An overview of history, pathogenesis and treatment of perforated peptic ulcer disease with evaluation of prognostic scoring in adults

Spontaneous duodenocutaneous fistula: a rare presentation of perforated duodenal ulcer

Objectives

Fistula formation between the duodenum and the skin of the anterior abdominal wall is a rare complication and reported most often following surgery. To the best of our knowledge, the development of a spontaneous duodenocutaneous fistula in association with duodenal ulcer has only been reported once.

Case presentation

A 52-year-old female patient presented at the emergency department with a painful ulcer and erythema on the right abdominal wall. On admission, she was in extremely poor general and nutritional condition. Laboratory analysis revealed inflammation. An empiric antibiotic therapy was initiated; parenteral nutrition, fluid, and electrolyte resuscitation were started. An enterocutaneous fistula was postulated and confirmed by endoscopy identifying a perforated duodenal ulcer. Surgery was not a valuable option and a Foley catheter was inserted through the fistula. During further endoscopic interventions, the Foley catheter was first replaced by a jejunal tube and later by a percutaneous endoscopic gastrostomy with a jejunal limb for enteral nutrition. The fistula output decreased, the local infection was controlled and the nutritional status improved.

Conclusions

Three months later the fistula was closed and the gastrostomy tube was removed. After 2 years the patient was in good general and nutritional condition.

Protective Effect of the Phycobiliproteins from Arthrospira maxima on Indomethacin-Induced Gastric Ulcer in a Rat Model

Gastric ulcers (GU) constitute a disease with a global prevalence ≈ 8.09 million. Of their causes, non-steroidal anti-inflammatory drugs (NSAIDs) such as indomethacin (IND) rank as the second most frequent etiologic agent. The pathogenic process of gastric lesions is given by the overproduction of oxidative stress, promotion of inflammatory processes, and inhibition of prostaglandin synthesis. Spirulina Arthrospira maxima (SP) is a cyanobacterium with a wide variety of substances with high nutritional and health values such as phycobiliproteins (PBPs) that have outstanding antioxidant activity, anti-inflammatories effects, and accelerate the wound healing process. This study aimed to determine the protective effect of PBPs in GU induced by IND 40 mg/kg. Our results show that the PBPs protected against IND-induced damage with a dose-dependent effect. At a dose of 400 mg/kg, a marked decrease in the number of lesions is observed, as well as the recovery of the main markers of oxidative stress damage (MDA) and antioxidant species (SOD, CAT, GPx) at close to baseline levels. The evidence derived from the present investigation suggests that the antioxidant effect of PBPs, together with their reported anti-inflammatory effects to accelerate the wound healing process, is the most reliable cause of their antiulcerogenic activity in this GU model.

The Global Incidence of Peptic Ulcer Disease Is Decreasing Since the Turn of the 21st Century: A Study of the Organisation for Economic Co-Operation and Development (OECD)

INTRODUCTION

Peptic ulcer disease (PUD) is a common cause of hospitalization worldwide. We assessed temporal trends in hospitalization for PUD in 36 Organisation for Economic Co-operation and Development (OECD) countries since the turn of the 21st century.

METHODS

The OECD database contains data on PUD-related hospital discharges and mortality for 36 countries between 2000 and 2019. Hospitalization rates for PUD were expressed as annual rates per 100,000 persons. Joinpoint regression models were used to calculate the average annual percent change (AAPC) with 95% confidence intervals (CIs) for each country, which were pooled using meta-analyses. The incidence of PUD was forecasted to 2021 using autoregressive integrated moving average and Poisson regression models.

RESULTS

The overall median hospitalization rate was 42.4 with an interquartile range of 29.7-60.6 per 100,000 person-years. On average, hospitalization rates (AAPC = -3.9%; 95% CI: -4.4, -3.3) and morality rates (AAPC = -4.7%; 95% CI: -5.6, -3.8) for PUD have decreased from 2000 to 2019 globally. The forecasted incidence of PUD hospitalizations in 2021 ranged from 3.5 per 100,000 in Mexico to 92.1 per 100,000 in Lithuania. Across 36 countries in the OECD, 329,000 people are estimated to be hospitalized for PUD in 2021.

DISCUSSION

PUD remains an important cause of hospitalization worldwide. Reassuringly, hospitalizations and mortality for PUD have consistently been falling in OECD countries in North America, Latin America, Europe, Asia, and Oceania. Identifying underlying factors driving these trends is essential to sustaining this downward momentum.

An insight into the anti-ulcerogenic potentials of medicinal herbs and their bioactive metabolites

ETHNOPHARMACOLOGICAL RELEVANCE

Peptic ulcer disease (PUD) ranks top among the most prominent gastrointestinal problems prevalent around the world. Long-term use of non-steroidal anti-inflammatory drugs, pathogenic infection by Helicobacter pylori, imbalances between gastrointestinal regulatory factors and pathological hyperacidity are major contributors towards the development of peptic ulcers. Although synthetic drugs of multiple pharmacological classes are abundantly available, inadequacy of such agents in ensuring complete recovery in not uncommon. Therefore, pharmacological explorations of herbal products including plant extracts and their respective isolated phytoconstituents, for potential gastroprotective and antiulcer properties, are regular practice among the scientific community. Moreover, the historical preferences of a significant share of world population towards herbal-based medication over modern synthetic drugs also contribute significantly to such endeavors.

AIM OF THE REVIEW

This review has endeavored to present ethnomedicinal and pharmacological prospects of a significant number of authenticated plant species in terms of their capacity to exert gastroprotection and antiulcer activities both in vitro and in vivo. The information delineated along the way was further subjected to critical analysis to ascertain the possible future prospects of such findings into designing plant-derived products in future for the treatment of peptic ulcer.

MATERIALS AND METHODS

Electronic version of prominent bibliographic databases, including Google Scholar, PubMed, Scopus, ScienceDirect, Wiley Online Library, SpringerLink, Web of Science, and MEDLINE were explored extensively for the identification and compilation of relevant information. The plant names and respective family names were verified through the Plant List (version 1.1) and World Flora Online 2021. All relevant chemical structures were verified through PubChem and SciFinder databases and illustrated with ChemDraw Ultra 12.0.

RESULTS

A colossal number of 97 plant species categorized under 58 diverse plant families have been discussed in the review for their gastroprotective and antiulcer properties. In vivo illustrations of the pharmacological properties were achieved for almost all the species under consideration. 29 individual phytoconstituents from these sources were also characterized with similar pharmacological potentials. Majority of the plant extracts as well as their constituents were found to exert their gastroprotective effects through antioxidative pathway featuring both enzymatic and nonenzymatic mechanism. Moreover, active inhibition of acid secretion, upregulation of gastroprotective mediators and downregulation of pro-inflammatory cytokines, were also associated with a prominent number of plants or products thereof.

CONCLUSIONS

Comparative evaluations of the plant sources for their antiulcer activities, both as individual and as combination formulations, are necessary to be conducted in human subjects under properly regulated clinical conditions. Moreover, the efficacy and safety of such products should also be evaluated against those of the currently available treatment options. This will further facilitate in ascertaining their suitability and superiority, if any, in the treatment of peptic ulcer diseases. Implementation of these endeavors may eventually lead to development of more efficient treatment options in the future.

Emerging role of mitochondrial DAMPs, aberrant mitochondrial dynamics and anomalous mitophagy in gut mucosal pathogenesis

Gastroduodenal inflammation and ulcerative injuries are increasing due to expanding socio-economic stress, unhealthy food habits-lifestyle, smoking, alcoholism and usage of medicines like non-steroidal anti-inflammatory drugs. In fact, gastrointestinal (GI) complications, associated with the prevailing COVID-19 pandemic, further, poses a challenge to global healthcare towards safeguarding the GI tract. Emerging evidences have discretely identified mitochondrial dysfunctions as common etiological denominators in diseases. However, it is worth realizing that mitochondrial dysfunctions are not just consequences of diseases. Rather, damaged mitochondria severely aggravate the pathogenesis thereby qualifying as perpetrable factors worth of prophylactic and therapeutic targeting. Oxidative and nitrosative stress due to endogenous and exogenous stimuli triggers mitochondrial injury causing production of mitochondrial damage associated molecular patterns (mtDAMPs), which, in a feed-forward loop, inflicts inflammatory tissue damage. Mitochondrial structural dynamics and mitophagy are crucial quality control parameters determining the extent of mitopathology and disease outcomes. Interestingly, apart from endogenous factors, mitochondria also crosstalk and in turn get detrimentally affected by gut pathobionts colonized during luminal dysbiosis. Although mitopathology is documented in various pre-clinical/clinical studies, a comprehensive account appreciating the mitochondrial basis of GI mucosal pathologies is largely lacking. Here we critically discuss the molecular events impinging on mitochondria along with the interplay of mitochondria-derived factors in fueling mucosal pathogenesis. We specifically emphasize on the potential role of aberrant mitochondrial dynamics, anomalous mitophagy, mitochondrial lipoxidation and ferroptosis as emerging regulators of GI mucosal pathogenesis. We finally discuss about the prospect of mitochondrial targeting for next-generation drug discovery against GI disorders.

