[CLINICAL, ENDOSCOPIC AND MORPHOLOGICAL FEATURES OF GASTROESOPHAGEAL REFLUX DISEASE IN PATIENTS WITH CERTAIN SURGICAL DISEASES OF THE UPPER GASTROINTESTINAL TRACT]

OBJECTIVE

To reveal the peculiarities of manifestations and treatment of gastroesophageal reflux disease (GERD) in patients with peptic ulcer disease of the stomach and duodenum, hiatal hernia (HH) and after stomach resection.

MATERIALS AND METHODS

387 patients with GERD, peptic ulcer disease of the stomach and duodenum (200 patients), after resection of the stomach Billroth II (150 patients), 37 patients with HH. Videoendoscopic equipment company OLYMPUS (Japan) was used. Biopsies of the mucous membranes of the pylorus, body, angle of the stomach and esophagus were studied to identify preneoplastic changes. HP was determined histologically, cytologically, urease tests.

RESULTS

The patients with GERD and peptic ulcer disease of the stomach and duodenum were complained on the heartburn, the patients after resection of the stomach--on feeling bitterness in the mouth, with HH--on the pain behind the breastbone. More severe degree of GERD (C and D) was endoscopic feature in patients with HH and A degree or endoscopic negative form--after resection of the stomach. Preneoplastic changes of the esophageal mucosa with columnar epithelium were found in cases of less severe degrees of inflammation. The degree of esophagitis, presence of preneoplastic changes were determined depending on the presence of Helicobacter pylori. Antireflux surgery was performed under strict indications.

CONCLUSION

Clinical features, endoscopic, morphological manifestations of GERD in patients with pectic ulcer disease of the stomach and duodenum, with resection of the stomach and patients with HH were determined. This is dictated the individual differentiated approach to the choice of the treatment.

[Acute pancreatitis after endoscopic evacuation of the gall stone, presenting as duodenal perforation: a case report]

We present the case of a 25-year-old patient who had sphincterotomy performed for the retrieval of gall stones form the common bile duct, and in whom, immediately after the procedure, signs and symptoms of the retroperitoneal, iatrogenic perforation of the duodenum had developed. Additionally, the patient showed clinical and biochemical symptoms of acute pancreatitis. The patient was operated on, and, intraoperatively, the duodenal perforation was not found, but excessive inflammatory infiltration of the retroperitoneal space, without bile leakage, and typical features for acute pancreatitis. The operation was confined to the duodenal and retroperitoneal space exposure, drainage and jejunostomy for nourishment. The postoperative course was uneventful, acute pancreatitis did not develop into the necrotising form, and the patient eventually recovered.

[Laparoscopy for perfored duodenal ulcer : conversion and morbidity factors: retrospective study of 290 cases]

BACKGROUND

feasibility and advantages of laparoscopic approach in performed duodenal ulcer have no longer to be demonstrated. Laparoscopic suture and peritoneal cleaning expose to a conversion rate between 10 and 23%. However less than laparotomy, morbidity of this approach is not absent.

AIM

This study aim to analyze factors exposing to conversion after laparoscopic approach of perforred duodenal ulcer. We also aim to define the morbidity of this approach and predictive factors of this morbidity Methods: Retrospective descriptive study was conducted referring all cases of perforated duodenal ulcer treated laparoscopically over a period of ten years, running from January 2000 to December 2010. All patients were operated by laparoscopy with or without conversion. We have noted conversion factors. A statistical analysis with logistic regression was performed whenever we have sought to identify independent risk factors for conversion verified as statistically significant in univariante. The significance level was set at 5%. Analytic univariant and multivariant study was performed to analyze morbidity factors.

RESULTS

290 patients were included. The median age was 34ans.T he intervention was conducted completely laparoscopically in 91.4% of cases. The conversion rate was 8.6%. It was selected as a risk factor for conversion: age> 32 years, a known ulcer, progressive pain, renal function failure, a difficult peritoneal lavage and having a chronic ulcer. Postoperative morbidity was 5.1%. Three independent risk factors of surgical complications were selected: renal failure, age> 45 years, and a chronic ulcer appearance.

CONCLUSION

Laparoscopic treatment of perforred duodenal ulcer expose to a conversion risk. Morbidity is certainly less than laparotomy and a better Knowledge of predictif's morbidity factors become necessary for a better management of this disease.

