Endoscopic management of nonvariceal upper gastrointestinal bleeding

Endoscopic therapy is the mainstay of treatment for nonvariceal upper gastrointestinal bleeding (NVUGIB). Injection plus mechanical or thermal therapy continues to be the most widely used option. New endoscopic devices such as the use of an inert powder or a new class of over-the-scope clip system have demonstrated encouraging results as a rescue therapy for difficult hemostasis. Emerging data suggest that Doppler ultrasound-guided endoscopic therapy may improve the outcome of peptic ulcer bleeding. This review sumarizes the recent advances in the management of NVUGIB. With increasing use of anti-platelet agents and anti-coagulants, the management of NVUGIB in patients on anti-thrombotic therapy is also discussed.

Gastroduodenal perforation in the pediatric population: a retrospective analysis of 20 cases

OBJECTIVE

The aim of this study was to investigate the pathogenesis, symptoms and individualized surgical management in pediatrics with gastroduodenal perforation (GDP).

METHODS

Patients diagnosed with GDP from January 2013 to December 2016 in our hospital were collected and divided into gastric perforation (GP) group and duodenal perforation (DP) group. Demographics, clinical events, etiological factors, symptoms, the time from symptom onset to operation, intraoperative findings and surgical procedures were analyzed. Follow-ups including ulcer, perforations occurrence, and digestive symptoms were carried out by out-patient review or telephones.

RESULTS

A total of 20 patients aged from 3 months to 14 years were enrolled in this study. The average age, main clinical presentations, size of perforations and operating time between two groups had no difference. The male to female ratio in DP group was higher than GP (P < 0.05). The high risk factor for DP was the use of dexamethasone, and for GP was HP infection. The most common site of perforation in DP group was duodenal bulb, and in GP group was pylorus area. Simple suture is the main management for both DP and GP, but distal gastrectomy combined with gastrojejunal Roux-en-Y anastomosis may be an alternative procedure for large perforation with diameter > 2 cm. The length of hospital days in GP group is shorter than DP group (P < 0.05). For follow-up, no patients had digestive symptoms.

CONCLUSIONS

The general condition had no difference between GP and DP patients. But the risk factors and surgical repair differ depending on the patient's fundamental illness and the complexity of the perforation.

Risk factors for peptic ulcer disease in patients with end-stage renal disease receiving dialysis

Background

Compared to the general population, patients with end-stage renal disease have more gastrointestinal symptoms and a higher prevalence of peptic ulcer. Risk factors for peptic ulcer disease in patients with end-stage renal disease, however, remain poorly defined. This study aims to better identify those risk factors.

Methods

We analyzed 577 patients with end-stage renal disease from 2004 to 2016. We excluded patients with life-threatening conditions. All patients underwent upper endoscopy. We analyzed patient medical records, medication history, and endoscopic findings. Independent sample t test, chi-square test, Fisher’s exact test, and multiple logistic regression analysis were used in statistical analyses.

Results

Of the 577 patients with end-stage renal disease, 174 had peptic ulcer disease (gastric or duodenal ulcer). Patients on hemodialysis had a higher prevalence of peptic ulcer disease than those on peritoneal dialysis. Patients with peptic ulcer disease had lower serum albumin level and higher blood urea nitrogen level than those without peptic ulcer disease. Positive scores on two or more nutritional indices (albumin, serum cholesterol, uric acid, and creatinine levels) were associated with peptic ulcer disease in end-stage renal disease.

Conclusion

Hemodialysis, hypoalbuminemia, and multiple malnutrition indices were associated with the prevalence of peptic ulcer disease in patients with end-stage renal disease receiving dialysis.

STRESS ULCER PROPHYLAXIS AS A RISK FACTOR FOR TRACHEAL COLONIZATION AND HOSPITAL-ACQUIRED PNEUMONIA IN INTENSIVE CARE PATIENTS: IMPACT ON LATENCY TIME FOR PNEUMONIA

