[Standards of clinico-diagnostic and treatment algorhythms in patients with peptic and chronic medicinal ulcers, complicated by acute gastrointestinal hemorrhage]

The results of the patients surgical treatment for peptic ulcer and chronic medicinal gastroduodenal ulcer, complicated by an acute gastrointestinal hemorrhage, were analyzed. The standards and protocols of treatment, the tactic of treatment, permitting to lower the complications rate and to reduce mortality significantly, were elaborated.

Incidence of duodenal ulcers and gastric ulcers in a Western population: back to where it started

BACKGROUND/OBJECTIVES

As recently as 40 years ago, a decline in the incidence of peptic ulcers was observed. The discovery of Helicobacter pylori had a further major impact on the incidence of ulcer disease. Our aim was to evaluate the trends in the incidence and bleeding complications of ulcer disease in the Netherlands.

METHODS

From a computerized endoscopy database of a district hospital, the data of all patients who underwent upper gastrointestinal endoscopy from 1996 to 2005 were analyzed. The incidence of duodenal and gastric ulcers, with and without complications, were compared over time.

RESULTS

Overall, 20,006 upper gastrointestinal endoscopies were performed. Duodenal ulcers were diagnosed in 696 (3.5%) cases, with signs of bleeding in 158 (22.7%). Forty-five (6.5%) of these ulcers were classified as Forrest I and 113 (16.2%) as Forrest II. Gastric ulcers were diagnosed in 487 cases (2.4%), with signs of bleeding in 60 (12.3%). A Forrest 1 designation was diagnosed in 19 patients (3.9%) and Forrest 2 in 41 patients (8.4%). The incidence of gastric ulcers was stable over time, while the incidence of duodenal ulcers declined.

CONCLUSIONS

The incidence of duodenal ulcer disease in the Dutch population is steadily decreasing over time. Test and treatment regimens for H pylori have possibly contributed to this decline. With a further decline in the prevalence of H pylori, the incidence of gastric ulcers is likely to exceed the incidence of duodenal ulcers in the very near future, revisiting a similar situation that was present at the beginning of the previous century.

13C-urea breath test for the diagnosis of Helicobacter pylori infection in bleeding duodenal ulcer

Helicobacter pylori (H. pylori) is the main etiologic factor for duodenal ulcer (DU). Bleeding is still a frequent and sometimes severe complication, with unacceptable mortality despite modern therapeutic modalities. The importance of diagnosing and treating H. pylori infection in bleeding DU is underlined by the fact that eradication therapy is effective in preventing recurrent bleeding. The aim of this study was to evaluate the prevalence of H. pylori infection by means of 13C urea breath test (13C-UBT) in patients with bleeding DU.

MATERIAL AND METHOD

Thirty-nine patients (25 men, 14 women) hospitalized with bleeding DU underwent emergency endoscopy and treated with intravenous proton pump inhibitors (PPIs), and a 13C-UBT was performed the day after the resuming oral feeding.

RESULTS

Twenty-seven patients (19 men, 8 women) (69.3%) had a positive 13C-UBT. All patients received intravenous PPIs (22 pantoprazole, 17 esomeprazole) after emergency endoscopy (80 mg bolus + 8 mg/hour infusion/day) for 3-4 days. The time elapsed between admission and performance of 13C-UBT did not differ significantly between patients having a positive or negative 3C-UBT (5.6 vs 6.1 days). Eight of the twelve patients (66.6%) with a negative 13C-UBT had a repeated test two month later, and five of them became positive; therefore, H. pylori infection was finally detected in 32 (82%) out of 39 patients with bleeding DU.

CONCLUSION

Most patients with bleeding DU have a positive 13C-UBT although they were taking PPIs.

Disseminated histoplasmosis presenting with biliary obstruction and duodenal ulcer

Disseminated histoplasmosis is an AIDS-defining illness which usually involves the liver and gastrointestinal tract, most commonly the small bowel. Abdominal pain, diarrhea, GI bleeding, hepatosplenomegaly and small bowel obstruction are well described presentations. Still gastrointestinal histoplasmosis often results in either vague symptomatology or no symptoms. Pancreaticobiliary disease related to disseminated histoplasmosis is not well characterized. We report the case of a young female with advanced HIV infection and biliary obstruction and a periampullary duodenal ulcer due to disseminated histoplasmosis.

