infections other thanH. pylori, and malignancy), is essential. The treatment should focus on the cause of the refractory peptic ulcer disease, avoiding smoking and nonsteroidal anti-inflammatory drug, the treatment of persistent H. pylori, use of high-dose proton pump inhibitors, or surgical excision of gastrinomas. Surgery should be considered in patients who are at high risk for complications and recurrent peptic ulcer disease despite medical treatment. In this review, I describe the diagnosis and treatment of refractory peptic ulcer disease. Key words: Anti-inflammatory agents, non-steroidal; Helicobacter pylori; Peptic ulcer; Ulcer, refractory

A Rare Complication of a Barium-Contrast Study

n 86-year-old woman was admitted for intracAtable vomiting and septic pneumonia. Her medical history included refractory peptic ulcer disease requiring Billroth II gastrectomy, complicated by gastric outlet obstruction with placement of gastrostomy and jejunostomy tubes. She reported having a barium swallow study for vomiting a week prior, after which her symptoms worsened progressively. She complained of diffuse abdominal pain, distension, and was uncertain of the timing of her last bowel movement. Physical examination was notable for a heart rate of 119 beats per minute, blood pressure of 75/35 mm Hg, and a distended tender abdomen with minimal bowel sounds throughout. Laboratory findings showed a hemoglobin level of 8.2 g/dL, a white blood cell count of 12.2 10/L, a creatinine level of 1.6 mg/dL, and a lactic acid level of 2.6 mmol/L. An abdominal radiograph and computed tomography scan of the abdomen and pelvis showed diffuse colonic and distal small-bowel dilatation with hyperdense intraluminal material and areas of focally dense intraluminal contents within the proximal descending colon corresponding with inspissated barium (Figures A and B). She was treated for septic shock with vasopressor support and showed hemodynamic improvement by the third day. Conservative management was attempted to relieve the barium impaction. No results were produced using polyethylene glycol, sodium polystyrene sulfonate, lactulose enemas, tap water enemas, mineral oil enemas, or manual disimpaction. Sigmoidoscopy on day 4 of the hospitalization showed large barium pellets; irrigation was attempted without success (Figure C). The patient underwent total colectomy with end-ileostomy on day 6 of the hospitalization. She was discharged in stable condition. Barium sulfate is an insoluble salt commonly used in radiologic studies and generally is considered a low-risk contrast medium. Rarely, it can precipitate and cause impaction. One systematic review found only 32 reported cases of bowel obstruction caused by barium inspissation that occurred over a 56-year period (1950–2006). Risk factors include advanced age, electrolyte imbalances, dehydration, changes to intestinal anatomy narrowing the lumen, and any drugs or medical conditions affecting colon motility (systemic lupus erythematosus, scleroderma, Parkinson’s disease, diabetes, or Ogilvie’s syndrome). Nearly half of the cases manifested themselves within the first 4 weeks after barium studies, however, it may take up to 2 years for this to occur. Methods used to relieve barium impaction in the past have been manual extraction, enemas, laxatives, and endoscopy. Colonoscopic dissolution was achieved using either high-pressure jet stream under general anesthesia, prolonged water irrigation, or combined mechanical destruction and irrigation. Nearly half of the cases required surgery, ranging from colotomy with barolith removal to total colectomy with ileostomy. Considering