Stress ulcer prophylaxis is associated with bacterial colonization of respiratory tract. The aims of our study were to determine risk factors for trachea colonization (TC), colonization of pharynx (CP) or stomach (CD) and hospital-acquired pneumonia (HAP), and divide the factors into those with high risk and low risk. The study population (ventilated intensive care unit (ICU) patients eligible to receive stress ulcer prophylaxis) was randomized to receive one of three different treatment protocols: ranitidine, sucralfate, and no stress ulcer prophylaxis (control group). Clinical data relative to pre-specified risk factors for TC or HAP were recorded, as follows: APACHE II score (second risk factor), duration of intubation or tracheotomy (third risk factor), duration of mechanical ventilation (fourth risk factor) and duration of hospitalization in the ICU (fifth risk factor). Gastric pH was recorded and microbiological data regarding stomach, pharynx and trachea were collected on the 1^st, 2^nd, 3^rd and 5^th day. Fifty-eight out of 81 patients developed HAP (including ventilator-associated pneumonia), which occurred later in patients with gastric content pH <4 or those that were tracheotomized. Stress ulcer prophylaxis was not associated with HAP; however, it was proved as a risk factor for TC. TC was detected in tracheotomized patients and was caused by gram-negative pathogens. CP was associated with TC, since the majority of patients had CP before TC. A combination of risk factors (APACHE II >18, age >65, mechanical ventilation and sedation) caused a higher incidence of HAP and lower incidence of TC. HAP was more frequent in patients staying in the ICU for >10 days and those with cardiovascular disease as the underlying disorder. Sedation and previous antibiotic therapy correlated with longer latent period (LAT), while higher values of gastric content pH were related to shorter LAT. The longest LAT was found in patients colonized with Acinetobacter spp. Risk factors that accelerated the occurrence of HAP were found to have caused previous colonization. A combination of risk factors increased the likelihood of TC and HAP, and shortened LAT between TC and HAP.

Magnitude of Helicobacter pylori and associated risk factors among symptomatic patients attending at Jasmin internal medicine and pediatrics specialized private clinic in Addis Ababa city, Ethiopia

BACKGROUND

More than 50% of the people are infected worldwide with H. pylori which causes significant public health morbidity and mortality. The distribution is quite different from country to country. Hence, early information is very important to prevent upper gastrointestinal complications. The current study aimed to assess the magnitude of H. pylori and associated risk factors among symptomatic patients attending at Jasmin internal medicine and pediatrics specialized private clinic from August 2017 until May 2018 in Addis Ababa city, Ethiopia.

METHODS

A cross-sectional study was conducted among 487 patients with upper gastrointestinal tract complaints attending at Jasmin internal medicine and pediatrics specialized private clinic from August 2017 until May 2018. Convenient sampling technique was used to enroll participants. Information regarding to risk factors was assessed using structured questionnaire. Stool samples were collected for H. pylori antigen test. Data was entered and analyzed using SPSS version20 statistical software and a p-value less than 0.05 was considered as statistically significant.

RESULTS

The overall prevalence of H. pylori among participants using stool antigen was 36.8% (n = 179/487). Regarding to family income status, those who have low monthly income were more likely to be infected with H. pylori infection (AOR = 6.056, CI 95% = 1.603-22.881, P = 0.037). In addition, families with low educational level were more likely to be infected with H. pylori infection than higher level education (AOR = 4.150, CI95% = 1.059-16.270, P = 0.041). Number of family members in the house-hold, type of toilet they used and source of drinking water were not significantly associated with H. pylori infection.

CONCLUSIONS

The prevalence of H. pylori infection was 36.8% and it was related to low income and low education levels. This finding calls for improving the socioeconomic status of the community. Moreover, further studies are needed to investigate potential risk factors for H. pylori infection.

Recent trends in the prevalence of Helicobacter Pylori in symptomatic children: A 12-year retrospective study in a tertiary centre

OBJECTIVE

Helicobacter pylori infection is common among Asians. However, evidence in the recent years has demonstrated a decrease in the prevalence of H. pylori infection among children and adults worldwide. Our aim was to update its prevalence in symptomatic children in our locality in the recent 12 years and compared to the results of our previous review published in 2005.

METHODS

A retrospective review was carried out between 2005 and 2017. All children who presented with dyspepsia or gastrointestinal bleeding and underwent oesophagogastroduodenoscopy with antral biopsy taken were included. Patient demographics, endoscopic, or histological diagnosis and the H. pylori status were recorded.

MAIN RESULTS

A total of 602 patients were included. There was a statistically significant decreasing trend of H. pylori infection rate between 2005 and 2017 (p = 0.003). The overall infection rate from this study was 12.8%, compared to 25.6% from our previous review. Overall failure of eradication with first-line antibiotic therapy has increased to 29.3% from 10% in our previous review.

CONCLUSION

There was a decrease in the prevalence of H. pylori infection among symptomatic children for the recent 12 years, comparing to our previous data from 2005. We hypothesize that the reduction in prevalence of H. pylori infection among adults and the decrease in the practice of sharing chopsticks during meals have led to a decrease in transmission of the bacteria among family members in Hong Kong. However, the failure of eradication with first line treatment was higher, possibly due to the increase in antibiotics usage and resistance.

LEVEL OF EVIDENCE

III.

