Role of Helicobacter pylori infection and nonsteroidal anti-inflammatory drug use in bleeding peptic ulcers in Japan

Background factors of idiopathic peptic ulcers and optimal treatment methods: a multicenter retrospective Japanese study

This study investigated the trends in idiopathic peptic ulcers, examined the characteristics of refractory idiopathic peptic ulcer, and identified the optimal treatment. The characteristics of 309 patients with idiopathic peptic ulcer were examined. We allocated idiopathic peptic ulcers that did not heal after 8 weeks' treatment (6 weeks for duodenal ulcers) to the refractory group and those that healed within this period to the healed group. The typical risk factors for idiopathic peptic ulcer (atherosclerosis-related underlying disease or liver cirrhosis complications) were absent in 46.6% of patients. Absence of gastric mucosal atrophy (refractory group: 51.4%, healed group: 28.4%; p = 0.016), and gastric fundic gland polyps (refractory group: 17.6%, healed group: 5.9%; p = 0.045) were significantly more common in the refractory group compared to the healed group. A history of H. pylori eradication (refractory group: 85.3%, healed group: 66.0%; p = 0.016), previous H. pylori infection (i.e., gastric mucosal atrophy or history of H. pylori eradication) (refractory group: 48.5%, healed group: 80.0%; p = 0.001), and potassium-competitive acid blocker treatment (refractory group: 28.6%, healed group, 64.1%; p = 0.001) were significantly more frequent in the healed group compared to the refractory group. Thus, acid hypersecretion may be a major factor underlying the refractoriness of idiopathic peptic ulcer.

Safety and Efficacy of Sedation During Emergency Endoscopy for Upper Gastrointestinal Bleeding: A Propensity Score Matching Analysis

BACKGROUND AND AIM

This study aimed to compare patients with and without sedation during emergency endoscopy for upper gastrointestinal bleeding (UGIB) and to clarify the safety and efficacy of sedation in emergency endoscopy.

METHODS

We retrospectively collected 389 patients who underwent emergency endoscopy for UGIB at Ureshino Medical Center from 2016 to 2021. Patients were divided into two groups: sedation group during emergency endoscopy and nonsedation group. Clinical characteristics, patient status on admission, and UGIB etiology were evaluated. Treatment outcomes and adverse events were evaluated using propensity score matching (PSM), and risk factors for mortality from UGIB were investigated using Cox multivariate analysis.

RESULTS

The sedation group was significantly younger, composed of a higher proportion of males, and had chronic liver disease. Blood pressure and hemoglobin level on admission were significantly higher in the sedation group. The main cause of bleeding was peptic ulcer, which was significantly higher in the nonsedation group. PSM created 133 matched pairs. The success rate of endoscopic hemostasis was similar in both groups, and procedure time was significantly shorter in the sedation group than in the nonsedation group (17.6 ± 10.0 versus 20.2 ± 10.2 min, P = 0.04). There were no significant differences in adverse events between groups. Cox multivariate analyses revealed that red blood cell transfusion [hazard ratio (HR) 4.45, P < 0.02] and rebleeding (HR 3.30, P = 0.03) were associated with increased risk of 30-day mortality from UGIB.

CONCLUSIONS

Sedation reduced the procedure time during emergency endoscopy for UGIB. Sedation during emergency endoscopy for UGIB is acceptable for safe endoscopic procedures.

Safety and Efficacy of the Noncessation Method of Antithrombotic Agents after Emergency Endoscopic Hemostasis in Patients with Nonvariceal Upper Gastrointestinal Bleeding: A Multicenter Pilot Study

BACKGROUND AND AIMS

The present study aimed to clarify the safety and efficacy of the noncessation method of antithrombotic agents after emergency endoscopic hemostasis in patients with nonvariceal upper gastrointestinal bleeding (UGIB).

METHODS

In this multicenter, prospective, pilot study, we performed emergency endoscopic hemostasis for nonvariceal UGIB in patients taking antithrombotic agents and resumed the medications without a cessation period (group A). The clinical characteristics, types of antithrombotic agents, UGIB etiology, treatment outcome, and adverse events were evaluated. We used propensity score matching to compare treatment outcomes and adverse events with our previous cohort (group B) in whom antithrombotic agents were transiently discontinued after emergency endoscopic hemostasis.

RESULTS

Forty-three consecutive patients were prospectively enrolled. The main antithrombotic agents were low-dose aspirin and direct oral anticoagulants; 11 patients (25.6%) were taking multiple antithrombotics. Peptic ulcers were the main cause of bleeding (95.4%). Endoscopic hemostasis was successful in all patients and the incidence of rebleeding within a month was 7.0%. Propensity score matching created 40 matched pairs. Endoscopic hemostasis was performed by soft coagulation significantly more frequently in group A than in group B (97.5% versus 60.0%, P < 0.001). Neither the rebleeding rate within a month nor thromboembolic event rate was different between the two groups. However, the mean duration of hospitalization was significantly shorter in group A than in group B (8.6 ± 5.2 d versus 14.4 ± 7.1 d, P < 0.001).

CONCLUSIONS

Antithrombotic agents possibly can be continued after successful emergency endoscopic hemostasis for nonvariceal UGIB.

Decline incidence in upper gastrointestinal bleeding in several recent years: data of the Japan claims database of 13 million accumulated patients

This study was to examine the recent trends in upper gastrointestinal bleeding in Japan using a large-scale real-world database. The incidence of upper gastrointestinal bleeding was evaluated in the Japan Medical Data Center claims database of 13,019,713 patients aged 20 to 74 years with traceability for 3 months from 2009 to 2014. The incidence was compared with peptic ulcers and gastroesophageal reflux disease. The prescription of medications was also evaluated. The incidence of bleeding was 0.137%, 0.121%, 0.113%, 0.106%, 0.099%, and 0.105% during 2009 to 2014 with a time-dependent decline (p<0.001). Peptic ulcers (>10 times higher than the incidence of bleeding) decreased with time (p<0.001), whereas gastroesophageal reflux disease increased (p = 0.006). Upper gastrointestinal bleeding was higher in male patients and older patients (60–74 years old) (p<0.001 respectively). The prescription rate of antithrombotic medications and proton pump inhibitors increased from 2009 to 2014 (p<0.001 respectively). The incidence of upper gastrointestinal bleeding decreased from 2009 to 2014 in this relatively large-scale real-world database in Japan, concomitant with the decrease in peptic ulcers. The decreased incidence might have been due to changes in the disease structure and therapeutic strategies over time.

Gastric foveolar-type adenomas endoscopically showing a raspberry-like appearance in the Helicobacter pylori -uninfected stomach

Background and study aims  Foveolar-type adenoma is described as a very rare tumor that occurs in individuals without Helicobacter pylori (HP) infection and diagnosed as adenocarcinoma in the Japanese Classification of Gastric Carcinoma (JCGC). However, we have frequently encountered patients with foveolar-type adenoma that endoscopically resembles a hyperplastic polyp, suggesting that it has just been overlooked to date. Here, we analyzed clinicopathological characteristics of a special subtype of foveolar-type adenoma showing specific endoscopic findings. Patients and methods  From a total of 212 patients with gastric cancer resected during a 22-month period, we enrolled 14 (6.6 %) diagnosed with foveolar-type adenoma (adenocarcinoma in JCGC). HP infection status was determined by eradication history, HP serum IgG antibody level, urea breath test, and endoscopic and histological findings. All lesions were observed using white-light endoscopy and narrow-band imaging with magnification endoscopy (NBIME). Endoscopically resected lesions were histologically examined. Results  None of 14 patients had a current or past history of HP infection. All lesions were visualized on non-atrophic gastric mucosa as small reddish protrusions with fine granular surface, showing a raspberry-like appearance. NBIME showed papillary or gyrus-like microstructures with irregular capillary. Lesions were histologically diagnosed as foveolar-type adenoma showing MUC5AC-positive gastric mucin phenotype. Ki-67 was overexpressed (median labeling index 69.9 %, range 28.4 - 92.1 %), though all lesions were an intraepithelial tumor without stromal invasion. p53 over-staining was not seen in any. Conclusions  Raspberry-like lesions on non-atrophic gastric mucosa in HP-uninfected individuals should be evaluated for the possibility of a special subtype of foveolar-type adenoma.