Case report: portal and systemic venous gas in a patient with perforated duodenal ulcer: CT findings

Gas within the portal circulation has been known to be associated with a number of conditions most commonly mesenteric ischemia and necrosis. Systemic venous gas is described with few conditions and is mostly iatrogenic in nature. We describe a case of combined portal and systemic venous gas detected by computed tomography in a patient with perforated duodenal ulcer.

Dual-priming oligonucleotide-based multiplex PCR using tissue samples in rapid urease test in the detection of Helicobacter pylori infection

AIM: To investigate whether tissue samples processed by the rapid urease test (RUT) kit are suitable for dual-priming oligonucleotide-based multiplex polymerase chain reaction (DPO-PCR) to detect Helicobacter pylori (H. pylori).

METHODS: A total of 54 patients with specific gastrointestinal symptom were enrolled in this study. During endoscopy, gastric biopsy specimens were taken for histology, RUT, and DPO-PCR. DPO-PCR was performed on gastric biopsy samples and tissue samples that were analyzed by RUT at 2 separate institutes. In detecting H. pylori, the concordance rate of the DPO-PCR tests between the tissue samples that had been submitted to RUT and the gastric biopsy samples was investigated.

RESULTS: H. pylori co-occurred with 76.0% (19/25) of gastric ulcers, 64.3% (9/14) of duodenal ulcers, and 33.3% (4/12) of gastritis cases. H. pylori infection was found in 100% (3/3) of the patients with both gastric and duodenal ulcers. Overall, H. pylori was detected in 35 of 54 (64.8%) patients. The diagnostic sensitivities of histology, RUT, and DPO-PCR were 85.7% (30/35), 74.3% (26/35), and 97.1% (34/35), respectively (P = 0.02). The positive predictive value (PPV) of DPO-PCR was 94.4%, whereas the negative predictive value (NPV) was 94.7%. In the rapid urease test (CLOtest)-negative cases, the frequency of positive DPO-PCR and histologic results was 20.0% (7/35). The concordance rate of the DPO-PCR tests between the tissue samples from the RUT kit and the gastric biopsy samples was 94.4% (51/54). The rate of DPO-PCR and silver stain positivity in the RUT-negative cases was 20.0% (7/35).

CONCLUSION: In diagnosing H. pylori infection, DPO-PCR can be performed on tissue samples that have been processed by the RUT kit. Particularly, in patients with RUT-negative results, DPO-PCR on these tissue samples could be helpful in detecting of H. pylori infection.

[Dynamics of a CD3-lymphocytes contents during intraabdominal sorption-transmembranous dialysis in patients with extended peritonitis]

The analysis of clinical and laboratory material in patients, suffering extended peritonitis,was conducted. There was established, that application of the sorption-transmembranous dialysis and abdominal cavity sanation guarantees the CD3 lymphocytes protection and the endotoxicosis severity reduction.

[Postoperative reflux in treatment of complicated forms of duodenal ulcer disease]

There were examined 46 patients, in whom operative treatment of perforative duodenal ulcer was conducted. Organ-preserving operations were performed in conjunction with selective proxymal or truncal vagotomy. In far-remote terms after the operation in 12 patients gastrooesophageal reflux have occurred, DeMeester index have constituted 17.5-38.5. Impact of operative trauma on antireflux power of gastro-oesophageal junction was noted.

[The course of coronary heart disease concurrent with peptic ulcer disease: clinical and pathogenetic aspects]

AIM

To make a comprehensive evaluation of the efficiency of eradication therapy in patients with coronary heart disease (CHD) concurrent with peptic ulcer disease (PUD).

SUBJECTS AND METHODS

The results of treatment were studied in 112 patients with CHD concurrent with PUD who were randomized into 3 groups: 1) adequate eradication therapy during treatment for CHD; 2) antisecretory therapy; 3) treatment for CHD only. The trend in the clinical symptoms of the diseases and the results of an exercise test were assessed.

RESULTS

After eradication therapy, Group 1 patients displayed a reduction in the frequency of angina attacks by 62.6% and weekly nitroglycerin needs by 70.4% and an increase in exercise tolerance by 45.3%. In Group 2 patients on antisecretory therapy, the similar indicators changed by 30.7, 21.2, and 26.5%, respectively. Group 3 patients showed no significant change in the study indicators.

