Refractory peptic ulcer disease

Refractory gastroduodenal ulcers: investigating non-peptic etiologies

This article presents two clinical cases of gastroduodenal peptic ulcers refractory to medical treatment. In both cases, malignancy was excluded following persistent lesions observed in repeated endoscopies, leading to the use of surgery as both a diagnostic and therapeutic approach. These refractory cases require a multidisciplinary approach with a broad differential diagnosis, including etiologies such as toxic substance exposure, persistent Helicobacter pylori infection, or poor adherence to medical treatment, along with less common conditions such as malignancy, acid hypersecretion syndromes, vascular disorders, or immune-mediated diseases.

Surgical Management of Upper Gastrointestinal Bleeding

The use of surgery in managing upper gastrointestinal (GI) bleeding has rapidly diminished secondary to advances in our understanding of the pathologies that underlie upper GI bleeding, pharmaceutical treatments for peptic ulcer disease, and endoscopic procedures used to gain hemostasis. A surgeon must work collaboratively with gastroenterologist and interventional radiologist to determine when, and what kind of, surgery is appropriate for the patient with upper GI bleeding.

Antiulcer activity of ethanolic leaf extract of Capparis zeylanica against chemically induced ulcers

Background

Peptic ulcer is the term which refers to acid peptic injury of the digestive tract, and it results in mucosal break reaching the submucosa. Leaves of Capparis zeylanica are used as counterirritant, rubefacient, as a cataplasm in piles, boils and swellings. The objective of the present study was to evaluate the antiulcer activity of C. zeylanica ethanolic extract against chemically induced ulcers. The leaves were extracted with ethanol (50%) as solvent using hot perforation method. The extract was evaluated against acute and chronic ulcer models. Further, extract was evaluated for gastric autopsy of animals infected with Helicobacter pylori bacteria. The genes of rats were evaluated by gel electrophoresis method. Morphology of stomach was also studied after treatment with plant extract.

Results

Results exhibited that the area of ulcer was significantly reduced in both acute [naproxen-induced ulcer model (3.62 mm2), histamine-induced ulcer model (3.2 mm2) and ethanol-induced ulcer model (106.4 mm2)] and chronic [chronic naproxen-induced ulcer model (2.14 mm2), chronic histamine-induced ulcer model (0.16 mm2)]. The animals of naproxen-induced ulcer infected with H. pylori showed 91.48% reduction of ulcer area on 9th week after treatment with C. zeylanica extract (360 mg/kg). The rapid urease test and DNA observation revealed that no infection was present from 4th week after treatment with C. zeylanica extract (480 mg/kg). Morphological studies showed less conspicuous petechial marks and hemorrhages in stomach tissues after treatment with test drugs. Histopathological study revealed that C. zeylanica extract reduced stomach damages and eradicated H. pylori infections.

Conclusion

It can be concluded from the study that C. zeylanica possess antiulcer and anti-helicobacter activities.

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

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

Gastrointestinal bleeding due to duodenal mucormycosis in an immunocompetent host mimicking malignancy

Mucormycosis is a rare and fatal infection, largely confined to immunocompromised hosts. Duodenal involvement is extremely rare. We report a case of a 67-year-old female presented with hematemesis eventually diagnosed with duodenal mucormycosis, while radiology characteristics suggested malignancy.

Evaluation and management of Non-variceal upper gastrointestinal bleeding

Non-variceal upper gastrointestinal bleeding continues to be an important cause of morbidity and mortality. The most common causes include peptic ulcer disease, Mallory-Weiss syndrome, erosive gastritis, duodenitis, esophagitis, malignancy, angiodysplasias and Dieulafoy's lesion. Initial assessment and early aggressive resuscitation significantly improves outcomes. Upper gastrointestinal endoscopy continues to be the gold standard for diagnosis and treatment. We present a comprehensive review of literature for the evaluation and management of non-variceal upper gastrointestinal bleeding.

Medical versus surgical treatment for refractory or recurrent peptic ulcer

BACKGROUND

Refractory peptic ulcers are ulcers in the stomach or duodenum that do not heal after eight to 12 weeks of medical treatment or those that are associated with complications despite medical treatment. Recurrent peptic ulcers are peptic ulcers that recur after healing of the ulcer. Given the number of deaths due to peptic ulcer-related complications and the long-term complications of medical treatment (increased incidence of fracture), it is unclear whether medical or surgical intervention is the better treatment option in people with recurrent or refractory peptic ulcers.

OBJECTIVES

To assess the benefits and harms of medical versus surgical treatment for people with recurrent or refractory peptic ulcer.