Role of Acid Suppression in Acid-related Diseases: Proton Pump Inhibitor and Potassium-competitive Acid Blocker

Proton pump inhibitors are commonly utilized for the treatment of gastric acid-related diseases, such as gastroesophageal reflux disease, peptic ulcer disease, and Helicobacter pylori infection, and for the prevention of low-dose aspirin or nonsteroidal anti-inflammatory drug-induced peptic ulcers. Vonoprazan is a first-in-class potassium-competitive acid blocker, which has distinct advantages compared to other conventional proton pump inhibitors in terms of the efficacy for acid suppression. Due to its strong gastric acid suppression capabilities, vonoprazan serves as an effective drug for the treatment of gastroesophageal reflux disease and H. pylori infection.

Stress ulcer prophylaxis with proton pump inhibitors or histamin-2 receptor antagonists in adult intensive care patients: a systematic review with meta-analysis and trial sequential analysis

PURPOSE

Most intensive care unit (ICU) patients receive stress ulcer prophylaxis. We present updated evidence on the effects of prophylactic proton pump inhibitors (PPIs) or histamine 2 receptor antagonists (H2RAs) versus placebo/no prophylaxis on patient-important outcomes in adult ICU patients.

METHODS

We conducted a systematic review with meta-analysis and trial sequential analysis (TSA) of randomised clinical trials assessing the effects of PPI/H2RA versus placebo/no prophylaxis on mortality, gastrointestinal (GI) bleeding, serious adverse events (SAEs), health-related quality of life (HRQoL), myocardial ischemia, pneumonia, and Clostridium (Cl.) difficile enteritis in ICU patients.

RESULTS

We identified 42 trials randomising 6899 ICU patients; 3 had overall low risk of bias. We did not find an effect of stress ulcer prophylaxis on mortality [relative risk 1.03, 95% confidence interval (CI) 0.94-1.14; TSA-adjusted CI 0.94-1.14], but the occurrence of any GI bleeding was reduced as compared with placebo/no prophylaxis (0.60, 95% CI 0.47-0.77; TSA-adjusted CI 0.36-1.00). The conventional meta-analysis indicated that clinically important GI bleeding was reduced (RR 0.63, 95% CI 0.48-0.81), but the TSA-adjusted CI 0.35-1.13 indicated lack of firm evidence. The effects of stress ulcer prophylaxis on SAEs, HRQoL, pneumonia, myocardial ischemia and Cl. difficile enteritis are uncertain.

CONCLUSIONS

In this updated systematic review, we were able to refute a relative change of 20% of mortality. The occurrence of GI bleeding was reduced, but we lack firm evidence for a reduction in clinically important GI bleeding. The effects on SAEs, HRQoL, pneumonia, myocardial ischemia and Cl. difficile enteritis remain inconclusive.

Gastro-protective effect of Biebersteinia multifida root hydro-methanolic extract in rats with ethanol-induced peptic ulcer

OBJECTIVE

Biebersteinia multifida is one of the native plants of Iran and its root is used in folk medicine. This study aimed to evaluate the gastro-protective effect of the hydro-methanolic extract of this plant's roots against ethanol-induced gastric ulcer in rats.

MATERIALS AND METHODS

The following five groups of seven rats were included in this study: control (C), gastric ulcer (GU), control omeprazole (CO) and two treatment groups (the latter 3 groups were rats with gastric ulcer that orally received omeprazole, 20 mg/kg, or the root extract at 150 and 300 mg/kg (BM 150 and BM 300, respectively) 1 hour before ulcer induction). One hour after ulcer induction, blood sampling was performed and after sacrificing animals, the stomachs were immediately removed. Gastric mucosal injury was studied grossly to determine the number and area of gastric ulcers. The level of nitric oxide (NO) and total antioxidant capacity (TAC) in gastric mucosa as well as serum TNF-α were determined.

RESULTS

In GU group, severe mucosal injuries were observed (p<0.0001 as compared to C group). The lesions in CO and treatment groups were much milder than GU group by regarding ulcer area and number (p<0.001 for all cases). In treated (BM 150 and BM 300) groups, the gastric mucosal TAC and NO level were significantly higher than GU group (p<0.05 for all cases). Serum TNF-α level was not significantly different between GU and other groups.

CONCLUSION

B. multifida possesses gastro-protective effects against ethanol-induced ulcer model; this effect is at least partly related to plant's antioxidant and NO production accelerating properties.

Surgical repair of perforated peptic ulcers: laparoscopic versus open approach

INTRODUCTION

Perforated peptic ulcers are a surgical emergency that can be repaired using either laparoscopic surgery (LS) or open surgery (OS). No consensus has been reached on the comparative outcomes and safety of each approach.

METHODS

Using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database, we conducted a 12-year retrospective review (2005-2016) and identified 6260 adult patients who underwent either LS (n = 616) or OS (n = 5644) to repair perforated peptic ulcers. To mitigate selection bias and adjust for the inherent heterogeneity between groups, we used propensity-score matching with a case (LS):control (OS) ratio of 1:3. We then compared intraoperative outcomes such as operative time, and 30-day postoperative outcomes including infectious and non-infectious complications, and mortality.

