Background: Before the advent of transcatheter arterial embolization (TAE), emergency surgery was the only choice for patients with peptic ulcer bleeding refractory to endoscopic therapy. This study compared the effectiveness of TAE and surgery in patients with peptic ulcer bleeding re- fractory to endoscopic hemostasis. Materials and Methods: This was a retrospective analysis of 116 patients with peptic ulcer bleeding refractory to endoscopic treatment at our institution. Eighty-three cases were treated with surgery, and 33 cases were managed with TAE. Clinical out- comes were evaluated. Results: There were no differences between groups with respect to the mortality rate (p > 0.05), length of hospital stay, or medical diseases related to mortality. The TAE group exhibited a significantly higher rebleeding rate (p < 0.05). Rebleeding predominantly oc- curred in patients with type Ia peptic ulcers (Forrest classification) irrespective of the treatment approach. The rebleeding rates in such patents were 30.2% and 56.3% in the surgery and TAE groups, respectively. Patients with rebleeding after further therapy showed high mortality rates (68.6%). The rebleeding rate was not significantly different between the subgroups of patients with type Ia lesions, although there was a higher mortality rate in the TAE group (27.9% vs. 75%, p = 0.001). Conclusions: TAE may be the first-choice therapy for patients with peptic ulcer bleeding refractory to endoscopic treatment, whereas emergency surgery may be used as an alternative in patients with type Ia bleeding at institutions with no 24-hour radiology service or when no expe- rienced radiologist is available.
Primary hyperparathyroidism revealed by thoracic spine brown tumor and peptic ulcer bleeding is rare. We presented a case of 33-year-old male patient who was admitted with paraplegia. Thoracic spine magnetic resonance imaging (MRI) showed extradural lesion at T4 level. He underwent surgical decompression in T4. According to histopathologic finding and elevated serum parathormone (PTH) and hypercalcemia (total serum calcium 12.1 mg/dL), the diagnosis of brown tumor was down. Ultrasonography of his neck showed a well-defined lesion of 26 × 14 × 6 mm. The day after surgery, he experienced 2 episodes of melena. Bedside upper gastrointestinal endoscopy showed gastric peptic ulcer with visible vessel. Treatment with intragastric local instillation of epinephrine and argon plasma coagulation was done to stop bleeding. After stabilization of the patient, parathyroidectomy was performed. Histologic study showed the parathyroid adenoma without any manifestation of malignancy. At discharge, serum calcium was normal (8.6 mg/dL). On 40th day of discharge, standing and walking status was normal.
The overall incidence of bleeding peptic ulcers between 1985–1986 and 2007–2008 remained unchanged in the population in this area of Norway. However, the incidence decreased by 54% in the age group 20–75 years and increased by 49% in those older than 75 years. The use of aspirin or NSAIDs prior to an ulcer bleeding increased from 31% to 67% between 1985–1986 and 2007–2008. In 2007–2008, only 10% of the patients with peptic ulcer bleeding were nonusers of low-dose aspirin or NSAIDs and H. pylori nega- tive. Dyspepsia prior to an emergency hospital admission for peptic ulcer bleeding declined from 60% to 12% in the same time period, which suggests an increasing frequency of acute bleeding ulcers caused by the use of ulcerogenic drugs.
The characteristics of patients and the endoscopic features of 196 patients with bleeding peptic ulcer in a multi- ethnic population were investigated. There was a male preponderance (M: F= 6.3: 1) and their mean age was 63.5 years. The prevalence of peptic ulcer bleeding in the Malays and Indians was similar to the ethnic distribution of population. However, the Chinese were over represented. Nearly 40% of patients studied had at least one co- existing medical illness. Hypertension and ischaemic heart disease were the most common diseases. History of non-steroidal anti-inflammatory drug usage was identified in 48% of the patients and it was the commonest risk factor associated with bleeding ulcers. More than 80% of bleeding ulcers were located in the duodenum and the pylorus. Endoscopic features of active bleeding or recent bleed were identified in more than 60% of the patients. The study notes that bleeding peptic ulcer is a serious and a potentially life threatening condition. It is a disease of the elderly and, with the steadily increasing elderly population in the country, the admissions rates of peptic ulcer bleeding is expected to rise. There is a need to plan for appropriate technical support, critical care facilities and expertise to avoid unacceptable outcomes.