Diagnostic strategy in suspected duodenal ulcer disease. A questionnaire study

In a questionnaire study of 89 Danish gastroenterologists the current diagnostic strategy in patients suspected of having duodenal ulcer disease was elucidated. A case summary concerning a patient with upper abdominal pain was presented. It was assumed that the patient had had a double-contrast barium meal examination or an upper gastrointestinal endoscopy performed. If the X-ray had revealed a deformity of the duodenal bulb, 30% of the gastroenterologists would offer the patient specific medical treatment (H2-blocking agent etc.), but a significantly higher number of gastroenterologists, 45%, (p less than 0.05) would offer specific medical treatment if a deformity was revealed at endoscopy. There was also a significant difference (p less than 0.01) between those who would offer specific treatment if X-ray (84%) or if endoscopy (100%) had revealed an ulcer. Considerable variation was found among experts in their decisions on the basis of X-ray and endoscopy in patients with suspected duodenal ulcer disease. Gastroenterologists generally rely more on endoscopic than on radiographic findings.

Perforated duodenal ulcer in a young child: an uncommon condition

Duodenal ulcer is an uncommonly diagnosed entity in children. H. pylori infection, blood group 'O' or secondary to medications like non steroidal anti-inflammatory drugs (NSAID) and corticosteroids or physiological stress in burns, head injury and mucosal ischemia are implicated as risk factors for their causation. The diagnosis is usually overlooked because of vague and variable symptoms and remote index of suspicion accounted for their low incidence in children. Undiagnosed or mistreated perforations may carry high morbidity and mortality. We report a successfully treated 41/2 year old male child who presented with features of perforation peritonitis and was incidentally found to have a perforated duodenal ulcer.

Clinical significance of pyloric aperture in the aetiology of peptic ulcer disease: a prospective study

Despite so much contributions reported in the literature, the aetiology of the duodenal ulcer remains an enigmatic subject to the medical profession. Findings of Helicobacter pylori seem to have overshadowed the real issue, in that, how a small area of the duodenal mucosa could be inflicted with the acid-pepsin injury has not been questioned? One hundred and sixty-eight consecutive patients, presented with epigastric pain were included in the endoscopic study. The aim of the study was to find out the prevalence and its clinical importance on the sizes of the pyloric aperture in the aetiology of peptic ulcer disease. Demographic data on the sizes of the pyloric aperture were divided into two groups, in that, those up to 3 mm in diameter were included in one and those over the size of 3 mm in another. Among the 168 cases, the gastric ulcer was found in 12 and duodenal ulcer in 27 patients. The sex ratio of men to women was 1.4:1 found in the former and 8:1 in the latter. Among other findings, a knuckle of duodenal mucoa was noticed prolapsing through the large pyloric aperture. It could be postulated that a knuckle of the mucosa that keeps peeping through the pylorus acts as a mucosal plug in empty stomach, like a cork in the acid bottle. The main physiological function is to protect the mucosa from being damaged by the acid-pepsin injury or by the reflux of bile, but the tip of the plug seems to be subjected to such injury. Furthermore, the surface epithelial cells could also be subjected to ischaemic change while prolapsing through the pylorus. This may lead to reduced production of the mucosal gel and bicarbonate secretion, thus exposing the damaged mucosa to acid bath. This supports the concept, how a small area of the stomach or duodenum could be inflicted with ulceration.

[Prophylaxis of acute pancreatitis during resection of the stomach for "difficult" complicated of duodenal ulcers]

The authors have performed 407 resections of the stomach for duodenal ulcers. In 9 cases the major duodenal papilla was found to be involved into the zone of ulcer destruction. It was noted that operations for "difficult" complicated ulcers of the duodenum with the involvement into the zone of destruction of the major duodenal papilla required a delicate surgical strategy directed to minimization of trauma and blockade of the main factors of the development of acute postoperative pancreatitis, the proximal duodenojejunoanastomosis being the operation of choice for "difficult" complicated ulcers of the duodenum.

[Microflora of the small intestine in patients with perforating duodenal ulcers]

The toxic phase of peritonitis in patients with perforating duodenal ulcers is accompanied with the development of syndrome of redundant bacterial colonization of the small intestine. However, it is less pronounced than in other forms of intra-abdominal infection. The greatest quantitative growth in all the patients is observed among the species of the family of enterobacteria and aerobic Gram-positive bacilli, the bacterial species dominating in the upper part of the intestine in health being the leading etiological agents of intra-abdominal infection in patients with perforating duodenal ulcers. Unlike peritonitis of other etiology strict anaerobic bacteria are found in the small intestine much rarer.