A case-control study of the risk of upper gastrointestinal mucosal injuries in patients prescribed concurrent NSAIDs and antithrombotic drugs based on data from the Japanese national claims database of 13 million accumulated patients

BACKGROUND

We aimed to identify the adverse effects of nonsteroidal anti-inflammatory drugs (NSAIDs) and antithrombotics on the upper gastrointestinal (GI) mucosa in a clinical setting as a case-control study using a large-scale medical database in Japan.

METHODS

We evaluated the risk of upper GI mucosal injuries in patients receiving NSAIDs and antithrombotics using the Japan Medical Data Center claims database with data for 13 million accumulated patients, from January 2009 to December 2014. Endoscopically evaluated upper GI mucosal injuries were peptic ulcers (n = 143,271), upper GI bleeding (n = 10,545), and gastroesophageal reflux disease (n = 154,755). For each patient, ten controls were matched by age, sex, and diagnosis month.

RESULTS

The odds ratio (OR) for peptic ulcers was 1.45, 1.31, 1.50, 1.53, and 1.62; for upper GI bleeding: 1.76, 1.62, 1.96, 1.82, and 2.38; and for gastroesophageal reflux disease: 1.54, 1.41, 1.89, 1.67, and 1.91 for NSAIDs, COX-2 selective inhibitors, low-dose aspirin, antiplatelet drugs, and anticoagulants, respectively (all statistically significant: P < 0.001). Polypharmacy with NSAIDs and antithrombotic drugs increased the risk of upper GI injuries compared with single-drug therapy. The injury risk was also increased by lifestyle-related diseases, including diabetes mellitus and hyperlipidemia.

CONCLUSIONS

This case-control study using the large organized Japanese claims database provided the risk of upper GI mucosal injuries in patients receiving NSAIDs and antithrombotic drugs.

Effectiveness of Endoscopic Hemostasis with Soft Coagulation for Non-Variceal Upper Gastrointestinal Bleeding over a 12-Year Period

BACKGROUND/AIMS

In this study, investigations were carried out to ascertain whether soft coagulation hemostasis for non-variceal upper gastrointestinal bleeding (UGIB) has ever been performed in a time-dependent manner.

METHODS

Medical records of 502 patients who had undergone emergency endoscopic hemostasis for non-variceal UGIB from 2003 to 2014 were checked and the modalities were used to achieve hemostasis compared between the first period from 2003 to 2008 (197 patients) and the second period from 2009 to 2014 (305 patients).

RESULTS

Endoscopic hemostasis was successfully achieved in 96.0% of study patients. Peptic ulcers were the main cause of bleeding (89.4%). Endoscopic hemostasis was performed by soft coagulation significantly more frequently during the second (71.1%) than the first period (11.7%; p < 0.001). Endoscopic hemostasis was mainly achieved by trainees during the second period (76.1%); these trainees comprised a significantly greater proportion of endoscopists than during the first period (56.3%; p < 0.001). Endoscopic-related complications did not differ between the 2 periods. The only risk factor for rebleeding after hemostasis was Helicobacter pylori infection; the use of soft coagulation and the fact that endoscopists were just trainees were not risk factors.

CONCLUSION

Our findings suggest that using soft coagulation to achieve endoscopic hemostasis for non-variceal UGIB is safe and effective, even when it is performed by trainees.

Guidelines for endoscopic management of non-variceal upper gastrointestinal bleeding

Japan Gastroenterological Endoscopy Society (JGES) has compiled a set of guidelines for endoscopic management of non-variceal upper gastrointestinal bleeding using evidence-based methods. The major cause of non-variceal upper gastrointestinal bleeding is peptic gastroduodenal ulcer bleeding. As a result, these guidelines mainly focus on peptic gastroduodenal ulcer bleeding, although bleeding from other causes is also overviewed. From the epidemiological aspect, in recent years in Japan, bleeding from drug-related ulcers has become predominant in comparison with bleeding from Helicobacter pylori (HP)-related ulcers, owing to an increase in the aging population and coverage of HP eradication therapy by national health insurance. As for treatment, endoscopic hemostasis, in which there are a variety of methods, is considered to be the first-line treatment for bleeding from almost all causes. It is very important to precisely evaluate the severity of the patient's condition and stabilize the patient's vital signs with intensive care for successful endoscopic hemostasis. Additionally, use of antisecretory agents is recommended to prevent rebleeding after endoscopic hemostasis, especially for gastroduodenal ulcer bleeding. Eighteen statements with evidence and recommendation levels have been made by the JGES committee of these guidelines according to evidence obtained from clinical research studies. However, some of the statements that are supported by a low level of evidence must be confirmed by further clinical research.

Time trends of the impact of Helicobacter pylori infection and nonsteroidal anti-inflammatory drugs on peptic ulcer bleeding in Japanese patients

BACKGROUND/AIMS

Helicobacter pylori infection and the use of nonsteroidal anti-inflammatory drugs (NSAIDs) are the main causes of peptic ulcers. The purpose of the present study was to elucidate the time trends of the impact of H. pylori infection and use of NSAIDs and/or antithrombotic agents on peptic ulcer bleeding (PUB) in Japanese patients.

METHODS

We retrospectively reviewed 719 patients who had received endoscopic hemostasis for PUB between 2002 and 2013. Subjects were divided into either the first-half group (2002-2007, n = 363) or the second-half group (2008-2013, n = 356). The clinical characteristics of the patients, including the prevalence of H. pylori infection and use of NSAIDs and antithrombotic agents, were compared between the two groups.

RESULTS

Compared to the first-half group, patients in the second-half group were characterized by older age (proportion of the patients above 60 years old, 63.9 vs. 76.7%, p = 0.0002), less frequent H. pylori infection (71.6 vs. 57.9%, p < 0.001) and more frequent NSAID intake (39.9 vs. 48.6%, p = 0.02). No significant difference was observed regarding the use of antithrombotic agents between the two groups (18.6 vs. 23.3%, p = 0.13). The prevalence of H. pylori infection and proportion of patients above 60 years old were significantly different between the two groups in a multivariate analysis.

CONCLUSION

The main cause of PUB has clearly shifted from H. pylori infection to the use of NSAIDs over the last decade.

