Clinical characteristics of peptic ulcer perforation in Korea

Changing trends and characteristics of peptic ulcer disease: A multicenter study from 2010 to 2019 in Korea

BACKGROUND

The clinical trend and characteristics of peptic ulcer disease (PUD) have not fully been investigated in the past decade.

AIM

To evaluate the changing trends and characteristics of PUD according to age and etiology.

METHODS

We analyzed seven hospital databases converted into the Observational Medical Outcomes Partnership-Common Data Model between 2010 and 2019. We classified patients with PUD who underwent rapid urease tests or Helicobacter pylori (H. pylori) serology into three groups: H. pylori-related, drug [nonsteroidal anti-inflammatory drugs (NSAIDs) or aspirin]-related, and idiopathic (H. pylori/NSAID/aspirin-negative) PUD and compared the yearly trends and characteristics among the three groups.

RESULTS

We included 26785 patients in 7 databases, and the proportion of old age (≥ 65 years) was 38.8%. The overall number of PUD exhibited no decrease, whereas PUD in old age revealed an increasing trend (P = 0.01 for trend). Of the 19601 patients, 41.8% had H. pylori-related, 36.1% had drug-related, and 22.1% had idiopathic PUD. H. pylori-related PUD exhibited a decreasing trend after 2014 (P = 0.01), drug-related PUD demonstrated an increasing trend (P = 0.04), and idiopathic PUD showed an increasing trend in the old-age group (P = 0.01) during 10 years. Patients with drug-related PUD had significantly more comorbidities and concomitant ulcerogenic drugs. The idiopathic PUD group had a significantly higher number of patients with chronic liver disease.

CONCLUSION

With the aging population increase, the effects of concomitant ulcerogenic drugs and preventive strategies should be investigated in drug-induced PUD. Further studies are required to clarify the relationship between idiopathic PUD and chronic liver disease.

Feasibility and Safety of Mesocolon Excision with Medical Imaging: A Systematic Review and Meta-Analysis

The development of new technologies based on electronic intelligent images is a very active research and promotion of new technologies in recent years. This article mainly summarizes the basic concept, development, and technology of electronic intelligent imaging technology, as well as the research, promotion, and application of electronic intelligent imaging technology in clinical treatment. It especially emphasizes the practicality and application of electronic intelligent imaging technology in the current clinical operation process and conducts a meta-analysis of the current mesorectal excision, so as to provide more scientific and professional guidance for clinical surgery. The results of the meta-analysis showed that 3291 documents were initially obtained and duplicate documents were deleted by searching for keywords in mesocolon excision. We excluded 2399 subjects and articles whose interventions did not meet the inclusion criteria of this study after reading the title and abstract. Then, we obtained 892 papers that may meet the inclusion criteria through preliminary screening. We further optimized the search strategy based on selection criteria and data integrity filtering principles and finally determined 111 references. 100 articles that did not meet the requirements were excluded, and 11 articles were finally included for meta-analysis. Medical imaging can effectively improve the therapeutic effect of mesocolon excision and reduce the occurrence of complications. Therefore, it is very important to combine medical intelligent images for preoperative evaluation, and the development of the combination of surgical treatment and medical images should not be underestimated in the future.

Clinical, endoscopic, and demographic characteristics of idiopathic duodenal ulcers compared with helicobacter pylori positive ulcers

Background

Helicobacter pylori infection is the most common cause of peptic ulcer disease. However, the prevalence rates of non-helicobacter pylori idiopathic peptic ulcers have increased over the past few years. This study aims to compare the characteristics of Helicobacter pylori-positive with idiopathic duodenal ulcers.

Methods

A cross-sectional cohort study was conducted on 950 patients which were excluded from the analysis process duo to the concomitant presence of gastric ulcer, malignancy, Zollinger Ellison syndrome, Crohn's disease, esophageal varices, history of taking anti-Helicobacter pylori therapy, and history of taking NSAID or aspirin. Eventually, 647 subjects were enrolled for the analysis process. In this case, these subjects were divided into two groups: (I) Helicobacter pylori-positive ulcer group and (II) Helicobacter pylori-negative and non-NSAID (idiopathic) ulcer group.