[Efficiency of combined endoscopic hemostasis in patients with peptic ulcer complicated by hemorrhage]

Results of endoscopic application of collagenous preparation thrombocol to the ulcer are presented. It is maintained that combined treatment of patients with peptic ulcer complicated by hemorrhage including endoscopic hemostasis (EH) and eradication therapy improves its outcome. Specifically, combined EH (adrenalin injection and subsequent application of thrombocol to the ulcer) reduces the frequency of recurrent hemorrhage and the need in urgent surgical intervention in patients with active hemorrhage (F Ia, Ib). Preventive EH with thrombocol in patients with active hemorrhage and high probability of its relapse (F IIa, IIb) reduces the frequency of recurrent hemorrhage and the necessity of emergency surgical treatment. In patients with active hemorrhage (F IIa, IIb, IIc) thrombocol promotes healing of the ulcer and decreases duration of hospitalization.

[Molecular-genetic typing of Helicobacter pylori: applied aspects of diagnosis and treatment of duodenal ulcer]

In this article genetic features of Helicobacter pylori in duodenal ulcer patients are studied, also a comparative estimation of this microorganism's genetic features is made in various Helicobacter pylori-positive conditions. In the article necessity of carrying out genetic typing of Helicobacter pylori for revealing potential microorganism virulence, strain resistance to claritromycin is proved that allows to define a forecast of a current of disease and to carry out individual selection of a therapy.

[Genetic features of Helicobacter pylori at patients with duodenal ulcer]

This article presents the results of original research, which showed that in St. Petersburg in patients with duodenal ulcer and chronic gastroduodenitis were identified more pathogenic strains of H. pylori, than in healthy voluntary infants infected with this microorganism. The most frequently detected genes, islands of H. pylori pathogenicity, in chronic gastroduodenitis--cagA and cagH, with peptic ulcer--cagA and cagE. Also found that in St. Petersburg in a greater percentage of cases circulating cagA + strains of H. pylori, as in Tajikistan. Based on these data, we can conclude that improved methods of molecular-genetic identification of H. pylori is a required condition for the optimization approaches to integrated diagnostics H. pylori-associated.

[Nonpharmacological therapy of duodenal ulcer in elderly patients]

AIM

To validate principles and policy of non-pharmacological treatment of duodenal ulcer (DLU) with onset at old age, to study medico-social efficacy of DU non-pharmacological treatment.

MATERIAL AND METHODS

The study was made of 234 cases of DU in patients aged 61-65 years (mean age 63.2 years). DU was diagnosed in them at an old age.

RESULTS

Non-pharmacological treatment of old DU patients was performed at three stages: outpatient basic treatment, inpatient rehabilitation with nonpharmacological methods, sanatorium remission and nonspecific resistance consolidation.

CONCLUSION

Nonpharmacological measures by 3-stage scheme have higher medico-social efficacy compared to one-stage management.

[The analysis of usefulness different diagnostic methods in children and adolescents with Helicobacter pylori infection]

A diagnostics of Helicobacter pylori infection in children and adolescents in practice sometimes is still difficult. Qualification to the tests for detecting infection with invasive and noninvasive methods should start from diligent anamnesis.

THE AIM OF THE STUDY

Is to present the clinical course and results of diagnostic tests in children and adolescents with suspicion of Helicobacter pylori infection.

MATERIAL AND METHODS

One hundred patients aged between 18 months and 18 years who underwent endoscopy with gastric biopsies, histology, culture and 13carbon urea breath test. There were 36 boys and 64 girls in analysed group, 10% of them were preschool children, 42% school children and 48% teenagers older than 12 years

RESULTS

Patients were symptomatic and most frequent were dyspeptic symptoms (91%). A symptom duration time was varied from several days to several years. On the basis of endoscopy and histology gastritis and/or duodenitis were found in 92 patients, esophagitis and gastritis in 5 patients, duodenal ulcer in 2 patients, in 1 case gastric and duodenal mucosa was normal. Helicobacter pylori infection was histopathologically confirmed in 37 patients. In 15 cases Helicobacter pylori strains were isolated with full in vitro sensitivity to amoxicillin, claritromycin and metronidazol. Urea breath test was conducted in 85 analyzed patients and 51 of them had abnormal result.

CONCLUSIONS

In clinical picture of Helicobacter infection most frequent were dyspepstic symptoms and by endoscopy chronic gastritis and/or duodenitis were shown. Culture of Helicobacter pylori has a limited usefulness in practice especially in patients who underwent antibiotic/eradication therapy. The statistical significant concordance occurred between culture and noninvasive 13carbon urea breath test.

[Long- and short-term results of staged treatment of ulcer patients working in oil production industry]

AIM

To determine clinical and cost-effect efficacy of staged (hospital-day hospital-outpatient clinic) treatment and rehabilitation of patients with ulcer disease (UD).