A Case of Barium Inspissation Resulting in Acute Constipation and Colectomy

Introduction: Barium sulfate is an insoluble salt commonly used in radiologic studies. It is generally considered a low-risk contrast medium with the most common complications including abdominal cramping, nausea, vomiting, and constipation. However, rarely, severe complications can occur including viscus perforation, barium inspissation, embolization, aspiration, and poisoning secondary to barium intravasation. These complications are important to recognize and often require drastic endoscopic and surgical measures. Case Report: An 86-year-old female with history of refractory peptic ulcer disease requiring previous Bilroth II surgery later complicated by gastric outlet stenosis resulting in placements of gastrostomy and jejunostomy tubes was admitted for intractable bilious vomiting and septic pneumonia. Patient reported diffuse abdominal pain and was uncertain of the timing of her last bowel movement. Symptoms started after a barium swallow study 1 week prior to presentation. Physical exam was notable for tachycardia, hypotension, and distended tender abdomen with minimal bowel sounds throughout. Her labs revealed a hemoglobin 8.2 g/dL, WBC 12.2 x 1000, creatinine 1.6 mg/dL, and lactate 2.6 mmol/L. CT of her abdomen showed diffuse colonic and distal small bowel dilatation with excessive amounts of intraluminal stool and inspissated barium solution. Patient required support with vasopressors and was treated with antibiotics. Polyethylene glycol, sodium polystyrene sulfonate, lactulose enemas, tap water enemas, mineral oil, manual disimpaction, and sigmoidoscopy were unsuccessful at disimpacting the colon. The patient subsequently underwent total colectomy 6 days into hospital stay with end-ileostomy and was discharged in stable condition. Discussion: Barium impaction is a rare complication of barium studies with 1 review reporting 31 reported cases between 1950 and 2006. However, it is associated with significant morbidity as nearly half of the reported cases required surgical intervention. Risk factors for barium inspissation are any changes to intestinal anatomy or intraluminal diameter and any medical conditions or drugs affecting colon motility. Prevention with proper hydration and administration of laxatives following barium studies is recommended in those at increased risk.

Diagnosis and treatment of gastrinoma in the era of proton pump inhibitors

The Zollinger-Ellison syndrome is characterized pathophysiologically by a significant hypergastrinemia derived from a gastrin-secreting neuroendocrine tumor with a primary location in the pancreas or duodenum. Chronic hypergastrinemia in turn triggers gastric acid hypersecretion yielding in chronic or recurrent or refractory peptic ulcer disease and/or chronic diarrhea. One half of patients with ZES will have distant metastases in the liver by the time the diagnosis is established and one half of all patients with ZES will experience chronic diarrhea as chief complaint rather than peptic ulcer-related symptoms and signs. Gastrinomas have been reported to either manifest sporadically or to occur in conjunction with the genetic background of the MEN-I syndrome. Diagnosis is based on the patients history which is typically characterized by recurrent episodes of peptic ulcer disease or by severe reflux esophagitis and/or diarrhea or by acid-related symptoms which fail to respond to standard treatment regimens. Upper gastrointestinal tract endoscopy will provide evidence for peptic ulcer disease in anatomical regions located aborally the duodenal bulb within the descending part of the duodenum or even farther distally within the jejunum. Peptic ulcers frequently occur in groups indicating some substantial acid hypersecretion. A gastric pH > 2 is mutually exclusive for ZES. Increased serum gastrin levels confirm the diagnosis biochemically. Gastrin secretion can be determined in the basal state or following stimulation with secretin or calcium. High sensitivity and specificity for the diagnosis of ZES is provided by determining the ratio of basal versus pentagastrin-stimulated gastric acid secretion: The ratio of BAO / MAO > 0.6 is highly specific for gastrinoma. To localize the gastrin-secreting tumor computer-assisted tomography, endoscopic ultrasound, and somatostatin receptor scintigraphy provide useful help but most recently, endoscopic ultrasound with high resolution transducers appear to improve preoperative site localization. If modern imaging techniques fail to elucidate the site of the tumor, intraoperative diaphany may help to detect gastrinomas within the duodenal wall. Definitive treatment will only be achieved by total surgical resection of the gastrin-producing tumor in the pancreas or duodenum including dissection of the regional lymph nodes. Control of symptoms will have to be achieved by administration of highly potent proton pump inhibitors in up to 2-3-fold increased standard doses to inhibit gastric acid hypersecretion. Elevation of gastric pH > 4 will be the therapeutic target to protect the mucosa of the upper gastrointestinal tract. Basal acid output should be reduced to less than 10 mEq H(+) per hour which requires administration of highly potent proton pump inhibitors with a recommended starting dose of 60 mg omeprazole equivalents per day.

