[A case of duodenal ulcer as prominent manifestation of IgG4-related disease]

A case of IgG4-related disease presented with a duodenal ulcer to improve the understan-ding of IgG4-related diseases was reported. A 70-year-old male presented with cutaneous pruritus and abdominal pain for four years and blackened stools for two months. Four years ago, the patient went to hospital for cutaneous pruritus and abdominal pain. Serum IgG4 was 3.09 g/L (reference value 0-1.35 g/L), alanine aminotransferase 554 U/L (reference value 9-40 U/L), aspartate aminotransferase 288 U/L (reference value 5-40 U/L), total bilirubin 54.16 μmol/L (reference value 2-21 μmol/L), and direct bilirubin 29.64 μmol/L (reference value 1.7-8.1 μmol/L) were all elevated. The abdominal CT scan and magnetic resonance cholangiopancreatography indicated pancreatic swelling, common bile duct stenosis, and secondary obstructive dilation of the biliary system. The patient was diagnosed with IgG4-related disease and treated with prednisone at 40 mg daily. As jaundice and abdominal pain improved, prednisone was gradually reduced to medication discontinuation. Two months ago, the patient developed melena, whose blood routine test showed severe anemia, and gastrointestinal bleeding was diagnosed. The patient came to the emergency department of Beijing Hospital with no improvement after treatment in other hospitals. Gastroscopy revealed a 1.5 cm firm duodenal bulb ulcer. After treatment with omeprazole, the fecal occult blood was still positive. The PET-CT examination was performed, and it revealed no abnormality in the metabolic activity of the duodenal wall, and no neoplastic lesions were found. IgG4-related disease was considered, and the patient was admitted to the Department of Rheumatology and Immunology of Beijing Hospital for further diagnosis and treatment. The patient had a right submandibular gland mass resection history and diabetes mellitus. After the patient was admitted to the hospital, the blood test was reevaluated. The serum IgG4 was elevated at 5.44 g/L (reference value 0.03-2.01 g/L). Enhanced CT of the abdomen showed that the pancreas was mild swelling and was abnormally strengthened, with intrahepatic and extrahepatic bile duct dilation and soft tissue around the superior mesenteric vessels. We pathologically reevaluated and stained biopsy specimens of duodenal bulbs for IgG and IgG4. Immunohistochemical staining revealed remarkable infiltration of IgG4-positive plasma cells into duodenal tissue, the number of IgG4-positive cells was 20-30 cells per high-powered field, and the ratio of IgG4/IgG-positive plasma cells was more than 40%. The patient was treated with intravenous methylprednisolone at 40 mg daily dosage and cyclophosphamide, and then the duodenal ulcer was healed. IgG4 related disease is an immune-medicated rare disease characterized by chronic inflammation and fibrosis. It is a systemic disease that affects nearly every anatomic site of the body, usually involving multiple organs and diverse clinical manifestations. The digestive system manifestations of IgG4-related disease are mostly acute pancreatitis and cholangitis and rarely manifest as gastrointestinal ulcers. This case confirms that IgG4-related disease can present as a duodenal ulcer and is one of the rare causes of duodenal ulcers.

Eosinophilic Gastroenteritis-associated Duodenal Ulcer Successfully Treated with Crushed Budesonide

Eosinophilic gastroenteritis (EGE)-associated duodenal ulcer is rare and its endoscopic and pathological features remain poorly described. A 15-year-old boy was referred to our hospital for further examination and treatment of duodenal ulcer. Esophagogastroduodenoscopy (EGD) revealed two A2-stage duodenal ulcers on the duodenal bulb. A biopsy revealed marked infiltration of eosinophils, suggestive of EGE-associated duodenal ulcers. Thus, treatment with crushed budesonide (9 mg/day) was started. EGD revealed healing of the duodenal ulcers seven months after treatment. To our knowledge, this is the first report describing EGE-associated duodenal ulcer successfully treated with crushed budesonide.