A systematic approach for the diagnosis and treatment of idiopathic peptic ulcers

An idiopathic peptic ulcer is defined as an ulcer with unknown cause or an ulcer that appears to arise spontaneously. The first step in treatment is to exclude common possible causes, including Helicobacter pylori infection, infection with other pathogens, ulcerogenic drugs, and uncommon diseases with upper gastrointestinal manifestations. When all known causes are excluded, a diagnosis of idiopathic peptic ulcer can be made. A patient whose peptic ulcer is idiopathic may have a higher risk for complicated ulcer disease, a poorer response to gastric acid suppressants, and a higher recurrence rate after treatment. Risk factors associated with this disease may include genetic predisposition, older age, chronic mesenteric ischemia, smoking, concomitant diseases, a higher American Society of Anesthesiologists score, and higher stress. Therefore, the diagnosis and management of emerging disease should systematically explore all known causes and treat underlying disease, while including regular endoscopic surveillance to confirm ulcer healing and the use of proton-pump inhibitors on a case-by-case basis.

A multicenter prospective study on the prevalence of Helicobacter pylori-negative and nonsteroidal anti-inflammatory drugs-negative idiopathic peptic ulcers in Japan

BACKGROUND AND AIM

The prevalence of Helicobacter pylori-negative and nonsteroidal anti-inflammatory drug-negative peptic ulcers, commonly known as idiopathic peptic ulcers (IPUs), has been reported to be very low (0.9-2.6%) in Japan based on data from the 1990s. However, recent trends have yet to be been reported. Herein, we present a multicenter prospective analysis between 2012 and 2013 investigating current trends in the prevalence and characteristics of IPUs in Japan.

METHODS

Clinical data of all peptic ulcer subjects detected via endoscopy at four participating hospitals were prospectively collected between April 2012 and March 2013. Enrolled subjects were classified according to H. pylori infection status and intake of nonsteroidal anti-inflammatory drugs. Multiple logistic regression analyses were used to determine the risk factors for IPUs.

RESULTS

Of 382 enrolled patients with peptic ulcers, 46 (12%) were judged to have IPUs. Compared with those with simple H. pylori-positive ulcers, patients with IPUs were significantly older (P < 0.02) and more often had underlying comorbidities such as hypertension (P < 0.02) and hyperlipidemia (P < 0.05). Multivariate regression analysis indicated that the presence of multiple underlying diseases was the only significant risk factor for IPUs, with an odds ratio of 3.8 (95% confidence interval, 1.3-11.1).

CONCLUSIONS

This study revealed that the prevalence of IPUs in patients with peptic ulcers in Japan is 12%, much higher than previously reported. Presence of multiple underlying comorbid diseases, rather than aging itself, is an important risk factor for IPUs.

Characteristics of patients with non-variceal upper gastrointestinal bleeding taking antithrombotic agents

BACKGROUND AND AIM

The present study aimed to clarify the features and management of non-variceal upper gastrointestinal bleeding (UGIB) in Japanese patients taking antithrombotic agents.

METHODS

We retrospectively investigated the medical records of 560 patients who underwent emergency endoscopy for UGIB from 2002 to 2013. The patients were divided into two groups: group A, antithrombotic agent use; and group NA, no antithrombotic agent use. We compared clinical characteristics, comorbidities, and causes of UGIB between the groups. We also investigated management with antithrombotics.

RESULTS

Of 560 patients with UGIB, 27.5% were taking antithrombotics, and this proportion gradually increased during the study period. Mean hemoglobin levels on admission were significantly lower in group A (8.0 ± 1.7 g/dL) than in group NA (8.9 ± 2.9 g/dL) (P < 0.001). Patients in group A developed more gastric ulcers and multiple ulcers than did patients in group NA. Incidence of Forrest Ia-type bleeding was lower in group A than in group NA (P < 0.001), and the rate of endoscopic hemostasis was significantly higher in group A (98.7%) than in group NA (94.3%) (P = 0.022). After the release of the 2012 Japan Gastroenterological Endoscopy Society guidelines, the antithrombotic agent cessation periods were significantly shortened (P < 0.001).

CONCLUSIONS

Among patients with UGIB, those taking antithrombotics exhibited more severe clinical signs. However spurting hemorrhage was rare. Antithrombotics may be resumed early after endoscopic hemostasis.

Randomised clinical trial: prevention of recurrence of peptic ulcers by rabeprazole in patients taking low-dose aspirin

BACKGROUND

Few studies have evaluated the effects of rabeprazole on low-dose aspirin (LDA)-induced gastroduodenal injuries.

AIM

To conduct a randomised, double-blind, triple-dummy, active-controlled, multicentre trial, named the PLANETARIUM study, to assess the efficacy, dose-response relationship and safety of rabeprazole for peptic ulcer recurrence in Japanese patients on long-term LDA therapy.

METHODS

Eligible patients had a history of endoscopically confirmed peptic ulcers and were receiving long-term LDA (81 or 100 mg/day) therapy for cardiovascular or cerebrovascular protection. Subjects were randomly segregated into three groups receiving rabeprazole 10 mg once daily (standard dose in Japan), rabeprazole 5 mg once daily, or teprenone (geranylgeranylacetone; mucosal protective agent commercially available in Japan) 50 mg three times per day as an active control. The primary endpoint was recurrence of peptic ulcers over 24 weeks.

RESULTS

Among 472 randomised subjects, 452 subjects (n = 151, 150, 151, respectively) constituted the full analysis set. The cumulative recurrence rates of peptic ulcers over 24 weeks in the 10- and 5-mg rabeprazole groups were 1.4% and 2.8%, respectively, both of which were significantly lower than that in the teprenone group (21.7%). The cumulative occurrence rate of bleeding ulcers over 24 weeks in the teprenone group was 4.6%, while bleeding ulcers were not observed in the 10- or 5-mg rabeprazole groups. Rabeprazole was well tolerated at both doses.

CONCLUSION

Rabeprazole prevents the recurrence of peptic ulcers with no evidence of a major dose-response effect in subjects on low-dose aspirin therapy.

Cigarette smoking and gastrointestinal diseases: the causal relationship and underlying molecular mechanisms (review)

Cigarette smoking is an important risk factor for gastrointestinal (GI) disorders, including peptic ulcers, inflammatory bowel diseases, such as Crohn's disease and cancer. In this review, the relationship between smoking and GI disorders and the underlying mechanisms are discussed. It has been demonstrated that cigarette smoking is positively associated with the pathogenesis of peptic ulcers and the delay of ulcer healing. Mechanistic studies have shown that cigarette smoke and its active ingredients can cause mucosal cell death, inhibit cell renewal, decrease blood flow in the GI mucosa and interfere with the mucosal immune system. Cigarette smoking is also an independent risk factor for various types of cancer of the GI tract. In this review, we also summarize the mechanisms through which cigarette smoking induces tumorigenesis and promotes the development of cancer in various sections of the GI tract. These mechanisms include the activation of nicotinic acetylcholine receptors, the formation of DNA adducts, the stimulation of tumor angiogenesis and the modulation of immune responses in the GI mucosa. A full understanding of these pathogenic mechanisms may help us to develop more effective therapies for GI disorders in the future.

Diarrhea caused by proton pump inhibitor administration: comparisons among lansoprazole, rabeprazole, and omeprazole

BACKGROUND

The number of patients who require treatment with proton pump inhibitors (PPIs) is increasing in Japan. One of their adverse effects is diarrhea.

OBJECTIVES

We investigated the incidence of diarrhea caused by 3 different PPIs: lansoprazole, rabeprazole, and omeprazole.

METHODS

Patients using PPIs for >1 month were enrolled. Enrolled patients recorded daily stool frequency, stool consistency using the Bristol Stool Scale Form, and impaired quality of life caused by diarrhea for 1 month. Their attending physicians described the types and dosages, and duration of PPI administration, as well as other necessary information.