RESULTS

Propensity-score matching created a total of 2462 matched pairs (616 in the LS group, 1846 in the OS group). Univariate analysis demonstrated successful matching of patient characteristics and baseline clinical variables. We found that OS was associated with a shorter operative time (67.0 ± 28.6 min, OS versus 86.9 ± 57.5 min, LS; P < 0.001) but a longer hospital stay (8.6 ± 6.2 days, OS versus 7.8 ± 5.9 days, LS; P = 0.001). LS was associated with a lower rate of superficial surgical site infections (1.5%, LS versus 4.2%, OS; P = 0.032), wound dehiscence (0.3%, LS versus 1.6%, OS; P = 0.030), and mortality (3.2%, LS versus 5.4%, OS; P = 0.009).

CONCLUSION

Fewer than 10% of patients with perforated peptic ulcers underwent LS, which was associated with reduced length of stay, lower rate of superficial surgical site infections, wound dehiscence, and mortality. Given our results, a greater emphasis should be provided to a minimally invasive approach for the surgical repair of perforated peptic ulcers.

Duodenal Ulceration following Holmium Laser Lithotripsy

The epidemiology of peptic ulcer disease (PUD) has changed considerably in the last several decades. Previously a chronic disease characterized by frequent recurrences with a high rate of surgical interventions, it is now largely a self-limited disease that is medically managed. The role of acid suppression was widely recognized as being important in the pathogenesis of PUD in the 19th century, while it was not until the 1980s and 1990s that the importance of Helicobacter pylori infection was identified. Today, PUD is largely caused by either H. pylori infection or nonsteroidal anti-inflammatory drug use. However, other less common etiologies of this disease are becoming more relevant as the prevalence of H. pylori decreases and proton pump inhibitor therapy is increasingly common. Here, we report a case of duodenal ulceration following bilateral rigid ureteroscopy with holmium laser lithotripsy.

Diagnostic value of serum pepsinogen in gastric diseases

Serum pepsinogen can reflect the functional status of the gastric mucosa. The pathological changes of the gastric mucosa include chronic gastritis, gastric ulcer, atrophic gastritis, and gastric cancer, and the relationship between serum pepsinogen and gastric cancer/atrophic gastritis is the most prominent. Since the detection of serum pepsinogen is simple, inexpensive, time-saving, highly sensitive, and highly specific, it has attracted great attention from scholars and is regarded as "serological biopsy". In this paper, we discuss the value of serum pepsinogen in the diagnosis of gastric diseases.

A case-control study of the risk of upper gastrointestinal mucosal injuries in patients prescribed concurrent NSAIDs and antithrombotic drugs based on data from the Japanese national claims database of 13 million accumulated patients

BACKGROUND

We aimed to identify the adverse effects of nonsteroidal anti-inflammatory drugs (NSAIDs) and antithrombotics on the upper gastrointestinal (GI) mucosa in a clinical setting as a case-control study using a large-scale medical database in Japan.

METHODS

We evaluated the risk of upper GI mucosal injuries in patients receiving NSAIDs and antithrombotics using the Japan Medical Data Center claims database with data for 13 million accumulated patients, from January 2009 to December 2014. Endoscopically evaluated upper GI mucosal injuries were peptic ulcers (n = 143,271), upper GI bleeding (n = 10,545), and gastroesophageal reflux disease (n = 154,755). For each patient, ten controls were matched by age, sex, and diagnosis month.

RESULTS

The odds ratio (OR) for peptic ulcers was 1.45, 1.31, 1.50, 1.53, and 1.62; for upper GI bleeding: 1.76, 1.62, 1.96, 1.82, and 2.38; and for gastroesophageal reflux disease: 1.54, 1.41, 1.89, 1.67, and 1.91 for NSAIDs, COX-2 selective inhibitors, low-dose aspirin, antiplatelet drugs, and anticoagulants, respectively (all statistically significant: P < 0.001). Polypharmacy with NSAIDs and antithrombotic drugs increased the risk of upper GI injuries compared with single-drug therapy. The injury risk was also increased by lifestyle-related diseases, including diabetes mellitus and hyperlipidemia.

CONCLUSIONS

This case-control study using the large organized Japanese claims database provided the risk of upper GI mucosal injuries in patients receiving NSAIDs and antithrombotic drugs.

Berberine-based quadruple therapy for patients with Helicobacter pylori associated peptic ulcer: A meta-analysis

AIM

To compare the efficacy and safety of berberine-based quadruple therapy and classical triple therapy (a proton pump inhibitor with two antibiotics) in patients with Helicobacter pylori (H. pylori) associated peptic ulcer.