Rare malignant ulcer related to primary intestinal diffuse large B-cell lymphoma: A case report

RATIONALE

The specific pathogenesis of the diffuse large B-cell lymphoma(DLBCL)is still indefinite and argumentative. It is known that DLBCL is the most common type of non-Hodgkin's lymphomas (NHL). A lot of cases of DLBCL such as primary gastric diffuse large B-cell lymphoma(PG-DLBCL) are reported. However, primary intestinal diffuse large B-cell lymphoma(PI-DLBCL) is unusual.

PATIENT CONCERNS

We present a case of a 57-year-old male diagnosed in the Gastroenterology Department, which presented a bleeding duodenal ulcer with irregular borders.

DIAGNOSES

The immunohistochemical staining showed: CD20(+++), CD10(+) and Ki-67>40%.

INTERVENTIONS

The patient was successfully treated by Poly-chemotherapy with R-CHOP (rituximab, cyclophosphamide, doxorubicin, vindesine and prednisolone).

OUTCOMES

After 6 courses of chemotherapy treatment, the duodenal ulcer was completely healed by reviewing the UGIE.

LESSONS

Our report might give further strength to avoiding the erroneous and missed diagnosis for PI-DLBCL which is different from common duodenal ulcer.

Carrying a 112 bp-segment in Helicobacter pylori dupA may associate with increased risk of duodenal ulcer

The discovery of Helicobacter pylori in 1983 challenged researchers around the world to identify this pathogen's major virulence factors. The main rationale for this kind of research was to identify a biomarker associated with specific diseases following H. pylori colonization. Among different investigated virulence factors, duodenal ulcer promoting gene A (dupA) has been found to be associated with duodenal ulcer (DU), but its effect was different in various geographical regions. To determine the prevalence of dupA, we applied both classic primer pairs and our newly developed primers producing a highly conserved segment in PCR method. In our survey, 143 (47%) H. pylori isolates were obtained from 304H. pylori-colonized individuals [age range of 19-92; 113 (37%) males with the mean age of 50 and 191 (63%) females with the mean age of 49]. The presence of the dupA gene was investigated by using the different specific primers. The prevalence of the 112 bp segment isolated from H. pylori strains recovered from DU, GU and atrophy groups were significantly higher (81%, p value = .002, 64%, p = .065, 68% and p = .047 38%, respectively) than our control group, where the prevalence of the 112 bp segment was only 38%. Interestingly, a significant relationship was observed between the occurrence of DU and the presence of the 112 bp segment [p = .002; OR: 6.98; (95% CI: 1.94-25.00)]. Taken as a whole, we believe the 112 bp region of H. pylori dupA may serve as the first detected biomarker for the early detection of DU in patients admitted to hospitals.

Virulence factor genotyping of Helicobacter pylori isolated from Costa Rican dyspeptic patients

BACKGROUND AND AIMS

Costa Rica is one of the countries with the highest incidence and mortality rates for gastric cancer. Helicobacter pylori infection rates are high in the whole country. We have previously shown that H. pylori CagA+ is significantly associated with atrophic gastritis (AG) of the antrum in a dyspeptic population. The aim of this work is to determine if other H. pylori virulence factors (vacA, dupA, oipA, iceA and babA2) are associated with atrophic gastritis (AG) or duodenal ulcer (DU).

METHODS

The presence of virulence genes in Costa Rican H. pylori isolates was analyzed by PCR in 151 cultured strains from patients with dyspeptic symptoms. Endoscopic and histopathological diagnoses were available. Odds-ratio and 95% confidence intervals for AG patients vs. non-atrophic gastritis (NAG) or DU patients vs. no duodenal ulcer (NDU) patients were calculated.

