Refractory Ulcers Research Articles

A Case of Refractory Rectal Ulcer due to a Large Amount of Ghost Pills

A Case of Refractory Rectal Ulcer due to a Large Amount of Ghost Pills

Epstein-Barr Virus Upper Gastrointestinal Tract Mucocutaneous Ulceration in a Renal Transplant Recipient with Leucopenia and Hypogammaglobulinaemia

Epstein-Barr virus (EBV) mucocutaneous ulceration is a rare complication of immunosuppression that results in painful ulceration of the tongue or gingiva, and less commonly, refractory ulceration of the gastrointestinal tract. High clinical suspicion is required, as failure to diagnose EBV mucocutaneous ulceration may result in significant morbidity and mortality. We report the case of a 64-year-old female renal transplant recipient requiring admission to hospital for management of severe oral and epigastric pain. Examination revealed a large, superficial, well-circumscribed ulcer at the base of the tongue. Blood tests suggested a secondary immunodeficiency characterised by mild leucopenia, hypogammaglobulinaemia, and low memory B-cells with normal immunophenotype. Endoscopy revealed four, cratered ulcers in the pre-pyloric region of the stomach. A core biopsy of the tongue ulcer confirmed EBV mucocutaneous ulceration. The patient’s immunosuppression was optimised, which resulted in complete resolution of the tongue and gastric ulcers at eight and twelve weeks of follow-up respectively.

A Case of Refractory Ulcer with Open Elbow Joint Treated with PAT Graft and NPWT

A Case of Refractory Ulcer with Open Elbow Joint Treated with PAT Graft and NPWT

Calcification in Werner syndrome associated with lymphatic vessels aging.

In addition to the symptoms of aging, the main symptoms in Werner syndrome (WS), a hereditary premature aging disease, include calcification of subcutaneous tissue with solid pain and refractory skin ulcers. However, the mechanism of calcification in WS remains unclear. In this study, the histological analysis of the skin around the ulcer with calcification revealed an accumulation of calcium phosphate in the lymphatic vessels. Moreover, the morphological comparison with the lymphatic vessels in PAD patients with chronic skin ulcers demonstrated the ongoing lymphatic remodeling in WS patients because of the narrow luminal cross-sectional area (LA) of the lymphatic vessels but the increment of lymphatic microvessels density (MLVD). Additionally, fluorescence immunohistochemical analysis presented the cytoplasmic distribution and the accumulation of WRN proteins in endothelial cells on remodeling lymphatic vessels. In summary, these results point out a relationship between calcification in lymphatic vessels and the remodeling of lymphatic vessels and suggest the significance of the accumulation of WRN mutant proteins as an age-related change in WS patients. Thus, cytoplasmic accumulation of WRN protein can be an indicator of the decreasing drainage function of the lymphatic vessels and the increased risk of skin ulcers and calcification in the lymphatic vessels.

Leukocyte- and Platelet-Rich Fibrin: A New Method for Scalp Defect Reconstruction.

Leukocyte- and Platelet-Rich Fibrin: A New Method for Scalp Defect Reconstruction.

Through-the-scope endoscopic suturing for the management of a large refractory duodenal ulcer

A 52-year-old man presented for endoscopic assessment because of recurrent abdominal pain and hematemesis. In the previous 2 years, he had undergone 10 EGDs for the management of severe pain and bleeding from a persistent 2-cm duodenal bulb ulcer despite using maximal pantoprazole, sucralfate, and misoprostol therapy. This ulcer had previously been treated with a variety of thermal and mechanical methods without resolution, seen on previous endoscopies (A). During this current hospitalization, a persistent duodenal ulcer was seen on endoscopic visualization (B), and a decision was made to oversew the ulcer by using a novel through-the-scope device performed in a figure-8 pattern (X-Tack, Apollo Endosurgery, Austin, Tex, USA) to achieve hemostasis and, theoretically, allow healing by preventing exposure of the ulcer’s submucosal vessels to gastric contents.

Successful Use of Infliximab for Refractory Genital Ulceration in a Patient With Multiple Sclerosis and Behçet Disease.

Successful Use of Infliximab for Refractory Genital Ulceration in a Patient With Multiple Sclerosis and Behçet Disease.

