Effect of Helicobacter pylori eradication on peptic ulcer disease complicated with outlet obstruction

Gastric outlet obstruction due to peptic ulcer disease in a 5 years-old female child. Case report. June 23, 2022

INTRODUCTION AND IMPORTANCE

Gastric outlet obstruction (GOO) is a spectrum of congenital and acquired conditions that prevent the passage of gastric contents beyond the proximal duodenum. Peptic ulcer disease (PUD), which causes GOO, is extremely rare in children, with an incidence of 1 per 100,000 live births. Because of the rarity of the disease in children, we report a case of GOO due to PUD in a 5-year-old child.

CASE PRESENTATION

We report a case of an acquired GOO due to PUD in a 5-year-old female child who presented with vomiting, weight loss, and epigastric pain of 3 months' duration. Her diagnosis of GOO secondary to PUD was made by upper gastrointestinal (UGI) endoscopy despite a negative stool H. pylori antigen. She was managed with proton pump inhibitor (PPI), which results in improvement of signs and symptoms. She has been on follow-up for the last 6 months and has remained asymptomatic.

CLINICAL DISCUSSION

H. pylori-positive GOO is successfully treated with PPI and antibiotic therapy. The role of H. pylori therapy in PUD-related GOO is less clear, although eradication is warranted as a primary intervention.

CONCLUSION

GOO secondary to PUD may occur in the absence of Helicobacter pylori infection (HPI). Our patient demonstrated response to medical management in the acute phase of ulceration.

Balloon dilatation in patients with gastric outlet obstruction related to peptic ulcer disease

BACKGROUND AND STUDY AIMS

Gastric outlet obstruction (GOO) is a rare complication of peptic ulcer disease (PUD). The endoscopic balloon dilatation (EBD) associated with medical treatment of Helicobacter pylori is a successful method in the management of pyloric stenosis. The aim of this study was to describe epidemiological, clinical, and endoscopic characteristics of GOO related to PUD and to evaluate the effectiveness, safety, and outcome of EBD.

PATIENTS AND METHODS

In a retrospective study of patients seen between 1999 and 2009 with symptoms of GOO secondary to PUD, pyloro-bulbar stenosis was confirmed by endoscopic examination. Balloon dilatation was performed when obstruction persisted after treatment with double-dose proton-pump inhibitor (PPI) intravenously for 7-10days. The H. pylori status was assessed with histology, and eradication therapy was prescribed for infection.

RESULTS

A total of 45 consecutive patients (38 males, 7 females median age, 51.9years; range, 20-58years) with symptoms of GOO secondary to PUD underwent EBD. Median follow-up time of the 45 patients was 32months (range, 4-126months). The immediate success rate of the procedure was 95.5%. Clinical remission was noted in 84.4% of the patients. Remission without relapse was observed in 55.8%, 30months after the dilatation. Pyloric stenosis relapsed in 15 patients (39.5%) after a median period of 22.9months. The dilatation was complicated in three patients (6.7%, two perforations and one bleeding). A total of 13 patients (29%) underwent surgery. H. pylori was found to be positive in 97.7% of the patients, and was eradicated in 78.4% of them. Smoking and failure of H. pylori eradication were associated with the relapse of the stenosis.

CONCLUSION

EBD is a simple, effective, and safe therapy for the GOO related to PUD, producing short- and long-term remission.

Two Cases of Helicobacter pylori-Negative Gastric Outlet Obstruction in Children

Gastric outlet obstruction (GOO) in children is most commonly caused by idiopathic hypertrophic pyloric stenosis. Prior to proton pump inhibitors and H2 blockers, peptic ulcer disease (PUD) secondary to H. pylori was a cause of GOO. Both patients presented with a history of weight loss, vomiting, and abdominal pain. Their diagnosis of PUD and GOO was made by EGD and UGI. H. pylori testing was negative for both on multiple occasions but still received H. pylori eradication therapy. Patient 1 after failing pharmaceutical management underwent surgery for definitive treatment. Patient 2 underwent six therapeutic pyloric dilations before undergoing surgery as definitive treatment. These cases suggest that GOO secondary to PUD occurs in the absence of H. pylori infection and surgical management can provide definitive therapy.