Association between the Dietary Inflammatory Index and Gastric Disease Risk: Findings from a Korean Population-Based Cohort Study

Evidence suggests that diets with high pro-inflammatory potential may play a substantial role in the origin of gastric inflammation. This study aimed to examine the association between the energy-adjusted dietary inflammatory index (E-DIITM) and gastric diseases at baseline and after a mean follow-up of 7.4 years in a Korean population. A total of 144,196 participants from the Korean Genome and Epidemiology Study_Health Examination (KoGES_HEXA) cohort were included. E-DII scores were computed using a validated semi-quantitative food frequency questionnaire. Multivariate logistic regression and Cox proportional hazards regression were used to assess the association between the E-DII and gastric disease risk. In the prospective analysis, the risk of developing gastric disease was significantly increased among individuals in the highest quartile of E-DII compared to those in the lowest quartile (HRquartile4vs1 = 1.22; 95% CI = 1.08–1.38). Prospective analysis also showed an increased risk in the incidence of gastritis (HRquartile4vs1 = 1.19; 95% CI = 1.04–1.37), gastric ulcers (HRquartile4vs1 = 1.47; 95% CI = 1.16–1.85), and gastric and duodenal ulcers (HRquartile4vs1 = 1.46; 95% CI = 1.17–1.81) in the highest E-DII quartile compared to the lowest quartile. In the cross-sectional analysis, the E-DII score was not associated with the risk of gastric disease. Our results suggest that a pro-inflammatory diet, indicated by high E-DII scores, is prospectively associated with an increased risk of gastric diseases. These results highlight the significance of an anti-inflammatory diet in lowering the risk of gastric disease risk in the general population.

Emerging Trends and their Impacts on Peptic Ulcer Diseases: Treatments and Techniques

Background:

Peptic ulcer disease (PUD) is prevalent in almost all parts of the world. PUD complications are creating a major source of preventable health care expenses. The major factors responsible for the incidence of PUD and its complication have changed over the past few decades after the identification of non-steroidal inflammatory drugs (NSAIDs) and Helicobacter pylori bacterial infection along with a marked increase in the use of proton-pump inhibitors (PPIs) as drug therapy. The management of PUD has become more complex and challenging due to antimicrobial resistance.

Objective:

The objective of the study was to highlight current therapy and novel techniques used in the treatment of peptic ulcer diseases.

Methods:

An exhaustive literature search has been conducted across PubMed, Google, Scopus and Web of Science as an electronic database to add the crucial information from the relevant literature.

Results:

In the present review, we have discussed PUD and its pathophysiology. The recent trends in PUD and possible treatments with novel techniques have also been discussed. The type and presence of ulcers cannot be predicted accurately based on symptoms. The available treatment approaches for peptic ulcers based on their clinical presentation and etiology are anti-secretary therapy, endoscopy to reveal ulcers followed by drug therapy, and triple therapy for H pylori infection.

Conclusion:

Thus, the popular and effective methods are very beneficial in controlling PUD. The treatment based on diagnosis is the foremost requirement for ameliorating any disorder. In this article, the emerging techniques and development in the treatment and diagnosis of PUD have been reviewed.

Impact of progesterone on the gastrointestinal tract: a comprehensive literature review

Women are more prone to gastrointestinal symptoms than men. A comprehensive literature search was performed to assess the impact of sex steroid hormone, especially progesterone, on the (healthy and diseased) gastrointestinal tract. Overall, 37 articles were identified. Based on these we conclude that progesterone has a dose-dependent and sex-dependent effect on gastric emptying (especially in mammals), slows down gastrointestinal motility, reduces the gallbladder's response to contractile stimulants, may support gastroesophageal reflux by reducing the esophageal sphincter pressure, may protect from Helicobacter pylori infection gastrointestinal sequelae (especially in mammals) and does not affect inflammatory bowel disease-specific symptoms. However, for several gastrointestinal symptoms and diseases no studies have yet been performed addressing the impact of sex hormone steroids.

Risk Factors of Mortality in Patients Hospitalized With Chronic Duodenal Ulcers

Background

We aimed to identify risk factors of mortality in patients hospitalized with duodenal ulcers (DUs).

Methods

A National Inpatient Sample–based retrospective cohort study from 2005 to 2014 was conducted on patients undergoing emergency admission for chronic DUs. Demographics, clinical data, and outcomes were collected. Multivariable logistic regression model was applied to find the risk factors of mortality.

Results

70 641 patients were included in this study, of which 30 525 (43%) were non-elderly (< 65 years) and 40 116 (57%) were elderly (65+ years) patients. 72% of non-elderly and 57% of elderly patients were males. Mortality rate of men vs women was similar in non-elderly group (1.9% vs 2%, respectively), whereas it significantly differed in elderly patients (4.5% vs 5.3%, respectively, P<.0001). Time to operation was 1.15 (1.83) days in survived vs 1.55 (3.86) days in deceased non-elderly patients ( P < .001). Time to operation was .85 (1.73) days in survived vs 1.79 (7.28) days in deceased elderly patients ( P < .001). In patients with operation, age, delayed operation, frailty, and presence of perforation were the main risk factors of mortality in both elderly and non-elderly patients. Invasive diagnostic procedure was shown as a protective factor in elderly patients. In the final model for patients with no operation, age, hospital length of stay, and frailty were the main risk factors of mortality in both elderly and non-elderly patients. Invasive diagnostic procedure was revealed as a protective factor in all patients as well.

Conclusion

Early operation in patients with DU requiring surgical intervention is essential to improve the outcomes.

Omental patch repair of large perforated peptic ulcers ≥25 mm is associated with higher leak rate

BACKGROUND AND AIM

Omental patch repair is the present gold-standard technique for patients with perforated peptic ulcers (PPUs). Data are lacking regarding the safe ulcer size for omental patch repair leak (OPL). We analyze our experience in managing PPU to identify an ulcer size cut-off for predicting OPL.

METHODS

Patients who had undergone omental patch repair for PPU between Jan 2004 and Apr 2016 were included. Demographic data, the American Society of Anesthesiologists score, ulcer size, operative approach, post-operative complications, and length of stay were recorded. OPL, intra-abdominal collection, repeat surgery, and 30-day mortality were recorded. The relationship between ulcer size, pre-operative characteristics, and OPL were investigated with univariate and multivariate logistic regression. Receiver operating characteristic curve analysis derived the ulcer size cut-off to predict OPL. In addition, we analyzed if ulcer size predicted mortality or malignancy.

RESULTS

Six hundred and ninety patients with a mean age of 55.1 years (range 16-94) were managed for PPU during the study period. Free air on X-ray was evident in 417 (60.4%) patients. Mean ulcer size was 7.8 mm (range 1-50). OPL occurred in 15 patients (2.2%) and 30-day mortality was 7.4% (n=51). Multivariate analysis found ulcer size increase of 10 mm (OR 3.30, 95% CI 1.81-6.02, P<0.001) predicted increased risk of OPL. At 25 mm cut-off, sensitivity was 26.7%, specificity was 97.2%, positive likelihood ratio was 9.47, and negative likelihood ratio was 0.76 for OPL.

CONCLUSION

Ulcer size increase in 10 mm increases leak rate by 3.3 times. Ulcer size ≥25 mm predicts OPL.

RELEVANCE FOR PATIENTS

Increased risk of OPL for ≥25 mm warrants need for close post-operative monitoring and lowers threshold for investigations in event of clinical deterioration. Decision for omental patch repair versus gastrectomy however should not be based on ulcer size alone.