The mortality rate for severe peptic ulcer bleeding has remained constant at 6-10% over the past 30 years.5-? Patients with peptic ulcer bleeding are almost exclusively of old age. Postoperative complications of severely bleeding peptic ulcers are many; nevertheles, mortality rates can be lowered with better hospital care including a combined medical and surgical approach, as well as the latest endoscopic therapies.8-Io In an attempt to reduce the mortality rate, several endoscopic hemostatic modalities have been developed over the past decade to prevent, further bleeding and thus obviate the need for high risk emergency surgery.I,IO-I2 Since 1978, heater probe thermocoagulation (HPT) has been reported as an excellent means of achieving hemostasis.4-6 It has been proposed as one of the most promising devices in arresting peptic ulcer bleeding.?-IO
This was a single center; prospective, randomized trial con- ducted in a tertiary teaching hospital (Changhua Christian Hospital) in Taiwan and was approved by the Institutional Review Board of the Changhua Christian Hospital and International Clinical Trial (NCT01123031). From April 2010 to Feb 2011, peptic ulcer patients with high-risk stig- mata were considered eligible if they fulfilled the following inclusion criteria: (i) underwent urgent endoscopy within 24 h after presentation, (ii) had peptic ulcers in the stom- ach or duodenum, (iii) had high-risk stigmata including ac- tive bleeding (Forrest IA, IB), or non-bleeding visible vessels (NBVV, Forrest IIA) and (iv) successful hemostasis was achieved with endoscopic heat probe thermocoagula- tion or hemoclip placement. Written informed consent was obtained from each patient before enrolment.
these data are derived from studies of the outcome of upper gastrointestinal bleeding, which includes – but is not confined to – bleeding peptic ulcer. Upper gastroin- testinal bleeding among young patients is more likely to be caused by lesions induced by excess alcohol consump- tion, e.g. oesophageal varices, Mallory-Weiss lesions, or hemorrhagic gastritis, whereas elderly patients are more likely to bleed from peptic ulcers [22,24]. Thus, the asso- ciation between age and the outcome of upper gastroin- testinal bleeding may be biased by the different spectrum of bleeding lesions. Few previous studies found comor- bidity to be an independent prognostic factor for compli- cated peptic ulcer. A recent Dutch study based on retrospectively reviewed medical records found that 10 of 13 death following peptic ulcer bleeding were unavoida- ble primarily because of severe comorbidities . The main strengths of the present study include its large size and the uniformly organized health system allowing a population-based design and the use of independent medical databases, which limits the risk of selection and information bias. A further advantage is the ability to adjust the analysis for the pre-hospitalisation use of ulcer- related drugs, which is an important potential confound- ing factor. However, residual confounding could stem from potential misclassification of drug use due to lack of compliance.
Aim: Dual endoscopic and pharmacologic therapy is currently the standard treatment for patients with high-risk peptic ulcer bleeding. The authors assess the efficacy of dual (endoscopic and pharmacologic) therapy versus endoscopic monotherapy in reducing rates of recurrent bleeding and death in patients with high-risk peptic bleeds. Methods: The authors carried out a post-hoc analysis of data on the use of intravenous proton pump inhibitors for the prevention of rebleeding ulcers and death (from an investigator-supported multicenter randomized trial in Italy). All the patients bleeding from high-risk peptic ulcers with a successful endoscopic hemostasis were treated with epinephrine injections alone (n = 157) or in combination with thermal therapy (n = 219). Results: Rebleeding occurred in 20 individuals (12.7%) in the monotherapy group, and in 21 individuals (9.6%) in the dual group (P = 0.33). Seven patients (4.5%) in the former group and 2 (0.9%) in the latter group died, with a 3.6% (95% CI: 0.3 to 8.1) absolute risk reduction. The mean number of units of blood transfused were 2.7 ± 1.7 and 3.2 ± 2.5 (P = 0.14), respectively, and the mean hospital stay was 6.7 ± 3.9 and 7.1 ± 4.3 days (P = 0.40), respectively. Multivariate analysis revealed that the sole independent predictor of death was ulcer size ≥ 20 mm [odds ratio (OR) = 6.56, 95% CI: 1.57 to 27.4]. Dual endoscopic and pharmacologic therapy provided a non-significant reduction in the risk of death (OR = 0.26, 95% CI: 0.05 to 1.34). Conclusion: When adjuvant proton pump inhibitors were administered, dual endoscopic and pharmacologic therapy was not superior to injection monotherapy for reducing rates of rebleeding and death.