RESULTS

Amongst the studied isolates, 82% had the cagA⁺, 76.2% had the vacA s1m1, 97.0% had the oipA⁺, 21.0% had the icea1, 79.0% had the iceA2, 44.0% had the babA2⁺ and 76.0% the dupA⁺ genotypes. Infection with H pylori cagA⁺, dupA⁺, oipA⁺, iceA, babA2⁺, and vacA s1m1 genotypes was not associated with AG risk. The frequency of the dupA gene was 78.7 and 60.9% in isolates from patients with NDU and DU, respectively, and its presence was significantly associated with decreased risk of duodenal ulcer [odds-ratio: 0.33, p = 0.024, confidence interval 95% (0.11-0.85)].

CONCLUSION

H. pylori dupA genotype is inversely associated with DU risk in this population.

Cumulative exposure to nighttime environmental noise and the incidence of peptic ulcer

BACKGROUND

Exposure to noise poses auditory and non-auditory effects on health. The gastrointestinal tract is considered as the site of adverse reactions to noise-induced stress; little attention has been paid to a potential link between noise and peptic ulcers.

OBJECTIVES

The aim of this study was to investigate whether cumulative exposure to environmental noise affects the incidence of peptic ulcer in adults.

METHODS

We analyzed the data from the National Health Insurance Service-National Sample Cohort (2002-2013). The final study sample comprised 217,308 adults assessed for gastric ulcer and 249,514 adults assessed for duodenal ulcer. The diagnosis of gastric (ICD-10: K25) and duodenal (ICD-10: K26) ulcers during an 8-year follow-up (2006-2013). Environmental noise data was obtained from the National Noise Information System, a nationwide monitors system of noise.

RESULTS

During the follow-up period, gastric ulcers occurred in 32.1% subjects and duodenal ulcers occurred in 10.7% subjects. The rate of diagnosis for gastric and duodenal ulcers was increased with the increases in cumulative mean levels of nighttime environmental noise. With increases in the increase in interquartile range (IQR) of nighttime noise, the hazard ratio (HR) was significantly increased by 12% (HR = 1.12; 95% CI, 1.10-1.13) for gastric ulcer and 17% (HR = 1.17; 95% CI, 1.15-1.20) for duodenal ulcer based on the fully adjusted model.

CONCLUSION

Our finding supports previous reports on the damaging effect of environmental noise on the gastrointestinal tract and suggests that cumulative exposure to environmental nighttime noise affects the development of peptic ulcers.

Gastrointestinal Complications of the Haemolytic Uraemic Syndrome

The haemolytic uraemic syndrome (HUS) is a well recognized cause of acute renal failure in children. Gastrointestinal involvement is common, and may result in rectal bleeding which can be an important presenting symptom. Previous publications have stressed the importance of correct diagnosis to avoid unnecessary surgery. Occasionally serious gastrointestinal complications do occur. We present five children with life-threatening gastrointestinal complications of the HUS and discuss the indications for laparotomy.

Perforated Duodenal Ulcer and Cigarette Smoking

Whilst the association between smoking and peptic ulceration has been reported previously, the relationship between smoking and the complications of ulcers, such as perforation, bleeding or acute painful exacerbation, has not been examined. In a retrospective study comparing 275 emergency admissions for peptic ulcer with 275 controls, cigarette smoking was significantly more common only in those with a perforated duodenal ulcer. Of 128 patients with perforated duodenal ulcers, 110 (86%) were cigarette smokers compared with 65 (51%) of the 128 matched controls (χ2, P<0.01). Cigarette smoking in patients with bleeding or acutely exacerbated ulcers was not significantly more common than in controls. These findings strongly suggest a particular association between smoking and perforated duodenal ulcer.

[Risk factors for adverse course of gastric and duodenal peptic ulcer]

OBJECTIVE

Introduction: High morbidity rate, frequent relapses, and significant economic losses give reasons for highlighting the peptic ulcer disease as the most topical medical-statistical problem. The aim of the study is to assess the influence of the main risk factors on the course of gastric and duodenal peptic ulcer.

PATIENTS AND METHODS

Materials and methods: We formed up the risk groups consisted of patients with 12 modified (4) and regular (8) factors, each characterized with its own signs and gradations. We performed the quantitative evaluation of the factors and scored the signs thereof, the results of which were used for determination of the most informative ones.