Short-term Results of Percutaneous Ablation of Perforators for Incompetent Perforating Veins Present in Lower Leg Skin Lipodermatosclerosis and Refractory Ulcer

下腿うっ滞性皮膚炎や難治性潰瘍皮下に存在する不全穿通枝（incompetent perforating vein: IPV）を遮断する術式として考案されたのが2014年に保険収載された内視鏡下筋膜下穿通枝切離術（subfascial endoscopic perforator surgery: SEPS）である．われわれもSEPSを行ってきたが，SEPSでは対応できないIPVも経験し，この解決策の一つが経皮的穿通枝焼灼術（percutaneous ablation of perforators: PAPs）で，63例65肢のIPV 102本にPAPsを行った．使用機器に変遷があり，現在は1470 nmレーザー装置と外径の細いレーザーファイバーを用い，linear endovenous energy densityは平均68.1±14.9 J/cmであった．PAPsの利点としては，目的のIPV閉塞を術中に超音波検査で確認できることで，術中閉塞率は100%であった．さらに，解剖学的理由でSEPSでは処理できない部位のIPVも処理可能であった．

A Royal Jelly Mixture with Berberine for Dressing Change on a Refractory Skin Ulcer: A Case Report

It has been reported that a 92-year-old female had got a bruise superficialwound on her right leg one and a half years ago, developing into refractoryskin ulcer due to improper management before. A prepared cream, mixedroyal jelly with berberine for dressing change, was made on the scenethrough the crush of berberine tablets, working with fresh royal jelly.Topical dressing change with the cream was done every 3 days, and twomonths later, such the ulcer became clean and was covered fully with freshgranulation tissue. This kind of cream consists of the ingredients of TCMpurely, free of antibiotic, and being quite effective clinically, also helpfulfor proper use of antibiotic.

A systematic review of ozone therapy for treating chronically refractory wounds and ulcers.

This study aims at evaluating the efficacy and safety of ozone therapy for chronic wounds. The Cochrane Library, PubMed, Ovid Embase, Web of Science, and Chinese Biomedical Literature Database were searched. Randomised controlled trials (RCTs) about participants with chronic wounds were included. Risk of bias assessment was performed by the Cochrane risk‐of‐bias tool. A randomised‐effects model was applied to pool results according to the types of wounds or ulcers. Among 12 included studies, ozone was implemented by topical application (ozone gas bath, ozonated oil, ozone water flushing) and systematic applications including autologous blood immunomodulation and rectal insufflation. The results indicated compared with standard control therapy for diabetic foot ulcers, ozone therapy regardless of monotherapy or combined control treatment markedly accelerated the improvement of the wound area(standardised mean difference(SMD) = 66.54%, 95% confidence interval (CI) = [46.18,86.90], P < .00001) and reduced the amputation rate (risk ration (RR) = 0.36, 95% CI = [0.24,0.54], P < .00001). But there is no improvement in the proportion of participants with completely healed wounds and length of hospital stay. No adverse events associated with ozone treatment have been reported. And the efficacy of ozone therapy for other wound types is still uncertain because of no sufficient studies. More high‐quality randomised controlled trials are needed to confirm the efficacy and safety of ozone therapy for chronic wounds or ulcers.

S2342 An Unusual Cause of Hematemesis Heralding as a Case of Polyarteritis Nodosa (PAN)

Introduction: Polyarteritis nodosa (PAN) is a systemic necrotizing vasculitis predominantly affecting medium-sized arteries, with incidence ranging from 2-9 cases per million individuals and peak prevalence in the 6th decade of life. While most cases of PAN are idiopathic in origin, about 7% of cases have been linked to hepatitis B infection. This disease tends to manifest with systemic symptoms and multi-organ involvement and can have gastrointestinal involvement in up to 65% of patients, including abdominal pain from mesenteric arteritis, vasculitis-induced ischemia, and gastrointestinal bleeding. We describe a rare case of PAN in a young male presenting with non-specific symptoms of subacute abdominal pain and gastrointestinal bleeding. Case Description/Methods: A 20-year-old man presented with a 3 week history of intermittent epigastric pain unrelated to meals, nearly daily episodes of hematemesis, as well as hematochezia, anorexia, weakness, and fatigue. Initial evaluation revealed a normocytic anemia with hemoglobin of 8.8 g/dL and hematocrit of 28%. Computed tomography (CT) angiography revealed greater than 20 aneurysms arising from the medium-sized and small branches of the splanchnic abdominal arterial vasculature, with the largest aneurysm being 1.8 x 1.7 cm (Figure 1). Given concern for underlying vasculitis, the patient completed an extensive workup (Table 1). He received a diagnosis of PAN and was started on a high dose prednisone course. Post hospital discharge he was found to have interval growth of underlying abdominal aneurysms after a month and thus was started on cyclophosphamide therapy. He eventually underwent prophylactic coil embolization of the left hepatic and gastric artery aneurysms with interventional radiology to prevent future rupture. Discussion: Our case demonstrates a rare presentation of gastrointestinal bleeding and subacute symptoms heralding a diagnosis of PAN in a young male. While these nonspecific complaints carry a very broad differential diagnosis, this case highlights the need to consider vasculitis in the right clinical context. PAN is diagnostically challenging due to its diverse presentation and lack of specific markers for diagnosis. Prompt identification is critical given PAN has an untreated 5-year mortality rate of 13% which improves to 80% with treatment. Underlying mesenteric arteritis can lead to serious complications, such as refractory ulcers, intestinal ischemia, and bowel perforation.Figure 1.: A) CT abdomen and pelvis with IV contrast showing a large left hepatic artery aneurysm (measured up to 16.5 x 15.9 mm). B) Abdominal arteriogram depicting numerous aneurysms of mid-sized and small branches in the splanchnic abdominal arterial vasculature.Table 1:: Inpatient labwork obtained for workup of vasculitis.