RESULTS

A total of 255 patients participated. Mean age of the patients was 70.7 years old. During the 1-month observation period, 3.5% of the patients complained of diarrhea. There was no significant difference for the incidence of diarrhea among the 3 types of PPIs. Furthermore, no correlations between diarrhea and length and dosage of PPI administration were found.

CONCLUSIONS

The incidence of diarrhea in patients receiving long-term therapy did not differ among 3 different PPIs. ClinicalTrials.gov identifier: UMIN ID 000005300.

Helicobacter pylori-negative, non-steroidal anti-inflammatory drug: Negative idiopathic ulcers in Asia

Since the discovery of Helicobacter pylori (H. pylori) infection in the stomach, the bacteria infection and non-steroidal anti-inflammatory drugs (NSAIDs) use had been considered to be the 2 main causes of peptic ulcers. However, there have been recent reports of an increase in the proportion of peptic ulcers without these known risk factors; these are termed idiopathic peptic ulcers. Such trend was firstly indicated in 1990s from some reports in North America. In Asia, numerous studies reported that idiopathic ulcers accounted for a small percentage of all ulcers in the 1990s, but in the 2000s, multiple studies reported that the proportion of idiopathic ulcers had reached 10%-30%, indicating that the incidence of idiopathic ulcers in Asia has also been rising in recent years. While a decline in H. pylori infection rates of general population in Asia is seen as the main reason for the increased incidence of idiopathic ulcers, it is also possible that the absolute number of idiopathic ulcer cases has increased. Advanced age, serious systemic complication, and psychological stress are considered to be the potential risk factors for idiopathic ulcers. Management of idiopathic ulcers is challenging, at present, because there is no effective preventative measure against recurrence in contrast with cases of H. pylori-positive ulcers and NSAIDs-induced ulcers. As it is expected that H. pylori infection rates in Asia will decline further in the future, measures to treat idiopathic ulcers will also likely become more important.

Low-dose aspirin and comorbidities are significantly related to bleeding peptic ulcers in elderly patients compared with nonelderly patients in Japan

OBJECTIVE

The present study was conducted using data accumulated from our earlier study of bleeding peptic ulcers, focusing on elderly patients.

METHODS

A total of 461 patients with bleeding peptic ulcers underwent emergency endoscopy at Saga Medical School Hospital between 1999 and 2011. Risk factors for bleeding peptic ulcers were compared between two groups: an elderly group (≥65 years old) and a nonelderly group (<65 years old). The relationship between drug use and age was examined using multiple logistic regression models. In the elderly group, the factors were compared between Period I (1999-2005) and Period II (2006-2011).

RESULTS

The proportion of men and the incidence of Helicobacter pylori infection were lower in the elderly group than in the nonelderly group. The use of low-dose aspirin, antithrombotic drugs and corticosteroids, but not nonsteroidal anti-inflammatory drugs, was higher in the elderly group. A multiple logistic regression analysis of prescribed medications indicated that low-dose aspirin was more frequently used in the elderly group. The rate of comorbidities was higher and the hemoglobin levels were lower in the elderly group. The rates of rebleeding within one week and death within one month did not differ in the elderly group. Compared with that observed in Period I, the incidence of Helicobacter pylori infection was decreased and the rate of comorbidities was increased in Period II.

CONCLUSION

This study indicates that factors related to bleeding peptic ulcers in elderly patients have shifted from Helicobacter pylori infection to comorbidities associated with low-dose aspirin, suggesting a close relationship between low-dose aspirin therapy and comorbidities in elderly patients with peptic ulcers.

More favorable outcomes with peptic ulcer bleeding due to Helicobacter pylori

BACKGROUND

Acute upper gastrointestinal bleeding is a common complication of peptic ulcer disease, often caused by Helicobacter pylori and nonsteroidal anti-inflammatory drug (NSAID) use. The purpose of this study was to determine whether the cause and biologic behavior of ulcers associated with acute upper gastrointestinal bleeding might lead to divergent patient outcomes.

METHODS

In this Institutional Review Board-approved study, we compared clinical features and outcomes of patients with acute upper gastrointestinal bleeding due to ulcers categorized into 4 groups: Helicobacter pylori positive or negative combined with NSAID usage positive or negative. Likelihood chi-squared analyses were utilized for group comparisons and stepwise multiple logistic regression models were utilized to determine which factors were related to bleeding outcomes.

RESULTS

Of 2242 patients with upper gastrointestinal bleeding, 575 (26%) had gastroduodenal ulcer disease, and of those with appropriate diagnostic testing, approximately half (228, 10% overall) had evidence of Helicobacter pylori infection and half (216, 10% overall) had no evidence of Helicobacter pylori infection. Patients without Helicobacter pylori infection had significantly more comorbid conditions than those with Helicobacter pylori and higher Charlson Index comorbidity scores (2.6 ± 2.6 [mean and SD] vs 1.9 ± 2.3, P = .003). Hospital length of stay was significantly longer for Helicobacter pylori-negative patients (mean 11.4 ± 21.7 vs 6 ± 8.5 days and median 5.5 vs 3 days, P <.001 and <.001, respectively). Rebleeding events within 30 days were more frequent in Helicobacter pylori-negative patients than Helicobacter pylori-positive patients (11% vs 5%, P = .009). Rebleeding was most frequent in patients without Helicobacter pylori and with no reported use of NSAIDS (18%, P = .01).

CONCLUSIONS

Helicobacter pylori-negative ulcers were associated with poorer outcomes regardless of use of NSAIDs. Patients with ulcers negative for Helicobacter pylori and no history of NSAID use had the worst outcomes and had more severe systemic disease.

Peptic ulcers after the Great East Japan earthquake and tsunami: possible existence of psychosocial stress ulcers in humans

BACKGROUND

Societal stress derived from an event that affects the whole society, e. g., a natural disaster, provides a unique, indirect way of determining the relationship between psychological stress and peptic ulcer disease in humans. In this study, we investigated the changing patterns of the incidence of peptic ulcers before and after the Great East Japan earthquake, which occurred on 11 March, 2011.

METHODS

Clinical data of patients with peptic ulcers were retrospectively collected during the 3 months after the earthquake (2011) from 7 major hospitals in the middle of the stricken area, and were compared with the data for the same period of the previous year (2010). The eligible subjects were classified into four groups according to Helicobacter pylori infection status and intake of nonsteroidal anti-inflammatory drugs (NSAIDs).

RESULTS

The incidence of all types of peptic ulcers was 1.5-fold increased after the earthquake, and in particular, the incidence of hemorrhagic ulcers was 2.2-fold increased; the gastric ulcer/duodenal ulcer ratio in hemorrhagic ulcers was also significantly increased (p < 0.05). Regarding the etiology of the peptic ulcers, the proportion of non-H. pylori and non-NSAID ulcers was significantly increased, from 13 % in 2010 to 24 % in 2011 after the earthquake (p < 0.05).

CONCLUSION

In addition to the increased incidence of peptic ulcers, compositional changes in the disease were observed after the Great East Japan earthquake. The significant increase in the proportion of non-H. pylori and non-NSAID ulcers after the earthquake indicated that psychological stress alone induced peptic ulcers in humans independently of H. pylori infection and NSAID intake.

A study of the changes in the cause of peptic ulcer bleeding

AIM: To clarify the frequency of and changes in the cause of peptic ulcer bleeding.

METHODS: This study retrospectively evaluated the out- and inpatients who underwent endoscopy between 2002 to 2008. The subjects were patients presenting with peptic ulcer bleeding. The details of these patients were obtained from their endoscopic reports and medical records.