Results

The findings showed that 417 patients (64.5%) had duodenal ulcers induced by Helicobacter pylori, and 111 patients (17.1%) had Helicobacter pylori-negative and non-NSAID ulcers. The mean ages of patients in Helicobacter pylori-positive and idiopathic ulcer groups were 39±15 and 42±17, respectively. In this case, 33 patients (29.7%) with idiopathic ulcers and 56 patients (25.1%) with Helicobacter pylori-positive ulcers had upper gastrointestinal bleeding. Also, 22 patients (21%) with idiopathic ulcers and 31 patients (16.5%) with Helicobacter pylori-positive ulcers had multiple duodenal ulcers.

Conclusion

The present study demonstrated that the idiopathic ulcers included 17.1% of duodenal ulcers. Also, it was concluded that patients with idiopathic ulcers were predominantly male with an age range older than the other group. In addition, patients in this group had more ulcers.

Clinical presentation and surgical management of perforated peptic ulcer in a tertiary hospital in Mogadishu, Somalia: a 5-year retrospective study

Background

Perforated peptic ulcer is a common surgical emergency condition worldwide, which is associated with significant morbidity and mortality if early diagnosis and immediate surgical management were not carried out. Perforation occurs in roughly 5% of PUD patients during their lifetime; this study aimed to explore the wide range of clinical presentations, associated risk factors, complications, and surgical management of perforated peptic ulcer patients.

Methods

A 5-year retrospective observational study on the clinical presentation and surgical management of perforated peptic ulcer is carried out in a tertiary hospital in Mogadishu, Somalia, Department of General Surgery, from January 2017 to December 2021. We included all patients undergoing operations with an intraoperative confirmed diagnosis of perforated peptic ulcer at the general surgery department. For operated patients, follow-up evaluation was performed in the outpatient department.

Results

Fifty-one patients underwent an emergency operation for perforated peptic ulcer during the study period. The sociodemographic distribution of patients was 45 (88.2%) males and 6 (11.8%) females, giving a male-to-female ratio of 7.5:1. The mean age of patients was 35.5 ± 16.8 years, and the peak frequency was in the third decade. The commonest presenting symptoms were sudden onset of severe epigastric pain in 42 (82.4%) patients. Patients who presented perforated peptic ulcer within 24 h of initiation of symptoms were free from complications. Age-group and delayed presentation > 48 h after onset of symptoms were linked to postoperative complications and were statistically significant (P 0.032 and P 0.005), respectively. Four patients died (mortality rate of 7.8%). Two patients were reoperated because of the failed primary repair, and 4 patients had > 5 cm intra-abdominal abscess image-guided percutaneous drainage, and the rest were given antibiotic therapy according to peritoneal fluid culture and sensitivity results. The most common microorganism isolated was E. coli 22% and Klebsiella 11%. Other rare microorganisms (pseudomonas, Staphylococcus aureus, and Candida spp.) were identified. In half (51%) of the patients with peritoneal fluid culture, no microorganism growth was seen.

Conclusion

The distribution of perforated peptic ulcer is common in the young age-group in the third decades of life. Delayed presentation of the disease is linked because most patients arrived from remote areas where proper facilities of health care and health education are not available and the patient might come to the hospital in an advanced stage of the disease. We suggest conducting further researches, health awareness related to complications over-the-counter drugs self-medication, and bad habit including smoking, and to improve health-seeking behaviors of society.

Prevalence of H. Pylori in Perforated Peptic Ulcer Disease at Saint Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia

BACKGROUND

Helicobacter Pylori is the most common cause of peptic ulcer disease with disputable association with perorated Peptic Ulcer disease (PPD). This study aims to determine magnitude of Helicobacter Pylori in PPD and the outcomes of treatment, at Saint Paul Hospital Millennium Medical College (SPHMMC).

