The management of gastric ulcers. A current review

Risk Factors for Mortality in Emergently Admitted Patients with Acute Gastric Ulcer: An Analysis of 15,538 Patients in National Inpatient Sample, 2005-2014

Background: Patients admitted emergently with a primary diagnosis of acute gastric ulcer have significant complications including morbidity and mortality. The objective of this study was to assess the risk factors of mortality including the role of surgery in gastric ulcers. Methods: Adult (18−64-year-old) and elderly (≥65-year-old) patients admitted emergently with hemorrhagic and/or perforated gastric ulcers, were analyzed using the National Inpatient Sample database, 2005−2014. Demographics, various clinical data, and associated comorbidities were collected. A stratified analysis was combined with a multivariable logistic regression model to assess predictors of mortality. Results: Our study analyzed a total of 15,538 patients, split independently into two age groups: 6338 adult patients and 9200 elderly patients. The mean age (SD) was 50.42 (10.65) in adult males vs. 51.10 (10.35) in adult females (p < 0.05). The mean age (SD) was 76.72 (7.50) in elderly males vs. 79.03 (7.80) in elderly females (p < 0.001). The percentage of total deceased adults was 1.9% and the percentage of total deceased elderly was 3.7%, a difference by a factor of 1.94. Out of 3283 adult patients who underwent surgery, 32.1% had perforated non-hemorrhagic ulcers vs. 1.8% in the non-surgical counterparts (p < 0.001). In the 4181 elderly surgical patients, 18.1% had perforated non-hemorrhagic ulcers vs. 1.2% in the non-surgical counterparts (p < 0.001). In adult patients managed surgically, 2.6% were deceased, while in elderly patients managed surgically, 5.5% were deceased. The mortality of non-surgical counterparts in both age groups were lower (p < 0.001). The multivariable logistic regression model for adult patients electing surgery found delayed surgery, frailty, and the presence of perforations to be the main risk factors for mortality. In the regression model for elderly surgical patients, delayed surgery, frailty, presence of perforations, the male sex, and age were the main risk factors for mortality. In contrast, the regression model for adult patients with no surgery found hospital length of stay to be the main risk factor for mortality, whereas invasive diagnostic procedures were protective. In elderly non-surgical patients, hospital length of stay, presence of perforations, age, and frailty were the main risk factors for mortality, while invasive diagnostic procedures were protective. The following comorbidities were associated with gastric ulcers: alcohol abuse, deficiency anemias, chronic blood loss, chronic heart failure, chronic pulmonary disease, hypertension, fluid/electrolyte disorders, uncomplicated diabetes, and renal failure. Conclusions: The odds of mortality in emergently admitted geriatric patients with acute gastric ulcer was two times that in adult patients. Surgery was a protective factor for patients admitted emergently with gastric perforated non-hemorrhagic ulcers.

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.

Acute upper gastrointestinal bleeding in operated stomach: Outcome of 105 cases

AIM: To compare the causes and clinical outcome of patients with acute upper gastrointestinal bleeding (AUGB) and a history of gastric surgery to those with AUGB but without a history of gastric surgery in the past.

METHODS: The causes and clinical outcome were compared between 105 patients with AUGB and a history of gastric surgery, and 608 patients with AUGB but without a history of gastric surgery.

RESULTS: Patients who underwent gastric surgery in the past were older (mean age: 68.1±11.7 years vs 62.8±17.8 years, P = 0.001), and the most common cause of bleeding was marginal ulcer in 63 patients (60%). No identifiable source of bleeding could be found in 22 patients (20.9%) compared to 42/608 (6.9%) in patients without a history of gastric surgery (P = 0.003). Endoscopic hemostasis was permanently successful in 26 out of 35 patients (74.3%) with peptic ulcers and active bleeding or non-bleeding visible vessel. Nine patients (8.6%) were operated due to continuing or recurrent bleeding, compared to 23/608 (3.8%) in the group of patients without gastric surgery in the past (P = 0.028). Especially in peptic ulcer bleeding patients, emergency surgery was more common in the group of patients with gastric surgery in the past [9/73 (12.3%) vs 19/360 (5.3%), P = 0.025]. Moreover surgically treated patients in the past required more blood transfusion (3.3±4.0 vs 1.5±1.7, P = 0.0001) and longer hospitalization time (8.6±4.0 vs 6.9±4.9 d, P = 0.001) than patients without a history of gastric surgery. Mortality was not different between the two groups [4/105 (3.8%) vs 19/608 (3.1%)].

CONCLUSION: Upper gastrointestinal bleeding seems to be more severe in surgically treated patients than in non-operated patients.