SEARCH METHODS

We searched the specialised register of the Cochrane Upper GI and Pancreatic Diseases group, the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, MEDLINE, EMBASE, Science Citation Index Expanded, and trials registers until September 2015 to identify randomised trials and non-randomised studies, using search strategies. We also searched the references of included studies to identify further studies.

SELECTION CRITERIA

We considered randomised controlled trials and non-randomised studies comparing medical treatment with surgical treatment in people with refractory or recurrent peptic ulcer, irrespective of language, blinding, or publication status for inclusion in the review.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified trials and extracted data. We planned to calculate the risk ratio, mean difference, standardised mean difference, or hazard ratio with 95% confidence intervals using both fixed-effect and random-effects models with Review Manager 5 based on intention-to-treat analysis.

MAIN RESULTS

We included only one non-randomised study published 30 years ago in the review. This study included 77 participants who had gastric ulcer and in whom medical therapy (histamine H2 receptor blockers, antacids, and diet) had failed after an average duration of treatment of 29 months. The authors do not state whether these were recurrent or refractory ulcers. It appears that the participants did not have previous complications such as bleeding or perforation. Of the 77 included participants, 37 participants continued to have medical therapy while 40 participants received surgical therapy (antrectomy with or without vagotomy; subtotal gastrectomy with or without vagotomy; vagotomy; pyloroplasty and suture of the ulcer; suture or closure of ulcer without vagotomy or excision of the ulcer; proximal gastric or parietal cell vagotomy alone; suture or closure of the ulcer with proximal gastric or parietal cell vagotomy). Whether to use medical or surgical treatment was determined by participant's or treating physician's preference.The study authors reported that two participants in the medical treatment group (2 out of 37; 5.4%) had gastric cancer, which was identified by repeated biopsy. They did not report the proportion of participants who had gastric cancer in the surgical treatment group. They also did not report the implications of the delayed diagnosis of gastric cancer in the medical treatment group. They did not report any other outcomes of interest for this review (that is health-related quality of life (using any validated scale), adverse events and serious adverse events, peptic ulcer bleeding, peptic ulcer perforation, abdominal pain, and long-term mortality).

AUTHORS' CONCLUSIONS

We found no studies that provide the relative benefits and harms of medical versus surgical treatment for recurrent or refractory peptic ulcers. Studies that evaluate the natural history of recurrent and refractory peptic ulcers are urgently required to determine whether randomised controlled trials comparing medical versus surgical management in patients with recurrent or refractory peptic ulcers or both are necessary. Such studies will also provide information for the design of such randomised controlled trials. A minimum follow-up of two to three years will allow the calculation of the incidence of complications and gastric cancer (in gastric ulcers only) in recurrent and refractory peptic ulcers. In addition to complications related to treatment and disease, health-related quality of life and loss of productivity should also be measured.

Diagnostic and Treatment Approaches for Refractory Peptic Ulcers

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

Management of the difficult duodenal stump in penetrating duodenal ulcer disease: a comparative analysis of duodenojejunostomy with "classical" stump closure (Nissen-Bsteh)

BACKGROUND

Duodenal stump insufficiency after surgery for penetrating gastroduodenal ulcer is associated with substantial mortality. "Classical" technique of closing a difficult duodenal stump (Nissen-Bsteh) has, up to now, not been compared with duodenojejunostomy (DJ) in larger patient sets. This also refers to the potential benefit of a gastric and biliary diversion under such conditions. The aim of the present study was to compare classical duodenal closure (CC) with DJ and to evaluate the impact of gastric and biliary diversion on postoperative outcome after surgery for penetrating, high-risk duodenal ulcer in a matched control study.

METHODS

Out of 321 patients, treated for penetrating duodenal ulcer disease, the perioperative outcome of 62 DJ patients was compared with 62 patients undergoing CC matched for age, gender, biliary diversion, and the operating surgeon collective. A total of 70 patients, equally distributed between DJ and CC subsets, received temporary biliary diversion.

RESULTS

Overall perioperative mortality was 10.5%. However, DJ significantly reduced the mortality rate (4.8%) associated with penetrating duodenal ulcer compared to CC (16.1%, P < 0.04). The overall morbidity in DJ patients nearly equalled that in the CC group (P = 0.4). Differences in the prevalence of duodenal leakage rate between DJ (14.5%) and CC (29%) patients were of borderline significance (P = 0.05). Temporary biliary diversion was identified as a prognostic factor for closure consistency with lower duodenal leakage rates in both DJ (odds ratio 0.05, 95% confidence interval 0.005-0.42) and CC patients (odds ratio 0.2, 95% confidence interval 0.05-0.6). In contrast, gastric diversion performed in a subset of 35 DJ patients had no protective effect.

CONCLUSION

Duodenojejunostomy combined with temporary biliary diversion substantially improves perioperative outcome in management of penetrating duodenal ulcer.