The reported incidence of UGIB in the USA and other countries is still between 48 and 160 cases per 100,000 adults per year, reaching a 14% associated mortality, in- creased hospital admissions and hospitalization costs [1, 2]. All improvements in the medical and endoscopic treat- ments are not sufficiently effective in treating the aging population with comorbid conditions that often have con- comitant treatment with non-steroidal anti-inflammatory or anti-clotting drugs . Peptic ulcer bleeding is seen pre- dominantly among the elderly, with 68% of patients over the age of 60 and 27% over the age of 80 . Elderly people with multiple comorbidities are among those who may fail endoscopic hemostasis and are poor candidates for surgery . Several options are recommended when rebleeding happens, including emergent repeated endos- copy or surgical intervention [5, 6]. TAE has been success- fully used for bleeding control, especially in old and multimorbid patients . The preventive mode of transar- terial embolization (TAE) has been used successfully as an additional option to decrease the rebleeding rate after endoscopic hemostasis . The goal of P-TAE is a reduc- tion of flow in the ulcer area by embolization of large ves- sels, such as the left gastric artery or gastroduodenal artery, secondary to ulcer localization in the gastric fundus, antral, pyloric, or duodenal part avoiding a superselective embolization of the vessel feeding the ulcer. This method is technically easier to perform, and it allows avoiding is- chemic complications. In a large study analyzing more than 1500 hospital admissions, TAE or surgery was neces- sary for 5.4% patients; half of them were operated on and another half underwent TAE. A significant part of TAE was done in a preventive mode, reaching a 12.5% mortality rate after TAE and 25.6% after surgery, while the rebleed- ing rate was 25% after TAE and 16.3% after surgery. The authors conclude that TAE should be the preferred hemostatic method when endoscopy fails ; other au- thors report similar conclusions [10, 11]. Preventive TAE after primary endoscopic hemostasis has been practiced in our institution since 2014. The reduction in the rebleeding rate after preventive TAE encouraged us to continue using this method. The aim of the study is an assessment of the intermediate results of preventive TAE following primary endoscopic hemostasis in patients with serious comorbid conditions and high rebleeding risk.
risk of complications and socioeconomic impact (absenteeism, high cost of the explora- tions and treatments). Studies led in Australia and in Great Britain gave prevalence between 5.2% and 9.9% in the general population . In Black Africa, since the intro- duction of endoscopy (1980), more and more publications show that this disease occu- pies a significant place in the pathology of the black African. In Mali, Togo and Congo the prevalence of the Peptic Ulcer Disease (PUD) was respectively 10.88%, 15.53% and 30.42%   .
the functional parietal cell volume or secretory capacity in smokers. Smoking causes mucosal injury by increasing content of free oxygen radicals, PAF, pituitary vasopressin, gastric endothelin and pituitary vasopressin. Smoking and nicotine stimulate pepsinogen secretion also by increasing chief cell number or with an enhancement of their secretory capacity. Long-term nicotine treatment in rats also significantly decreases total mucus neck cell population and neck-cell mucus volume. Bile salt reflux rate and gastric bile salt concentration are increased thereby increasing duodenogastric reflux that raises the risk of gastric ulcer in smokers. Smoking and nicotine not only induce ulceration, but they also potentiate ulceration caused by H.pylori, alcohol, NSAID or cold restrain stress. Smoking also alter processes important in gastric and duodenal mucosal integrity or protection such as mucosal bicarbonate secretion, prostaglandin content, mucosal blood flow, or epidermal growth factor [95,96] .
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GI bleeding events result in signiﬁ cant mortality similar to that of an AMI after adjusting for the initial hospitalization. In this study, we identiﬁ ed a lower overall mortality among patients with upper GI bleeding compared to other published studies. This favorable mortality could be a reﬂ ection of the average mortality in the community at large. It could also be due to improved techniques of diagnosis and more frequent use of effective endoscopic therapy in this patient popula- tion. This research can help physicians weigh the risks of GI bleeding against the beneﬁ ts of therapies that may contribute
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Several scoring systems have been developed and tested in the cases of acute upper gastrointestinal bleeding. These scores aim to easily estimate and predict the severity of the bleeding and possible prognosis and outcomes, based only on clinical information (from the history or physical examination). Moreover, some of these systems can be used to plan management more properly. 3 Based on these scores, physicians could also assess the need of immediate endoscopic procedure in the patient. One important scoring system is the Blatchford Score. It is a validated scoring system used in cases of upper gastrointestinal bleeding cases. It depends on both clinical and laboratory information and can predict the necessity of endoscope. 3 This score can range between 0 and 23. The higher the score is, the more likely the patient will need to undergo endoscopic procedure. Another important scoring system that is widely used in the assessment of acute upper gastrointestinal bleeding is the Rockall score. It is considered to be the most commonly used scoring system that stratifies patients with upper gastrointestinal bleeding according to their risk. The Rockall scoring system has been tested and validated in several health care systems. 