MATERIAL AND METHODS

Of 160 patients with duodenal ulcer 80 patients (controls) received treatment in hospital and 80 patients (the study group) were treated in hospital and day hospital. Efficacy of the treatment was assessed by clinical data, results of device and cost-effect investigations.

RESULTS

Clinical and endoscopic remission of duodenal ulcer was achieved for the same time in both the groups. The cost of the treatment of 1 patient was 23,393 and 21,163 rub in the controls and in the study group, respectively. Therefore, treatment in a day hospital reduced cost of the treatment. Later, the remission was consolidated by active follow-up in an outpatient clinic.

CONCLUSION

Staged treatment of UD provides good therapeutic and economic effects compared to hospital treatment.

[Influence of three point mutations in TNF-alpha promoter gene in clinical manifestations and complications of stomach and duodenal ulcer]

The purpose of our study was to investigate whether polymorphisms -238G/A, -308G/A, and -863C/A within the promoter of the TNF-alpha gene are associated with clinical features of gastric and duodenal ulcer disease in a Russian population. DNA samples of 381 unrelated patients with gastric and duodenal ulcer disease and 216 sex- and age-matched healthy controls were used to determine the TNF-alpha gene polymorphisms by PCR-RFLP assay. Logistic regression analysis has revealed significant associations of polymorphism -308G/A with size of ulcerous defect (p=0.03) and intestinal dyspepsia (p=0.05), polymorphism -238G/A with gastric dyspepsia (p=0.04) and reflux-esophagitis (p=0.05), polymorphism -863C/A with perforation of ulcer (p=0.04). The study results highlight impact of the TNF-alpha gene polymorphisms on various clinical features in patients with peptic ulcer disease.

[Timing of the surgery in patients with stopped bleeding from duodenal ulcers with the threat of recurrent bleeding]

This article is devoted choosing the optimal time of operation at patients with stopped ulcerative duodenal bleeding. It has been shown that surgical treatment during the first two days at patients with a high probability of recurrence of bleeding leads to statistically significant mortality reduction in compared with patients who were operated upon within the time frame 3-12 days after stopping bleeding. It is concluded that active surgical tactics at patients with a high probability of recurrence of bleeding at the current stage of modern medicine is more justified than waiting tactic.

[Endoscopic diagnosis of erosive and ulcerative lesions in the stomach and duodenum using NBI technology]

The study was designed to assess the value of a new NBI-based digital videoendoscopic system for the diagnosis of erosive and ulcerative lesions in the stomach and duodenum of 136 patients in comparison with 185 ones examined with the use of conventional fiber-optic and videoendoscopes. Patients of group 1 were examined using a GIF-H180 EVIS Exera-I apparatus ("Olympus", Japan), controls with GIF-Q40 and GIF-Q160 EVIS Exera-II endoscopes ("Olympus", Japan). Endoscopic signs of inflammation, its extent and severity were recorded. NBI endoscopy revealed perifocal inflammatory changes associated with ulcerative lesions in the stomach and duodenum as spots of different tones of blue. This method allowed for the detection of lesions not visualized by conventional techniques. The use of NBI technology for routine endogastroduodenoscopy in patients with erosive and ulcerative lesions in the stomach and duodenum improves visualization of even minor changes in gastric and duodenal mucosa (p < 0.05).

[Endovideosurgical technology in diagnosis and treatment of perforating gastroduodenal ulcers]

The authors have analyzed their experiences with using endovideosurgical technologies in surgical treatment of 67 patients with perforation of gastroduodenal ulcers. The diagnosis was made in all the patients using laparoscopy, in 56.7% esophagogastroduodenoscopy was used. In 91% of the cases ulcers were localized on the anterior wall of the duodenum bulb, in 9%--in the area of the pylorus. The diameter of the perforation orifice could be from 1 to 7 cm. In 35 (52.2%) patients the perforation defect was sutured with intracorporeal formation of the nodes. The intracorporeal nodes could not give complete closure of perforations with the diameter of more than 1 cm. So, in 18 patients (26.7%) closure of the defect was made using extracorporeal node after Roeder. The zone of suturing was additionally peritonized with an omentum strand. Ulcer could not be sutured in one patient, which required conversion. All patients recovered. The duration of staying at hospital was from 3 to 5 days.