METHODS

Electronic databases including Medline, EMBASE, Web of Science, Cochrane Central Register of Controlled Trial, Wanfang Database, and VIP Database were searched with the search terms of "berberine AND H. pylori AND eradication". A funnel plot was adopted to evaluate publication bias. The meta-analysis was performed using a fixed effects model in case of low heterogeneity and a randomized effects model in case of high heterogeneity.

RESULTS

A total of seven randomized controlled trials (RCTs) with 948 subjects were included. The eradication rate (86.78% vs 70.04%), healing rate of ulcer (50.73% vs 40.30%), and total effective rate (94.57% vs 81.66%) in the berberine group were significantly higher than those in the control group. In addition, the total incidence of side effects in the berberine group was significantly lower than that of the control group (26.54% vs 40.44%).

CONCLUSION

Compared with proton pump inhibitor-based triple therapy, berberine-based quadruple therapy might improve eradication rate and promote the healing of gastric ulcer in patients with H. pylori associated peptic ulcer. In addition, berberine-based quadruple therapy might reduce the side effects throughout the therapy. More RCTs with high quality are expected to confirm our finding.

Evaluation of anti-ulcer and ulcerative colitis of Sonchus oleraceus L

Sonchus oleraceus L. was evaluated for its gastro antiulcerogenic and anti-ulcerative colitis activities Different extracts and fractions from Sonchus oleraceus aerial parts and roots were evaluated at different dose; total alcohol extracts of aerial parts SA and roots SR were evaluated doses 250 & 500 mg/kg, While Successive extracts (SAL, SRL, CSA, CSR, BSA & BSR) were evaluated at dose of 150 mg/kg. Absolute ethanol-induced ulcer model was used for evaluation of the anti-ulcerogenic activity. The root extract showed promising antiulcerogenic activity as the total alcohol extract of the root SR (500 mg/kg) produced 88.5% protection from control ulcer which is significantly more effective than the standard drug omeprazole (20 mg/kg), in addition, the butanol fraction of the root extract BSR also produced 76.66% protection from control ulcer. On the other hand, the aerial parts total extract SA showed low antiulcerogenic activity in both tested doses (250 & 500 mg/kg) as it produced 25% & 28.33% protection from control ulcer respectively. Only the butanol fraction of the aerial parts extract BSA showed promising activity 54.16%. In the acetic acid-induced ulcerative colitis model, among the investigated extracts of Sonchus oleraceus; only the total extract of the aerial parts (SA) at dose 500 mg/kg showed strong anti-ulcerative colitis activity and this activity is followed by the activity of the butanol and chloroform fractions of the aerial parts, they produced 77.28%, 57.4% & 47.68% protection from control colitis respectively. The standard drug dexamethasone produced 63.36% protection from control colitis. The total alcohol extracts SR & SA showed no alteration on liver and kidney functions and these extracts are safe up to 5000 mg/kg. Phytochemical screening of the investigated extracts revealed the presence of carbohydrates, flavonoids, tannins, unsaturated sterols, proteins and lactones which could be responsible for the activities.

The Impacts of Peptic Ulcer on Functional Outcomes of Ischemic Stroke

BACKGROUND AND PURPOSE

Studies have shown that peptic ulcer increased the risk of ischemic stroke and stroke recurrence. This study aimed to evaluate the impacts of peptic ulcer on functional outcomes of ischemic stroke.

METHODS

Patients with first-ever ischemic stroke were grouped as with and without history of peptic ulcer. Functional outcomes were evaluated with modified Rankin scale at 90 days after the index stroke. Favorable functional outcomes were defined as with a modified Rankin scale score of 0-2. Logistic regression was used to identify predictors for favorable functional outcomes at 90 days.

RESULTS

Among the 2577 enrolled patients with ischemic stroke, 129 (5.0%) had a history of peptic ulcer. The proportion of favorable outcome was higher in patients without peptic ulcer than those with (59.3% versus 42.6%, P < .001). Multivariate logistic analysis detected that history of peptic ulcer (odds ratio [OR] = 2.89, 95% confidence interval [CI], 1.03-8.10, P = .043), National Institute of Health Stroke Scale score (OR = 2.11, 95% CI, 1.79-2.48, P < .001), and large-artery atherosclerosis stroke subtype (OR = 4.08, 95% CI, 1.11-15.03, P = .035) decreased the likelihood of favorable outcomes.

CONCLUSIONS

Ischemic stroke patients with peptic ulcer may have an increased risk of less favorable neurological outcome at 90 days after the index stroke.

