Association between clinical manifestations of complicated and uncomplicated peptic ulcer and visceral sensory dysfunction

Valentino's syndrome: Simulation of acute appendicitis in the context of peptic ulcer perforation. Case report and literature review

INTRODUCTION AND IMPORTANCE

Abdominal pain (AP) is one of the main reasons for consultation in the emergency department worldwide. The causes of AP are gathered in a broad group of pathologies whose incidence and prevalence vary according to various factors. The great importance of an adequate approach to AP lies in ruling out or confirming the presence of acute abdomen that requires emergency surgical management. Valentino's Syndrome (VS) simulates the clinical manifestations of acute appendicitis whose origin is the perforation of a peptic ulcer. This is an infrequent entity, with very few reports in the literature, this being the second case reported in Colombia.

CASE PRESENTATION

We present a case of VS in a 59-year-old male patient who was admitted to the emergency department with 3 days of pain in the right iliac fossa that met the diagnostic criteria for acute appendicitis. However, upon surgical exploration, it was determined that the cause was secondary to peptic ulcer perforation (PPU).

DISCUSSION

PPU is one of the most infrequent complications of the disease, occurring in close to 10 % of cases, and is considered a surgical emergency. Minimally invasive surgery provides a significant benefit over open surgery, outcomes that directly lead to decreased healthcare costs and increased patient satisfaction.

CONCLUSION

PPU represents a diagnostic challenge due to the variability of the symptoms and clinical features. Laparoscopic approach fulfills diagnostic and therapeutic roles with lesser morbidity and mortality rates, which is why it should be standardized. Malignancy should be ruled out in all cases.

Complete symptom resolution as predictor of Helicobacter pylori eradication and factors affecting symptom resolution: Prospective follow up study

BACKGROUND

Symptom resolution is the most common clinical practice during assessment and evaluation of helicobacter pylori infected patients after employing eradication therapy.

OBJECTIVE

Prediction of eradication of H. pylori with symptom resolution and assess factors affecting symptom resolution.

METHOD

Facility based follow up study was done on consented H. pylori positive adult patients who received standard triple therapy consisting of a proton pump inhibitor, amoxicillin, and clarithromycin from May 2016 to April 2018 at Bahir Dar city in Ethiopia. Sociodemographic and clinical data was collected before and after eradication therapy by using pre-developed structured questionnaire. Both positive and negative predictive values were calculated. SPSS version 23 was used to conduct bivariate and backward stepwise multivariate logistic regression to analyze data. P-value < 0.05 at 95%CI was considered as significant.

RESULT

The study involved a total of 421 patients who completed follow up. Patients' mean age and body weight (±SD) were 30.63 (± 10.74) years and 56.71 (± 10.19) kg, respectively. Complete symptom resolution was achieved in 84.3% of the patients and eradication of H. pylori was successful in 90% of patients. Positive predictive value of complete symptom resolution for H. pylori eradication was 98.9% (351/355) and whereas negative predictive value was 57.6%(38/66). Factors associated with complete symptom resolution were regimen completion (AOR: 2.77 95%CI (1.12-6.86), p = 0.028) and no use of traditional homemade supplements prepared from Fenugreek or Flaxseed (AOR: 2.09 95%CI (1.22-3.58), p = 0.007).

CONCLUSION

Complete symptom resolution is a powerful predictor of success of H. pylori eradication and can be used to assess H. pylori status after eradication therapy. Assessment of complete symptom resolution should consider regimen completion and traditional practice of using homemade supplements prepared from Fenugreek or Flaxseed.

Gastroprotective and Healing Effects of Polygonum cuspidatum Root on Experimentally Induced Gastric Ulcers in Rats