RESULTS

Results: Among the regular factors, we placed emphasis on gender, age, burdened heredity, and 0(I), Rh+ blood type. The risk of peptic ulcer in hereditary tainted young men of the working age with parental lineage (+2.3) and in males with 0(I) Rh+ blood type (+1.4) was proved. Helicobacter pylori (Hp) infection is a key contributor (a predictor of) to severity of the disease course (+9.7) among the modified risk factors. Negative effect of a concomitant pathology (+5.0), including hepatobiliary lesions (+3.8), hypertension (+4.0), and diabetes mellitus (+1.3) is also significant. Diet violation (+3.7), tobacco smoking (+3.2) and stress (+3.0) were ranked third.

CONCLUSION

Conclusions: The results of quantitative evaluation of the factors scoring suggest of the underlying H.pylori infection (the significance of which is growing along with the growth of the disease incidence) and irrational diet as the most informatively important ones. We have established the direct dependence between the most important peptic ulcer risk factors, severity of the disease, and duration and periodicity of treatment thereof.

Eosinophilic gastroenteritis presenting as upper gastrointestinal hematoma and ulcers after endoscopic biopsy: A case report and literature review

RATIONALE

Eosinphilic gastroenteritis (EG) is a gastrointestinal disorder characterized by eosinophilic infiltration with various manifestations. The diagnosis is usually confirmed by an endoscopic biopsy, which is considered a safe and routine procedure for the majority.

PATIENT CONCERNS

We report a 54-year-old male who was presented with intermittent periumbilical pain and melena, and only revealed verrucous gastritis by endoscopy.

DIAGNOSES

The patient's condition worsened two days after the endoscopic biopsy, and another endoscopy found hematoma and ulcers in upper gastrointestinal tract. He was diagnosed with EG by the pathological analysis of biopsy specimen.

INTERVENTIONS

Oral methylprednisolone and Montelukast were prescribed.

OUTCOMES

The patient got remission after initiation of the treatment.

LESSONS

This case highlights an extremely rare but potentially severe complication of endoscopic biopsies in patients with EG. Physicians should be cautious with hematoma or ulceration, and consider it in such patients who undergo this procedure.

Upper gastrointestinal haemorrhage in severe dengue: To scope or not to scope?

Upper gastrointestinal haemorrhage (UGIH) in severe dengue represents a clinical dilemma in term of management. The recommended treatment in dengue with UGIH involves blood product transfusion support and proton pump inhibitor (PPI) infusion. Despite being the mainstay of treatment in non-dengue UGIH, the role of endoscopic haemostatic intervention in severe dengue remains controversial. In the present report, we present a case of severe dengue complicated with upper gastrointestinal haemorrhage successfully underwent early therapeutic endoscopic intervention in a district hospital.

Successful Treatment with Adalimumab for Intestinal Behcet's Disease during Pregnancy

A 36-year-old Japanese woman with intestinal Behcet's disease was admitted to our hospital due to a recurrent ileocecal ulcer. Because infliximab (IFX) showed secondary failure, IFX was switched to adalimumab (ADA). After the third injection of ADA, she was unexpectedly 4-weeks pregnant. ADA was continued until 20 gestational weeks. Remission of the disease activity was maintained during pregnancy, and the birth was uneventful. The ileocecal ulcer disappeared after her delivery. ADA was detected in the umbilical blood after 119 days from the last infusion. The placental transition and timing of neonatal vaccination should be considered in cases of pregnancy with TNF antibody therapy.