RESULTS: The rates of Helicobacter pylori (H. pylori) infection were significantly low (P = 0.039), while the proportion of nonsteroidal antiinflammatory drugs (NSAIDs) users and vascular disease significantly increased over the period studied (P = 0.034 and P = 0.04, respectively). However, there was no significant difference in the proportion of low-dose aspirin users (P = 0.832).

CONCLUSION: It’s found that the primary cause of peptic ulcer bleeding changed from H. pylori infection to use of NSAIDs over the 7-year period of study. It seems that the number of low-dose aspirin users has increased with the increase in the proportion of vascular disease. It is necessary to take measures to prevent peptic ulcer bleeding among NSAIDs and low dose aspirin users.

Burden of nonsteroidal anti-inflammatory and antiplatelet drug use in Asia: a multidisciplinary working party report

BACKGROUND & AIMS

We established a working group to examine the burden of atherothrombotic and musculoskeletal diseases in Asia and made recommendations for safer prescribing of nonsteroidal anti-inflammatory drugs (NSAIDs) and low-dose aspirin.

METHODS

By using a modified Delphi process, consensus was reached among 12 multidisciplinary experts from Asia. Statements were developed by the steering committee after a literature review, modified, and then approved through 3 rounds of anonymous voting by using a 6-point scale from A+ (strongly agree) to D+ (strongly disagree). Agreement (A+/A) by ≥ 80% of panelists was defined a priori as consensus.

RESULTS

We identified unique aspects of atherothrombotic and musculoskeletal diseases in Asia. Asia has a lower prevalence of degenerative arthritis and coronary artery disease than Western countries. The age-adjusted mortality of coronary artery disease is lower in Asia; cerebrovascular accident has higher mortality than coronary artery disease. Ischemia has replaced hemorrhage as the predominant pattern of cerebrovascular accident. Low-dose aspirin use is less prevalent in Asia than in Western countries. Traditional Chinese medicine and mucoprotective agents are commonly used in Asia, but their efficacy is not established. For Asian populations, little is known about complications of the lower gastrointestinal tract from use of NSAIDs and underutilization of gastroprotective agents. Our recommendations for preventing ulcer bleeding among users of these drugs who are at high risk for these complications were largely derived from Asian studies and are similar to Western guidelines.

CONCLUSIONS

By using an evidence-based, multidisciplinary approach, we have identified unique aspects of musculoskeletal and atherothrombotic diseases and strategies for preventing NSAID-related and low-dose aspirin-related gastrointestinal toxicity in Asia.

Continuous proton pump inhibitor treatment decreases upper gastrointestinal bleeding and related death in rural area in Japan

BACKGROUND AND AIMS

Proton pump inhibitors (PPI) have been rarely used for prevention of upper gastrointestinal bleeding (UGIB) induced by non-steroidal anti-inflammatory drugs (NSAIDs) and/or aspirin in Japan. The increased incidence of UGIB in the aged society is becoming a serious problem. The aim of this study was to retrospectively evaluate whether PPI can prevent UGIB.

METHODS

We examined records of 2367 patients (aged 67.9 ± 15.1 years, male 1271) attending the only hospital serving the rural area, with little population movement. We investigated the correlation between the frequency of usage of medicine (PPI, histamine 2 receptor antagonists [H2RA], NSAIDs, aspirin) and incidence of UGIB over 12 years. UGIB was defined as cases with hematemesis and/or melena and definite bleeding at upper gastrointestinal endoscopy. The annual incidence of UGIB of inhabitants (16,065 ± 375.3 persons/year) was evaluated. The frequency of usage of medicine was compared with the total number of patients prescribed any medication (1080 ± 33.2 persons/year).

RESULTS

The frequency of PPI usage has increased significantly 4.6%→30.8% (P < 0.05). NSAIDs and aspirin usage increased significantly in the latter half of the survey period (P < 0.05). The annual incidence of UGIB significantly decreased 160.8 →23.6/100,000 inhabitants per annum (P ≤ 0.05) due to widespread use of PPI. No patients died due to UGIB after 2006. The incidence of UGIB and the prevalence of PPI usage were found to have a negative correlation (r = -0.804, P = 0.0016).

CONCLUSIONS

By widespread use of PPI, UGIB and related death has declined significantly. This survey showed that continuous PPI treatment decreases UGIB and related death in community medicine.

NSAIDs are a significant risk factor for colonic diverticular hemorrhage in elder patients: evaluation by a case-control study

BACKGROUND AND AIM

Diverticular bleeding is a common cause of lower gastrointestinal hemorrhage. Several factors, including use of non-steroidal anti-inflammatory drugs (NSAIDs), antithrombotic agents and arteriosclerosis, could be risk factors. The aim of this study is to identify these risk factors.

METHODS

Between January 2000 and December 2008, 51 patients among 178 acute lower gastrointestinal hemorrhages who visited Saga Medical School were diagnosed as colonic diverticular hemorrhage, established by emergency endoscopy and diagnostic criteria. Gender and age matched control cases were selected from patients of other diseases hospitalized during the same period. We evaluated by using logistic regression analysis the influences of comorbidities such as cerebrovascular disease, ischemic heart disease, hypertension, hyperlipidemia, diabetes mellitus, chronic kidney disease, and osteoporosis, medications including NSAIDs and antithrombotic agents, and habits of smoking, alcohol, and chronic constipation.

RESULTS

Fifty one patients out of 178 acute lower gastrointestinal bleeding (28.7%) were diagnosed as diverticular hemorrhage, which was the most common cause of lower gastrointestinal hemorrhage. Sex ratio of men versus women for colonic diverticular hemorrhage was 35:16. NSAIDs were a significant risk factor for colonic diverticular hemorrhage in elder patients (odds ratio [OR] = 7.492, 95% CI: 1.516-37.024, P = 0.0135). Hypertension and hyperlipidemia had significant association with diverticular hemorrhage among patients younger than 65 years old. This study also indicated that use of NSAIDs was a risk factor for re-bleeding (OR = 5.4, 95% CI: 1.01-28.78, P = 0.048).

CONCLUSION

This case-control study revealed that the use of NSAIDs was a significant risk factor for colonic diverticular hemorrhage in elder patients. In addition, use of NSAIDs is a risk factor for re-bleeding from colonic diverticula.

Characteristics of Japanese patients with chronic gastritis and comparison with functional dyspepsia defined by ROME III criteria: based on the large-scale survey, FUTURE study

OBJECTIVE

To clarify the clinical characteristics of patients diagnosed with chronic gastritis in Japan, a large scale clinical survey of patients with chronic upper gastrointestinal symptoms was conducted. Patients diagnosed with functional dyspepsia (FD) according to the ROME III criteria were selected from among patients with chronic gastritis and the clinical characteristics of patients with FD and those with chronic gastritis were compared.

PATIENTS AND METHODS

Patients with upper abdominal symptoms and diagnosed with chronic gastritis were enrolled in the study. Their main complaints, duration of symptoms, clinical characteristics, mental state, and results of endoscopic examinations, if available, were prospectively surveyed. Quality of life (QOL) impairment caused by abdominal symptoms was also surveyed using the Izumo QOL scale.