SR-5, the specific ratio of Korean multi-herbal formula: An evaluation of antiulcerogenic effects on experimentally induced gastric ulcers in mice

Purpose

Previously, we demonstrated that the specific ratio of Korean multi-herbal formula (SR-5) exhibits hepatoprotective properties against ethanol-induced hepatic damage in rats. Chronic and excessive alcohol consumption is a major etiological factor involved in gastric disease and ulcer development induced by the inflammatory response and oxidative stress.

Methods

The present study evaluated the gastroprotective effects of SR-5 (100, 150, and 200 mg/kg) against hydrochloride acid/ethanol (HCl/EtOH)-induced and indomethacin/hydrochloride acid (INDO/HCl)-induced gastritis in a mouse model and the mechanisms involved.

Results

All the tested doses of SR-5 significantly inhibited gastric lesions in the HCl/EtOH-induced ulcer model mice. Similarly, all the tested doses of SR-5 significantly inhibited gastric lesions in the INDO/HCl-induced ulcer model mice. Furthermore, mice pretreated with SR-5 had significantly increased gastric levels of enzymatic and nonenzymatic antioxidants, namely, catalase (CAT) and glutathione (GSH), with concomitant reductions in malondialdehyde (MDA) and reactive oxygen species (ROS) levels compared with those in the HCl/EtOH or INDO/HCl group. SR-5 suppressed the expression of nuclear factor-kappa B (NF-κB)/p65, inducible nitric oxide synthase (iNOS), tumor necrosis factor-α (TNF-α), and cyclooxygenase-2 (COX-2) to their normal values.

Conclusion

These findings are the first to demonstrate the powerful protective effect of SR-5 against gastric injury development and provide hope for clinical application.

Pattern of Presentation, Management and Early Outcome in Patients with Perforated Peptic Ulcer Disease in a Semi-urban Tertiary Hospital

BACKGROUND

Perforated peptic ulcer is a life-threatening complication with a high morbidity and mortality. It is the most common indication for emergency operation in peptic ulcer disease (PUD) patients. This study aimed to describe the pattern of presentation, management and early outcome in patients with perforated PUD.

METHODS

This was a prospective study of patients who had operation for perforated PUD at Ekiti State University Teaching Hospital (EKSUTH), Ado-Ekiti, Southwestern Nigeria from June 2015 to May 2020.

RESULTS

Forty-six patients were studied with their ages ranging from 21-85 years. Their mean age was 49.9±16.3 years while the median was 54 years. Males outnumbered females by a ratio of 5.5:1. Majority (56.5%) of the patients were farmers and artisans. Duration of symptoms was 6 hours to 9 days (mean 2.7±1.9 days). Non-steroidal anti-inflammatory drugs use, herbal concoction, alcohol and smoking was found in 54.3%, 52.2%, 30.4% and 21.7% respectively. More duodenal perforations (63.0%) were recorded. Graham's patch closure was done for 27 (58.7%) while the remaining (41.3%) had primary closure with omentoplasty. Sixteen (34.8%) had postoperative complications with wound infection predominating. Overall postoperative mortality was 17.4%. Age ≥ 60 years (p=0.04), premorbid illness (p=0.01), delayed presentation ≥ 48 hours (p=0.01), shock (p=0.01) and intraperitoneal effluent ≥ 2000ml (p=0.03) were associated with mortalities.

CONCLUSION

Perforated PUD accounts for high morbidities and mortalities in our setting. Abuse of NSAIDs and herbal concoction ranked highest among the risk factors. Efforts at curtailing indiscriminate sales of NSAIDs and herbal concoction will reduce the menace.

Anti-ulcerogenic effect of methanolic extract of Elaeagnus conferta Roxb. seeds in Wistar rats

ETHNOPHARMACOLOGICAL RELEVANCE

Elaeagnus conferta Roxb. (Elaeagnaceae) is a subtropical shrub mainly native to India, Vietnam, Malaysia and South China, whose various parts are used for treatment of diabetes, gastric ulcers, pain, oxidative stress and pulmonary disorders. Though the other parts of the plant have been reported for their ethnic use i.e. fruits as astringent locally and for cancer systemically, leaves for body pain and flowers for pain in chest and the seeds are mentioned as edible, there is no report per se on the medicinal use of seeds. Based on the fact that seeds of closely resembling species i.e. Elaeagnus rhamnoides has demonstrated significant anti-gastroulcerative property, the probability of the seeds of E. conferta possessing similar activity seemed quite significant.

AIM OF THE STUDY

Phytochemical investigation and assessment of pharmacological mechanism(s) involved in anti-ulcer effect of methanolic extract of the seeds of E. conferta.

MATERIALS AND METHODS

Bioactive phytoconstituents were isolated by column chromatography. These were identified by spectroscopic techniques including infrared (IR) spectroscopy, nuclear magnetic resonance (NMR) and mass spectrometry. Methanolic extract (MEC) of the seeds was prepared by cold maceration and its anti-ulcerogenic potential was evaluated using indomethacin (50 mg/kg) and water immersion stress models in male rats. The animals were pre-treated with different doses of MEC (400 and 800 mg/kg) and the therapeutic effect was compared with standard drug i.e. ranitidine (RANT; 50 mg/kg). The ameliorative effects of MEC were investigated on gastric juice pH, total acidity, free acidity and ulcer index. The assays of malionaldehyde (MDA), catalase (CAT), superoxide dismutase (SOD), glutathione (GSH) and pro-inflammatory cytokines i.e. interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-α) were carried out to find out the possible mechanism(s) of protection. Further, histopathological changes were also studied.

RESULTS

Chromatography studies and further confirmation by spectroscopic techniques revealed the presence of four different compounds in MEC i.e oleic acid (1), stearic acid (2), ascorbic acid (3) and quercetin (4). MEC exhibited anti-ulcerogenic effect in dose dependent manner which may be attributed to suppression of pro-inflammatory cytokines (IL-6, TNF-α) and MDA (112.7%), and up-regulation of protective factors such as CAT (90.48%), SOD (92.77%) and GSH (90.01%). Ulcer inhibition, reduction in total and free acidity and increase in gastric juice pH were observed in MEC treated rats as compared to disease control animals. Histopathological findings confirmed decreased cell infiltration, less epithelial cell damage and regeneration of gastric mucosa in dose dependent manner.

CONCLUSIONS

The anti-ulcer effect of MEC may be attributed to its ability to scavenge free radicals and anti-inflammatory property via suppression of TNF-α and IL-6, thus offers a complete and holistic approach for management of peptic ulcer.

The Burden of Duodenal Ulcers Among Dyspeptic Patients

INTRODUCTION

Dyspepsia is a common presenting complaint of various upper gastrointestinal disorders. Duodenal ulcer is one of the rare endoscopic findings in patients with dyspepsia, but it can present with upper gastrointestinal bleed. The aim of this study was to determine the frequency of duodenal ulcers among dyspeptic patients undergoing esophagogastroduodenoscopy (EGD).

SUBJECT AND METHODS

All patients who fulfilled the inclusion criteria were recruited during the period of six months, i.e., from July to December 2020 in the Department of Gastroenterology, Liaquat National Hospital and Medical College, Karachi. After obtaining informed and written consent, history, and clinical examination, the EGD was performed to assess the outcome, i.e., frequency of duodenal ulcers.

RESULTS

A total of 156 patients with dyspepsia were included. Eighty-seven (55.8%) were male and 69 (44.2%) were female with the mean age of 36.96+11.71 years. The most common symptom at presentation was epigastric burning seen in 76 patients (48.7%) followed by postprandial fullness in 59 patients (37%). Duodenal ulcers were noted in 18 patients (11.5%) and were significantly associated with alcohol intake, smoking, epigastric pain, postprandial fullness with p-values of 0.001, 0.001, 0.001, and 0.013, respectively.

CONCLUSION

Duodenal ulcer is an uncommon endoscopic finding in patients with dyspepsia; it is seen in younger age, smokers, alcohol use, and patients presenting with epigastric pain and postprandial fullness.

Interplay of Biochemical, Genetic, and Immunohistochemical Factors in the Etio-Pathogenesis of Gastric Ulcer in Rats: A Comparative Study of the Effect of Pomegranate Loaded Nanoparticles Versus Pomegranate Peel Extract

Background

Few data are available about the role of herbal extract loaded nanoparticles as an alternative safe medicine for the management of a gastric ulcer.