Polygonum cuspidatum is widely used as food and medicine in Korea, China, and Japan. Its major bioactive components, resveratrol and emodin, reportedly protect against gastric lesions. We therefore aimed to investigate: (1) the gastroprotective effects of P. cuspidatum roots in hydrochloric acid/ethanol (HCl/EtOH)- and indomethacin-induced acute gastric ulcer rat models; (2) the healing effects in an acetic acid-induced ulcer model; and (3) potential mechanisms by measuring gastric acid secretion-related parameters in a pyloric ligation-induced ulcer model, and by measuring antioxidant enzyme and prostaglandin E₂ levels in the gastric tissue of HCl/EtOH-treated rats. Oral administration of P. cuspidatum extract (PCE) at doses of 100 and 300 mg/kg significantly decreased HCl/EtOH- and indomethacin-induced gastric lesions. PCE at 300 mg/kg significantly reduced gastric lesions in acetic acid-induced ulcers. PCE increased superoxide dismutase (SOD)activity and glutathione(GSH) and prostaglandin E₂ levels in gastric tissue, whereas it did not alter gastric acid secretion-related parameters. Our findings indicate that PCE has gastroprotective effects against HCl/EtOH and non-steroidal anti-inflammatory drugs(NSAIDs) and promotes healing of acetic acid-induced ulcers. These gastric mucosal protection and ulcer healing effects are associated with antioxidant effects and the augmentation of prostaglandin E₂ and suggest that P. cuspidatum might be a promising preventive and therapeutic agent for treating gastric ulcers.

The influence of the Chuyou Yuyang granule on the Toll-like receptor/nuclear factor-κB signal pathway in Helicobacter pylori-positive peptic ulcer patients

BACKGROUND

The cure rate of Helicobacter pylori (HP)-positive peptic ulcer has appeared to downward trend, and the resistance of the ulcer relapse has become a hot issue.

METHODS

Hematoxylin and eosin staining was used to detect the repair of the damaged tissues in patients after treatment with the Chuyou Yuyang granule (CYYY). Elisa was used to analyze the expression of cytokine interleukin 18 (IL-18) and tumor necrosis factor α (TNF-α) in the patients' serum. Western blot analysis was used to explore the mechanism of the CYYY. Reverse-transcription polymerase chain reaction (RT-PCR) was used to detect the expression of microRNA-155a (miR-155a) and miR-146a in the blood of the patients and to confirm whether CYYY could cure peptic ulcer through regulation of miR-155a and miR-146a.

RESULTS

The damaged gastric mucosal tissues of ulcer patients were significantly repaired by treating with CYYY. The pro-inflammatory cytokine IL18 and TNF-α were notably repressed after treating with CYYY. In addition, CYYY played a key role in regulation of the Toll-like receptor (TLR4)/nuclear factor-κB (NF-κB) signal pathway and the expression of miR-155a and miR-146a.

CONCLUSION

CYYY was a highly effective therapeutic method for peptic ulcer patients by inhibiting the activation of the TLR4/NF-κB signal pathway and suppressing the expression of miR-155a and miR-146a.

The stomach in health and disease

The stomach is traditionally regarded as a hollow muscular sac that initiates the second phase of digestion. Yet this simple view ignores the fact that it is the most sophisticated endocrine organ with unique physiology, biochemistry, immunology and microbiology. All ingested materials, including our nutrition, have to negotiate this organ first, and as such, the stomach is arguably the most important segment within the GI tract. The unique biological function of gastric acid secretion not only initiates the digestive process but also acts as a first line of defence against food-borne microbes. Normal gastric physiology and morphology may be disrupted by Helicobacter pylori infection, the most common chronic bacterial infection in the world and the aetiological agent for most peptic ulcers and gastric cancer. In this state-of-the-art review, the most relevant new aspects of the stomach in health and disease are addressed. Topics include gastric physiology and the role of gastric dysmotility in dyspepsia and gastroparesis; the stomach in appetite control and obesity; there is an update on the immunology of the stomach and the emerging field of the gastric microbiome. H. pylori-induced gastritis and its associated diseases including peptic ulcers and gastric cancer are addressed together with advances in diagnosis. The conclusions provide a future approach to gastric diseases underpinned by the concept that a healthy stomach is the gateway to a healthy and balanced host. This philosophy should reinforce any public health efforts designed to eradicate major gastric diseases, including stomach cancer.

Gastrointestinal causes of abdominal pain

Gastrointestinal causes of abdominal pain are numerous. These causes are reviewed in brief here, divided into 2 categories: acute abdominal pain and chronic abdominal pain. They are further subcategorized by location of pain as it pertains to the abdomen.

Complicated and uncomplicated peptic ulcer disease: altered symptom response to a nutrient challenge linked to gastric motor dysfunction

BACKGROUND

Bleeding peptic ulcer (BPU) frequently occurs in the absence of preceding dyspeptic symptoms. We have observed that patients with BPU had a diminished symptom response to nutrient challenge test compared to uncomplicated peptic ulcer disease (uPUD). We postulated that more symptoms are manifest in patients with uPUD than BPU because there are greater derangements in gastric motor function.