METHOD

Between January 9, 2013 and February 7, 2018, all patients operated for PPD were recruited retrospectively. Data was extracted from patient's medical records using pretested questionnaire. Data analysis was done by SPSS version 20.

RESULT

During the 5 years, 46 patients fulfilling inclusion criteria were included in the study. H. Pylori test was positive for stool antigen in 10 (21.7%) and serology eleven (23.9 %) of patients. Overall, nineteen (41.3%) of patients had positive result regardless of the type of test used. Out of 46 patients, twenty-six (56.5%) patients were given eradication therapy and thirty-four (73.9%) patients were given PPI alone or as a part of eradication therapy. During their hospital stay, five (10.9%) patients developed deep and superficial surgical site infection and two (4.3%) of patients have died.

CONCLUSION

The prevalence of H. Pylori among PPD patients in this study is lower compared to most studies. Further prospective studies should be conducted in the future to understand association with H. Pylori and provide recommendations on eradication treatment.

Clinical Characteristics of Primary Repair for Perforated Peptic Ulcer: 10-Year Experience in a Single Center

Background: Perforated peptic ulcer (PPU) is a disease whose incidence is decreasing. However, PPU still requires emergency surgery. The aim of this study was to review the clinical characteristics of patients who received primary repair for PPU and identify the predisposing factors associated with severe complications. Method: From January 2011 to December 2020, a total of 75 patients underwent primary repair for PPU in our hospital. We reviewed the patients’ data, including general characteristics and perioperative complications. Surgical complications were evaluated using the Clavien-Dindo Classification (CDC) system, with which we classified patients into the mild complication (CDC 0–III, n = 61) and severe complication (CDC IV–V, n = 14) groups. Result: Fifty patients had gastric perforation, and twenty-five patients had duodenal perforation. Among surgical complications, leakage or fistula were the most common (5/75, 6.7%), followed by wound problems (4/75, 5.3%). Of the medical complications, infection (9/75, 12%) and pulmonary disorder (7/75, 9.3%) were common. Eight patients died within thirty days after surgery (8/75, 10.7%). Liver cirrhosis was the most significant predisposing factor for severe complications (HR = 44.392, p = 0.003). Conclusion: PPU is still a surgically important disease that has significant mortality, above 10%. Liver cirrhosis is the most important underlying disease associated with severe complications.

Platelet to Lymphocyte Ratio Associated with Prolonged Hospital Length of Stay Postpeptic Ulcer Perforation Repair: An Observational Descriptive Analysis

BACKGROUND

The predictive role of platelet to lymphocyte ratio (P/LR) in patients with perforated peptic ulcer (PPU) is not well-studied. We aimed to investigate the association between the P/LR ratio and the hospital length of stay (HLOS) for surgically treated PPU.

METHOD

This is a retrospective observational study for surgically treated adult cases of PPU at Hamad Medical Corporation during the period from January 2012 to August 2017. Patients were categorized into two groups based on their HLOS (I week). The receiver operating characteristic (ROC) curve was plotted to determine the cutoff value for lymphocyte count, neutrophil to lymphocyte ratio, and P/LR ratio for predicting the prolonged hospitalization.

RESULTS

One hundred and fifty-two patients were included in the study. The majority were young males. The mean age was 38.3 ± 12.7 years. Perforated duodenal ulcer (139 patients) exceeded perforated gastric ulcer (13 patients). The HLOS > 1 week was observed in 14.5% of cases. Older age (p = 0.01), higher preoperative WBC (p = 0.03), lower lymphocyte count (p = 0.01), and higher P/LR ratio (p = 0.005) were evident in the HLOS > 1 week group. The optimal cutoff value of P/LR was 311.2 with AUC 0.702 and negative predictive value of 93% for the prediction of prolonged hospitalization. Two patients died with a mean P/LR ratio of 640.8 ± 135.5 vs. 336.6 ± 258.9 in the survivors.