[Combined therapy of acid-dependent gastrointestinal disorders with the use of antacidic drug Relcer]

The aim of the study was to evaluate clinical efficiency of antacidic drug Relcer included in combined therapy of gastroesophagal reflux disease (GERD) and ulcer disease (UD). Group 1 comprised 47 patients with GERD and group 2 49 patients with gastric and duodenal UD. Each group was divided into study (A) and control (B) subgroups. All GERD patients were given rabeprazole and metoclopramide, patients with UD received rebaprazole, clarithromycin and amoxicillin. Relcer was additionally prescribed to 24 patients in group 1A and 26 in 2A. Duration of therapy in all groups was 14 days. By the end of the study, all symptoms of GERD were eliminated in 100% of the patients in group 1A and in 78.3% in 1B. Pain and heartburn in group 1A were reduced or eliminated within 5 and 7.8 min respectively after the first dose of Relcer. The same complaints in 69.9% of 1B patients were resolved by the end of the first day. The remaining ones benefited from combined treatment on day 2 Rapid and complete elimination of UD symptoms was finally achieved in 21.7-26.1% of 2A patients whereas moderate dyspeptic syndrome persisted in those of subgroup 2B. Ulcer scarring completed by day 14 in 88.5 and 87% of the patients in subgroups 2A and 2B respectively. Eradication of H. pylori was achieved in 92.3 and 87% of the patients in these groups. It is concluded that introduction of Relcer into combined therapy of GERD and UD improves its results and accelerates elimination of clinical symptoms.

[Diagnostic role of upper gastrointestinal endoscopy in pediatric inflammatory bowel diseases]

THE AIM OF THIS STUDY

To evaluate the frequency and type of endoscopic and histopathological changes in upper gastrointestinal tract in children with inflammatory bowel diseases.

MATERIAL AND METHODS

The study included 97 patients aged from 3 to 18 years (mean age 12.8 years, 45 girls and 52 boys) with inflammatory bowel diseases (IBD), treated in the 2nd Chair and Department of Pediatrics, Gastroenterology and Feeding of Children from 2005 to 2007. These children were divided into 3 groups depending on the clinical diagnosis: group 1: 38 children with ulcerative colitis (UC), group 2: 26 children with Crohn's disease (CD), and group 3: 33 children with indeterminate colitis (IC). In all patients upper gastrointestinal endoscopy was performed. During endoscopy biopsies were routinely taken from the stomach (antral region), the duodenum and all mucosal changes. H. pylori infection was detected by a positive culture. The obtained results were analyzed using 2 test (p<0.05).

RESULTS

Esophageal changes were observed in 27.8% children with IBD, most frequently in CD and IC groups, respectively in 34.6% and 36.3% of children. No endoscopic abnormalities in the esophagus were noted in 72.2% of IBD children and the figure rises to 84.3% in UC children (p<0.05). Endoscopic examination of the stomach revealed no changes in 23.7% of IBD children, in 76.3% of these patients inflammatory lesions were observed. Only in 11.5% of the CD patient were no abnormalities in the stomach observed (p<0.05). In the CD group children mild endoscopic changes were observed in 53.8%, and severe in 34.6% of these patients. Ulceration of the duodenum, often in the descending part was revealed in 23.1% of CD children. Helicobacter pylori infection was found in 10.3% of the IBD children, most frequently in the IC group (12.1%). Histopathological examination confirmed esophageal changes in 31.9% of IBD patients, in the stomach and duodenum respectively in 77.3% and 48.4% of these children. Noncaseating granulomas were noted in 3.1% of the CD patients, partial villus atrophy was noted in 1 child with CD.

CONCLUSIONS

In the group of IBD children, various inflammatory changes during the upper endoscopy were observed. Endoscopic examination most frequently revealed inflammatory changes of the stomach, less frequently of the duodenum and of the esophagus. Histopathological examination of IBD patients most frequently confirmed stomach changes. Less frequently histopathological changes were observed of the duodenum and of the esophagus, particularly in CD children. In the group of IBD children H. pylori infection was noted in few of the patients. Upper endoscopy in the IBD children is an important diagnostic tool and should be a part of monitoring the activity of the disease and results of the therapy.

[Hospital admissions for digestive diseases: 1995-2003 morbidity in a military hospital]

Digestive diseases are still currently one of the leading causes of illness. The study was conducted of those individuals admitted to hospital during the 1995-2003 period, whose main diagnosis at admission to hospital had been encoded according to the International Disease Classification as a digestive disease. The highest rate of admissions was in civilian males (the military hospital assures health care services for militaries and their families), due to duodenal ulcer and liver diseases. The superior level of education could be considered as a source of stress, and a risk factor for duodenal ulcer (odd ratio = 1.058). Key