11 Rockall scores can be done in two steps. The first step, which is known as the clinical Rockall score, is usually calculated depending only on clinical information obtained from history and physical examination of the patient. The next step is usually calculated after undergoing endoscopy, and the score is calculated on both clinical information and endoscopic findings. The complete Rockall scoring system is generally used to assess the risk of rebleeding and mortality of the patient. The result of Rockall scoring system can range between zero to eleven, with eleven indicating the worst prognosis, and zero indicating the best prognosis with no risk of complications. 11 When it comes to predicting the necessity of undergoing endoscopic procedures, the Blatchford score has been found to produce more accurate estimates 12 . Moreover, the Blatchford score can also help decide if patients can be soon discharged following endoscopy. In fact, it has been estimated that the use of the Blatchford score to determine patients to discharge was associated with 25% reduction in unnecessary hospitalization after acute upper gastrointestinal bleeding. 13
Ambient air pollution contributes to the development of a number of medical conditions . Air pollution has been associated with an increased risk of cardiovascular disease (e.g. myocardial infraction) [14, 15], respiratory disease (e.g. chronic obstructive pulmonary disease, asthma) [16–19], stroke , cancer , and premature mortality . Recent discoveries suggest that air pollut- ants affect the gastrointestinal tract and contribute to the development of inflammatory bowel disease [23, 24], appendicitis [25, 26], and non-specific abdominal pain . Furthermore, exposure to air pollutants has been shown to affect the physiology of the gastrointestinal tract by altering intestinal permeability, microbial composition and diversity, and intestinal immunity, which may help promote the development of gastric ulcers [28–31]. Finally, one study has demonstrated a correlation between death from peptic ulcer disease and exposure to air pollution .
Peptic ulcer is the commonest cause of upper GI haemorrhage and the majority of the ulcers are located in the duodenum. Other common causes of hematemesis and malena are ruptured oesophageal varices and erosive gastritis. Sex and blood group distribution are almost similar with other studies conducted at home and abroad. But age distribution varies from country to country and it is a little bit lower in countries like us than those of western countries.
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Hydrophobic surfactant - like phospholipids secretion in the gastric epithelial cells is also stimulated by the prostaglandin. Volume of gastric secretion is an important factor in the production of ulcer due to exposure of unprotected lumen of the stomach to the accumulating acid. The antiulcer property of Gunmathi Chooranam in pylorus ligation model is evident from its significant reduction in free acidity, total acidity, number of ulcers and ulcer index. Gunmathi Chooranam treated animals significantly inhibited the formation of ulcers in the pylorus ligated rats and also decreased both the concentration and increased the pH, it is suggested that Gunmathi Chooranam can suppress gastric damage induced by aggressive factors. It is suggested that, the active compounds would be able to stimulate mucus, bicarbonate and the prostaglandin secretion and counteract with the deteriorating effects of reactive oxidants in gastrointestinal lumen. So the antiulcer activity of Gunmathi Chooranam may be attributed to its active principle.
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samples were grouped in terms of age range. It was found that oral peroxidase activity gradually increased by aging in peptic ulcer patients, while normal subjects showed less enzyme activity when aged. This can be explained by the considering that more free radical damage caused by the ulcer in older patients. The partial antioxidant effect of saliva can block oxidative damage of biological molecules at normal salivary pH (6.8-7.5). However, in stomach medium (pH 2-3) this type of antioxidant effect is not expected due to structural changes of effective molecules mostly antioxidant enzymes 26 .
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Angiogenesis and VEGF play a major role in many repair processes such as healing of gastric ulceration resulting from a disturbed balance between factors which damage the gastric mucosa barrier and those which have a protective role. Several studies have provided evidence for a role of VEGF in gastric ulcer healing. Jones et al observed enhanced ulcer healing in rats following a single injection of naked DNA encoding VEGF 54.
NSAIDs are inevitably linked to peptic ulcer disease .Individuals who are on treatment for rheumatoid arthritis and osteoarthritis take NSAIDs.these patients are affected to 10- 15% with PUD . The prevalence of peptic Ulcer disease among persons who use NSAID is about 24%. These involve 15% mainly gastric ulcer and 10% include duodenal disease PUD complaints such as perforation and bleeding are more common in NSAID users. most of the patients are brought into focus only after facing the complications the risk of getting complications and adverse effects in patients using NSAID is higher when compared to controls.The risk is higher and older age group.
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Penetration occurs when a peptic ulcer burrows through the wall of the stomach or duodenum but, instead of perforating freely into the peritoneal cavity, the crater bores into an adjacent organ 15 . Duodenal ulcers that involve the posterior wall of the bulb can penetrate into the pancreas. Penetrating gastric ulcers often involve the left lobe of the liver. Rarely, penetrating peptic ulcers can result in the development of fistulas between the duodenum and the common bile duct (choledochoduodenal fistula) or between the stomach and the colon (gastrocolic fistula).
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