Refractory Peptic Ulcer Disease: A Rare Presentation of Annular Pancreas

Case: A 28-year old Caucasian male presented with epigastric pain, nausea, and vomiting. There was no history of NSAID use. He had normal LFTs, amylase and lipase. EGD revealed an ulcerated mass/narrowing in the descending duodenum. Biopsies showed duodenitis, H. pylori negative. An UGI series showed a focal constriction in the descending duodenum. Abdominal CT showed an incomplete annular pancreas (AP) encircling the anterior and lateral aspect of the descending duodenum with narrowing of the duodenal lumen. The patient's symptoms initially responded to high dose PPI, but recurred four months later. Repeat EGD showed severe narrowing of the descending duodenum. The patient underwent gastrojejunostomy with relief of the symptoms. Repeat EGD revealed healed ulcers/erosions. Discussion: AP is a rare congenital anomaly (incidence 1:20,000) characterized by a ring of pancreatic tissue surrounding the descending duodenum. It results from failure of the ventral anlage of the pancreas to rotate with the duodenum. There are two main etiologic theories: (1) Lecco's Theory – adherence of the ventral bud to the duodenal wall prior to rotation results in its persistence and encirclement of the duodenum, and (2) Baldwin's theory – persistence and enlargement of the ventral bud. It can present at any age, including infants. Most adults present between 20 and 50 years of age. Most are asymptomatic. Presenting symptoms include abdominal pain, nausea, postprandial fullness, vomiting, UGI bleeding (from peptic ulcer), acute or chronic pancreatitis, and rarely biliary obstruction. 15% of adults with AP have duodenal stenosis. 33% have PUD. PUD is believed to be due to prolonged stasis of antral contents. The treatment is bypass surgery of the annulus, by duodenojejunostomy, duodenoduodenostomy, or a gastrojejunostomy. Conclusion: This is an unusual presentation of AP in adulthood as a DU and constriction refractory to PPI therapy, which responded to gastrojejunostomy. AP should be strongly considered in the differential diagnosis of a benign idiopathic PUD in the descending duodenum associated with severe focal duodenal narrowing, and refractory to PPI therapy. AP should be excluded by appropriate imaging studies.[figure1]Figure

The role of proton pump inhibitors in the treatment of Zollinger–Ellison syndrome

Zollinger–Ellison syndrome is characterised by refractory peptic ulcer disease, diarrhoea and gastric acid hypersecretion associated with a gastrin-secreting tumour. The incidence is unknown, but, in the US, the frequency is 0.1 – 3.0 million people. Zollinger–Ellison syndrome is associated with multiple endocrine neoplasia type 1 in 25 – 35% of the cases. The diagnosis of Zollinger–Ellison syndrome is suggested when plasma gastrin is > 1000 pg/ml and the basal acid output is > 15 mEq/h or when associated with a pH < 2. The treatment is focused on controlling gastric acid hypersecretion and localisation of the tumour and its metastases. Proton pump inhibitors are the most effective antisecretory drugs and can be administered at high dosages. This review focuses on the role of the proton pump inhibitors in the management of gastric acid hypersecretion in Zollinger–Ellison syndrome.

Severe and Refractory Peptic Ulcer Disease: The Diagnostic Dilemma

The recognition of Helicobacter pylori infection as a cause of peptic ulcer disease, medical regimens to eradicate the organism, and the widespread use of proton pump inhibition to suppress gastric acid secretion have revolutionized the management of peptic ulcer disease. As a result, successful medical management of peptic ulcer disease has largely supplanted the need for gastric surgery by general surgeons. Surgery is reserved for complications of the disease, refractory disease, or rare causes of ulcer disease such as gastrinoma and Zollinger-Ellison syndrome. In this report, we describe a case of intractable peptic ulcer disease that progressed to gastric outlet obstruction despite maximal medical therapy. We review the diagnostic studies utilized to evaluate the potential etiologies of peptic ulcer disease and the difficulty in diagnosing gastrinoma and Zollinger-Ellison in the setting of potent medical acid suppression therapy.