Aim

This work is targeted at exploring the physiological effects of pomegranate loaded nanoparticles (PLN) against an indomethacin IND-induced gastric ulcer and comparing the results with traditional pomegranate peel extract (PPE).

Methods

Twenty-four rats were equally distributed into four groups: control, IND-treated, PLN-treated, and PPE-treated groups. Gross examination of gastric mucosa, and the calculation of ulcer and inhibition indices were done. Serum malondialdehyde (MDA), total antioxidant capacity (TAC), interleukin 2 (IL-2), IL-6, IL-10, gastric homogenate prostaglandin E₂ (PGE₂), and nitric oxide (NO) were estimated. Mucosal endothelial nitric oxide synthase (eNOS mRNA) expression was identified by qPCR. Histological and immuno-histochemical staining of Tumor necrosis factor-α (TNF-α) and eNOS of stomach mucosa were performed.

Results

In comparison with the control group, IND-treated rats showed visible multiple ulcers with ulcer index, serum MDA, IL-2 and IL-6 were elevated while IL-10, PGE₂, NO, and eNOS mRNA expression were significantly reduced. Damaged surface epithelium with disrupted glandular architecture and heavy leucocyte infiltration of lamina propria was noticed. Immunohistochemical staining of stomach mucosa revealed marked increased TNF-α and reduced eNOS. Oral administration of PLN and PPE succeeded in improving the gross mucosal picture, and all biochemical, histological, and immunohistochemical alterations.

Conclusion

Both PLN and PPE potently alleviated IND-induced gastric ulceration via increasing TAC, PGE₂, NO, eNOS mRNA, and protein expression. However, the healing effect of PLN was obviously greater than PPE-treated rats.

Acupuncture at Back-Shu and Front-Mu Acupoints Prevents Gastric Ulcer by Regulating the TLR4/MyD88/NF-κB Signaling Pathway

Purpose

To assess the preventive effects of acupuncture at back-shu and front-mu acupoints on rats with restraint water-immersion stress (RWIS)-induced gastric ulcer.

Methods

Thirty-six rats were randomly divided into four groups for 10 days of treatment as follows: the normal group received no treatment; the model group received RWIS-induced gastric ulcer; the omeprazole group was administered omeprazole orally every 2 days; and the electroacupuncture group received electroacupuncture at the RN12 and BL21 acupoints every 2 days. After 10 days of treatment, except for the normal group, all rats were induced with gastric ulcer by RWIS for 3 h. The ulcer index (UI), ulcer inhibition rate, and histopathological score were calculated. We determined the levels of tumor necrosis factor (TNF)-α and interleukin (IL)-6 in serum, and the activities of myeloperoxidase (MPO), malondialdehyde (MDA), superoxide dismutase (SOD), nitric oxide (NO), and glutathione peroxidase (GSH-Px) in serum and gastric tissues. Protein expression of MyD88, nuclear factor (NF)-κB (p65), and toll-like receptor (TLR) 4 was quantified in gastric tissues.

Results

The electroacupuncture and omeprazole groups were equivalent in terms of UI, ulcer inhibition rate, and histopathological score. The serum levels of TNF-α and IL-6 were significantly lower in the electroacupuncture group compared with the omeprazole group (P < 0.05). Compared with the model group, there were significant changes in the levels of NO, MPO, GSH-Px, and MDA in all other groups, while the expression of TLR4, MyD88, and NF-κB p65 in gastric tissue decreased significantly in the electroacupuncture group. The expression of TLR4 was substantially lower in the electroacupuncture group compared with the omeprazole group.

Conclusion

Acupuncture at back-shu and front-mu acupoints played a role in preventing gastric ulcer by inhibiting extracellular signals, stimulating kinases in serum and gastric tissues, and activating the inhibition of the TLR4 signaling pathway.

Surgical management of hiatal hernia vs medical therapy to treat bleeding Cameron lesions: a systematic review and meta-analysis

INTRODUCTION

Cameron lesions (CL) are an under-recognized cause of gastrointestinal bleeding. Diagnosis is often impaired by technical difficulty, and once diagnosed, management remains unclear. Typically, patients are medically managed with proton pump inhibitors (PPI). Small studies have demonstrated improved therapeutic success with surgical management, hypothesizing that reversing mechanical gastric trauma and ischemia allows CL healing. This systematic review and meta-analysis aim to compare therapeutic success of surgical versus medical management of Cameron lesions (CL).

METHODS AND PROCEDURES

A comprehensive search and systematic review selected manuscripts using the following inclusion criteria: (1) Endoscopically diagnosed CL (2) Treated surgically (3) Follow-up for resolution of anemia or CL (4) n ≥ 5 (5) Excluding non-English, animal, and studies with patients < 18 years old Meta-analysis was performed to compare resolution of CLs with medical and surgical therapy.

RESULTS

Systematic search retrieved 1664 studies, of these, 14 were included (randomized controlled trial = 1; prospective = 2; retrospective = 11). Patients had a mean age of 61.2 years (range 24-91) and were more often female (59.3%). Follow-up was between 3 and 120 months, and 82.9% of patients had hernias > 5 cm. Surgical management was associated with therapeutic success (OR 5.20, 1.83-14.77, I² = 42%, p < 0.001) with 92% having resolution, compared to 67.2% for those treated with PPI. Surgical complications occurred in 42/109 (38.5%) of patients (48.1% for Open Hill Repair, 15.4% for laparoscopic fundoplication). 40.0% of patients underwent a laparoscopic Nissen or Collis fundoplication, 21.7% underwent open modified Hill repair, and 38.3% had unspecified operations. Hemoglobin improved from 8.85 g/dL pre-operatively to 13.60 g/dL post-operatively. In six studies, surgical patients previously failed medical management.

CONCLUSIONS

This is the first systematic review comparing surgical and medical treatment of CL. Surgical management significantly improved therapeutic success. Our study supports therapeutic benefit of surgery in these patients.

Clinical comparative analysis of various duodenal diseases in different age groups

BACKGROUND/AIMS

This study aimed to investigate the differences and relevance of various common duodenal diseases in different parts in the aspects of age, gender, helicobacter pylori (H. pylori) infection, application of nonsteroidal anti-inflammatory drugs (NSAIDs), smoking, or alcohol consumption.

MATERIALS AND METHODS

The medical records of various duodenal diseases were collected and tested for difference using the χ2 test or the Fisher exact probability method.

RESULTS

1) The proportions of duodenal ulcer (DU), inflammation, and duodenal bulb diseases in the adult group (A) (47.98%, 36.70%, and 66.63%) were higher than those in the elderly group (E) (41.38%, 29.83%, and 56.82%), but the proportions of duodenal diverticulum (DD) and tumor diseases in the descending and ascending segments (2.95%, 1.43%, 9.14%, and 0.14%) were lower than those in group E (13.73%, 3.69%, 19.41%, and 0.76%) (p<0.001). 2) The positive rate of H. pylori (63.64%) in the duodenal bulb diseases was higher than that in the bulb-descending segment (53.75%), but the application rate of NSAIDs (16.44%) in the duodenal bulb-descending diseases was lower than that in the descending segment (24.81%) (p<0.001).

CONCLUSION

1) DU, inflammation, and duodenal bulb diseases are common in adults, but DD and tumor diseases in the descending and ascending segments are more common in the elderly. 2) Compared with the duodenal bulb-descending diseases, the application of NSAIDs has greater impact on the diseases in the descending segment, and the rate of H. pylori infection is higher in duodenal bulb diseases.

A Comprehensive Review on the Screening Models for the Pharmacological Assessment of Antiulcer Drugs

BACKGROUND

Due to inappropriate diet, smoking, alcohol consumption, regular use of drugs like NSAIDs and sedentary lifestyle, one may feel upper abdominal pain which may be the predictor of the gastrointestinal disorder called Peptic Ulcer. When an imbalance occurs between the defensive factor and aggressive factor of the stomach, ulcer formation in the esophageal lining, stomach, or duodenum takes place. This leads to the formation of small sores that cause pain. Another condition that synergizes the abdominal pain is vomiting materials which look like coffee grounds, blood in the stool, black or tarry stools. This pain may increase after lunch or dinner. This problem persists, that often leads to the gastroenterologist's consultation.

OBJECTIVE

There are many antiulcer screening models present for the determination of antiulcer activity of the drug molecule. The main objective of this study is to find which model is best for the determination of antiulcer activity.

