Epidemiology in peptic ulcer disease. Current status and future aspects

Graham Patch Repair of a Prepyloric Ulcer Complicated by Recurrent Abdominal Abscesses and Leukocytosis: A Case Report

This case report describes the clinical course of a 51-year-old Caucasian woman with a history of anemia who presented to the emergency department with worsening diffuse abdominal pain and weakness two days after dental surgery. The patient's condition rapidly deteriorated, manifesting as tachycardia, diaphoresis, and a peritonitic abdomen. A CT scan revealed a perforated gastric ulcer, prompting emergent laparoscopy, Graham patch repair, and abdominal washout. Postoperatively, the patient developed leukocytosis, and imaging indicated the formation of an abscess. Despite initial attempts at percutaneous drainage, a subsequent exploratory laparotomy was performed. The patient's leukocytosis eventually resolved, and she was discharged after 21 days with outpatient follow-up. The discussion delves into the declining incidence of peptic ulcer disease but a constant rate of complications, emphasizing the role of factors such as nonsteroidal anti-inflammatory drug use. The diagnostic approach using CT scans in suspected perforated peptic ulcers is highlighted. The study also explores risk stratification scoring systems, with a preference for operative management. The laparoscopic omental patch repair (Graham patch) is discussed, citing its safety and efficacy. The case presented an uncommon occurrence of failed primary percutaneous abscess drainage, leading to subsequent surgical drainage. The discussion concludes by noting variables that may contribute to drainage failure and emphasizes the need for further research to understand such complications.

Typical and atypical symptoms of gastro esophageal reflux disease: Does Helicobacter pylori infection matter?

AIM: To analyze whether the presence of Helicobacter pylori (H. pylori) infection could affect the quality of symptoms in gastro-esophageal reflux disease (GERD) patients.

METHODS: one hundred and forty-four consecutive patients referred to our Unit for suspected GERD were recruited for the study. All patients underwent esophageal pH-metric recording. For those with a positive test, C₁₃ urea breath test was then performed to assess the H. pylori status. GERD patients were stratified according to the quality of their symptoms and classified as typical, if affected by heartburn and regurgitation, and atypical if complaining of chest pain, respiratory and ears, nose, and throat features. H. pylori-negative patients were also asked whether they had a previous diagnosis of H. pylori infection. If a positive response was given, on the basis of the time period after successful eradication, patients were considered as “eradicated” (E) if H. pylori eradication occurred more than six months earlier or “recently eradicated” if the therapy had been administered within the last six months. Patients without history of infection were identified as “negative” (N). χ² test was performed by combining the clinical aspects with the H. pylori status.

RESULTS: one hundred and twenty-nine of the 144 patients, including 44 H. pylori-positive and 85 H. pylori-negative (41 negative, 21 recently eradicated, 23 eradicated more than 6 mo before), were eligible for the analysis. No difference has been found between H. pylori status and either the number of reflux episodes (138 ± 23 vs 146 ± 36, respectively, P = 0.2, not significant) or the percentage of time with pH values < 4 (6.8 ± 1.2 vs 7.4 ± 2.1, respectively, P = 0.3, not significant). The distribution of symptoms was as follows: 13 typical (30%) and 31 atypical (70%) among the 44 H. pylori-positive cases; 44 typical (52%) and 41 atypical (48%) among the 85 H. pylori-negative cases, (P = 0.017 vs H. pylori+; OR = 2.55, 95%CI: 1.17-5.55). Furthermore, clinical signs in patients with recent H. pylori eradication were similar to those of H. pylori-positive (P = 0.49; OR = 1.46, 95%CI: 0.49-4.37); on the other hand, patients with ancient H. pylori eradication showed a clinical behavior similar to that of H. pylori-negative subjects (P = 0.13; OR = 0.89, 95%CI: 0.77-6.51) but different as compared to the H. pylori-positive group (P < 0.05; OR = 3.71, 95%CI: 0.83-16.47).

CONCLUSION: Atypical symptoms of GERD occur more frequently in H. pylori-positive patients than in H. pylori-negative subjects. In addition, atypical symptoms tend to decrease after H. pylori eradication.

Comparative Analysis of Vagotomy and Drainage Versus Vagotomy and Resection Procedures for Bleeding Peptic Ulcer Disease: Results of 907 Patients from the Department of Veterans Affairs National Surgical Quality Improvement Program Database

BACKGROUND

The purpose of this study was to determine postoperative outcomes and risk factors for morbidity and mortality in patients requiring surgery for bleeding peptic ulcer disease (PUD). Vagotomy and drainage procedures are technically simpler but are usually associated with higher ulcer recurrence rates. In contrast, vagotomy and resection approaches offer lower ulcer recurrences but represent much more challenging operations and are associated with considerable morbidity and mortality.

STUDY DESIGN

Data collected through the Department of Veterans Affairs National Surgical Quality Improvement Program database from 1991 to 2001 were submitted for stepwise logistic regression analysis for prediction of 30-day postoperative morbidity and mortality, rebleeding, and postoperative length of stay. The study population included all patients operated on for bleeding PUD within an 11-year period.

RESULTS

The 30-day morbidity, mortality, and rebleeding rates were comparable between surgical groups. Age, American Society of Anesthesiologists class, presence of ascites, coma, diabetes, functional status, hemiplegia, and history of steroid use were predictors of postoperative death. Risk factors for rebleeding included dependent functional status, history of congestive heart failure, smoking, steroid use, and preoperative transfusions. Having a resective procedure, American Society of Anesthesiologists class, hemiplegia, history of COPD, and requiring ventilator-assisted respirations before surgery were positively associated with increased length of hospital stay.