AIM

To assess gastric emptying in patients with BPU, uPUD and healthy controls (HC).

METHODS

We studied 17 patients with BPU, 10 with uPUD, and 15 HC. After an 8-hour fast, subjects ingested 200 ml of an enteral feeding solution, containing 5 MBq (99m)Tc-rhenium sulphide colloid, every 5 min up to a cumulative volume of 800 ml. Gastric emptying was measured by scintigraphy for the total, proximal and distal stomach.

RESULTS

Patients with uPUD had significantly higher gastric retention in the proximal and total stomach at 100 min than HC and BPU, while BPU had similar percent retention to HC. Patients with uPUD had significantly higher cumulative symptom response to the nutrient challenge than did HC and BPU, while BPU had similar symptom responses to HC.

CONCLUSIONS

Patients with uPUD have significantly delayed gastric emptying compared to HC and BPU. Data suggest that in addition to alterations of visceral sensory function, altered gastric motor function occurs during a nutrient challenge in uPUD but not BPU. Gastric motor function may contribute to the manifestation of dyspeptic symptoms in PUD.

The stomach-brain axis

The stomach has distinct functions in relation to the ingestion and handling of solids and liquids. These functions include storage of the food before it is gradually emptied into the duodenum, mechanical crushing of larger food particles to increase the surface area, secretion of an acidic enzyme rich gastric juice and mixing the ingested food with the gastric juice. In addition, the stomach 'senses' the composition of the gastric content and this information is passed via the vagal nerve to the lateral hypothalamus and the limbic system, most likely as palatability signals that influence eating behaviour. Other sensory qualities related to the stimulation of gastric tension receptors are satiety and fullness. Receptors that respond to macronutrient content or gastric wall tension influence appetite and meal related hormone responses. The ingestion of food - in contrast to an infusion of nutrients into the stomach - has distinct effects on the activation of specific brain regions. Brain areas such as thalamus, amygdala, putamen and praecuneus are activated by the ingestion of food. Gastric nutrient infusion evokes greater activation in the hippocampus and anterior cingulate. The brain integrates these interrelated neural and hormonal signals arising from the stomach as well as visual, olfactory and anticipatory stimuli that ultimately influence eating and other behavioural patterns. Furthermore, there is now good evidence from experimental studies that gastric afferents influence mood, and animal studies point towards the possibility that gastric dysfunction may be a risk factor for mood disorders such as anxiety and depression. The stomach is also not only colonised by Helicobacter pylori but a large array of bacteria. While there is sufficient evidence to suggest that H. pylori may alter caloric intake and mood, the role of other gastric microbiome for the brain function is unknown. To address this appropriate targeted gastric microbiome studies would be required instead of widely utilised opportunistic stool microbiome studies. In summary, it is now well established that there are important links between the brain and the stomach that have significant effects on gastric function. However, the stomach also influences the brain. Disturbances in the crosstalk between the stomach and the brain may manifest as functional GI disorders while disturbances in the stomach-brain communication may also result in an altered regulation of satiety and as a consequence may affect eating behaviour and mood. These observations may enable the identification of novel therapies targeted at the gastroduodenum that positively alter brain function and treat or prevent conditions such as obesity or functional gastrointestinal disorders.

Delayed massive bleeding two years after Roux-en-Y gastric bypass

Delayed massive bleeding from an ischemic ulcer after Roux-en-Y gastric bypass is a rare and challenging event for the gastroenterologist as well as the bariatric surgeon.

Introduction:

Delayed massive bleeding from an ischemic ulcer is a complication after Roux-en-Y gastric bypass (RYGB). Ischemic ulcers that present with massive bleeding are rare and challenging for the gastroenterologist as well as the bariatric surgeon.

Case Description:

This report reviews the case of a 63-year-old man who underwent an uncomplicated laparoscopic RYGB for morbid obesity and experienced two episodes of massive hemorrhage after the procedure, almost 1 year apart.

Conclusion:

To our knowledge, there are only a few such specific cases reported. Here, we describe the treatment and outcome for such a case and present a review of the literature.