Helicobacter pylori-related gastric outlet obstruction: is there a role for medical treatment?

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.

Endoscopic therapy of benign pyloric stenosis and gastric outlet obstruction

PURPOSE OF REVIEW

To examine the short and long-term success rates of balloon dilation of pyloric stenosis.

RECENT FINDINGS

Several large studies have demonstrated high rates of success for the relief of symptoms from pyloric stenosis using through-the-scope balloons. These dilating balloons readily increase the diameter of the stenotic pylorus on average from 6 to 16 mm. Patients who require more than two dilations are at high risk of endoscopic failure and the need for surgical intervention. Rapid re-stenosis rates are observed in patients with malignant pyloric obstruction. Since many patients with benign pyloric stenosis have underlying ulcer disease, helicobacter infection is a relatively common finding. Eradication of this infection at the time of balloon dilation will ensure higher long-term success rates.

SUMMARY

In summary, benign pyloric stenosis can be readily treated with endoscopic balloon dilation and should be the first-line 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.

Duodenal Carbonic Anhydrase: Mucosal Protection, Luminal Chemosensing, and Gastric Acid Disposal

The duodenum serves as a buffer zone between the stomach and jejunum. Over a length of only 25 cm, large volumes of strong acid secreted by the stomach must be converted to the neutral-alkaline chyme of the hindgut lumen, generating large volumes of CO2, which the duodenum then absorbs. The duodenal mucosa consists of epithelial cells connected by low-resistance tight junctions, forming a leaky epithelial barrier. Despite this high permeability, the epithelial cells, under intense stress from luminal mineral acid and highly elevated P(CO2), maintain normal functioning. Furthermore, the duodenum plays an active role in foregut acid-base homeostasis, absorbing large amounts of H+ and CO2 that are recycled by the gastric parietal cells. Prompted by the high expression of cytosolic and membrane carbonic anhydrase (CAs) in duodenal epithelial cells, and the intriguing observation that CA activity appears to augment cellular acid stress, we formulated a novel hypothesis regarding the role of CA in duodenal acid absorption, epithelial protection, and chemosensing. In this review, we will describe how luminal CO2/H+ traverses the duodenal epithelial cell brush border membrane, acidifies the cytoplasm, and is sensed in the subepithelium.

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.

Gastric surgery

Significant advances in the role of gastric surgery in the management of disease in the past year have focused on three broad areas: morbid obesity, gastric cancer, and peptic ulcer disease. Although vertical banded gastroplasty and Roux-en-Y gastric bypass are the two procedures most commonly used in the United States to induce weight loss in the morbidly obese patient, long-term follow-up continues to support the durability of the gastric bypass in maintaining a sustainable outcome with a minimum of complications. It is not surprising, therefore, that increasing interest has accrued in simplifying this operation and decreasing potential complications even further by employing laparoscopic technology. In the area of gastric cancer, several reports have provided important new information regarding its pathogenesis, factors influencing long-term survival, and strategies for management when diagnosed early. Finally, in patients developing the complications of peptic ulcer disease (eg, obstruction and perforation), conservative management has been emphasized over more radical traditional approaches. This review highlights these advances.