METHODS

A literature search was conducted on the databases namely Science direct and PubMed with the help of different keywords such as "Anti-ulcer", "In-vitro models" and "In-vivo models". The search was customized by applying the appropriate filters so as to get the most relevant articles to meet the objective of this review article.

RESULT

There are different research and review papers based on the antiulcer screening models for the determination of antiulcer activity of new drug molecules.

CONCLUSION

On the basis of our study, we found some useful models for the antiulcer activity of drugs and suggested that, if we use in-vitro and in-vivo methods together, then we may obtain the most relevant result in our research area.

Effects of Paeonol and Gastroretention Tablets of Paeonol on Experimental Gastric Ulcers and Intestinal Flora in Rats

Paeonol, a major ingredient isolated from Moutan Cort, has various pharmacological effects. Our previous studies have shown that paeonol can exert antioxidant and anti-inflammatory therapeutic effects on ethanol-induced experimental gastric ulcer (GU). Therefore, in this study, we designed two GU models in rats induced by pyloric ligation (PL) and acetic acid and evaluated the protective effects of paeonol and gastroretention tablets of paeonol (GRT-Ps; 24, 48, and 96 mg/kg) on GU in rats and the effect of paeonol (48 mg/kg) on the intestinal flora. In vivo experiments showed that paeonol or GRT-Ps remarkably reduced gastric mucosal damage in a dose-dependent manner in the different types of models and improved the superoxide dismutase (SOD) activity and the malondialdehyde (MDA) content. And in fact, the sustained-release effect of GRT-Ps is more conducive to the improvement of GU compared with the rapid clearance of free drugs. In the PL-induced model, gastric secretion parameters, that is, pH and total acid, showed significant differences compared with the model group. In addition, paeonol treatment can improve the richness and diversity of the intestinal flora and increase the amount of beneficial bacteria, such as Lactobacillus. Paeonol and its stable sustained-release tablet GRT-Ps can promote ulcer healing by inhibiting oxidative stress and regulating the intestinal flora. This study can provide basis for the clinical treatment of GU with paeonol. Graphical Abstract.

Infiltrating the Curriculum: Integrating Medical History with Existing Surgical Pathology Tutorials

This article was migrated. The article was marked as recommended. Objective: To assess medical students' perspective on medical history embedded into a pre-existing learning module. Design, Setting, and Participants: This study was performed in 2018 at the University of Tasmania; participants were medical students in year three of the Bachelor of Medicine Bachelor of Surgery course. This was a cross-sectional study which used a mixed-method survey before and after a lecture series to assess medical students' perspectives on history of medicine. Intervention: Historical perspectives were incorporated into existing surgical pathology tutorials. Main outcome measures: Students completed a survey on medical history before and after the lecture series. The survey used both qualitative and quantitative measures to assess students' perception of the utility of medical history and how it was taught in this project. Results: In the initialquestionnaire, students indicated they believed medical history would help make them better doctors and enhance their learning of pathology. In the final questionnaire, students agreed that learning medical history was important in becoming a doctor. Students enjoyed the content and found the integration of history and pathology beneficial to learning. Conclusion: This study demonstrates one method by which to increase medial history teaching without major alterations to an existing medical curriculum.

The prospective curative role of lipoxin A4 in induced gastric ulcer in rats: Possible involvement of mitochondrial dynamics signaling pathway

This study purposed to examine the prospective curative role of lipoxin A₄ (LXA₄ ) in induced gastric ulcer in rats and explore the possible involvement of mitochondrial dynamics signaling pathway. Forty-eight male Wistar rats were divided into four groups: control, indomethacin (IND), IND + omeprazole (IND + Omez), and IND+ LXA₄ groups. At the end of the experiment, the gastric pH, gastric fluid volume, total gastric acidity, ulcer index, and curative index were estimated. The gene expression of mitochondrial related protein 1 and mitofusin 2 were determined. In addition, some mitochondrial parameters include mitochondrial transmembrane potential, complex-I activity and reactive oxygen species were measured. Also, some gastric biochemical parameters, histopathological, and immunohistochemical analyses of the gastric mucosa were determined. We found that IND induced gastric ulcer, as manifested by the biochemical, histopathological, and immunohistochemical analyses. Both Omez and LXA₄ treatment for 15 days alleviated the IND-induced gastric ulcer as explored by ameliorating the biochemical, histopathological, and immunohistochemical findings. We concluded that LXA₄ mitigated the IND-induced gastric ulcer via improving the mitochondrial dynamic imbalance and mitochondrial dysfunction, in addition to its anti-apoptotic, anti-inflammatory, and antioxidant properties.

Successful closure of chronic recurrent Enterocutaneous fistula with a concurrent over-the-scope closure and a stent placement

Gastrointestinal ulcers and perforations can occur as a complication of nonsteroidal anti-inflammatory drugs (NSAID). Emerging endoscopic technologies can be utilized to successfully intervene perforations that fail surgical intervention. We report a case of perforated duodenal ulcer that failed surgical intervention and, however, was successfully closed with over-the-scope clip (OTSC) closure with concomitant placement of fully covered stent.

Potent therapeutic effects of ruscogenin on gastric ulcer established by acetic acid

BACKGROUND/OBJECTIVE

The present study investigated the potent therapeutic effects of Ruscogenin, main steroid sapogenin of traditional Chinese plant called 'Ophiopogon japonicas', on chronic ulcer model established with acetic acid in rats.

METHODS

24 rats were attenuated to the sham (2 ml/kg/day isotonic solution), control (untreated ulcer) and treatment (3 ml/kg/day ruscogenin) groups. After treatment for 2 weeks, gastric tissues were collected and prepared for light microscopic (H&E), immunohistochemical (Collagen I, III and IV) and biochemical analysis [Epidermal growth factor (EGF), Prostaglandin E2 (PGE2), Tumor Necrosis Factor alpha (TNF-α), Interleukin 6 and 8 (IL-6 and IL-8), Lipid Peroxidase (LPO), Myeloperoxidase (MPO), Glutathione (GSH) and Glutathione Peroxidase (GSH-Px)] and transmission electron microscopy (TEM).

RESULTS

Macroscopic scoring showed that the ulceration area of ruscogenin-treated group decreased compared with control group. Immunohistochemical analysis revealed ruscogenin ameliorated and restored the levels of Collagen I and IV to the levels of sham group. Tissue levels of EGF and PGE2 enhanced significantly in untreated ulcer group while were higher in treated ulcer group than the control group. TNF-α, IL-6, IL-8, LPO, MPO levels increased significantly in control group whereas decreased in treated rats after ruscogenin treatment. However, levels of GSH and GSH-Px increased significantly in treatment group. TEM showed chief cells and parietal cells of ulcer group having degenerated organelles while ruscogenin group had normal ultrastructure of cells.

CONCLUSION

There are potent anti-inflammatory and anti-oxidant effects of ruscogenin on gastric ulcer and may be successfully used as a safe and therapeutic agent in treatment of peptic ulcer.

Novel chitosan oligosaccharide-based nanoparticles for gastric mucosal administration of the phytochemical "apocynin"

Background: Apocynin (APO) is a bioactive phytochemical with prominent anti-inflammatory and anti-oxidant activities. Designing a nano-delivery system targeted to potentiate the gastric antiulcerogenic activity of APO has not been investigated yet. Chitosan oligosaccharide (COS) is a low molecular weight chitosan and its oral nanoparticulate system for potentiating the antiulcerogenic activity of the loaded APO has been described here. Methods: COS-nanoparticles (NPs) loaded with APO (using tripolyphosphate [TPP] as a cross-linker) were prepared by ionic gelation method and fully characterized. The chosen formula was extensively evaluated regarding in vitro release profile, kinetic analysis, and stability at refrigerated and room temperatures. Ultimately, the in vivo antiulcerogenic activity against ketoprofen (KP)-induced gastric ulceration in rats was assessed by macroscopic parameters including Paul's index and antiulcerogenic activity, histopathological examination, immunohistochemical (IHC) evaluation of cyclooxygenase-2 (COX-2) expression level in ulcerated gastric tissue, and biochemical measurement of oxidative stress markers and nitric oxide (NO) levels. Results: The selected NPs formula with COS (0.5 % w/v) and TPP (0.1% w/v) was the most appropriate one with drug entrapment efficiency percentage of 35.06%, particle size of 436.20 nm, zeta potential of +38.20 mV, and mucoadhesive strength of 51.22%. It exhibited a biphasic in vitro release pattern as well as high stability at refrigerated temperature for a 6-month storage period. APO-loaded COS-NPs provoked marvelous antiulcerogenic activity against KP-induced gastric ulceration in rats compared with free APO treated group, which was emphasized by histopathological, IHC, and biochemical studies. Conclusion: In conclusion, APO-loaded COS-NPs could be considered as a promising oral phytopharmaceutical nanoparticulate system for management of gastric ulceration.