CONCLUSIONS

No differences were observed in 30-day mortality, morbidity, or rebleeding rates between surgical groups. Having a resective procedure was a predictor of prolonged postoperative stay. Dependent status and chronic use of steroids were predictors of both rebleeding and postoperative mortality.

Gastric disease in the dog and cat

The physiology of the normal gastric defence mechanisms in the dog and cat is reviewed to emphasize the routes by which drugs can be used to protect the gastric mucosa. The action of the main anti-ulcer and pro-kinetic drugs are discussed in relation to the diseases that they may be used to treat. Gastric disease in the form of gastric dilatation/volvulus, chronic vomiting without obstruction and gastric outflow disease are described from the point of view of diagnosis and treatment.

Peptic ulcer haemorrhage in Tartu County, Estonia: epidemiology and mortality risk factors

BACKGROUND

The aim of the study was to assess the epidemiology and mortality risk factors of peptic ulcer haemorrhage (PUH) in Tartu County, Estonia.

METHODS

In a prospective unselected defined area study, data for 144 patients aged > or = 15 years with new cases of PUH were analysed during a 2-year period.

RESULTS

The incidence of PUH was 57 per 100,000 adult population per year, increasing from 12 in patients aged 20-29 years to more than 135 in those > or = 70 years. The incidence was 2.3-fold higher for men. The incidence of gastric ulcer haemorrhage was 26 (men, 33; women, 20) and that of duodenal ulcer 22 (men, 39; women, 9). Of the women 72% and of the men 37% were > or = 60 years. Nonsteroidal anti-inflammatory drugs (NSAIDs) were used by 45% of the patients (64% of women, 36% of men). Helicobacter pylori infection was present in 93% of the duodenal ulcer patients and in 81% of the gastric ulcer patients. Mortality (8%) was related to age, shock, haemoglobin < 80 g/l, cardiac comorbidity, and recurrence of haemorrhage.

CONCLUSIONS

The incidence of PUH is relatively high owing to a high incidence among the younger population in Tartu County. Women with PUH are older, have consumed more NSAIDs, and have mainly gastric ulcer; men are younger, have consumed less NSAIDs, and are prone to duodenal ulcer haemorrhage. H. pylori infection is common in PUH patients. Mortality risk factors coincide with those reported by other researchers.

Diagnostic procedures and health outcomes. Upper gastrointestinal tract investigations in the elderly

OBJECTIVES

To examine the use of upper gastrointestinal endoscopy in people 65 years of age and over in New South Wales, and compare its use between geographic areas, sex and age groups. Also, to investigate the relationship between endoscopy use and peptic ulcer mortality.

DESIGN

A retrospective review of upper gastrointestinal tract (GIT) endoscopy hospital separation data for NSW from 1986 to 1989-1990 and peptic ulcer mortality data from 1979 to 1989.

MAIN OUTCOME MEASURES

Rates per 1000 population aged 65 years and over were calculated for upper GIT endoscopy for each of the four-year age groups and by sex. Peptic ulcer and other digestive system disease rates for endoscopy patients were determined. Correlations between hospital standardised separation rates for endoscopy and standardised mortality rates for gastric cancer and peptic ulcers were calculated. Age and sex standardised death rates were calculated for each year between 1979 and 1989, and changes in death rates over time were determined by regression analysis.

RESULTS

The rate of endoscopies increased significantly (P < 0.001) over the period 1986 to 1989-1990, with the highest rate and greatest increase occurring in patients aged 70 years and over. Men had significantly higher endoscopy rates than women (P < 0.001). Geographic variations in the use of endoscopy were found and were not explained by geographic differences in the proportion of peptic ulcers diagnosed, deaths from peptic ulcers or malignant neoplasms. Despite the increase in endoscopies performed, there was no corresponding significant increase in the rate of peptic ulcers detected. Between 1979 and 1989 peptic ulcer mortality rates for women over 74 years of age increased significantly (P < 0.05); the rate for men did not change.

CONCLUSION

Many endoscopies are performed in people aged 65 years and over in NSW and there has been a substantial increase in endoscopy rates in recent years. While the increase in upper GIT endoscopy may have resulted in a number of health benefits, it does not appear to have resulted in a reduction in peptic ulcer related mortality.

Quality of Life assessments in patients with peptic ulcer during treatment and follow-up

Quality of Life (QOL) has traditionally not been evaluated in patients with peptic ulcer disease. In this study, QOL was evaluated before treatment (day 0), during treatment (day 15), 14 days after treatment stopped (mean day 38), after 6 months and 1 year. Investigation was done by using a questionnaire which was mailed to the patient and mailed back within a few days. Psychological General Well-Being (PGWB) was used as a QOL base. Patients were treated with effective acid reduction. A total of 392 patients were included and the questionnaire response rate was 95%. The general QOL score for PGWB, which initially was low, increased significantly during treatment to a maximum two weeks post-treatment. At the six and twelve-month follow-up the scores dropped slightly. It is concluded that QOL assessments seem useful in the evaluation of medical regimens for peptic ulcer disease. The scores follow the clinical state, which enables future comparisons of different regimens.

Acute upper gastrointestinal bleeding in elderly persons

We have seen that UGI bleeding is a serious and apparently growing problem for seniors. Of special concern in the older patient are the frequency with which serious peptic disease presents silently, the limitation frequently imposed on adequate pain relief from NSAIDs, and the higher complication rates from most of the causes of UGI bleeding. Care of the elderly would be enhanced by research focused on defining those older patients most at risk of experiencing NSAID-induced peptic complications, improved methods for preventing or treating NSAID-induced ulceration that are well tolerated and cost-effective, and better regimens for preventing the recurrence of ulcers and UGI bleeding in these patients. In regard to the last, future investigation of the role of H. pylori, methods for successfully eliminating the organism, and the effect of eradication on patients' subsequent course may be particularly helpful.