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.

326 Healing properties of fetal cells beyond pregnancy

Chronic leg ulcers are a severe and disabling condition that still constitute a significant global health issue and for which there has been no therapeutic innovation during the last decades. Sickle cell disease (SCD) leads to prolonged and refractory human ulcers. Fetal microchimeric cells (FMCs) are transferred to mothers during pregnancy and niche into maternal bone marrow where they persist for decades. We have shown that during pregnancy, they are recruited to maternal wounds and improve wound healing. In this work, we sought to evaluate whether the healing capacities of FMCs were sustained after pregnancy in both normal and delayed wound healing in a sickle cell mice model (SAD). We found that healing kinetics were similarly improved in pregnant and post-partum wild-type mice, through increased cell proliferation and angiogenesis. Post-partum SAD mice also showed an accelerated healing compared to virgin mice, associated with the recruitment of FMCs to the wound and increased neovascularization. We then analyzed clinical parameters in both nulliparous or ever-parous women suffering from sickle cell disease and leg ulcers. The analysis of multiple parameters such as number of leg ulcers episodes, hospital admission, infection rate, pain severity and skin graft requirements showed an overall better prognosis in ever-parous SCD women as compared to nulliparous women. Taken together, these results indicate that healing capacities of FMCs are maintained long after delivery. This supports a potential therapeutic use of FMCs to treat delayed wound healing in post-partum women.

Over-the-scope clip versus transcatheter arterial embolization for refractory peptic ulcer bleeding-Apropensity score matched analysis.

BackgroundTranscatheter arterial embolization (TAE) or surgery are standard treatment of peptic ulcer bleeding (PUB) refractory to endoscopic hemostasis. Over‐the‐scope clips (OTSC) have shown superiority to standard endoscopic treatment.ObjectiveTo compare OTSC treatment to TAE in refractory peptic ulcer bleeding.Patients and MethodsIn this retrospective, multicenter study, 128 patients treated with OTSC (n = 66) or TAE (n = 62) for refractory PUB between 2009 and 2019 in four academic centers were analyzed. Primary endpoint was clinical success (hemostasis + no rebleeding within 7 days). Secondary endpoints were adverse events, length of ICU stay, and mortality. Propensity score matching was performed to adjust for differences in baseline characteristics.ResultsPatients characteristics were similar in both groups but ulcers in the TAE group were larger, more often located in the duodenal bulb (85.5% vs. 65.2%; p = 0.014), and that the proportion of Forrest Ia bleedings was higher (38.7% vs. 19.7%; p = 0.018). Clinical success was comparable in both groups (74.2% vs. 59.7%; p = 0.092). Stay on the intensive care unit (ICU) was significantly longer in the TAE group (mean 8.0 vs. 4.7 days; p = 0.002). Serious adverse events after re‐therapy (12.9% vs. 1.5%; p = 0.042) and in‐hospital mortality were significantly higher in the TAE group (9.1 vs. 22.6%, OR 2.92 [95% CI 1.04–8.16]; p = 0.05). After propensity score matching, the differences found regarding ICU stay (4.9± 5.9 and 9.2 ± 11.2; p = 0.009) and in‐hospital mortality (5% vs. 22.5%; OR 5.52 [95% CI: 1.11–27.43]; p = 0.048) stayed significant.ConclusionsOTSC treatment for refractory PUB was superior to TAE in terms of ICU stay and in‐hospital mortality.

Optimized Manufacture of Lyophilized Dermal Fibroblasts for Next-Generation Off-the-Shelf Progenitor Biological Bandages in Topical Post-Burn Regenerative Medicine.