Evaluation of Gastro-protective Activity of Myristica fragrans on Ethanol-induced Ulcer in Albino Rats

Myristica fragrans seeds are traditionally used to treat dyspepsia, vomiting and abdominal pain. The purpose of this study was to investigate the protective effect of Myristica fragrans in ethanol induced gastric ulcer. Study was carried out on rats, divided into four groups; negative control, positive control, standard drug control, and Myristica fragrans extract treated rats. The pH, ulcer index, acidity values and histopathological examination of stomach were evaluated. Myristica fragrans significantly (P<0.05) reduced gastric lesions by 41.68% in ethanol induced ulcer model at 200 mg/kg when compared to sucralfate (60.41%). However, histopathological findings appeared similar in Myristica fragrans extract treated and standard drug control groups, where stomachs were found with mild erosion of superficial epithelium and few infiltrated inflammatory cells. pH of gastric contents of rats from extract treated was increased (4.25 ± 0.25) as compared to positive control group (2.25 ± 0.25). Ulcer index of extract treated rats was improved (41.74%). Moreover, total acidity of extract treated group (60.0 ± 0.47) was decreased as compared to control group (74.50 ± 1.04). It is concluded that Myristica fragrans showed significant protecting activity in ethanol induced ulcer. Isolation and purification of phytochemicals responsible for gastroprotective activity becomes necessary.

Assessment of PULP score in predicting 30-day perforated duodenal ulcer morbidity, and comparison of its performance with Boey and ASA, a retrospective study

Background

/aim: Scores commonly employed to risk stratify perforated peptic ulcer patients include ASA (American Society of Anesthesiologists), Boey and peptic ulcer perforation score (PULP). However, few studies assessed and compared the accuracy indices of these three scores in predicting post PPU repair 30-day morbidity. We assessed accuracy indices of PULP, and compared them to Boey and ASA in predicting post perforated duodenal (PDU) ulcer repair 30-day morbidity.

Methods

Retrospective chart review of all PDU patients (perforated duodenal ulcers only) at the largest two hospitals in Qatar (N = 152). Data included demographic, clinical, laboratory, operative, and post repair 30-day morbidity. Area under the Curve (AUC), sensitivity and specificity were computed for each of the 3 scores. Multivariate logistic regression assessed the accuracy indices of each score.

Results

All patients were males (M age 37.41 years). Post PDU repair 30-day morbidity was 10.5% (16 morbidities). Older age, higher ASA (≥3), Boey (≥1) or PULP (≥8) scores, shock on admission and preoperative comorbidities; and conversely, lower hemoglobin and albumin were all positively significantly associated with higher post PDU 30-day morbidity. PULP displayed the largest AUC (72%), and was the only score to significantly predict 30-day morbidity. The current study is the first to report the sensitivity and specificity of these three scores for post PDU repair 30-day morbidity; and first to assess accuracy indices for PULP in predicting post PDU repair 30-day morbidity.

Conclusion

PULP score had the largest AUC and was the only score to significantly predict post PDU repair 30-day morbidity.

•

The current study is the first to report the sensitivity and specificity of the three scoring systems (ASA, Boey and PULP) for post perforated duodenal ulcer repair 30-day morbidity.

•

It is also the first study to assess accuracy indices for PULP in predicting post perforated duodenal ulcer repair 30-day morbidity.

•

Compared with ASA and Boey, PULP score had the largest area under the curve and was the only score to significantly predict post perforated duodenal ulcer repair 30-day morbidity.

Intestinal Obstruction due to Bezoar in Elderly Patients: Risk Factors and Treatment Results

Purpose

Bezoars are foreign particles from the accumulation of indigestible materials in the gastrointestinal system and a rare cause of mechanical intestinal obstruction. We aimed at investigating differences in risk factors for the development of intestinal obstruction associated with bezoar in elderly patients.

Methods

Hospital records of patients who underwent surgery associated with phytobezoar between January 2004 and May 2016 were retrospectively evaluated. Patients were divided into two groups [<65 years (Group 1) and ≥65 years (Group 2)]. Data were examined regarding presence of comorbidity, history of abdominal surgery, operation time, bezoar site, surgical technique, length of hospitalization, morbidity, and mortality.

Results

Of 121 patients enrolled, 48 (39.7%) were male and 73 (60.3%) were female (range: 24-86 years). Group 1 consisted of 69 patients aged < 65, while Group 2 consisted of 52 patients aged ≥ 65. Comorbidity was reported in 52 (42.9%) patients (mostly diabetes mellitus, 20.7%), while 60 patients (49.6%) had history of abdominal surgery (mostly peptic ulcer, 27.3%). No statistical differences were found between the two groups in terms of sex, bezoar site, surgical technique preferred, history of abdominal surgical intervention, pre- and postoperative CT examination, morbidity rates, and length of hospitalization. But, ratio of peptic ulcer operations history, presence of total comorbidity, and time of surgery decision was higher in Group 2 patients.

Conclusion

In bezoar-related intestinal obstruction, duration and outcome of treatment are not affected by age distribution. Possibility of bezoar should primarily be considered in elderly patients with history of peptic ulcer operation.

Mechanisms underlying gastroprotective effect of paeonol against indomethacin-induced ulcer in rats

Paeonol, a natural phenolic compound, possesses diverse beneficial effects including antioxidant and anti-inflammatory effects. Gastric ulcer is still the most prevalent irritant illness among the gastrointestinal diseases. The present study explored the protective effect of paeonol at two dose levels in indomethacin (IND)-induced gastric ulcer in rats. Forty-eight male Wistar rats were arranged into six groups: control, paeonol-treated, IND-treated, IND/paeonol (low and high doses)-treated, and ranitidine-treated groups. The oxidative status was evaluated by determining malondialdehyde level, superoxide dismutase activity, reduced glutathione content as well as hemoxygenase-1 (HO-1) gene expressions, and the antioxidant protein; NAD(P)H quinone oxidoreductase 1 (NQO1) immunostaining. The pro-inflammatory genes nuclear factor κB (NF-κB) and interleukin 1β (IL-1β) were estimated together with the proapoptotic gene of caspase 3. IND caused multiple gastric ulcers with evident oxidative damage and elevated pro-inflammatory and proapoptotic markers. Paeonol protected significantly, in a dose-dependent manner, the gastric mucosa from ulcerative lesion of IND similar to the reference drug ranitidine. Paeonol pretreatment diminished gastric oxidative stress and restored the gastric antioxidant capacity by elevating gastric gene expression of HO-1 and protein expression of NQO1. Paeonol also reduced NF-κB, IL-1β, and caspase 3 gene expressions. In conclusion, paeonol offered a gastroprotection dependent on its antioxidant, anti-inflammatory, and antiapoptotic effects.

Fruit-Derived Polysaccharides and Terpenoids: Recent Update on the Gastroprotective Effects and Mechanisms

Ulceration in the stomach develops in peptic ulcer disease when there is a loss of protective mucosal layers, particularly in Helicobacter pylori infection. Antibiotic therapy has failed to eradicate and impede the colonization of H. pylori. Despite given treatment, recurrent bleeding can occur and lead to death in the affected individual. The disease progression is also related to the non-steroidal inflammatory drug and stress. There are extensive research efforts to identify the gastroprotective property from various alkaloids, flavonoids, and tannins compounds from plants and marine. These natural products are believed to be safe for consumption. However, not much attention was given to summarize the carbohydrate and terpenoidal anti-ulcer compounds. Hence, this review will cover the possible mechanisms and information about acidic hydroxylans, arabinogalactan and rhamnogalacturon; and limonene, pinene, lupeol, citral, ursolic acid and nomilin to exemplify on the gastroprotective properties of polysaccharides and terpenoid, respectively, obtained from fruits. These compounds could act as a prebiotic to prevent the inhabitation of H. pylori, modulate the inflammation, suppress gastric cancer growth, and capable of stimulating the reparative mechanisms on the affected regions. Finally, this review provides the future research prospects of these natural compounds in an effort to develop new therapy for gastrointestinal tissue healing.

