Influence of the site of a duodenal ulcer on its mode of presentation

Bulbar and post-bulbar duodenal ulcers: characteristics based on location

OBJECTIVES

Most research on duodenal ulcers has focused on bulbar ulcers; details on post-bulbar ulcers remain largely unknown. This study was conducted to determine the characteristics of patients with post-bulbar duodenal ulcers depending on their location.

METHODS AND MATERIALS

We conducted a retrospective study of hospitalized patients newly diagnosed with duodenal ulcers on endoscopy at a tertiary referral center in Japan between April 2004 and March 2019. Five hundred fifty-one patients diagnosed with duodenal ulcers were extracted for analysis.

RESULTS

Ulcers were observed only in the bulbus in 383 cases, only in the post-bulbar duodenum in 82 cases, and were co-existing in both areas in 86 cases. The Bulbar group had less comorbidities and was more likely to have atrophic gastritis, while the Post-bulbar and Co-existing groups were more likely to be admitted for non-gastrointestinal conditions. Regular acid suppressant use was more common in the post-bulbar group than in the Bulbar group. Bulbar ulcers were associated with a shorter length of stay relative to post-bulbar and co-existing ulcers, but ulcer location was not an independent predictor of length of stay. Patients with co-existing bulbar and post-bulbar ulcers have characteristics similar to those with post-bulbar ulcers alone.

CONCLUSION

Patients with post-bulbar ulcers and those with co-existing bulbar and post-bulbar ulcers have different characteristics and outcomes relative to patients with bulbar ulcers.

Duodenal Perforation With Transplant Hepatic Artery Pseudoaneurysm

A transplant hepatic artery pseudoaneurysm is a rare postorthotopic liver transplant complication. Bleeding is a common complication of posterior duodenal ulcer secondary to erosion into the gastroduodenal artery. We report the case of a post-transplant patient who presented with massive upper gastrointestinal hemorrhage in the setting of nonsteroidal anti-inflammatory drug use. Endoscopy demonstrated a duodenal ulcer with high-risk stigmata not amenable to hemostasis. Subsequently, an arteriogram revealed a hepatic artery pseudoaneurysm. Transplant professionals should be aware of the possibility of an ulcer eroding into the liver vasculature and in the differential diagnosis for bleeding and pseudoaneurysms in post-transplant patients.

Duodenal Ulceration into the Cystic Artery with Resultant Massive Hemorrhage

Anterior duodenal ulceration with erosion into the cystic artery is an extremely rare source of upper gastrointestinal hemorrhage. Interventions that have previously been reported include open exploration with cholecystectomy, open exploration while leaving the gallbladder in situ, and angiographic management. We report a case of massive upper gastrointestinal bleeding related to duodenal ulcer penetration of the cystic artery and discuss potential management strategies.

Duodenal ulceration into the cystic artery with massive hemorrhage

This is a case presentation of a unique cause of intestinal bleeding. A duodenal ulcer eroded into the superficial branch of the cystic artery, causing massive intestinal hemorrhage. The patient, a 76-year-old woman, presented with left upper abdominal and left back pain secondary to cystic lesions in the pancreas body and tail. Stress after operation and complication of leakage of pancreatic juice after distal pancreatectomy with splenectomy and diclofenac sodium administration may have caused a deep peptic ulcer to erode the cystic artery. We performed a transfixing ligation of the bleeding vessel, serosal suture of ulcer of the gallbladder, and simple closure of the duodenal ulcer with covering greater omentum. There were no serious complications after the operation, and the patient made an uneventful recovery.

Histologic findings and Helicobacter pylori in duodenal biopsies

We have studied the morphologic aspects of the duodenal bulb in relation to Helicobacter pylori infection in a large group of patients with endoscopically assessed duodenitis to learn more about the pathogenesis of nonspecific duodenitis (bulbitis) and to clarify the specific role of H. pylori. Eight duodenal biopsy specimens in the four quadrants of the first part of the bulb and four gastric antral biopsy specimens were taken in 208 patients. Specimens were fixed in formalin, or in glutaraldehyde, then slides were stained with hematoxylin and eosin, periodic acid-Schiff, and Alcian-Giemsa, and with toluidine blue for semithin sections. Duodenal histology revealed inflammation in 155 (74.5%) and H. pylori-like bacterial bodies in 153 (73.5%) of the patients; H. pylori infection in the gastric antrum was diagnosed in 173 (83.1%) of the patients. Distinguishing histologic aspects appeared to be related to the presence of H. pylori infection. We believe that the present histologic grading of duodenitis correlates better with the natural history of H. pylori infection in the duodenal bulb, and better fits the requirements of a modern classification than the classification commonly used in duodenitis. We conclude that the term H. pylori-linked bulbitis should be adopted as the proper term to identify the particular kind of duodenitis predisposing to peptic ulcer.

Clinical courses and predictors for rebleeding in patients with peptic ulcers and non-bleeding visible vessels: a prospective study

Detailed characterisation of non-bleeding visible vessels in terms of colour, size evolution, and time of rebleeding is important in determining the natural history of these lesions. The colour and size of non-bleeding visible vessels were observed endoscopically every day for three days and then every other day until rebleeding or flattening of visible vessels occurred in 140 patients. Rebleeding happened in 61 (44%) patients. Of them, 59 (97%) rebled within 72 hours. Flattening of visible vessels happened in 79 (56%) patients and 77 of 79 (98%) had flattening of visible vessels within 72 hours. Rebleeding rate increased with increasing length of exposed vessels (r = 0.96, p < 0.001). Coffee ground fluid or blood retention in the stomach and ulcer size > or = 2.0 cm were independent predictors for rebleeding using multivariate analysis. It is suggested that patients with non-bleeding visible vessels and independent predictors for rebleeding may need early aggressive treatment.

Management of bleeding ulcers

Hemorrhage is a common complication of peptic ulcer disease and is increased in frequency and severity with aspirin and NSAID use. A variety of clinical and endoscopic factors associated with an increased mortality rate from ulcer bleeding have been identified, the most important of which are presentation in shock and ongoing or recurrent bleeding after routine resuscitative measures. After hemodynamic stabilization, the goal of therapy is to diminish the chance that an ulcer will continue to bleed or will rebleed. Currently, this is best achieved by one of several endoscopic interventions in carefully selected patients. The most effective endoscopic techniques for decreasing the risk of ulcer rebleeding are multipolar electrocoagulation, heater probe thermal coagulation, and injection therapy in patients with active bleeding or a visible vessel in the ulcer base. Injection therapy may be used alone or in combination with either of the other two techniques. The major impact of therapeutic endoscopy appears to be a reduction in the number of emergent operations necessary to control hemorrhage. The mortality of emergent surgery for bleeding ulcer is prohibitive, and any means of reducing the need for surgery is likely to have a beneficial effect on survival.

Duodenal ulceration into the cystic artery

We report two cases of massive gastrointestinal bleeding due to anterior duodenal ulceration into the cystic artery, with gallbladder infarction as a complication. These cases indicate the potential dangers of laser therapy or embolization in bleeding anterior duodenal ulcers penetrating the cystic artery, as such therapy will arrest blood flow through the cystic artery and may precipitate gallbladder infarction.