RESULTS

A total of 9,125 patients with a clinical diagnosis of chronic gastritis were enrolled in the survey. Of those, approximately 60% had more than 2 symptoms and QOL impairment was greater in cases with multiple symptoms. Endoscopic examinations were performed in 2,946 cases (32.3% of enrolled patients), during which gastric and/or esophageal carcinoma was found in only 0.2%, though organic diseases were found in 6.2%. Endoscopic examinations were not done for patients with high risks of organic diseases. Of patients with organic diseases excluded by an endoscopic examination, only 362 (12.3% of patients who underwent an endoscopy) were diagnosed with FD according to the ROME III criteria, mainly because of short symptom duration. There were no remarkable differences in regard to clinical characteristics, including symptoms and mental state, between patients with chronic gastritis and those with FD.

CONCLUSION

Clinical characteristics of patients with chronic gastritis were similar to those with FD, except for shorter symptom duration.

Systematic review: Helicobacter pylori and the risk of upper gastrointestinal bleeding risk in patients taking aspirin

BACKGROUND

Aspirin is widely used to modify the risk of recurrent vascular events. It is, however, associated with increased upper gastrointestinal bleeding risk. The influence of Helicobacter pylori on this risk is uncertain.

AIM

To determine the influence of H. pylori on upper gastrointestinal bleeding risk in patients taking aspirin.

METHODS

MEDLINE and EMBASE databases were searched. All studies providing data regarding H. pylori infection in adults taking aspirin and presenting with upper gastrointestinal bleeding were included.

RESULTS

A total of 13 studies that included 1 case-control, 10 cohort studies and 2 randomized-controlled trials (RCTs) were analysed. The case-control study (n = 245) determined H. pylori to be a significant independent risk factor for upper gastrointestinal bleeding. The cohort studies were heterogeneous, varying in inclusion criteria, doses and duration of aspirin used, mode of H. pylori testing and causative GI pathology considered. Comprising 5465 patients, H. pylori infection was tested for in 163 (0.03%) aspirin users with upper gastrointestinal bleeding. The RCTs yielded no significant results.

CONCLUSIONS

The current data are not sufficient to allow meta-analyses. The widely held belief that H. pylori is a risk factor for upper gastrointestinal bleeding in regular aspirin users is not supported by the very limited evidence available.

Time trends in incidence of peptic ulcer bleeding and associated risk factors in Norway 1985-2008

Objective:

The aim of this study was to examine time trends in the incidence of peptic ulcer bleeding and risk factors in a defined geographical area in Norway.

Material and methods:

Retrospective data were collected for 306 patients with bleeding peptic ulcers admitted to one hospital during the 1985–1986, 1995–1996, and 2007–2008 periods.

Results:

The incidence in 1985–1986 was 52/100,000 and in 2007–2008 was 45/100,000. In the group aged 20–75 years, the incidence decreased by 54% from 54/100000 in 1985–1986 to 25/100000 in 2007–2008 (P = 0.001) and increased by 49% in the group aged >75 years from 272/100000 to 406/100000 (P = 0.0001). The use of aspirin or nonsteroidal anti-inflammatory steroid drugs (NSAIDs) was 31% in 1985–1986 and increased to 67% in 2007–2008 (P = 0.004). In patients using aspirin or NSAIDs, Helicobacter pylori was present in 73% in 1995–1996 and in 51% in 2007–2008. H. pylori infection declined from 84% to 52% between 1995–1996 and 2007–2008.

Conclusions:

The incidence rate of peptic ulcer bleeding did not change between 1985–1986 and 2007–2008, but decreased in the age group ≤75 years and increased in the age group >75 years. The use of low-dose aspirin and NSAIDs increased substantially over time, and H. pylori infection was still present in 51% of these patients in 2007–2008.

Evaluation of hemostasis with soft coagulation using endoscopic hemostatic forceps in comparison with metallic hemoclips for bleeding gastric ulcers: a prospective, randomized trial

BACKGROUND

Endoscopic high-frequency soft coagulation, recently developed in Japan, is available for the management of gastric bleeding in cases of bleeding gastric ulcers and bleeding during endoscopic submucosal dissection. The aim of this study was to evaluate the efficacy of hemostasis with soft coagulation for bleeding gastric ulcers by comparing it with hemoclips in a prospective, randomized trial.

METHODS

During the period of April 2006 to March 2008, 96 patients that had gastric ulcers with bleeding or nonbleeding visible vessels were enrolled in this study. All of the 96 patients were randomly divided into two groups: endoscopic hemostasis with soft coagulation (Group I) or endoscopic hemoclipping (Group II).

RESULTS

A total of 41 (85%) out of 48 patients in Group I and 38 (79%) out of 48 patients in Group II were successfully treated with soft coagulation or clipping alone, respectively. The endoscopic hemostasis rate for the initial modality in combination with another endoscopic procedure performed after the initial method was 98% in both groups. One patient in Group I (2%) and five patients in Group II (10%) experienced recurrent bleeding. The time required to achieve hemostasis was shorter in Group I compared with Group II (9.2 +/- 11.1 vs. 13.6 +/- 9.4 min; P < 0.05).

CONCLUSIONS

This study revealed that soft coagulation is as effective as hemoclipping for treating bleeding gastric ulcers. The time required to achieve hemostasis was shorter with the soft coagulation procedure.

Non-invasive testing for Helicobacter pylori in patients hospitalized with peptic ulcer hemorrhage: a cost-effectiveness analysis

PURPOSE

Guidelines recommend routine invasive screening for Helicobacter pylori in patients with peptic ulcer hemorrhage (PUH). However, compliance with screening remains suboptimal. The aim of this study was to determine if a simplified approach based on noninvasive screening is cost effective in PUH.

RESULTS

In the base case, post-endoscopy urea breath test (UBT) dominated the invasive testing with 34 fewer hemorrhages and cost savings of $406,600 in a cohort of 10,000 patients. When compliance with invasive testing decreases to 60%, post-endoscopy UBT leads to 109 fewer hemorrhages and cost savings of $1,089,600. The invasive strategy becomes the preferred choice if the sensitivity of UBT reduces to <75%, such as in patients taking proton-pump inhibitors (PPI) before hospitalization.

CONCLUSIONS

Post-endoscopy UBT is cost effective in PPI-naïve patients presenting with PUH. This strategy, once prospectively validated, can prove to be a preferred approach in institutions where compliance with invasive testing is suboptimal.

Risk factors for complications of endoscopic submucosal dissection in gastric tumors: analysis of 478 lesions

PURPOSE

Endoscopic submucosal dissection (ESD) technique has facilitated en bloc removal of widely spread lesions from the stomach. This retrospective study aimed to determine factors associated with serious complications of ESD.

METHODS

Between December 2001 and March 2007, we have performed ESD for 478 lesions in 436 patients. We experienced 39 patients with post-operative bleeding and 17 patients with perforation. Risk factors of patients who received ESD in gastric mucosal tumors for complications were evaluated, focusing on resected size, location, scar lesions, operation time, and experience of endoscopists. We evaluated the patients' background characteristics including sex, age, body mass index (kg/m(2)), drug history of anticoagulant, and underlying diseases including cerebrovascular disorder, ischemic heart disease, liver dysfunction, renal dysfunction, hyperuricemia, hypertension and diabetes mellitus.

RESULTS

Multivariate analysis indicated a risk factor for perforation was long operation time. Multivariate analysis indicated a significant risk factor for post-operative bleeding was size of the resected tumor.

CONCLUSIONS

This study indicated risk factors for serious complications of ESD. Large resected tumor size was a risk factor for post-operative bleeding, while long operation time was a risk factor for perforation. Information regarding operation risk factors should be useful for planning strategies for ESD.