CONCLUSION

The findings suggest that eradication therapy has a positive impact on the course of CHD, which manifests itself as an antianginal effect and hence a change in the clinical picture.

Perforation of a duodenal ulcer into a non-parasitic liver cyst: a rare case of a penetrate hole blockaded with conservative medical management

An 88-year-old Japanese woman was admitted to our hospital for abdominal pain with a raised inflammatory reaction. Esophagogastroduodenoscopy (EGD) and computed tomography (CT) showed a duodenal ulcer punching a liver cyst. Since neither ascites nor free air were detected on CT and her family did not wish for aggressive medical treatment, the patient received clinical observation and conservative management. Antibiotic and proton-pump inhibitor therapy was effective, and she exhibited an uneventful recovery. A reexamination of EGD and CT confirmed that the fistulous tract between the liver cyst and duodenum was blockaded.

A new prognostic scoring system for perforation peritonitis secondary to duodenal ulcers

OBJECTIVE

To identify prognostic factors for perforated duodenal ulcers and to devise and assess a new scoring system.

METHODS

The observational prospective study was conducted at the Mayo Hospital, Lahore in two phases: from March 2010 to September 2011; and from October 2011 to July 2012. It included patients with duodenal ulcer perforation who were observed for identifying factors predicting 30-day prognosis. Each of the predictive factor was given a score based on its severity to devise a new scoring system. Chi-square was used for univariate analysis. Multivariate analysis was done using forward stepwise regression. Accuracy of the new scoring system was calculated using receiver operating curve analysis and its validity was evaluated in the second phase of the study.

RESULTS

Predictors of poor prognosis included multiple gut perforations, size of largest perforation >0.5cm, amount of peritoneal fluid >1000ml, simple closure, development of complications, post-operative systemic septicaemia and winter/autumn season of presentation. Overall 30-day mortality rate was 32.3% (n=32) and morbidity rate was 21.2% (n=21). The mean score was higher in the ones with poor prognosis (p=0.001). Similarly, the mean score was greater in those with grave prognosis (p=0.001). The scoring system had an overall sensitivity of 85.12% and specificity of 80.67% and was favourably comparable to other scoring systems.

CONCLUSION

The new scoring system is a useful tool in predicting 30-day prognosis for perforated duodenal ulcers in acid peptic disease.

[Treatment of chronic aphthous stomatitis combined with duodenal ulcer]

It is currently proved ulcerous stomatitis and duodenal ulcer to have common pathogenetic infectious link (the most studied agent being Helicobacter pylori) by concominant decrease of local and general immunity with hyperoxidation events. Eighty patients (44 female and 36 male aged 15-60) with chronic aphthous stomatitis (AS) combined with duodenal ulcer were included in the study and divided in two equal groups according to treatment received (control group of 40 patients was treated according to conventional scheme, while in 40 patients a new formulation Vipromak was added to treatment protocol). The symptoms of AS tend to resolve faster in vipromak group thus proving its efficiency in treatment of AS and duodenal ulcer.

[Psychoemotional status and "adaptation diseases" at patients with the peptic ulcer in Ural Federal Territory]

RESEARCH OBJECTIVE

To study the psycho-emotional status and prevalence of the coronary heart disease (CHD) and the idiopathic hypertensia (IH) at patients with the peptic ulcer of a stomach (PUS) and at patients with a peptic ulcer of a duodenum is (YaB DPK).

MATERIALS AND METHODS

Examination of 226 patients with an exacerbation of a peptic ulcer was conducted. Patients were distributed in 3 groups of observation depending on localization of ulcerative process. At all surveyed questioning was carried out, data on heriditary burdeness, smoking, alcohol intake, existence of somatopathies were specified, clinic-morphological implications of a peptic ulcer were studied.