Upper gastrointestinal hemorrhage in patients with peptic ulcer: Risk factors and treatment

AIM

To investigate the clinical features, risk factors, and treatment of peptic ulcer (PU) combined with upper gastrointestinal hemorrhage.

METHODS

One hundred and sixty patients with PU combined with upper gastrointestinal hemorrhage treated at Wuxing District People's Hospital of Huzhou from February 2016 to December 2017 were selected as an observation group, and 160 PU patients without upper gastrointestinal hemorrhage were selected as a control group. The clinical features and risk factors for PU combined with upper gastrointestinal hemorrhage were then analyzed. The patients with PU combined with upper gastrointestinal hemorrhage were then divided into two groups according to treatment method: those given basic treatment and proton pump inhibitor triple therapy (group A, n = 84) and those receiving basic treatment, endoscopic batroxobin, and proton pump inhibitor triple therapy(group B, n = 76). The clinical efficacy, blood transfusion volume after 3 d, rebleeding rate, and incidence of adverse reactions during treatment were compared between the two groups. The eradication rate of Helicobacter pylori (H. pylori) after 30 d of treatment was also recorded.

RESULTS

Main clinical manifestations of the patients with PU combined with upper gastrointestinal hemorrhage were melena, hematemesis, and melena combined with hematemesis, usually with dizziness. The bleeding volume was less than 500 mL in most of the patients. Drinking, smoking, onset in autumn and winter, male gender, use of non-steroidal anti-inflammatory drugs (NSAIDs), gastric ulcer, complex ulcer, and ulcer duration ≥ 6 mo were risk factors for PU combined with upper gastrointestinal hemorrhage. The total effective rate and H. pylori eradication rate were significantly lower in group A than in group B, while the rebleeding rate and blood transfusion volume were significantly higher in group A than in group B (P < 0.05).

CONCLUSION

Unhealthy living habits, male gender, use of NSAIDs, gastric ulcer, complex ulcer, and ulcer duration ≥ 6 mo are high risk factors for PU combined with upper gastrointestinal hemorrhage. Endoscopic interventional treatment combined with proton pump inhibitor triple therapy is safe and reliable in the treatment of PU combined with upper gastrointestinal hemorrhage.

Association of IL-1B+3954 and IL-1RN Polymorphisms in Chronic Gastritis and Peptic Ulcer

BACKGROUND

Helicobacter pylori are the main cause of chronic inflammation and peptic ulcer. We aimed to determine if IL-1B+3954 and IL-1RN polymorphisms are associated with the risk of chronic gastritis and peptic ulcer in Iranian population.

METHODS

In this case-control study, from 198 individuals enrolled by Mohammadi Hospital, Bandar Abbas, southern Iran from 2012 to 2014 and who showed the symptoms of chronic gastritis and 84 with peptic ulcer participated in the case group, two biopsies were taken from the body, antrum, or ulcer edge of each patient. Individuals without chronic gastritis or peptic ulcer were selected as the control group and we also confirmed the presence of anti-H. pylori serum IgG in 321 control subjects. IL-1B+3954C/T polymorphism was analyzed through PCR-RFLP, while the IL-1RN polymorphism was analyzed via PCR-based VNTR.

RESULTS

IL-1B+3954 TT was associated with a high risk of gastritis and peptic ulcer [Odds Ratio (OR)]=2.63, 95% Confidence Interval (CI)= (1.47-4.70) (OR=3.40, CI=1.72-6.71) respectively and the IL-1B+3954 T allele was associated with chronic gastritis (OR=1.64, 95% CI=1.13-2.36). Moreover, patient carrying IL-1RN L/2 and allele 2 showed an increased risk of peptic ulcer (OR=2.97, CI=1.72-5.11, OR=1.64, CI=1.13-2.36), respectively.

CONCLUSION

IL-1B and IL-1RNare associated with an increased risk for chronic gastritis and peptic ulcer disease.

Transcatheter Arterial Embolization for Bleeding Peptic Ulcers: A Multicenter Study

PURPOSE

To investigate the outcomes of transcatheter arterial embolization (TAE) for the treatment of peptic ulcer bleeding (PUB).

MATERIALS AND METHODS

This is a retrospective, multicenter study, which investigated all patients who underwent TAE for the treatment of severe upper gastrointestinal hemorrhage from peptic ulcers in five European centers, between January 1, 2012 and May 1, 2017. All patients had undergone failed endoscopic hemostasis. Forty-four patients (male; mean age 74.0 ± 11.1 years, range 49-94), with bleeding from duodenum (36/44; 81.8%) or gastric ulcer (8/44; 18.2%) were followed up to 3.5 years (range 2-1354 days). In 42/44 cases, bleeding was confirmed by pre-procedural CT angiography. In 50% of the cases, coils were deployed, while in the remaining glue, microparticles, gel foam and combinations of the above were used. The study's outcome measures were 30-day survival technical success (occlusion of feeding vessel and/or no extravasation at completion DSA), overall survival, bleeding relapse and complication rates.

