Pyloric obstruction complicating peptic ulcer

Long-term prognosis in patients continuing taking antithrombotics after peptic ulcer bleeding

AIM

To investigate the long-term prognosis in peptic ulcer patients continuing taking antithrombotics after ulcer bleeding, and to determine the risk factors that influence the prognosis.

METHODS

All clinical data of peptic ulcer patients treated from January 1, 2009 to January 1, 2014 were retrospectively collected and analyzed. Patients were divided into either a continuing group to continue taking antithrombotic drugs after ulcer bleeding or a discontinuing group to discontinue antithrombotic drugs. The primary outcome of follow-up in peptic ulcer bleeding patients was recurrent bleeding, and secondary outcome was death or acute cardiovascular disease occurrence. The final date of follow-up was December 31, 2014. Basic demographic data, complications, and disease classifications were analyzed and compared by t- or χ²-test. The number of patients that achieved various outcomes was counted and analyzed statistically. A survival curve was drawn using the Kaplan-Meier method, and the difference was compared using the log-rank test. COX regression multivariate analysis was applied to analyze risk factors for the prognosis of peptic ulcer patients.

RESULTS

A total of 167 patients were enrolled into this study. As for the baseline information, differences in age, smoking, alcohol abuse, and acute cardiovascular diseases were statistically significant between the continuing and discontinuing groups (70.8 ± 11.4 vs 62.4 ± 12.0, P < 0.001; 8 (8.2%) vs 15 (21.7%), P < 0.05; 65 (66.3%) vs 13 (18.8%), P < 0.001). At the end of the study, 18 patients had recurrent bleeding and three patients died or had acute cardiovascular disease in the continuing group, while four patients had recurrent bleeding and 15 patients died or had acute cardiovascular disease in the discontinuing group. The differences in these results were statistically significant (P = 0.022, P = 0.000). The Kaplan-Meier survival curve indicated that the incidence of recurrent bleeding was higher in patients in the continuing group, and the risk of death and developing acute cardiovascular disease was higher in patients in the discontinuing group (log-rank test, P = 0.000 for both). Furthermore, COX regression multivariate analysis revealed that the hazard ratio (HR) for recurrent bleeding was 2.986 (95%CI: 067-8.356, P = 0.015) in the continuing group, while HR for death or acute cardiovascular disease was 5.216 (95%CI: 1.035-26.278, P = 0.028).

CONCLUSION

After the occurrence of peptic ulcer bleeding, continuing antithrombotics increases the risk of recurrent bleeding events, while discontinuing antithrombotics would increase the risk of death and developing cardiovascular disease. This suggests that clinicians should comprehensively consider the use of antithrombotics after peptic ulcer bleeding.

[Results of selective proximal vagotomy after 13 years]

This study reports the long-term results of 216 patients after highly selective vagotomy (HSV) for duodenal ulcers operated from 1970 through 1978 with a mean follow-up of 12.8 years (8.3-15). 26 patients developed symptomatic ulcer recurrences (12%) within 4 to 135 months following surgery, the cumulative recurrence rate (Kaplan-Meier) at 13 years was 20.3%. Acidity analyses showed a postoperative mean reduction of basal acid output (BAO) and maximal acid output (MAO) values of 80.7% and 74.8% respectively with no differences according to recurrences. The risk of recurrence was similar for duodenal (22/194) and pyloric ulcers (4/22) and no differences were found with respect to sex, additional drainage procedure, smoking habits, acute or elective operation and first or recurrent ulcers. Risk was slightly higher for complicated ulcers (p less than or equal to 0.07), but without reaching statistical significance. 78.5% of patients showed (very) good results (Visick I or II), only 6% were Visick III. HSV is therefore regarded as a valuable therapeutic measure for the treatment of duodenal ulcer independent of patient compliance.

Preliminary experience with hydrostatic balloon dilation of gastric outlet obstruction

In treating a group of 15 patients with gastric outlet obstruction, 12 (80%) had good to excellent relief of symptoms. Two patients required surgical intervention. One patient has symptoms that were persistent but mild enough to forego surgery. Balloon dilation offers an alternative to the surgical management of gastric outlet obstruction.

The prognosis of gastric outlet obstruction

A retrospective study was undertaken to examine the prognosis of gastric outlet obstruction with specific reference to patients with obstruction due to peptic ulcer. During the 10-year period 1970-1979, 68 patients with gastric outlet obstruction were admitted to our hospital. Obstruction was caused by peptic ulceration in 55 of these patients, all of whom initially were managed conservatively. Thirty-four, however, required surgical decompression during their first admission for obstruction, and 11 needed surgery for a subsequent episode of obstruction. Of the ten patients who have not undergone surgery, six died within 3 years of their first episode of obstruction and three of the four survivors continue to have recurrent obstructive symptoms. Overall, 92% (45/49) of patients who have lived for more than 3 years after their presentation with gastric outlet obstruction due to peptic ulcer have required surgery for relief of obstruction.

The interrelationship between bleeding, perforation, and stenosis in duodenal ulceration

The interrelationship of gastrointestinal bleeding, acute perforation, and pyloroduodenal stenosis was examined in a hospital series of 1,457 patients with duodenal ulcers. The proportion of each complication among the total number of ulcer patients after various periods of ulcer symptoms was determined. There was little variation in the proportion with bleeding as the duration of symptoms increased, whereas the proportion with perforation decreased and the proportion with stenosis increased with increasing duration of ulcer dyspepsia. The association of bleeding with perforation (26 patients) was more common than the association of bleeding with stenosis (12 patients), and more so than the association of perforation with stenosis (4 patients). To explain the paradoxical relationship of perforation and stenosis it was proposed that perforation occurred when the pathological process in ulceration was such that there was more tissue destruction. than tissue repair, and that stenosis would result if there was more tissue repair than tissue destruction

Obstructing duodenal ulcer

The incidence, pathogenesis, symptoms, roentgenographic, and endoscopic findings of patients with gastric outlet obstruction from a chronic duodenal ulcer have been reviewed. In the experience of many surgeons, including myself, vagotomy and an adequate drainage procedure (Finney pyloroplasty, gastrojejunostomy, or gastroduodenostomy) provide excellent decompression of the obstructed stomach. as well as excellent control of the ulcer disease in most patients. Postvagotomy gastric atony has not been a problem.