RESULTS

Feeling of alarm was present at 109 (48.2%) patients with a peptic ulcer, from them at 92 (40.7%) the subclinical level of alarm is noted, and at 17 (7.5%) clinically expressed form is taped. At 39.3% of the examined patients the depression is defined, from them two thirds of patients had the subclinical level of a depression, and 13 people suffered from clinically expressed depression form. Communication of recurrence with a stress was noted at 86.0% of patients, professionally caused stress--at 44.4%. In our research at the time of the beginning of a disease prevalence of an ischemic heart disease among patients with an ulcer of a duodenum (DPK) made 18.2%. In group of patients with the combined localization of ulcerative defect in a stomach and in DPK which already had an ischemic heart disease before emergence of the second ulcerative defect there were 26.6% that statistically significantly doesn't differ. However that by the time of emergence of the combined lesion this category of patients made already 73.4% is indicative. In case of DPK ulcer prevalence of an ischemic heart disease increased from the moment of the beginning of a disease until carrying out research twice (to 36.4%), but patients with the combined ultserozny lesion nevertheless distinguished both larger initial prevalence of an ischemic heart disease, and more expressed its gain. At the time of the beginning of a disease of GB met in a group of persons with the isolated ulcerative defect authentically more often (36.4% against 18.7% in group of patients with the combined localization of an ulcer). At the time of carrying out research prevalence of GB among patients with DPK ulcer (47.7%) whereas in group of the combined lesion of a stomach and DPK of GB without ischemic heart disease there was only every fourth patient remained significant by 2,7 times (DI 1.2-6.3). The combination of associated diseases of an ischemic heart disease and GB at patients with the advent of an ulcer at the same time in a stomach and DPK practically always met at the persons abusing alcohol and tobacco smoking that in general enlarges risk of development of an ulcer of the second localization by 7,6 times

CONCLUSION

At the peptic ulcer (PU) of any localization the previous stress conducting quite often to formation of alarm and a depression conducts to also education a stress--the induced conditions, for example, of an arterial hypertonia, and later--to an ischemic heart disease. As specific to every second patient with the combined form of a peptic ulcer of a stomach and a duodenum it is possible to consider a polisintropiya from such the comorbidity diseases as coronary heart disease and an idiopathic hypertensia. The combination of these associated diseases to alcohol intake and tobacco smoking progressively enlarges risk of development of a peptic ulcer of the combined localization by 7,6 times in comparison with the isolated duodenum canker.

RESEARCH OBJECTIVE

To define influence of the comorbidity diseases and risk.

[Laparoscopic treatment of perforated ulcers]

It was done comparative analysis the results of different treatment options using of laparoscopic treatment of 331 patients with perforated ulcers. It was defined that postoperative complications frequency is increased to 1.6% in case of perforated ulcers suturing with diameter to 0.7 cm. This indication is increased to 7.1% in case of perforated ulcers suturing and plugging by greater omentum with holes diameter to 1.0 cm. The complications are absent in case of perforated ulcer excision with subsequent vagotomy and pyloroplasty.

Laparoscopic versus open repair of perforated gastroduodenal ulcer: a National Surgical Quality Improvement Program analysis

BACKGROUND

Surgical repair of perforated gastroduodenal ulcers remains a common indication for emergent surgery. The aim of this study was to test the hypothesis that the laparoscopic approach (LA) would be associated with reduced length of stay compared to the open approach.

METHODS

Patients with acute, perforated gastroduodenal ulcer were identified in the National Surgical Quality Improvement Program database, of whom 50 had the LA. One-to-one case/control matching on the basis of age, American Society of Anesthesiologists class, gender, and cardiac disease was evaluated for outcome analysis.

RESULTS

After matching, the 2 groups had similar characteristics. The rates of wound complications, organ space infections, prolonged ventilation, postoperative sepsis, return to the operating room, and mortality tended to be lower for the LA, although not significantly. Length of hospital stay was, however, significantly shorter for the LA by an average of 5.4 days.

CONCLUSIONS

The LA appears to be safe in mild to moderately ill patients with perforated peptic ulcer disease and is associated with reduced use of hospital resources.

An upper gastrointestinal ulcer still bleeding after endoscopy: what comes next?

INTRODUCTION

Recurrent bleeding from an upper gastrointestinal ulcer when endoscopy fails is a reason for radiological or surgical treatment, both of which have their advantages and disadvantages.

CASE

Based on a patient with recurrent gastrointestinal bleeding, we reviewed the available evidence regarding the efficacy and safety of surgical treatment and embolisation, respectively.

DISCUSSION

Transarterial embolisation (TAE) and surgical treatment are both options for recurrent gastrointestinal bleeding when endoscopy fails. Both therapies have serious complications and a risk of rebleeding. Choosing the therapy depends on the capability of the patient to tolerate haemodynamic instability, resuscitation and hypotension.