A 3-year prospective study of the incidence of gastric ulcers in pigs slaughtered at Base Abattoir in Rwanda

AIM

Determination of the incidence of gastric ulcers in pigs slaughtered at Base Abattoir in Rwanda.

MATERIALS AND METHODS

Stomachs from all 5040 pigs that were slaughtered at Base Abattoir in Rwanda from August 2012 to August 2015 were examined for the presence and location of gastric ulcers. The results of the inspections were recorded and analyzed. Statistical analysis for Chi-square values was performed using the Software Package for Social Sciences version 16.0. The Z test for comparison of proportions was used and p<0.05 was considered significant.

RESULTS

Overall as well as per district, significantly more male pigs than female pigs were slaughtered (p<0.05). The incidence of gastric ulcers in slaughter pigs was 12.86%. The incidence of gastric ulcers in males (13.36%) was not significantly different (p>0.05) from that in female pigs (12.84%) in all three districts. A significantly greater proportion of these ulcers (69.03%) was located in the esophageal region than in the glandular region of the stomach (30.97%) in slaughtered males (p<0.05). A significantly greater proportion of these ulcers (79.59%) was located in the esophageal region than in the glandular region of the stomach (20.41%) in slaughtered females (p<0.05). The overall incidence of esophageal ulcers (9.44%) in the slaughtered pigs was significantly (p<0.05) higher than that of glandular region ulcers (3.41%). Pigs with carcass weight over 60 kg showed a significantly (p<0.05) higher (44.44%) incidence of ulcers than those between 40 and 60 kg (33.33%) and those below 40 kg (22.22%).

CONCLUSIONS

It was concluded that the incidence of gastric ulceration in slaughter pigs at Base Abattoir was not associated with source (district) or sex of pigs but was associated with the carcass weight.

Human Gut Microbiota: Toward an Ecology of Disease

Composed of trillions of individual microbes, the human gut microbiota has adapted to the uniquely diverse environments found in the human intestine. Quickly responding to the variances in the ingested food, the microbiota interacts with the host via reciprocal biochemical signaling to coordinate the exchange of nutrients and proper immune function. Host and microbiota function as a unit which guards its balance against invasion by potential pathogens and which undergoes natural selection. Disturbance of the microbiota composition, or dysbiosis, is often associated with human disease, indicating that, while there seems to be no unique optimal composition of the gut microbiota, a balanced community is crucial for human health. Emerging knowledge of the ecology of the microbiota-host synergy will have an impact on how we implement antibiotic treatment in therapeutics and prophylaxis and how we will consider alternative strategies of global remodeling of the microbiota such as fecal transplants. Here we examine the microbiota-human host relationship from the perspective of the microbial community dynamics.

Low serum albumin may predict the need for gastric resection in patients with perforated peptic ulcer

PURPOSE

Perforated peptic ulcer (PPU) is a common surgical emergency and treatment involves omental patch repair (PR). Gastric resection (GR) is reserved for difficult pathologies. We audit the outcomes of GR at our institution and evaluate the pre-operative factors predicting the need for GR.

METHODS

This is a single-institution, retrospective study of patients with PPU who underwent surgery from 2004 to 2012. Demographics, clinical presentation and intra-operative findings were studied to identify factors predicting the need for GR in PPU. An audit of clinical outcomes and mortality for all patients with GR is reported.

RESULTS

537 (89.6 %) patients underwent PR and 62 (10.4 %) patients GR. Old age (p < 0.0001), female sex (p = 0.0123), non-steroidal anti-inflammatory drugs (NSAIDs) usage (p = 0.0008), previous history of peptic ulcer disease (PUD) (p = 0.0159), low hemoglobin (p < 0.0001), low serum albumin (p < 0.0001), high serum creatinine (p = 0.0030), high urea (p = 0.0006) and large ulcer size (p < 0.0001) predict the need for GR. On multivariate analysis only low serum albumin (OR 5.57, 95 % CI 1.56-19.84, p = 0.008) predicted the need for GR. The presence of Helicobacter pylori infection was protective against GR (OR 0.25, 95 %CI 0.14-0.44, p < 0.0001). Morbidity and mortality of GR was 27.7 and 24.2 %, respectively.

CONCLUSION

GR is needed in one in ten cases of PPU. Low serum albumin predicted the need for GR on multivariate analysis. Morbidity and mortality of GR remains high.

Gastroduodenal Ulceration in Small Animals: Part 1. Pathophysiology and Epidemiology

Gastroduodenal ulceration in small animals is a complex and important comorbidity that occurs when the physiological homeostasis of the gastrointestinal tract is disrupted secondary to administration of medications or the presence of local or systemic diseases. The aim of this article is to provide a comprehensive review of the veterinary literature regarding the pathophysiology, epidemiology, and risk factors associated with gastroduodenal ulceration in small animals. Pertinent concepts from the human literature will be integrated into the discussion. This article serves as an introduction to the second part of this series, which will review current evidence regarding the use of H2-receptor antagonists and proton pump inhibitors in small animals.

Association of Dementia and Peptic Ulcer Disease: A Nationwide Population-Based Study

OBJECTIVE

We determine the association between dementia and the subsequent peptic ulcer disease (PUD).

METHODS

We identified patients with diagnosed dementia in the Taiwan National Health Insurance Research Database. A comparison cohort without dementia was frequency-matched by age, sex, and comorbidities, and the occurrence of PUD was evaluated in both cohorts.

RESULTS

The dementia and control cohort consisted of 6014 patients with dementia and 17 830 frequency-matched patients without dementia, respectively. The incidence of PUD (hazard ratio, 1.27; 95% confidence interval, 1.18-1.37; P < .001) was higher among patients with dementia. Cox models showed that being female, diabetes mellitus, chronic kidney disease, coronary artery disease, and chronic obstructive pulmonary disease were independent risk factors for PUD in patients with dementia.

CONCLUSION

Dementia might increase the risk of developing PUD.

Outcome of nonsurgical intervention in patients with perforated peptic ulcers

BACKGROUND

Although surgical intervention is the favorable treatment modality for perforated peptic ulcer, nonsurgical treatment is another option. The aim of this study is to analyze the results of conservative treatment for perforated peptic ulcer.

METHODS

Between 2003 and 2014, 403 patients were admitted to our hospital for perforated peptic ulcer, and 383 patients underwent surgery, whereas 20 were allocated to conservative treatment. The results of nonsurgical intervention in these patients were analyzed retrospectively.

RESULTS

The overall mortality rate of conservative treatment was 40%. Eleven patients remained hospitalized less than 2 weeks; among them, patients with a high (≥IV) American Society of Anesthesiologists class at admission had higher mortality than those with a low (<IV) American Society of Anesthesiologists class (83.3% vs 0%, P=.015). However, when patients remained hospitalized longer than 2 weeks, the mortality rates did not differ between patients with the low and high American Society of Anesthesiologists classes. Eight patients presented with a high American Society of Anesthesiologists class, of which 3 received early enteral feeding, and all of them survived. In contrast, the survival of patients without early enteral feeding was 0%, suggesting that early enteral feeding improved survival of patients with the high American Society of Anesthesiologists class (P=.018).

CONCLUSIONS

A higher American Society of Anesthesiologists class correlated with mortality in patients undergoing conservative treatment during the first 2 weeks of hospitalization. Early enteral feeding might improve the outcome of conservative treatment in patients with high American Society of Anesthesiologists class.

Depression and the Risk of Peptic Ulcer Disease: A Nationwide Population-Based Study

The risk of peptic ulcer disease (PUD) among patients with depression has raised concern. This study determined the association between depression and the subsequent development of PUD using claims data.Patients newly diagnosed with depression in 2000 to 2010 were identified as depression cohort from the Taiwan National Health Insurance Research Database. The comparison cohort was randomly selected from subjects without depression, frequency matched by age and gender and diagnosis date, with a size 2-fold of the size of the depression cohort. The incidence of PUD was evaluated for both cohorts by the end of 2011. We calculated the hazard ratios (HRs) and 95% confidence intervals (CIs) of PUD using the Cox proportional hazards regression model.The depression cohort consisted of 23,536 subjects (129,751 person-years), and the comparison cohort consisted of 47,069 subjects (285,592 person-years). The incidence of PUD was 2-fold higher in the depression cohort than in the comparison cohort (33.2 vs 16.8 per 1000 person-years) with an age adjusted HR of 1.97 (95% CI = 1.89-2.06) or a multivariable adjusted HR of 1.35 (95% CI = 1.29-1.42).Depression might increase the risk of developing PUD. Prospective clinical studies of the relationship between depression and PUD are warranted.