RESULTS

The technical success was 100%. The 30-day survival rate was 79.5% (35/44 cases). No patients died due to ongoing or recurrent hemorrhage. Re-bleeding occurred in 2/44 cases (4.5%) and was successfully managed with repeat TAE (one) or surgery (one). The rate of major complications was 4.5% (2/44; one acute pancreatitis and one partial pancreatic ischemia), successfully managed conservatively. According to Kaplan-Meier analysis survival was 71.9% at 3.5 years.

CONCLUSIONS

TAE for the treatment of PUB was technically successful in all cases and resulted in high clinical success rate. Minimal re-bleeding rates further highlight the utility of TAE as the second line treatment of choice, after failed endoscopy.

Comparison of Oral versus Intravenous Proton Pump Inhibitors in Preventing Re-bleeding from Peptic Ulcer after Successful Endoscopic Therapy

BACKGROUND

Proton pump inhibitors (PPIs) are now widely prescribed for the management of patients with acute upper gastrointestinal bleeding; although its optimal dose and route of administration has remained a controversial issue. The aim of this study was to assess the clinical effectiveness of high dose oral versus intravenous (IV) PPI after successful endoscopic therapy in patients with bleeding peptic ulcer disease.

METHODS

178 patients with active upper gastrointestinal bleeding due to a peptic ulcer with stigmata of high risk for re-bleeding entered the study. After successful endoscopic hemostasis, they were randomized to receive either high dose oral pantoprazole (80 mg stat and 80 mg twice daily for 3 days) or high dose intravenous pantoprazole (80 mg IV infusion within 30 minutes and 8 mg per hour for 3 days). After the 3rd day, the patients in both groups received oral pantoprazole 40 mg twice daily for one month. The end points were comparing the rate of re-bleeding or mortality, and the need for blood transfusion or surgery during the first month between the two groups.

RESULTS

There were not significant statistical differences between the two groups in the volume of blood transfusion, mean duration of hospital stay, need to surgery, or mortality rates. However, the rates of re-bleeding were 2.3% (2:88) in the IV group and 3.3% (3:90) in the oral group (p = 0.6).

CONCLUSION

According to our findings, it seems that high dose oral PPI can be a good alternative to high dose IV PPI in patients with bleeding peptic ulcer who are at high risk of re-bleeding. Due to the lower cost and the availability of oral PPIs, their use can be economically much more affordable.

Endotherapy of Peptic Ulcer Bleeding

Peptic ulcer bleeding is common and associated with significant morbidity and mortality. We discuss the endoscopic assessment of peptic ulcers and the rationale for treatment. We also review the evidence for the available endoscopic therapies, both individually and in combination, to draw conclusions on the optimum endoscopic management of peptic ulcer bleeding.

Effect of Banxia Xiexin decoction on Helicobacter pylori-related peptic ulcers and its possible mechanism via the TGF-β/Smad signaling pathway

OBJECTIVE

To investigate the effect of Banxia Xiexin decoction (BXD) on Helicobacter pylori (Hp)-related peptic ulcers (PUs) and the possible mechanism underlying BXD actions via the transforming growth factor-¦Â/small mothers against decapentaplegic (TGF-β/Smad) signaling pathway.

METHODS

PU patients with cold-heat complex syndrome were randomly assigned to groups that received Chinese or Western medicines with 20 patients in each group. Serum was collected after 7 d of treatment. The healthy group included 20 individuals. Gastric mucosal epithelial cell line GES-1 was cultured in vitro and randomly divided into the following seven groups: control, model, healthy, Western Medicine, prior treatment, low dosage, and high dosage. After 72 h of treatment with the corresponding serum, the mRNA and protein expression levels of TGF-β1, Smad3, and Smad7 were measured by reverse transcription quantitative polymerase chain reaction and western blotting, respectively.

RESULTS

The mRNA expression levels of TGF-β1 and Smad3 in GES-1 cells were increased after Hp introduction, and these increased levels were reduced by the BXD-containing serum. The protein levels of p-Smad3, but not TGF-β1 or Smad3, were significantly increased in Hp-treated GES-1 cells, and treatment with the BXD-containing serum markedly decreased the protein levels. Smad7 expression was significantly enhanced following treatment with the BXD-containing serum at transcriptional and protein levels in a dose-dependent manner.

CONCLUSION

BXD regulates the TGF-β/Smad signaling pathway by inhibiting the expression of TGF-β1 and Smad3, and increasing the expression of Smad7.