Giant gastric ulcer: its natural history and outcome in the H2RA era

OBJECTIVE

The aim of this paper is to study the natural history and outcome of medical treatment of giant gastric ulcer in the histamine H2-receptor antagonist era.

METHODS

All patients with gastric ulcer were prospectively followed. We assessed the special features (in particular, demography and treatment outcome) in patients with giant gastric ulcer, defined as ulcers large enough to occupy at least one wall.

RESULTS

Between 1976 and 1991, 537 patients with gastric ulcer were seen, of whom 129 (24%) had giant gastric ulcer. Giant gastric ulcer patients were significantly older (p < 0.05) than patients with smaller ulcers and had more aggressive disease, reflected by a higher incidence of bleeding, anorexia, weight loss, and emergency admission. More giant gastric ulcers were located in the body of the stomach and a higher proportion looked malignant. Four of 129 patients died immediately (bleed n = 3, unrelated cause n = 1), 15 had urgent surgery (bleed n = 11, perforation n = 2, suspected cancer n = 2) and 110 were treated medically, mainly with cimetidine 1 g daily. Healing occurred in 97 of 110 (88%), including 14 of 15 with refractory disease, i.e., healing took >3 months and/or needed cimetidine 2-3 g daily. Of the remaining 13 patients, six died (from unrelated causes), three had surgery for failed medical treatment, two defaulted, and two were still on treatment (one with refractory ulcer). Refractoriness was more common in patients with associated major medical illness (42% vs 12%, p < 0.01) or with giant gastric ulcers that looked malignant although they were benign (53% vs 21%, p < 0.01). Relapse off treatment was higher (13 of 26) than on maintenance treatment with cimetidine 0.4-2 g daily (14 of 70). Complications occurred in six patients: four off treatment and two on maintenance treatment. Only two giant gastric ulcers finally proved to be malignant. Of the 129 patients, 47 (36%) died, 14 within 3 months (two from bleeding, three postoperatively, nine from unrelated causes) and 33 later (two with gastric cancer and 31 from unrelated causes).

CONCLUSIONS

Giant gastric ulcer is uncommon. Patients are more seriously ill than those with smaller ulcers. Most giant gastric ulcers heal with histamine H2-receptor antagonist treatment. The condition is a marker of poor general health, reflected by the high long term mortality.

APACHE II score: a useful tool for risk assessment and an aid to decision-making in emergency operation for bleeding gastric ulcer

BACKGROUND

Operating for bleeding gastric ulcer remains controversial. Gastric resection bears a higher surgical risk while limited operation may result in more postoperative hemorrhage. There has been little discussion of effective risk assessment of patients. The aim of this study is to define surgical risk by using the APACHE II scoring system, and to determine optimal management.

STUDY DESIGN

Records from October 1990 to December 1996 were retrospectively reviewed for patients (n=101) with bleeding gastric ulcer who had undergone emergency operation after failed endoscopic therapy. Mortality rates were examined according to different APACHE II scores, and the surgical risk was defined. From January 1997 to December 1997, 35 consecutive patients were enrolled for prospective study. Partial gastric resection (PGR) was performed for patients with huge ulcers (>2 cm) and for low-risk patients with ulcers at the antrum or angularis, while limited operation (oversewing or excision of bleeding ulcer) was reserved for others. The results were compared with the retrospective study.

RESULTS

In the retrospective study, the mortality rates for the group with a score < 15 and > or = 15 were 5% (3 of 63) and 58% (22 of 38), respectively (p < 0.05). In the group with a score < 15, PGR was performed on 27 patients, and one died. For those patients with a score > or = 15, PGR carried a lower mortality than limited operation, although this was not statistically significant (47% vs 65%). Limited operation resulted in an overall rate of 22% postoperative hemorrhage and 12% reoperation rate, in which all patients with a score > or = 15 died. In the prospective study, the mortality rates in those scoring <15 and > or = 15 were 6% and 50%, respectively. This is not significantly different than the retrospective study. However, the rate of postoperative hemorrhage was diminished (5%).

CONCLUSIONS

APACHE II score is a useful tool for assessing risk in patients with bleeding gastric ulcer. The mortality is minimal in those with a score <15, and PGR can be performed with low risk. Although high-risk patients have dreadful outcomes, limited operation cannot improve them if postoperative hemorrhage occurs. Decision making in emergency operation for such patients should be based on the ulcer conditions and the patient's hemodynamic status.

Gastroduodenal disease in the elderly patient

Benign and malignant diseases of the stomach and duodenum are common in the elderly. Atypical presentations frequently are seen, making early diagnosis difficult. Aggressive surgical and medical management regimens are usually possible, giving cure rates comparable to those seen in the younger population.