Visual loss and idiopathic intracranial hypertension in children with Alagille syndrome

BACKGROUND

Alagille syndrome (AGS) is an autosomal dominant, multisystem disorder defined by developmental abnormalities of the liver, heart, eye and skeleton. Although visual problems are recognised, the severity of visual loss and its link with idiopathic intracranial hypertension (IIH) has not been reported.

AIM

To review the incidence of visual loss and IIH in children with AGS managed at a National Paediatric Liver Unit between 1989 and 2004.

SUBJECTS AND METHODS

Retrospective case note review of children who fulfilled criteria for diagnosis of AGS and had an ophthalmic examination by a paediatric ophthalmologist.

RESULTS

Fifty-five children with AGS were evaluated. Of these, 41 children fulfilled diagnostic criteria and had a documented ophthalmic examination. Six children had undergone liver transplantation. Three children had a definite diagnosis of IIH, 2 of whom developed postliver transplant. All 3 were treated medically, but 1 child with IIH required lumboperitoneal shunting. All 3 children with definite IIH have normal vision after treatment. Another child with probable undiagnosed IIH has bilateral optic atrophy and is registered blind. Two children with AGS are registered partially sighted, one with rod cone dystrophy and the other with pigmentary retinopathy and right disc atrophy.

SUMMARY

Although visual abnormalities are well described in children with AGS, a minority of children have significant progressive visual loss. Idiopathic intracranial hypertension has been identified as a potentially treatable precipitating factor.

CONCLUSIONS

We recommend annual fundoscopy in the follow-up of children with AGS to facilitate early detection and appropriate management of IIH to prevent visual loss.

Proton pump inhibition is a feasible primary alternative to surgery and balloon dilatation in adult peptic pyloric stenosis (APS): report of six consecutive cases

INTRODUCTION

Surgery has been the gold standard in the treatment of adult pyloric stenosis (APS). The introduction of proton pump inhibitors (PPIs) in 1989 revolutionised the treatment of peptic ulcer disease and its complications.

PATIENTS AND METHODS

We carried out a prospective study to evaluate the effectiveness of PPIs as an alternative to surgery for treatment of APS. Six consecutive patients admitted with a diagnosis of adult peptic pyloric stenosis between November 1999 and August 2002 were studied. The diagnosis was confirmed with endoscopy. All patients were commenced on a twice-daily dose of intravenous PPI. This was changed to oral treatment after 2 days. Main outcome measures evaluated were resolution of symptoms on PPIs and failure of medical therapy.

RESULTS

There were five females and one male. Median age at diagnosis was 72 years (range, 30-90 years). Median duration of symptoms was 2 weeks (range, 1-5 weeks). Of the patients, five had a history of peptic ulcer disease. Complete resolution was achieved in 5 patients (83%). Median duration for resolution of symptoms was 9 days (range, 5-14 days). All patients were changed to oral PPIs after 2 days. One patient did not respond to oral therapy and required surgical intervention (pyloroplasty). Median follow-up was 26 months (range, 6-48 months). There was no recurrence of symptoms. All patients were discharged on low-dose PPI.

CONCLUSIONS

This study supports the view that proton pump inhibitors are a safe and feasible alternative to surgery in adult pyloric stenosis secondary to peptic ulcer disease.

Endoscopic balloon dilation for benign gastric outlet obstruction with or without Helicobacter pylori infection

BACKGROUND

Endoscopic balloon dilation has been used to treat patients with gastric outlet obstruction caused by peptic stricture. This study assessed the role of endoscopic balloon dilation in patients with gastric outlet obstruction with or without Helicobacter pylori infection.

METHODS

Consecutive patients seen between January 1996 and September 2001 with benign gastric outlet obstruction (defined as stenosis preventing the passage of a 9-mm diameter endoscope, vomiting, succussion splash, and recent weight loss) were prospectively studied. Exclusion criteria were the following: refusal to undergo dilation, and gastric outlet obstruction because of malignancy. At endoscopy, antral biopsy specimens were obtained for histopathologic evaluation and for a rapid urease test for Helicobacter pylori infection. Patients then underwent dilation with through-the-scope balloons. After balloon dilation, patients with Helicobacter pylori infection were treated to eradicate the infection.

