Refractory peptic ulceration following radiation therapy in primary gastric lymphoma: A report of two cases

Therapeutic approach of adipose-derived mesenchymal stem cells in refractory peptic ulcer

Peptic ulcer is one of the most common gastrointestinal tract disorders worldwide, associated with challenges such as refractory morbidity, bleeding, interference with use of anticoagulants, and potential side effects associated with long-term use of proton pump inhibitors. A peptic ulcer is a defect in gastric or duodenal mucosa extending from muscularis mucosa to deeper layers of the stomach wall. In most cases, ulcers respond to standard treatments. However, in some people, peptic ulcer becomes resistant to conventional treatment or recurs after initially successful therapy. Therefore, new and safe treatments, including the use of stem cells, are highly favored for these patients. Adipose-derived mesenchymal stem cells are readily available in large quantities with minimal invasive intervention, and isolation of adipose-derived mesenchymal stromal stem cells (ASC) produces large amounts of stem cells, which are essential for cell-based and restorative therapies. These cells have high flexibility and can differentiate into several types of cells in vitro. This article will investigate the effects and possible mechanisms and signaling pathways of adipose tissue-derived mesenchymal stem cells in patients with refractory peptic ulcers.

Aggressive primary gastric lymphoma (PGL) masquerading as hepatocellular cancer (HCC) in alcoholic cirrhosis

Background

The gastrointestinal tract is sa well-known site for extranodal Non-Hodgkin lymphomas, with the stomach is known to be the most common site on lymphoma, primary gastric lymphoma (PGL). The lymphoproliferative disorder rarely occurs in patients with cirrhosis. We report a unique case of metastatic PGL in a patient with cirrhosis.

Case presentation

A middle-aged male with decompensated alcoholic cirrhosis presented with two weeks of epigastric abdominal pain, abdominal distension, and jaundice. Abdominal triple-phase CT scan was consistent with cirrhosis, ascites, and multiple new hypodense liver lesions classified as an intermediate probability for HCC based on the LI-RADS classification system (LI RADS 3). Due to the CT findings in the setting of cirrhosis, a provisional diagnosis of HCC was made. Upper endoscopy revealed new multiple umbilicated submucosal nodules in the gastric body. Biopsy and immunostaining consistent with high-grade B-cell lymphoma. Targeted liver biopsy with similar morphology and immunostaining profile consistent with metastatic primary gastric DLBCL.

Conclusions

The case highlights the importance of recognizing metastatic PGL in patients with underlying cirrhosis to differentiate lymphoma from hepatocellular cancer. Targeted liver biopsies with lymphoma immunostaining are required to make a diagnosis.

Diagnostic and Treatment Approaches for Refractory Peptic Ulcers

Refractory peptic ulcers are defined as ulcers that do not heal completely after 8 to 12 weeks of standard anti-secretory drug treatment. The most common causes of refractory ulcers are persistent Helicobacter pylori infection and use of nonsteroidal anti-inflammatory drugs (NSAIDs). Simultaneous use of two or more H. pylori diagnostic methods are recommended for increased sensitivity. Serologic tests may be useful for patients currently taking proton pump inhibitors (PPIs) or for suspected false negative results, as they are not affected by PPI use. NSAID use should be discontinued when possible. Platelet cyclooxygenase activity tests can confirm surreptitious use of NSAIDs or aspirin. Cigarette smoking can delay ulcer healing. Therefore, patients who smoke should be encouraged to quit. Zollinger-Ellison syndrome (ZES) is a rare but important cause of refractory gastroduodenal ulcers. Fasting plasma gastrin levels should be checked if ZES is suspected. If an ulcer is refractory despite a full course of standard PPI treatment, the dose should be doubled and administration of another type of PPI considered.