CONCLUSION

Choosing between TAE and surgery depends a great deal on the case presented, haemodynamic stability and the skills and tools available at that moment.

[Surgical tactics at "difficult" perforative duodenal ulcers]

Bacteriological research of abdominal cavities exsudate is conducted to 264 patients on perforative duodenal ulcers and the dynamics of peritonitis motion is studied in a postoperative period. It is set that already hour-long after the perforation of duodenal ulcer, according to information of peritoneal maintenance pH-metry and it's bacteriologic research, the optimum conditions for progress of inflammatory and infectious factors are created in an abdominal cavity. Therefore a formal term from the moment of perforation can not be the index of degree of inflammation (bacterial contamination) of peritoneum. The methods of duodenoplasty are improved at the giant perforative ulcers of duodenum and ulcers, combined with tubular stenosis of duodenum, allowed to avoid development of purulent-septic postoperative complications through insolvency of stitches and severe motor function disturbances.

[Modern approach to prognostication of the acute hemorrhage recurrence from duodenal ulcer]

There was 2223 of 2285 patients, treated in the Kyiv's municipal center of gastrointestinal hemorrhage in 1994-1996 yrs (the control group) and in 2004-2008 yrs (the main group) for an acute hemorrhage from duodenal ulcer. The integral prognostic index (IPI) was determined for the early recurrence risk (ERR) assessment. The point prognostication system, based on the step by step discriminant analysis, was transformed while its application. While in a control group of an acute hemorrhage early recurrence prognostication and its low risk (ERR was 5.6%) the IPI have had constituted 7-9 points, in the middle risk (ERR was 34%) the IPI have measured 10-16 points and in the conditions of a high risk (ERR have constituted 89.1%), the IPI was 17-22 points, vs in the main group in conditions of application of potent intravenous proton pump inhibitors and effective endoscopic hemostasis measures in a low risk group (the realized ERR was 1.2%) the IPI have measured 7-12 points, in middle ERR (realized ERR 7.15%) the IPI raised to 13-19 points and in a high ERR (realized ERR was 23.81%) 20-22 points.

[Intestinal cystic pneumatosis revealed by stenosis of a gastrointestinal anastomosis: report of a case]

La pneumatose kystique intestinale est la présence de bulles gazeuses dans la paroi et les séreuses du tube digestif. Il s'agit d'une pathologie bénigne, rare, de diagnostic radiologique et de traitement médical. Nous rapportons le cas d'un homme âgé de 42ans, opéré il y a 6ans pour une sténose du bulbe duodénal d'origine ulcéreuse, il avait bénéficié d'une gastro-entéro-anastomose avec bivagotomie tronculaire. Il a été hospitalisé pour des vomissements associés à des épigastralgies. le patient a bénéficié d'une fibroscopie oeso-gastro-duodénale qui a trouvé une stase gastrique gênant toute exploration, ce qui a conduit à la réalisation d'une tomodensitométrie abdominale qui a objectivé un énorme estomac de stase en amont d'une sténose de l'anastomose gastro jéjunale, une pneumatose kystique intestinale et un pneumopéritoine. Le patient a été opéré et l'exploration a trouvé une ascite, un volumineux estomac de stase et des adhérences entre le grêle et le colon droit, sièges de la pneumatose, provoquant un tour de spire (volvulus) de l'ancienne anastomose gastro-jéjunale. L'estomac était atone. Une gastrectomie des 2/3 emportant l'ancienne anastomose suivie d'une anastomose type Finsterer manuelle a été réalisée. Les suites post opératoires étaient simples. La pneumatose kystique intestinale est une affection bénigne, de diagnostic radiologique. Le scanner permet d’étudier la diffusion des gaz dans les séreuses digestives. Son traitement est habituellement médical alors que ses complications peuvent relever d'un traitement chirurgical comme pour notre patient.

[Remote results of conservative and operative treatment of patients with duodenal ulcer complicated by bleeding]

Analyzed long-term outcomes of 690 patients with duodenal ulcer, complicated by bleeding in Kyiv City Centre gastrointestinal bleeding for the periods 1994-1996 (control group) and 2004-2008 (main group). In the late period of patients who were found giperhlorgidry (moderate and severe), increased by 1.4 tImes, indicating a higher voltage continuous acid production In the main group. With the introduction of modern circuits Helicobacter therapy incidence of H. pylori reduced by half. Improving modern tactical approaches to conservative treatment helped to reduce the frequency of relapses in duodenal ulcer remote period by 2.2 times, acute bleeding--in 1.9 times, increase the frequency of excellent results--in 2.8 times.