Low-dose aspirin is a prominent cause of bleeding ulcers in patients who underwent emergency endoscopy

OBJECTIVE

This study aimed to clarify the current situation of bleeding peptic ulcers and examined the temporal changes in the pathogenic mechanisms requiring emergency endoscopy.

PATIENTS AND METHODS

Study subjects were 285 bleeding peptic ulcer patients who received emergency endoscopy in Saga Medical School Hospital between 2000 and 2007. The ratios of H. pylori infection, NSAID use and low-dose aspirin use were analyzed for differences between the two periods by chi-square test. Logistic regression analysis was used to investigate factors such as patient characteristics that influenced the differences between each period.

RESULTS

A total of 221 (77.5%) patients were identified as H. pylori-positive. One hundred (35.1%) patients reported a history of NSAID use within 4 weeks. Among NSAID users, 41 patients received daily low-dose aspirin. One hundred forty-one patients had bleeding ulcers in 2000-2003 and 144 patients in 2004-2007. The odds ratio (OR) between the periods was 0.806 (95% CI, 0.461-1.409) for H. pylori infection and 1.590 (95% CI, 0.973-2.598) for NSAID usage. In contrast, the proportion of patients who took low-dose aspirin was 9.9% in the first period and 18.8% in the second period, and the difference was statistically significant (OR 2.093; 95% CI, 1.047-4.185). Logistic regression analysis revealed that cardiovascular disease and cerebral vascular disease were associated with aspirin use.

CONCLUSION

This study indicates that the causes of bleeding ulcers are changing, and the increasing use of low-dose aspirin might become a major cause of bleeding ulcers.

[Acute massive gastrointestinal bleeding in the elderly]

AIM

Acute massive gastrointestinal bleeding appears to be becoming more frequent and complex in elderly patients with increasing longevity and a variety of diseases. because of long-term medication such as anti-thrombotic agents (ATA) for the prevention of cardiovascular diseases, anti-dementia drugs for the treatment of dementia, with increasing longevity and a variety of diseases. We, therefore, conducted a study to clarify these problems from a clinical view point in geriatric medicine.

METHODS

The bleeding sites and the causes were studied in 85 consecutive patients with melena, hematemesis or acute blood loss, on the basis of clinical and emergency endoscopic findings.

RESULTS

The patients were aged 66 to 95 (40 men and 45 women), and the underlying diseases were mainly cerebral infarction in the chronic phase, osteoarthropathy, atrial fibrillation, and dementia. Ten patients had a previous history of peptic ulcer. As initial symptoms, melena, hematemesis and acute anemia were seen in 49, 18 and 18 patients, respectively. Based on assessable endoscopic findings n=83), the bleeding sites were a gastroduodenal ulcer, reflux esophagitis/acute gastric mucosal lesion, colon diverticulum, or alimentary tract cancers in 43.4%, 13.2%, 16.9%, and 16.9%, respectively. A total of 75 patients were treated with some medications (on average 5.3 kinds of medication per patient). Non-steroidal anti-inflammatory drugs (NSAIDs) and/or ATA were common in 63.5% of 85 patients; particularly two thirds of the patients with hemorrhagic gastroduodenal ulcer had used non-aspirin NSAIDs for treatment of osteoarthropathy or acute upper respiratory inflammation, and/or low-dose aspirin for prevention of vascular events. Patients taking ATA over a long period had bleeding from various sites. Steroids, acetylcholinesterase inhibitor (AchEI), selective serotonin-reuptake inhibitor (SSRI), and bisphosphonates were taken by 5, 9, 3 and 3 patients, respectively, frequently in combination with NSAIDs or ATA. Cerebral infarction occurred in 3 of 38 patients after withdrawal of ATA.

CONCLUSIONS

AchEI, SSRI and bisphosphonates, a newly developed group of drugs, have become widely available as geriatric medication. However, it appears that the incidence of drug-related gastrointestinal bleeding is extremely high not only in patients who underwent long-term treatment with NSAIDs or ATA, but also in patients treated chronically with AchEI, SSRI or bisphosphonates in combination with occasional use of NSAIDs. Therefore, to manage elderly patients safely, it is necessary to clarify both the drug and previous histories and consider NSAIDs use with caution even when they are indicated.

Role of antithrombotic therapy and nonsteroidal anti-inflammatory drug use in bleeding gastroduodenal ulcers

OBJECTIVE

The aim of this study was to analyze the effects of anti-thrombotic therapy and nonsteroidal anti-inflammatory drugs (NSAIDs) on gastroduodenal bleeding.

PATIENTS AND METHODS

The study subjects were 544 patients (421 males and 123 females, mean age, 64.2 years) who were treated endoscopically for bleeding gastroduodenal ulcers from January 1995 to August 2008. Of the 544 patients, 276 (50.7%) had a history of treatment for > or =1 month with an antithrombotic agent or NSAIDs, including low-dose aspirin (n=94), other NSAIDs (n=91), warfarin (n=43), or any combination of the three (combination treatment group; n=48). On the other hand, 268 patients had not previously received any of these drugs (control group). Clinical features and endoscopic therapeutic results were assessed and compared.

RESULTS

Helicobacter pylori infection was detected in 187 of the 241 (77.6%) patients examined. Of the 544 patients, 199 (36.6%) attended the Department of Cardiology or Cardiovascular Surgery, and 170 (31.3%) patients were already being treated with antiulcer medication, including proton pump inhibitors (n=18 [3.3%]). Forty (7.4%) patients suffered from rebleeding after intervention; the incidence of ulcer rebleeding was not significantly different between patients being treated with any such drugs (4.7% [13/276]) and those that had not previously received any antithrombotic agent or NSAIDs (10.1% [27/268]).

CONCLUSION

Antithrombotic therapy and NSAIDs use contributed to bleeding in 50.7% of patients with gastroduodenal ulcers. These drugs are a major cause of ulcer bleeding, but are not necessarily considered a risk factor for rebleeding after endoscopic hemostasis.

Endoscopic hemostasis with metallic hemoclips for iatrogenic Mallory-Weiss tear caused by endoscopic examination

AIM

Applied endoscopic techniques including mucosal resection, sclerotherapy and endoscopic retrograde cholangiopancreatography (ERCP) have been advanced and iatrogenic complications including Mallory-Weiss tear (MWT) occasionally occur in daily endoscopic procedures. The present study aimed to examine the advantages of clipping for MWT complications that occur during endoscopic examination.

METHODS

Over 10 years, we experienced 47 patients with bleeding caused by MWT. Metallic hemoclips were applied for 38 patients for hemostasis. These patients were categorized into two groups: 18 patients in group A whose bleeding tear occurred during endoscopic examination in an iatrogenic condition, and 20 patients in group B visited the emergency unit due to other etiology of MWT.

RESULTS

The background characteristics, including length of tears, were not different between the two groups. Initial hemostasis was 100% in groups A and B. Rebleeding was 0/18 (0%) in group A and 1/20 (5 %) in group B. Number of patients who received blood transfusion was significantly higher in group B (group A: 0/18, group B: 4/20). Hemoglobin level before hemostasis was 12.5 g/dL in group A which was not different to that in group B, 10.9 g/dL.

CONCLUSION

Application of hemoclips was effective for bleeding MWT during endoscopic procedures, which warranted prophylactic application of hemoclips on MWT during endoscopic examination.

Duodenal ulcers dominate acute upper gastrointestinal tract bleeding in childhood: a 10-year experience from Hong Kong

OBJECTIVE

Systematic reports on acute upper gastrointestinal bleeding in children/adolescents are scanty. The aim of this study is to analyze its presentation, pathology and outcome in Hong Kong.

