Perforated duodenal ulcer: which operation?

Between January 1968 and December 1977 a total of 230 patients with a perforated duodenal ulcer underwent emergency operation in the Royal Victoria Hospital. Simple suture closure of the perforation was carried out in 205, and in the remaining 25 a definitive ulcer procedure was performed in addition. Four patients died following operation, a mortality rate of 1.7%.During a mean follow-up period of 10.3 years at least 107 patients (52%) who had simple suture closure of their perforation developed further ulcer symptoms. Of these, seven re-perforated and a further 56 required elective definitive ulcer surgery. A strong case can be made for a definitive ulcer operation at the time of emergency surgery for a perforated chronic duodenal ulcer.

[Endoscopic treatment of severe digestive hemorrhage by hemostatic injection]

The results of emergency endoscopic treatment of severe non variceal bleeding in the upper and lower gastrointestinal tract by hemostatic injections are reported. Most of the 44 patients were seriously ill and had a high surgical risk. Definitive hemostasis was obtained in 88.6 per cent of cases. Twenty-five patients had active bleeding which was arrested in 84 per cent of cases. There were no serious complications related to the technique. The overall survival rate was 52 per cent. Ten of the 13 deaths were not due to gastrointestinal hemorrhage. The authors advocate this simple, effective and inexpensive method as the initial treatment of ulcerated gastrointestinal bleeding in critically ill patients.

Percutaneous treatment of an intrahepatic abscess caused by a penetrating duodenal ulcer

We present a well-documented case of duodenal ulcer that penetrated into the quadrate lobe of the liver with subsequent abscess and fistula formation. An accurate diagnosis depended on the use of ultrasound to identify the presence of an abnormal gas pattern in the liver which had been mistaken for bowel on computed tomography. Successful percutaneous drainage under ultrasound guidance was then accomplished. This is the first recorded case we can find in which percutaneous drainage combined with antibiotic and H2 blocker therapy was able to supplant the surgical treatment of liver abscess with an enteric fistula. The diagnosis and management of this condition are discussed. Special reference is made to the use of ultrasound to overcome a major pitfall in the use of computed tomography for diagnosing liver abscesses with fistula formation.

Fatal gastrointestinal hemorrhage caused by cytomegalovirus duodenitis and ulceration after heart transplantation

The case of a 61-year-old man, in whom heart transplantation was complicated by fatal gastrointestinal hemorrhage from duodenal ulcers 50 days after surgery, is described. Autopsy examination revealed extensive mucosal ulceration and hemorrhage into the bowel and peritoneal hemorrhage. Microscopy showed classical cytomegalovirus inclusions in clusters of cells in necrotic foci in the duodenum, lungs, and colon. This unusual case is the first reported example of cytomegalovirus-associated fatal gastrointestinal hemorrhage after heart transplantation. It is discussed in the context of the known features of the morbidity and mortality associated with cytomegalovirus infection in transplant patients.

Conservative management of bleeding duodenal ulcer without a visible vessel: prospective randomized trial

Between January 1983 and December 1985, 305 patients were admitted to our hospital because of bleeding duodenal ulcer. A subgroup of 69 patients aged 50 or above in whom emergency endoscopy showed non-arterial bleeding or signs of recent haemorrhage without a visible vessel entered a prospective therapeutic trial. The patients were randomized to receive either (1) early surgery, implying immediate operation, or (2) expectant management, with surgery reserved only for patients with further haemorrhage. The two groups were homogeneous with respect to age, sex, prior ingestion of ulcerogenic drugs, mode of bleeding, admission haematocrit, number with hypovolaemic shock and number with active bleeding on initial endoscopy. Overall mortality was 8.6 per cent. Mortality in patients submitted to early surgery was five times higher than that in those allocated to expectant therapy (14.7 per cent versus 2.9 per cent; risk ratio 5.07). The results suggest that expectant management is advisable in patients with bleeding duodenal ulcer not bleeding massively and in whom endoscopy does not disclose spurting arterial bleeding or a visible vessel.

Peptic ulcer disease in childhood: long-term prognosis

Information concerning the natural history of peptic ulcer disease commencing in childhood is limited. We have followed up 19 individuals in whom this diagnosis had been made in childhood 14-27 years previously. Strict diagnostic criteria were used. A high incidence of morbidity persisting into adult life was found. On investigation 9 (47%) had had a proven ulcer since entering adult life. Ten (53%) were no longer prone to recurring abdominal pain, but four of these had undergone vagotomy and pyloroplasty (three after the age of 21) for intractable symptoms. Thus, only six patients (31%) had made a lasting and spontaneous recovery. Serious complications had occurred at some time in the past in 10 cases (53%). Overt gastrointestinal bleeding had occurred in eight (42%), and this had been after the age of 18 years in three. Duodenal perforation occurred in one subject, and severe pyloric stenosis in another, both of whom were aged 21 years. One subject developed a penetrating duodenal ulcer at the age of 24 years. Seven (37%) had undergone surgery, and in two of these cases more than one operation had been performed. Fifty-eight percent of complications suffered and 89% of surgical operations performed involved patients of 21 years or older. These findings firmly reinforce the opinion that the disorder frequently persists into adult life. The impact of modern means of medical therapy, such as the H2 receptor antagonists, has not yet been fully evaluated.