Cancer of the stomach. A patient care study by the American College of Surgeons

OBJECTIVE

The major purpose of this study was to document the modes of presentation, diagnostic methods, clinical management, and outcome of gastric cancer as reported by tumor registries of US hospitals and cancer programs approved by the American College of Surgeons.

SUMMARY BACKGROUND DATA

Gastric cancer continues to diminish in the US, but the stage of disease and survival outcome after surgical resection is unchanged despite increased availability and sophistication of diagnostic techniques. This is in contrast to the marked improvement in survival outcome in Japanese and other Eastern series over the last decades. Possible reasons for the improved Japanese results have been earlier detection secondary to active diagnostic surveillance of the population and widespread adoption of aggressive surgical resection emphasizing wide-field node (R2) dissection. Although selected US centers using the Japanese approach report better survival data, the approach has not been widely adapted by US treatment centers.

METHODS

Tumor registries at American College of Surgeons (ACS) approved hospitals were mailed a study protocol in 1987. They were instructed to review 25 consecutive patients with gastric cancer treated in 1982 (long-term study) and 25 patients treated in 1987 (short-term study). A detailed protocol included significant history, diagnostic results, staging, pathology findings, and treatment results. The data forms on 18,365 patients were returned and analyzed (11,264 patients in the long-term study and 7101 patients in the short-term study).

RESULTS

Of 18,365 patients, 63% were males. The median ages were 68.4 years in males and 71.9 years in females. There was a history of gastric ulcer in 25.5% of the patients. Lesion location was upper third in 31%, middle third in 14%, distal third in 26%, and entire stomach in 10% of patients (and the site was unknown in 19%). Gastric resection was performed for 80% of upper third cancers and 85% of distal third cancers; 50% of patients with total gastric involvement had gastric resection. The extent of gastric resection varied according to location. For lower third lesions, subtotal gastrectomy was done in 55% of the cases, extended resection in 21%, and total gastrectomy in 6%. For proximal lesions, 29% had subtotal, 4.6% had total, and 41% had extended gastrectomies (including esophagus), and 13.6% had dissection of celiac nodes. The operative mortality rate was 7.2%. Staging (American Joint Committee on Cancer [AJCC]) was as follows: I, 17%; II, 17%; III, 36%; and IV, 31%. The overall survival rate reflecting deaths from all causes was 14% among 10,891 patients diagnosed in 1982, and it was 19% in patients having resection. The disease specific survival rate was 26%. The survival rate after resection was 19% and 21% for lower and mid third cancers, 10% for upper third cancers, and 4% if the entire stomach was involved. The stage-related survival rates were 50% (stage I), 29% (stage II), 13% (stage III), and 3% (stage IV). Among patients with pathologically clear margins, the survival rate was 35% versus 13% in those with microscopically involved margins, and it was 3% in those with grossly involved margins.

CONCLUSION

This report of gastric cancer treatment by American College of Surgeons approved institutions in the US provides an overview of the disease as commonly treated throughout the US. Although the results are less favorable than those reported by centers with large institutional experiences with this disease and are inferior to those of the Japanese and other Eastern centers, they suggest potential for increasing survival by upstaging through earlier diagnosis and using resectional techniques demonstrated to more adequately control local regional disease.

Factors predicting failure of medical therapy for gastric ulcers

We reviewed the charts of all patients admitted with a diagnosis of gastric ulcer from January 1970 to December 1980. Multiple risk factors were recorded in patients receiving medical treatment and compared in those patients successfully treated medically versus those requiring operation after a failed course of medical treatment. One hundred patients were treated medically without surgical intervention, and 34 patients underwent operation after medical therapy failed. Significant risk factors in patients requiring operative therapy included smoking (p = 0.03), multiple trauma and sepsis (p = 0.02), large ulcers (p = 0.03), and multiple ulcers (p = 0.02). We have identified a set of factors associated with a high risk of failure of medical therapy. Patients with any of these risk factors may be treated most effectively by a limited trial of medical therapy with close follow-up. If their ulcer disease does not respond readily to standard medical therapy, they should be considered for early elective surgery.