METHODS

A retrospective review of the hospital database for admissions up to the age of 18 years with signs of acute upper gastrointestinal bleeding between 1 June 1996 and 31 May 2006.

RESULTS

During the 10-year period 76 patients (55 boys) were admitted with signs of upper gastrointestinal bleeding. The median age was 13.5 (range 0.25-18) years. Melena and hematemesis were by far the most frequent presentations. Medication was implicated in 16 cases (21%) as the possible cause for the bleeding. Endoscopic findings were a duodenal ulcer in 57 (75%) patients (50 boys) and a gastric ulcer in eight (10.5%). Helicobacter pylori infection was identified in 42 (55%) patients, of which 38 were found in duodenal ulcer patients. Eleven patients (14.5%) had interventions to achieve hemostasis: six epinephrine spray only, three thermal probe and two vessel ligation. After a median follow-up time of 3.5 years six patients had a recurrent duodenal ulcer. Three patients died of unrelated illnesses.

CONCLUSION

Acute upper gastrointestinal tract bleeding in children and adolescents in Hong Kong is dominated by a duodenal ulcer in 75% of the patients. Acute bleeding is more frequent in boys (boy to girl ratio 2.6:1). Medication is a predisposing factor in 20% of the bleedings. Six patients (8%) have recurrent duodenal ulcers.

Bleeding and stenosis caused by reflux esophagitis was not common in emergency endoscopic examinations: a retrospective patient chart review at a single institution in Japan

BACKGROUND

Bleeding and stenosis are serious complications of reflux esophagitis, although few studies have been performed in Japan regarding these complications. This study aimed to indicate the characteristics of reflux esophagitis observed during emergency endoscopic examination in Japan.

METHODS

All subjects who had emergency endoscopic examination performed between 1990 and 2004 at Saga Medical School Hospital were evaluated. Patients with endoscopic reflux esophagitis were evaluated with a retrospective patient chart review.

RESULTS

A total of 1621 subjects underwent emergency endoscopy; 1420 of the endoscopies were because of hematemesis or melena. Endoscopic examination revealed that 19 cases with bleeding were caused by reflux esophagitis (19/1621, 1.2%). The 19 patients with bleeding and the four patients with stenosis (0.2%) had emergency endoscopy performed for complications of reflux esophagitis. The Los Angeles classification of these 23 cases showed that most were severe esophagitis (grade A, 0; B, 2; C, 8; and D, 13). The frequency of comorbidity with diabetes mellitus and collagen disease and the proportion of heavy drinkers were higher in patients who received emergency endoscopy because of reflux esophagitis than in those diagnosed with reflux esophagitis but who received emergency endoscopy because of other diseases.

CONCLUSIONS

Relatively small numbers of patients with reflux esophagitis undergo emergency endoscopy in Japan, and most such patients have underlying diseases, including diabetes mellitus and collagen disease. This finding is supported by a previous report that severe esophagitis is not common in Japan.

Case series of endoscopic balloon dilation to treat a stricture caused by circumferential resection of the gastric antrum by endoscopic submucosal dissection

BACKGROUND

Endoscopic submucosal dissection (ESD) plays an important role in the management of gastric neoplasms. There are few reports regarding stricture development caused by ESD of gastric neoplasms.

OBJECTIVE

The present study aimed to determine the incidence of gastric stricture formation after ESD of gastric neoplasms and to report on the outcome and management of this complication: endoscopic intervention (ie, balloon dilation) versus surgery; the outcome of balloon dilation (success or failure/perforation).

DESIGN

A case series from a retrospective review of gastric ESDs performed at Saga Medical School over a defined period of time.

SETTING

Double-center territory, referral hospital.

PATIENTS

An evaluation was performed in 532 patients with gastric mucosal tumors treated by ESD. A stricture was reported in 5 patients. All the 5 cases were located in the antrum. ESD that was performed in the cardia or the proximal stomach did not induce a stricture.

RESULTS

Of the 5 cases of symptomatic gastric outlet obstruction, 1 patient required surgical intervention because of a near total gastric outlet obstruction not amenable to endoscopic intervention. The 4 patients underwent step-serial through-the-scope balloon dilations; in 2 patients, the procedure was successful, but in the other 2 patients, the procedure was complicated by a gastric perforation (50% incidence of perforation).

LIMITATION

A retrospective study.

CONCLUSIONS

Circumferential or subcircumferential resection by ESD in the antrum caused a stricture. Balloon dilation of the ESD gastric outlet obstruction might be a choice, but it is a risky treatment.

Incidence and etiology of acute non-malignant upper gastrointestinal bleeding in northern Greece

AIM

To evaluate the incidence and etiology of acute non-malignant upper gastrointestinal bleeding (ANMUGIB) in northern Greece due to increased use of non-steroidal anti-inflammatory drugs (NSAIDs), including low-dose aspirin (L-A), exposure and geographical variability of Helicobacter pylori (Hp) seroprevalence.

METHODS

A retrospective study of 110 patients admitted for hematemesis or melena during a 6-month period. All patients had undergone a gastrointestinal (GI) endoscopy during hospitalization. The presence of Hp was identified by biopsies and a (13)C-urea breath test in the case of Hp(-) biopsy bleeding peptic ulcer (BPU). The activity of ANMUGIB was assessed according to Forrest's classification. Statistical analysis was made by the chi(2)-test and Yates' correction.

RESULTS

Most patients were in the two medium age groups with no significant difference between them (P < 0.001). NSAID or L-A (100 mg/day) use was reported in 42.73% of patients in a ratio 1:1 (P > 0.1) and Hp infection was found in 29.09% of patients. BPU, with approximately two-thirds in the bulb, erosions and varices were the most frequent sources. Hp infection was found in 60.65% of BPU, 65.57% were related to NSAIDs or L-A and 8.19% were non-Hp non-NSAID/L-A BPU. Flat spots were most commonly found with a significant difference (P < 0.001) to other stigmata of recent bleeding, except for clean base.

CONCLUSIONS

In northern Greece, persons aged over 40 years are prone to ANMUGIB with a non-significant relationship to males. Hp infection and medication use, such as NSAIDS and L-A, are deeply involved in its etiology. Non-Hp non-NSAID/L-A BPU are a small proportion. ANMUGIB seems to have a generally good prognosis.

Dysphagia in adult Japanese is not equivalent to the grade of endoscopic reflux esophagitis

OBJECTIVE

This study was aimed to evaluate the correlation between dysphagia, detected by nursing staff in a brief interview and endoscopic findings in reflux esophagitis.

PATIENTS AND METHODS

A total of 8,031 Japanese subjects without medication for gastrointestinal disease were briefly asked about the presence of heartburn, dysphagia, odynophagia, and acid regurgitation by nursing staff before endoscopy for assessment of esophagitis utilizing the Los Angeles Classification.

RESULTS

The grade of endoscopic esophagitis was not equivalent to symptoms of dysphagia in 8,031 subjects. We evaluated the characteristics of subjects who complained of only dysphagia. Univariate analysis indicated that non-smoking, and non-drinking females were associated with a higher risk for dysphagia, and multivariate analysis indicated the gender was associated with dysphagia. There was no association of dysphagia with herniation and distribution of age.

CONCLUSION

This study indicated that dysphagia was not equivalent to the endoscopic findings according to a brief interview by nursing staff and that dysphagia might be more common in females and those who do not smoke or drink.