Perforated duodenal ulcer: An unusual manifestation of allergic eosinophilic gastroenteritis

Spontaneous perforation of a duodenal ulcer secondary to allergic eosinophilic gastroenteritis (EGE) has not been previously reported. We present such a case in a teenager who presented with peritonitis. After exploration and operative repair of his ulcer, he continued to experience intermittent abdominal pain, and further evaluation revealed eosinophilic gastroenteritis in the setting of multiple food allergies. His EGE resolved after adhering to a restrictive diet. Both duodenal ulcers and EGE are very rarely seen in pediatric patients. EGE has a variable presentation depending on the layer(s) of bowel wall affected and the segment of the gastrointestinal tract that is involved. Once diagnosed, it may respond to dietary changes in patients with recognized food allergies, or to steroids in patients in whom an underlying cause is not identified. Our case highlights the need to keep EGE in the differential diagnosis when treating pediatric patients with duodenal ulcers. The epidemiology, pathophysiology, and treatment of EGE are also discussed, along with a review of the current literature.

[The drugs for H. pylori eradication therapy]

H. pylori eradication significantly inhibited ulcer recurrence in Japanese peptic ulcer patients. In Japan, 12 months after treatment, gastric ulcers had recurred in 11.4% of those with successful H. pylori eradication and 64.5% of those with unsuccessful H. pylori eradication. Duodenal ulcers had recurred in 6.8% of patients for whom H. pylori eradication was successful and in 85.3% of patients in whom eradication failed. About long-term study, 4 years after treatment, gastric ulcers had recurred in 9.3% of those with successful H. pylori eradication and duodenal ulcers recurrence was occurred in 6.2% of those. The annual recurrence rates of gastric, duodenal ulcer were 2.3% and 1.6%, respectively. However, in current Japan, the decrease of the primary eradication rate is reported by the increase of clarithromycin-resistant strains. The increase of metronidazole-resistant strains used for the second eradication is not recognized so far, but in future, increase is concerned about. Therefore, the making of the regimen of the third-line eradication therapy is needed now.

[Gastric ulcer, duodenal ulcer]

Recently, the acid secretion amount is increased by westernization of foods and Helicobacter pylori (H. pylori) infected patient's decrease in Japanese. Therefore, the recent tendencies are decrease of peptic ulcer diseases by H. pylori infection and increase of non-steroidal anti-inflammatory drugs(NSAIDs) ulcers. The endoscopic hemostasis should be performed for upper gastrointestinal bleeding from peptic ulcers in the first choice. A surgery or interventional radiology (IVR) should be performed in the unsuccessfulness of endoscopic hemostasis. H. pylori eradication therapy is effective for healing and prevention of recurrence from peptic ulcers. For prevention of recurrence of NSAIDs ulcers, therapy with proton pump inhibitor is effective.

[Ulcerated duodenitis revealing Henoch-Schönlein purpura]

Inflammation and duodenal ulcers can meet many etiologies. We report the case of a young adult with an ulcerated duodenitis revealing Henoch-Schönlein purpura. The abdominal symptoms preceded the emergence of the classical cutaneous signs of the disease.

Role of dietary polyphenols in the management of peptic ulcer

Peptic ulcer disease is a multifactorial and complex disease involving gastric and duodenal ulcers. Despite medical advances, the management of peptic ulcer and its complications remains a challenge, with high morbidity and death rates for the disease. An accumulating body of evidence suggests that, among a broad reach of natural molecules, dietary polyphenols with multiple biological mechanisms of action play a pivotal part in the management of gastric and duodenal ulcers. The current review confirmed that dietary polyphenols possess protective and therapeutic potential in peptic ulcer mediated by: improving cytoprotection, re-epithelialization, neovascularization, and angiogenesis; up-regulating tissue growth factors and prostaglandins; down-regulating anti-angiogenic factors; enhancing endothelial nitric oxide synthase-derived NO; suppressing oxidative mucosal damage; amplifying antioxidant performance, antacid, and anti-secretory activity; increasing endogenous mucosal defensive agents; and blocking Helicobacter pylori colonization associated gastric morphological changes and gastroduodenal inflammation and ulceration. In addition, anti-inflammatory activity due to down-regulation of proinflammatory cytokines and cellular and intercellular adhesion agents, suppressing leukocyte-endothelium interaction, inhibiting nuclear signaling pathways of inflammatory process, and modulating intracellular transduction and transcription pathways have key roles in the anti-ulcer action of dietary polyphenols. In conclusion, administration of a significant amount of dietary polyphenols in the human diet or as part of dietary supplementation along with conventional treatment can result in perfect security and treatment of peptic ulcer. Further well-designed preclinical and clinical tests are recommended in order to recognize higher levels of evidence for the confirmation of bioefficacy and safety of dietary polyphenols in the management of peptic ulcer.