CONCLUSION

High preoperative P/LR value predicts prolonged HLOS in patients with repaired perforated peptic ulcer. Further larger multicenter studies are needed to support the study findings.

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Clinical Guidelines for Drug-Related Peptic Ulcer, 2020 Revised Edition

Korean guidelines for nonsteroidal anti-inflammatory drug (NSAID)-induced peptic ulcer were previously developed in 2009 with the collaboration of the Korean College of Helicobacter and Upper Gastrointestinal Research and Korean Society of Gastroenterology. However, the previous guidelines were based mainly upon a review of the relevant literature and expert opinion. Therefore, the guidelines need to be revised. We organized a guideline Development Committee for drug-related peptic ulcer under the auspices of the Korean College of Helicobacter and Upper Gastrointestinal Research in 2017 and developed nine statements, including four for NSAIDs, three for aspirin and other antiplatelet agents, and two for anticoagulants through a de novo process founded on evidence-based medicine that included a literature search and a meta-analysis, A consensus was reached through the application of the modified Delphi method. The primary target of these guidelines is adult patients undergoing long-term treatment with NSAIDs, aspirin or other antiplatelet agents and anticoagulants. The revised guidelines reflect the expert consensus and is intended to assist clinicians in the management and prevention of druginduced peptic ulcer and associated conditions.

[Clinical Guidelines for Drug-induced Peptic Ulcer, 2020 Revised Edition]

The Korean guidelines for nonsteroidal anti-inflammatory drug (NSAID)-induced peptic ulcers were previously developed under co-work with the Korean College of Helicobacter and Upper Gastrointestinal Research and Korean Society of Gastroenterology at 2009. On the other hand, the previous guidelines were based mainly on a literature review and expert opinions. Therefore, the guidelines need to be revised. In this study, a guideline development committee for drug-induced peptic ulcers was organized under the Korean College of Helicobacter and Upper Gastrointestinal Research in 2017. Nine statements were developed, including four for NSAID, three for aspirin and other antiplatelet agents, and two for anticoagulants through de novo processes based on evidence-based medicine, such as a literature search, meta-analysis, and the consensus was established using the modified Delphi method. The primary target of this guideline was adult patients taking long-term NSAIDs, aspirin, or other antiplatelet agent and anticoagulants. The revised guidelines reflect the consensus of expert opinions and are intended to assist relevant clinicians in the management and prevention of drug-induced peptic ulcers and associated conditions.

Clinical comparative analysis of various duodenal diseases in different age groups

BACKGROUND/AIMS

This study aimed to investigate the differences and relevance of various common duodenal diseases in different parts in the aspects of age, gender, helicobacter pylori (H. pylori) infection, application of nonsteroidal anti-inflammatory drugs (NSAIDs), smoking, or alcohol consumption.

MATERIALS AND METHODS

The medical records of various duodenal diseases were collected and tested for difference using the χ2 test or the Fisher exact probability method.

RESULTS

1) The proportions of duodenal ulcer (DU), inflammation, and duodenal bulb diseases in the adult group (A) (47.98%, 36.70%, and 66.63%) were higher than those in the elderly group (E) (41.38%, 29.83%, and 56.82%), but the proportions of duodenal diverticulum (DD) and tumor diseases in the descending and ascending segments (2.95%, 1.43%, 9.14%, and 0.14%) were lower than those in group E (13.73%, 3.69%, 19.41%, and 0.76%) (p<0.001). 2) The positive rate of H. pylori (63.64%) in the duodenal bulb diseases was higher than that in the bulb-descending segment (53.75%), but the application rate of NSAIDs (16.44%) in the duodenal bulb-descending diseases was lower than that in the descending segment (24.81%) (p<0.001).