Optimal treatment of Zollinger-Ellison syndrome and related conditions in elderly patients.

Zollinger-Ellison syndrome is characterised by refractory peptic ulcer disease, severe diarrhoea and gastric acid hypersecretion associated with an islet-cell tumour of the pancreas (gastrinoma). The true incidence and prevalence of this rare disease is unknown; in the US, the frequency is one per one million people and the age at presentation varies from 7 to 90 years. Zollinger-Ellison syndrome is sporadic in 62-80% of cases and in 20-38% of cases is associated with multiple endocrine neoplasia type 1 (MEN 1). The diagnosis of Zollinger-Ellison syndrome is certain when the plasma gastrin is >1000 pg/mL and the basal acid output is >15 mEq/h in patients with an intact stomach, >5 mEq/h in gastrectomised patients, or when this hypergastrinemia is associated with a pH <2. The treatment is based on control of gastric acid hypersecretion and of the malignant tumour and its possible metastases. Proton pump inhibitors are the most effective antisecretory drugs and can be administered in the elderly at high dosages without drug-related adverse effects. As an initial therapy, daily dosages of omeprazole 80-100 mg or pantoprazole 40-160 mg are employed. In long-term treatment the doses can be greatly reduced once effective control of the gastric output has been established. Intravenous proton pump inhibitors may be administered when patients cannot take oral therapy, particularly in acute conditions. All sporadic localised gastrinomas should be excised if possible. When liver metastases are also present, their debulking may improve symptoms and survival, and facilitate medical treatment. There is some controversy as to the surgical approach for gastrinomas associated with MEN 1. Somatostatin analogues can be useful in reducing gastric acid hypersecretion, serum gastrin and gastric enterochromaffin-like (ECL) cells and can thus contribute to treating the disease more effectively. Their antiproliferative effect can be used in treating liver metastases. Chemotherapy is not the therapy of choice in patients with gastrinomas and is indicated only in those with malignant progressive disease; interferon alpha, embolisation and chemoembolisation are not advisable for the elderly. The treatment of elderly Zollinger-Ellison syndrome patients, similarly to all elderly oncological patients, should be based on the use of comprehensive geriatric assessment. This will enable the clinician to define the functional status of the elderly person, to decide whether the patient can tolerate surgery and/or the stress of antineoplastic therapy, and finally, to determine whether this patient can tolerate an aggressive treatment for Zollinger-Ellison syndrome or whether the only possible choice is palliative relief of symptoms.

Compliance with restrictions on the subsidized use of proton pump inhibitors in Australia.

To determine among a cohort of patients newly dispensed a prescription for a proton pump inhibitor (PPI) the extent of prior use of other less expensive agents such as antacids and H2-receptor antagonists as evidence of a 'stepped care' approach to peptic ulcer and oesophageal disease. A retrospective drug utilization study was conducted within the Pharmaceutical Benefits Scheme (PBS) claims database in Australia. A cohort of social security recipients, who received approval for PPI supply in the month of October 1996, had no prior PPI approval in the previous 18 months and went on to have the drug dispensed, was assembled. This group of 'new PPI starters' was then examined for supply of less expensive prescription medicines to treat peptic ulcer and oesophageal disease in the 12 months prior to obtaining their PPI approval. In a cohort of 4554 defined new PPI users, 1205 (26.5%) showed no use of H2-receptor antagonists, antacids, cisapride, cytoprotectants or antiregurgitants in the 12 month period prior to commencing the PPI. The major reason for use given by prescribers for PBS supply was 'severe refractory ulcerating oesophagitis'. Subsidized supply is currently restricted on cost-effectiveness grounds to refractory peptic ulcer disease or severe oesophageal disease. Despite this, utilization and epidemiological data suggest that there is widespread leakage of use outside these indications particularly to less severe forms of oesophageal disease. This patient tracking study has shown within the PBS database that around a quarter of the patients are treated directly with a PPI without being prescribed less expensive agents at least in the preceding 12 months.