Role of dietary phospholipids and phytosterols in protection against peptic ulceration as shown by experiments on rats

Geographically the prevalence of duodenal ulceration is related to the staple foods in the diet in regions of developing countries where the diet is stable. It is higher in regions where the diet is based on milled rice, refined wheat or maize, yams, cassava, sweet potato, or green bananas, and is lower in regions where the staple diet is based on unrefined wheat or maize, soya, certain millets or certain pulses. Experiments on rat gastric and duodenal ulcer models showed that it was the lipid fraction in staple foods from low prevalence areas that was protective against both gastric and duodenal ulceration, including ulceration due to non-steroidal anti-inflammatory drugs (NSAIDs). It also promoted ulcer healing. The lipid from the pulse, Dolichos biflorus, horse gram which was highly protective was used to identify the fractions with protective activity in the lipid. The protective activity lay in the phospholipid, sterol and sterol ester fractions. In the phospholipid fraction phosphatidyl choline (lethicin) and phosphatidyl ethanolamine (cephalin) were predominant. In the sterol fraction the sub-fractions showing protective activity contained β-sitosterol, stigmasterol, and an unidentified isomer of β-sitosterol. The evidence from animal models shows that certain dietary phospholipids and phytosterols have a protective action against gastroduodenal ulceration, both singly and in combination. This supports the protective role of staple diets in areas of low duodenal ulcer prevalence and may prove to be of importance in the prevention and treatment of duodenal ulceration and management of recurrent ulcers. A combination of phospholipids and phytosterols could also play an important role in protection against ulceration due to NSAIDs.

A Duodenal Ulcer Caused by Pancreatic Ductal Hypertension with Chronic Pancreatitis

We herein describe the case of a 67-year-old woman with a duodenal ulcer thought to be caused by elevated pancreatic ductal pressure. The patient complained of continuous upper abdominal pain. Her medical history included idiopathic chronic pancreatitis. Endoscopy revealed a huge duodenal ulcer located on the inferior duodenal angle, which had not been seen on endoscopic retrograde pancreatography two months previously. A combination study using endoscopy and contrast imaging confirmed the relationship between the duodenal ulcer and the pancreatic branch duct. To our knowledge, this is the first case of duodenal ulcer thought to be caused by elevated pancreatic ductal pressure.

Bleeding gastric metastases from cutaneous melanoma

7% of gastrointestinal tract (GIT) involvements with metastatic cutaneous melanoma concerns the stomach. The aim of the study was to describe a rare case of the cutaneous melanoma metastazing to the stomach.

MATERIAL AND METHODS

. Bearing in mind the rarity of such cases, we present our experiences based on the history of 42-year-old woman, who underwent surgical excision of skin tumour located on the trunk.

RESULTS

Histopathological examination of the skin tumor led to the diagnosis of melanoma (Clark IV, Breslow 5mm) with ulceration and a number of mitoses 40/10 HPF. PET-CT demonstrated multiple organ dissemination. Patient was admitted to the hospital due to severe, symptomatic anaemia. RBC and FFP transfusions were necessary. Gastroscopy revealed multiple gastric and duodenal ulcers and histopathology confirmed metastatic melanoma. Attempts to achieve endoscopic hemostasis were ineffective due to the extent of lesions.

CONCLUSION

In the presence of any alarming GIT symptoms or unclear anaemia, any physician treating patient with a history of melanoma should exclude metastatic tumour. Endoscopy may be useful both for the diagnosis and local treatment of gastric metastases and should be routinely and cautiously conducted.