RESULTS

Fifty-one patients (33 men, 18 women; median age 65 years; IQR 44-79 years) were studied; 33 consented to endoscopic balloon dilation. Symptom resolution occurred in 25 patients (14 Helicobacter pylori positive, 11 Helicobacter pylori negative). During a median follow-up of 24 months (IQR 16-40 months), 3 of 14 patients in the Helicobacter pylori positive group and 6 of 11 in the Helicobacter pylori negative group developed further ulcer complications (p=0.039).

CONCLUSIONS

After endoscopic dilation for gastric outlet obstruction, eradication of Helicobacter pylori infection is associated with fewer ulcer complications.

How Helicobacter Pylori changed the life of surgeons

Helicobacter Pylori infection has been identified as a pathogenic factor in a number of gastroduodenal diseases, most importantly in gastric and duodenal ulcer disease. This association and the development of H. PYLORI eradication therapies has had a tremendous influence on the surgical therapy for these disorders. Decades ago, surgery was the therapy of choice for gastric and duodenal ulcers. Now, however, the first line of therapy includes treatment of H. PYLORI infection, suppression of gastric acid secretion, and protection of gastric mucosal barriers combined with a range of endoscopic procedures. These developments have had a major impact on the indications for surgery in benign gastroduodenal diseases. In addition, advances in our understanding of the pathogenetic mechanisms of H. PYLORI infection have also changed our views of gastric mucosa-associated lymphoid tissue lymphoma, gastric cancer, and gastroesophageal reflux disease.

Review article: Helicobacter pylori infection and gastric outlet obstruction - prevalence of the infection and role of antimicrobial treatment

The prevalence of Helicobacter pylori infection in peptic ulcer disease complicated by gastric outlet obstruction seems to be, overall, lower than that reported in non-complicated ulcer disease, with a mean value of 69%. However, H. pylori infection rates in various studies range from 33% to 91%, suggesting that differences in variables, such as the number and type of diagnostic methods used or the frequency of non-steroidal anti-inflammatory drug intake, may be responsible for the low prevalence reported in some studies. The resolution of gastric outlet obstruction after the eradication of H. pylori has been demonstrated by several studies. It seems that the beneficial effect of H. pylori eradication on gastric outlet obstruction is observed early, just a few weeks after the administration of antimicrobial treatment. Furthermore, this favourable effect seems to remain during long-term follow-up. Nevertheless, gastric outlet obstruction does not always resolve after H. pylori eradication treatment and an explanation for the failures is not completely clear, non-steroidal anti-inflammatory drug intake perhaps playing a major role in these cases. Treatment should start pharmacologically with the eradication of H. pylori even when stenosis is considered to be fibrotic, or when there is some gastric stasis. In summary, H. pylori eradication therapy should be considered as the first step in the treatment of duodenal or pyloric H. pylori-positive stenosis, whereas dilation or surgery should be reserved for patients who do not respond to such medical therapy.

Operations for peptic ulcer disease: paradigm lost

Over the past several decades, the pharmacologic and endoscopic treatment of peptic ulcer disease (PUD) has dramatically improved. To determine the effects of these and other changes on the operative management of PUD, we reviewed our surgical experience with gastroduodenal ulcers over the past 20 years. A computerized surgical database was used to analyze the frequencies of all operations for PUD performed in two training hospitals during four consecutive 5-year intervals beginning in 1980. Operative rates for both intractable and complicated PUD were compared with those for other general surgical procedures and operations for gastric malignancy. In the first 5-year period (1980 to 1984), a yearly average of 70 upper gastrointestinal operations were performed. This experience included 36 operations for intractability, 15 for hemorrhage, 12 for perforation, and seven for obstruction. During the same time span, 13 resections were performed annually for gastric malignancy. By the most recent 5-year interval (1994 to 1999), the total number of upper gastrointestinal operations had declined by 80% (14 cases), although the number of operations for gastric cancer had changed only slightly. Operations decreased most markedly for patients with intractability, but the prevalence of operations for bleeding, obstruction, and perforation was also decreased. We conclude that improved pharmacologic and endoscopic approaches have progressively curtailed the use of operative therapy for PUD. Elective surgery is now rarely indicated, and emergency operations are much less common. This changed paradigm poses new challenges for training and suggests different approaches for practice.