Gastroduodenal ulceration in dogs. Retrospective study of 43 cases and literature review

Forty three dogs with non-neoplastic canine gastric and/or duodenal ulcers were diagnosed at the University of Tennessee Veterinary Teaching Hospital (UTVTH) and reviewed in conjunction with dogs reported in the literature. No age, sex, or breed predilection was found. Most of the 43 UTVTH dogs presented with clinical signs referable to gastrointestinal disease, but evidence of hemorrhage was not always present. Nonregenerative anemia was a common (33/43 dogs) finding. Diagnosis of ulcer disease was made by contrast radiography, with clinical evidence of gastrointestinal hemorrhage, or surgery, endoscopy, or necropsy. Treatment with nonsteroidal, anti-inflammatory drugs (NSAIDs) and hepatic disease were the two most common predisposing factors for ulcer disease. Dogs with liver disease tended to have duodenal ulcers, dogs receiving NSAID treatment tended to have pyloroantral ulcers, and dogs with mastocytosis had ulcers in multiple locations. Three dogs with duodenal ulcers receiving NSAID treatment had an additional predisposing factor. Surgical treatment (with or without medical treatment) had a good outcome when the predisposing factors could be controlled or eliminated. Only 3 of 27 dogs in both the surgical and medically treated groups died from ulcer disease, whereas 6 of 16 dogs in the untreated group died from ulcer disease.

Impact of endoscopy on mortality from occult cancer in radiographically benign gastric ulcers. A probability analysis model

Endoscopy is commonly used in the management of patients with radiographically benign gastric ulcers to detect occult malignancy. Clinical studies examining the cost-effectiveness of using endoscopy in such patients, however, have not been done. To address this issue using probability analysis, a probability tree was designed incorporating the possible clinical courses of patients with radiographically benign gastric ulcers managed with and without endoscopy, and probability estimates for each course were derived by compiling data from the literature. Probability and sensitivity analysis was used to compare the impact on overall mortality rate and cost-effectiveness of six commonly practiced methods of using endoscopy to manage patients with radiographically benign gastric ulcers: (1) all follow-up by upper gastrointestinal x-ray only; (2) endoscopy for nonhealing ulcers only; (3) endoscopy for all ulcers before medical therapy with all follow-up by upper gastrointestinal x-ray; (4) endoscopy for all ulcers after an initial trial of medical therapy; (5) endoscopy for all ulcers before therapy and for nonhealers; (6) endoscopy before therapy, and all follow-up by endoscopy. This analysis predicts that the greatest decrease in mortality rate occurs when endoscopy is used before medical therapy and for all follow-up, reducing the estimated number of deaths per 1000 patients with radiographically benign gastric ulcers from 36.7 with follow-up by upper gastrointestinal x-ray only to 27.2. However, initial endoscopy with all subsequent follow-up by upper gastrointestinal x-ray increased the overall death rate by only a small amount, to 28.0, and was consistently the most cost-effective method, requiring 116 endoscopies and approximately 60,000 diagnostic dollars per additional 5-yr survivor.

A thousand operations for ulcer disease

A retrospective study of 1068 patients who had operations for peptic ulcer disease in the 12-year period from January 1, 1974, to January 1, 1986, permits these conclusions: The number of patients admitted to the Massachusetts General Hospital (MGH) has declined steadily in the years of this study--1974-1986. The average number of patients admitted with a diagnosis of peptic ulcer disease in precimetidine years--1974, 1975, and 1976--and in recent years--1982, 1983, and 1984--shows a decline of 39.3% in admissions. In the same periods, the average number of operations per year has declined from 92 in precimetidine years to an average of 71 (16.5%) recently. The decline has been greatest in patients operated on electively for duodenal ulcer. Operations for massive hemorrhage and acute perforations and the number of deaths have remained nearly constant. The overall mortality rate was 10.3%. The mortality following elective operations for pain was 0.5%; for urgent operations, including those for obstruction, 4.5%, and for bleeding other than massive, 7.5%; and for emergency operations, including those for acute perforation, 20.9%, and for massive hemorrhage, 22.1%. The main causes of death were organ failure (most commonly of the lungs) and sepsis. Early complications were documented 345 times and were followed by reoperation in 84 cases, or 7.4% of the total. Delayed stomal function was noted in 63 cases and required reoperation in 14. It was most common after Roux anastomoses and required operative intervention most commonly after gastric resection, Billroth I (GRBI). Delay was three times as common when vagotomy (V) was added to GR. Early postoperative hemorrhage was a serious complication when it occurred after operations for acute perforations or massive hemorrhage. The incidence was 3.7% after suture of a perforation; after operations for acute massive hemorrhage, it was 4.3% after pyloroplasty and vagotomy, with or without arterial ligation [PV(L)], and 0.3% after GR, with or without arterial ligation [GR(L)]. Late complications led to reoperation in 66 cases (6.2%). The most important were recurrent ulceration and alkaline gastritis. Recurrence rates after a minimum follow-up of 5 years (based on survivors of initial procedures and a second operation, both in the MGH) were 20.5% after suture of a perforation, 6.2% after PV, 2.3% after GRBII, and 0.4% after GRVBII. These figures are lower than expected; incomplete follow-up and improved medical care are factors.(ABSTRACT TRUNCATED AT 400 WORDS)