Endoscopic diagnosis of gastritis: causative factors in 100 patients

The frequency of gastritis in relation to its various predisposing conditions is unclear, as is the respective distribution of damage caused by its predisposing conditions. We studied 100 patients with the endoscopic diagnosis of gastritis. The incidence of gastritis in our university gastroenterology endoscopy service was 23%. A history of aspirin (ASA) or nonsteroidal anti-inflammatory drug (NSAID) use was present in 42%. No predisposing factors were found in 28% of cases. Stress gastritis was present in 10% of patients, all of whom were in the intensive care unit. Alcoholism, gastric resection, and portal hypertension were considered causative in 19%. Multiple predisposing factors were uncommon (3%). Coincident duodenal ulcer(s) and erosive duodenitis were common and were more frequent in the patients having idiopathic gastritis (46%) than in those who used ASA or NSAIDs (29%). The antrum was the portion of the stomach most frequently involved. This antral distribution of damage was predominant in both the ASA/NSAID-associated cases and in the idiopathic group. In contrast, patients with stress gastritis were more likely to have involvement of the gastric fundus and body.

[Comparison of methods for the identification of Campylobacter pylori in gastric biopsies of patients with dyspepsia]

Campylobacter pylori has been associated with gastro-duodenal inflammatory disease. Ninety-five adults with dyspepsia were examined for the presence of C. pylori in the gastric antrum and near gastric or duodenal ulcers (when present) by means of culture, Gram and acridine orange stains, and urease activity of biopsies. C. pylori was identified from 51 out of 67 patients with chronic gastritis, from 9 out of 9 patients with duodenal ulcer, and from 8 out of 10 patients with gastric ulcer. Acridine orange stain revealed the highest number of positive cases, followed by culture, Gram stain and urease test. The latter showed a 100% specificity when carried out with a selective urea broth containing colistin, trimethoprim, vancomycin and amphotericin B. It has to be considered a further diagnostic tool which enables clinicians and microbiologists to diagnose the etiology of a dyspeptic syndrome even at the patient's bedside.

Gastric pseudolymphoma. Case report

Gastric pseudolymphoma (GPL) is a rare entity which closely mimicks malignant lymphoma. Controversy still exists concerning the risk of malignant transformation. In this report a case of GPL occurring 8 years after a gastric resection due to duodenal ulcer is described. The patient has been followed for more than 10 years with annually performed upper GI endoscopies. The histological and endoscopic findings are described.

Conservative surgery in Zollinger-Ellison syndrome: report of a case with an eight-year follow-up

The patient described here, with malignant non-beta islet cell tumor of the head of the pancreas, was treated by resection of the tumor and metastases. Additional pathology of perforated duodenal ulcer and pyloric stenosis required vagotomy and pyloroplasty. The maintenance of normal gastrin levels after the operation indicates a good prognosis. We believe that the low-risk Zollinger-Ellison patient should be treated surgically and the tumor removed. When no tumor can be detected, parietal cell vagotomy should be performed to assist the pharmacological control of the gastric acid hypersecretion. Extensive surgery, such as total gastrectomy, is no longer the treatment of choice and is reserved for the so-called "cimetidine failure."

[Mechanism of activation of the kallikrein-kinin system in human plasma in stomach and duodenal ulcer]

Activity of kallikrein and content of prekallikrein were studied in blood serum of patients with gastroduodenal ulcer accompanied (or not accompanied) by hemorrhage. The rate of the kallikrein-kinin system activation was higher under conditions of the disease complicated by hemorrhage. Extracts of bioptic samples obtained from ulcerous zones as well as the extracts of leukocytes were shown to activate prekallikrein and Hageman factor in human blood plasma. At the same time, the activating effect of these extracts was distinctly lowered in the ulcer accompanied by hemorrhage. The phenomenon observed might occur due to high intensity of polymorphonuclear leukocytes degranulation during hemorrhage in the ulcer area.

Biliary involvement in the evolution of gastric and duodenal ulcer

The complex clinical, biological and radiologic study of 1000 patients with gastric ulcer (GU) and duodenal ulcer (DU) showed biliary involvement (BI) in 141 (14.10%) cases, more frequently in women (57.44%) in the 30 to 39 years age group (35.76%). With reference to the onset or the clinical form, the frequency of BI increases with the duration of the ulcer. After the development of biliary distress, the clinical picture changes rendering the diagnosis more difficult. Ulcer being the cause of BI by functional, inflammatory and adhesion factors, a pathogenetic treatment is obligate.

[Endoscopic diagnosis of acute erosions and ulcers of the stomach and duodenum]

Under analysis was an experience with using fibroesophagogastroduodenoscopy in 114 patients with acute erosions and ulcers of digestive organs, including 33 patients in dynamics from 2 to 4 times. In 13 patients erosions and ulcers were not complicated, 95 patients had bleeding ulcers, 6 patients had perforated ulcers. The authors have shown the diagnostic informative value to be as high as 96.5%. It was stressed that fibroendoscopy allowed to determine the character and localization of the process, complications (bleedings in particular), to follow the development of the process in dynamics, to control the efficacy of the curative and prophylactic measures.

Perforated ulcers in critical illness

Although gastroduodenal ulcers rarely perforate during critical illness, this occurrence causes specific and difficult problems of diagnosis and management. In our review of the records of 19 critically ill patients whose ulcers perforated, we found that classical symptoms were frequently absent. The perforations often were manifested by nonspecific clinical events, such as unexplained ileus or hypotension. Diagnosis was typically delayed and on occasion was first suspected after observing pneumoperitoneum on a routine x-ray. While the ulcers were characteristically very large (greater than 2 cm), minimal inflammation surrounded them. Mortality was 56% in the 16 patients whose perforations were diagnosed before death or discharge. Fifteen patients were treated with simple patching of the ulcer. Perforated ulcers in critically ill patients differ in several important ways from those occurring in otherwise healthy individuals.