In vitro characterization of the anti-bacterial activity of SQ109 against Helicobacter pylori

The most evident challenge to treatment of Helicobacter pylori, a bacterium responsible for gastritis, peptic ulcers and gastric cancer, is the increasing rate of resistance to all currently used therapeutic antibiotics. Thus, the development of novel therapies is urgently required. N-geranyl-N'-(2-adamantyl) ethane-1, 2-diamine (SQ109) is an ethylene diamine-based antitubercular drug that is currently in clinical trials for the treatment of tuberculosis (TB). Previous pharmacokinetic studies of SQ109 revealed that persistently high concentrations of SQ109 remain in the stomach 4 hours post oral administration in rats. This finding, combined with the need for new anti-Helicobacter therapies, prompted us to define the in vitro efficacy of SQ109 against H. pylori. Liquid broth micro-dilution was used for susceptibility studies to determine the antimicrobial activity of SQ109 against a total of 6 laboratory strains and 20 clinical isolates of H. pylori; the clinical isolates included a multi-drug resistant strain. All strains tested were susceptible to SQ109 with MIC and MBC ranges of 6-10 µM and 50-60 µM, respectively. SQ109 killing kinetics were concentration- and time-dependent. SQ109 killed H. pylori in 8-10 h at 140 µM (2MBCs) or 4-6 h at 200 µM (~3MBCs). Importantly, though the kinetics of killing were altered, SQ109 retained potent bactericidal activity against H. pylori at low pH. Additionally, SQ109 demonstrated robust thermal stability and was effective at killing slow growing or static bacteria. In fact, pretreatment of cultures with a bacteriostatic concentration of chloramphenicol (Cm) synergized the effects of typically bacteriostatic concentrations of SQ109 to the level of five-logs of bacterial killing. A molar-to-molar comparison of the efficacy of SQ109 as compared to metronidazole (MTZ), amoxicillin (AMX), rifampicin (RIF) and clarithromycin (CLR), revealed that SQ109 was superior to MTZ, AMX and RIF but not to CLR. Finally, the frequency of resistance to SQ109 was low and electron microscopy studies revealed that SQ109 interacted with bacterial inner membrane and cytoplasmic content(s). Collectively, our in vitro data demonstrate that SQ109 is an effective monotherapy against susceptible and multi-drug resistant strains of H. pylori and may be useful alone or in combination with other antibiotics for development as a new class of anti-Helicobacter drugs.

Mortality and need of surgical treatment in acute upper gastrointestinal bleeding: a one year study in a tertiary center with a 24 hours / day-7 days / week endoscopy call. Has anything changed?

BACKGROUND

Acute upper gastrointestinal bleeding, previously often a surgical problem, is now the most common gastroenterological emergency.

AIM

To evaluate the current situation in terms of mortality and need of surgery.

SUBJECTS AND METHODS

Retrospective non-randomised clinical study performed between 1st January-31st December 2011, at "Professor Dr. Octavian Fodor" Regional Institute of Gastroenterology and Hepatology in Cluj Napoca. 757 patients with upper gastrointestinal bleeding were endoscopically examined within 24 hours from presentation in the emergency unit. Data were collected from admission charts and Hospital Manager programme. Statistical analysis was performed with GraphPad 2004, using the following tests: chi square, Spearman, Kruskall-Wallis, Mann-Whitney, area under receiver operating curve.

RESULTS

Non-variceal etiology was predominant, the main cause was bleeding being peptic ulcer. In hospital global mortality was of 10.43%, global rebleeding rate was 12.02%, surgery was performed in 7.66% of patients. Urgent haemostatic surgery was needed in 3.68% of patients with nonvariceal bleeding. The need for surgery correlated with the postendoscopic Rockall score (p=0.0425). In peptic ulcer, the need for surgery was not influenced by time to endoscopy or type of treatment (p=0.1452). Weekend (p=0.996) or night (p=0.5414) admission were not correlated with a higher need for surgery.

CONCLUSIONS

Over the last decade, the need for urgent surgery in upper gastrointestinal bleeding has decreased by half, but mortality has remained unchanged.