Cultured fibroblast progenitor cells (FPC) have been studied in Swiss translational regenerative medicine for over two decades, wherein clinical experience was gathered for safely managing burns and refractory cutaneous ulcers. Inherent FPC advantages include high robustness, optimal adaptability to industrial manufacture, and potential for effective repair stimulation of wounded tissues. Major technical bottlenecks in cell therapy development comprise sustainability, stability, and logistics of biological material sources. Herein, we report stringently optimized and up-scaled processing (i.e., cell biobanking and stabilization by lyophilization) of dermal FPCs, with the objective of addressing potential cell source sustainability and stability issues with regard to active substance manufacturing in cutaneous regenerative medicine. Firstly, multi-tiered FPC banking was optimized in terms of overall quality and efficiency by benchmarking key reagents (e.g., medium supplement source, dissociation reagent), consumables (e.g., culture vessels), and technical specifications. Therein, fetal bovine serum batch identity and culture vessel surface were confirmed, among other parameters, to largely impact harvest cell yields. Secondly, FPC stabilization by lyophilization was undertaken and shown to maintain critical functions for devitalized cells in vitro, potentially enabling high logistical gains. Overall, this study provides the technical basis for the elaboration of next-generation off-the-shelf topical regenerative medicine therapeutic products for wound healing and post-burn care.

Phlegmon Formation due to Perforated Marginal Ulcer After One Anastomosis Gastric Bypass; Conversion to Roux-en-Y Gastric Bypass: a Video Case Report

One anastomosis gastric bypass is now an accepted bariatric procedure in many countries. A rare but serious complication of OAGB is perforation of marginal ulcer with 0.5-1% incidence that needs urgent diagnosis and intervention. In cases of complicated or refractory ulcers, conversion to RYGB could be a definitive therapy.

Enhanced cellular engraftment of adipose-derived mesenchymal stem cell spheroids by using nanosheets as scaffolds

The short survival time of transplanted adipose-derived mesenchymal stem cells (ASCs) is a problem for skin wound healing. Transplantation after the formation of cellular spheroids has been investigated as a promising method for prolonging cellular survival. However, there have been technical restrictions for transplantation of spheroids in clinical practice. Here, we show an effective method for transplantation of ASC spheroids onto skin wounds in order to efficiently cure refractory ulcers. To assist anchoring of spheroids onto skin wounds, we used a 120-nm-thick free-standing film (nanosheet) that has a highly adhesive property. Bioluminescence imaging showed that ASC spheroids carried by the nanosheet survived for 14 days, which is about two-times longer than that previously reported. Wounds treated with a nanosheet carrying ASC spheroids were 4-times smaller than untreated wounds on day 14. This method for transplantation of spheroids could be applied to cell therapy for various refractory skin wounds.

A rare case of refractory and severe duodenal ulcers associated with olmesartan

A rare case of refractory and severe duodenal ulcers associated with olmesartan

Novel endoscopic therapy for anemia secondary to refractory anastomotic ulceration in Crohn’s disease

Novel endoscopic therapy for anemia secondary to refractory anastomotic ulceration in Crohn’s disease

Efficacy of conjunctival flap surgery for deep corneal ulcers.

Aim: To evaluate the clinical efficacy of a selective, partial, pedicle conjunctival flap in the treatment of deep corneal ulcers with or without perforation, resistant to medical treatment.Method: This interventional self-controlled retrospective study included 31 eyes of 31 patients with deep corneal ulcers who underwent conjunctival flap surgery in a tertiary eye care unit between 2017 and 2019. Of these, 9 eyes exhibited corneal perforation. The follow-up period was 12 months. The primary outcome measures were restoring ocular surface integrity and secondary outcome measures were improvement in visual acuity and postoperative complications encountered. Results: Out of the total of 31 patients, 17 patients (55%) were males and 14 patients (45%) were females. The mean age was 56.03 ± 15.46 years. The mean disease duration was 64.10 ± 35.01 days, the mean diameter of the ulcer was 3.61 ± 1.02 mm and the mean depth of the ulcer was 70.65 ± 20.28% of the thickness of the cornea. The etiology was extensive and the corneal ulcers were categorized as infectious (12), noninfectious (16), and unknown (3). An anatomic cure was obtained in 29 (94%) of 31 eyes. Conjunctival flap surgery was unsuccessful in 2 eyes that required evisceration. The postoperative visual acuity (BCVA) improved in 13 (42%) of the 31 eyes, decreased in 9 eyes (29%) and remained unchanged in 9 eyes (29%). The most frequent complications after conjunctival flap surgery were pseudopterygium, cataract and corneal opacity and less frequent complications were glaucoma, astigmatism, flap retraction, corneal perforation and endophthalmitis.Conclusions: Conjunctival flap surgery can successfully treat refractory deep corneal ulcers. It can restore ocular surface integrity and provide metabolic and mechanical support for corneal healing. Also, it can avoid emergency penetrating keratoplasty or create appropriate conditions for a future optic keratoplasty.