Gastroprotective and antioxidant effects of fluvoxamine on stress-induced peptic ulcer in rats

Objectives

Stress-induced peptic ulcer disease (SPUD) refers to erosions in the mucosa of the upper gastrointestinal tract that are caused by stress. Some antidepressants are reported to have antioxidant and antiulcer effects. However, histopathological and biochemical evaluation of the anti-ulcer activity of a comparable antidepressant, fluvoxamine, has not been adequately investigated. This study aims to determine the anti-ulcer efficacy of fluvoxamine in reducing stress-induced histopathological and biochemical changes in the gastric mucosa.

Methods

Thirty adult male albino rats were divided into three groups of 10 rats each: the control groups, the SPUD group, and the fluvoxamine-pre-treated group, which received fluvoxamine for eight days before stress exposure. The cold-restraint stress method was used to induce stomach ulcers in the SPUD and fluvoxamine groups. Afterward, the stomachs of rats were removed, opened, and ulcer indices were calculated. Light microscopy was performed following haematoxylin and eosin staining, periodic acid Schiff's, Masson's trichrome staining, and proliferating cell nuclear antigen immunostaining. Gastric tissue levels of oxidative stress markers were measured and compared among groups.

Results

The stomachs of the fluvoxamine-treated rats showed a significantly lower number of ulcers with minimal mucosal injury compared with those of rats from the SPUD group. The oxidative stress marker levels and SPUD ulcer indices were significantly different among groups.

Conclusion

Fluvoxamine pre-treatment exerted a gastroprotective effect against ulcer development and promoted healing of the developed lesions.

The Effect of H2 Receptor Antagonist in Acid Inhibition and Its Clinical Efficacy

The first histamine H₂ receptor antagonists (H₂RAs) were developed in the early 1970s. They played a dominant role in treating peptic ulcer disease and gastroesophageal reflux disease (GERD). H₂RAs block the production of acid by H⁺, K⁺-ATPase at the parietal cells and produce gastric luminal anacidity for varying periods. H₂RAs are highly selective, and they do not affect H1 receptors. Moreover, they are not anticholinergic agents. Sequential development of H₂RAs, proton pump inhibitors (PPIs), and discovery of Helicobacter pylori infection changed the paradigm of peptic ulcer disease with marked decrease of morbidity and mortality. PPIs are known to be the most effective drugs that are currently available for suppressing gastric acid secretion. Many studies have shown its superiority over H₂RAs as a treatment for acid-related disorders, such as peptic ulcer disease, GERD, and Zollinger-Ellison syndrome. However, other studies have reported that PPIs may not be able to render stomach achlorhydric and have identified a phenomenon of increasing gastric acidity at night in individuals receiving a PPI twice daily. These nocturnal acid breakthrough episodes can be eliminated with an addition of H₂RAs at night. The effectiveness of nighttime dose of H₂RA suggests a major role of histamine in nocturnal acid secretion. H₂RAs reduce secretion of gastric acid, and each H₂RA also has specific effects. For instance, nizitidine alleviates not only symptoms of GERD, but also provokes gastric emptying, resulting in clinical symptom improvement of functional dyspepsia. The aim of this paper was to review the characteristics and role of H₂RAs and assess the future strategy and treatment of upper gastrointestinal disease, including acid related disorders.

The Impacts of Peptic Ulcer on Stroke Recurrence

BACKGROUND

Peptic ulcer has been associated with an increased risk of stroke. This study aimed to evaluate the impacts of peptic ulcer on stroke recurrence and mortality.

SUBJECTS AND METHODS

Patients with first-ever ischemic stroke were retrospectively confirmed with or without a history of peptic ulcer. The primary end point was defined as fatal and nonfatal stroke recurrence. Risks of 1-year fatal and nonfatal stroke recurrence were analyzed with the Kaplan-Meier method. Predictors of fatal and nonfatal stroke recurrence were evaluated with the Cox proportional hazards model.

RESULTS

Among the 2577 enrolled patients with ischemic stroke, 129 (5.0%) had a history of peptic ulcer. The fatal and nonfatal stroke recurrence within 1 year of the index stroke was higher in patients with peptic ulcer than in patients without peptic ulcer (12.4% versus 7.2%, P = .030). Cox proportional hazards model detected that age (hazard ratio [HR] = 1.018, 95% confidence interval [CI] 1.005-1.031, P = .008), hypertension (HR = 1.397, 95% CI 1.017-1.918, P = .039), and history of peptic ulcer (HR = 1.853, 95% CI 1.111-3.091, P = .018) were associated with stroke recurrence.

CONCLUSIONS

Ischemic stroke patients with peptic ulcer may have an increased risk of stroke recurrence. The results emphasize the importance of appropriate prevention and management of peptic ulcer for secondary stroke prevention.