Increased Subsequent Risk of Peptic Ulcer Diseases in Patients With Bipolar Disorders

Previous studies have reported that patients with bipolar disorders (BDs) exhibit increased physical comorbidity and psychological distress. Studies have shown that schizophrenia and anxiety increase the risk of peptic ulcer diseases (PUDs). Therefore, we conducted this study to determine the association between these 2 diseases and examine the possible risk factors. We used patients diagnosed with BDs from the Taiwan National Health Insurance Research Database. A comparison cohort comprising patients without BDs was frequency matched by age, sex, and comorbidities, and the occurrence of PUDs was evaluated in both the cohorts. The BD and non-BD cohort consisted of 21,060 patients with BDs and 84,240 frequency-matched patients without BDs, respectively. The incidence of PUDs (hazard ratio, 1.51; 95% confidence interval, 1.43-1.59; P < 0.001) was higher among the patients with BDs than the control patients. Cox models showed that irrespective of comorbidities, BDs were an independent risk factor for PUDs. Patients with BDs exhibit a substantially higher risk for developing PUDs. According to our data, we suggest that, following a diagnosis of BD, practitioners could notice the occurrence of PUD and associated prevention. Further prospective clinical studies investigating the relationship between BDs and PUDs are warranted.

Global validation of the WSES Sepsis Severity Score for patients with complicated intra-abdominal infections: a prospective multicentre study (WISS Study)

BACKGROUND

To validate a new practical Sepsis Severity Score for patients with complicated intra-abdominal infections (cIAIs) including the clinical conditions at the admission (severe sepsis/septic shock), the origin of the cIAIs, the delay in source control, the setting of acquisition and any risk factors such as age and immunosuppression.

METHODS

The WISS study (WSES cIAIs Score Study) is a multicenter observational study underwent in 132 medical institutions worldwide during a four-month study period (October 2014-February 2015). Four thousand five hundred thirty-three patients with a mean age of 51.2 years (range 18-99) were enrolled in the WISS study.

RESULTS

Univariate analysis has shown that all factors that were previously included in the WSES Sepsis Severity Score were highly statistically significant between those who died and those who survived (p < 0.0001). The multivariate logistic regression model was highly significant (p < 0.0001, R2 = 0.54) and showed that all these factors were independent in predicting mortality of sepsis. Receiver Operator Curve has shown that the WSES Severity Sepsis Score had an excellent prediction for mortality. A score above 5.5 was the best predictor of mortality having a sensitivity of 89.2 %, a specificity of 83.5 % and a positive likelihood ratio of 5.4.

CONCLUSIONS

WSES Sepsis Severity Score for patients with complicated Intra-abdominal infections can be used on global level. It has shown high sensitivity, specificity, and likelihood ratio that may help us in making clinical decisions.

Pharmacokinetic comparison study of a combination containing 500 mg of Naproxen and 20 mg of Esomeprazole: a randomized, single-dose, 2-way crossover, open-label study in healthy Korean men

PURPOSE

Nonsteroidal anti-inflammatory drugs have been used for analgesic, anti-inflammatory, and antithrombotic effects, but they carry a risk of major gastrointestinal damage. This risk can be greatly reduced by the coadministration of inhibitors of gastric acid secretion, such as proton pump inhibitors. This study was performed for the subsequent marketing of a combination drug that contained 500 mg of naproxen and 20 mg of esomeprazole in Korea. We evaluated the comparative bioavailability and tolerability of the test and reference formulations in healthy men.

METHODS

A total of 60 healthy men were enrolled in this single-dose, randomized, open-label, 2-period, 2-sequence, crossover study. During each period, men received a combination of 500 mg of naproxen and 20 mg of esomeprazole for test or reference, and between each period, there was a 1-week washout period. Blood samples were obtained 21 times throughout each period before dosing and 0.17, 0.33, 0.5, 0.75, 1, 1.5, 2, 2.5, 3, 3.5, 4, 4.5, 5, 6, 8, 10, 12, 24, 48, and 72 hours after oral administration. Plasma concentrations were determined using LC-MS/MS. The pharmacokinetic parameters, including Cmax, AUC0-t, AUC0-∞, and Tmax, were measured, and all treatment-emergent adverse events and their associations with the study medications were recorded throughout the entire study.

FINDINGS

A total of 59 men completed the study. No significant differences were found in the prevalence of AEs between the 2 formulations. In addition, there were no serious or unexpected AEs during the study. Both formulations had very similar Cmax, AUC, and t½ values, but the Tmax of naproxen appeared earlier in the test formulation than in the reference formulation and that of esomeprazole appeared later in the test formulation than in the reference formulation.

IMPLICATIONS

This study suggests that the test and reference formulations of a combination of 500 mg of naproxen and 20 mg of esomeprazole are bioequivalent in the extent of absorption and peak concentration. We anticipate that the test formulation will treat those who need relief from pain and inflammation and will decrease the risk of developing gastric ulcers. cris.nih.go.kr identifier: KCT0001117.

Helicobacter pylori and nonmalignant diseases

Peptic ulcer bleeding and recurrence rate are strongly linked to Helicobacter pylori infection even if nonsteroidal anti-inflammatory drugs (NSAIDs) play a relevant role in this setting. Further studies confirm that H. pylori eradication lowers the risk of recurrent peptic ulcer bleeding. Therefore, a test-and-treat strategy appears to be mandatory for patients with a history of ulcer bleeding and NSAIDs and/or aspirin use. Concerning gastroesophageal reflux disease (GERD), evidence clearly shows that H. pylori status has no effect on symptoms and treatment. Therefore, H. pylori treatment is not contraindicated in patients with GERD. The exact role of H. pylori in functional dyspepsia (FD) remains controversial. Novel possible mechanisms by which H. pylori may elicit dyspeptic symptoms include alterations of gastric motility, as well as endocrine and acid-secretory abnormalities. Hunger sensations, acid secretion, and gastrointestinal motility are regulated by ghrelin, particularly produced by the gastric enteroendocrine cell compartment. The improvement of symptoms correlates with enhanced plasma ghrelin levels. Apart from the need for more trials on this topic, these findings may give insight into the underlying pathophysiology of FD symptoms. Recent reports suggest that the presence of bacterial DNA in the oral cavity may be relevant to its transmission. A potential protective role of H. pylori on inflammatory bowel diseases needs to be better elucidated.

First Report of Preoperative Imaging Diagnosis of a Surgically Confirmed Case of Valentino's Syndrome

Perforation of a duodenal ulcer (DU) into the retroperitoneal space presenting with clinical features of acute appendicitis is known as Valentino's syndrome. Post duodenal perforation, the gastric and duodenal fluids tend to settle in the right paracolic gutter causing peritonitis and clinically mimicking acute appendicitis. Only three cases of Valentino's syndrome have been reported till date in the published literature and there is only one previous report of its preoperative imaging diagnosis. To our knowledge, this is the first reported case of preoperative imaging diagnosis in a surgically confirmed case of Valentino's syndrome. In most cases, patients with undiagnosed Valentino's syndrome are operated for acute appendicitis, and on finding a normal appendix, search is made for the cause of peritonitis, which then leads to retroperitoneal perforation of duodenum. The diagnosis of Valentino's syndrome by computed tomography (CT) imaging is easy and can help in avoiding the surgery or directing the surgeon directly to the repair of the duodenal perforation. It is, therefore, essential for emergency physicians, surgeons, and radiologists to know about this entity and consider it in the differential diagnosis.

Anti-ulcer activity of essential oil constituents

Essential oils have attracted considerable worldwide attention over the last few decades. These natural products have wide-ranging pharmacological activities and biotechnological applications. Faced with the need to find new anti-ulcer agents and the great effort on the development of drugs for the treatment of ulcers, in this review, the anti-ulcer activities of 21 bioactive compounds found in essential oils are discussed.