CONCLUSION

1) DU, inflammation, and duodenal bulb diseases are common in adults, but DD and tumor diseases in the descending and ascending segments are more common in the elderly. 2) Compared with the duodenal bulb-descending diseases, the application of NSAIDs has greater impact on the diseases in the descending segment, and the rate of H. pylori infection is higher in duodenal bulb diseases.

Analysis of risk factors affecting the development of peptic ulcer perforation: case-control study

AIM

The aim of the to determine the risk factors associated with increased risk of peptic ulcer perforation (PUP).

MATERIAL AND METHODS

The demographic, clinic, and biochemical parameters of 65 patients (PUP group) who underwent PUP surgery at our clinic between June 2009 and September 2016 were compared with the data of 134 patients (control group) who underwent endoscopy at a gastroenterology clinic for dyspeptic complaints. The control group were matched at random in a 1 : 2 ratio with the PUP group. Univariate analyses were used to compare different variables and variables with clinical significance, and p ≤ 0.05 was used in the backward stepwise logistic regression model.

RESULTS

This study included 65 patients with peptic ulcer perforation aged 17 to 92 years (PUP group) and 134 patients with dyspeptic complaints aged 18 to 87 years (control group). Univariate analysis showed that statistically significant differences were found between groups in terms of non-steroidal anti-inflammatory drugs usage (p = 0.042; OR = 1.868), smoking (p < 0.001; OR = 5.124), old age (p = 0.003), low body mass index (BMI) (p < 0.001), and low hemoglobin (Hb) (p = 0.002). However multivariate analysis showed that increasing age (p = 0.004; OR = 1.035), smoking (p = 0.007; OR = 3.591), decreasing Hb (p = 0.042; OR = 1.277), and decreasing BMI (p < 0.001; OR = 1.669) were independent clinically significant risk factors for development of PUP.

CONCLUSIONS

This study showed that decreased BMI, decreased Hb, increased age, and smoking were independent risk factors for development of PUP. Thus, this group of patients needs particular attention paid to suggestive symptoms with early diagnosis and optimal management of peptic ulcer disease.

Efficacy and safety of Syferol-IHP for the treatment of peptic ulcer disease: a pilot, double-blind randomized trial

Background

To our knowledge, there is no prior randomized study on the utility of Syferol-IHP (blend of virgin coconut oil and Ocimum sanctum oil) when coadministered with a triple therapy schedule.

Aim

This study determined the efficacy and safety of Syferol-IHP as adjunct to conventional triple therapy for the treatment of peptic ulcer disease (PUD).

Methods

A pilot double-blind randomized trial was conducted in patients with confirmed diagnosis (endoscopy-guided biopsy) of PUD. Eligible patients were randomized to Pylorest (a three-in-one tablet containing rabeprazole 20 mg, amoxicillin 1 g, and clarithromycin 500 mg) and Syferol-IHP for 2 weeks, followed by rabeprazole and Syferol-IHP for 2 weeks or Pylorest and placebo for 2 weeks, followed by rabeprazole and placebo for 2 weeks. Repeat endoscopy-guided biopsy and histology were done 4 weeks posttherapy. Primary outcome measures were the healing of ulcer and eradication of Helicobacter pylori. Secondary outcome measures were the disappearance of epigastric pain, gastritis, and duodenitis. Analysis was by intention-to-treat.

Results

Of the 63 patients enrolled, 60 patients had complete evaluation, with 37 patients receiving Pylorest and Syferol-IHP and 23 patients receiving Pylorest and Placebo. Healing of the PUD in favor of Pylorest and Syferol-IHP was significantly higher for gastric ulcer (RR=0.000, 95% CI=undefined, P=0.048) but not for duodenal ulcer (RR=0.400, 95% CI=0.07–2.37, P=0.241). H. pylori eradication was 100% with Syferol-IHP vs 50% with placebo (P=0.066). Epigastric pain (reduction to 16.2% vs 43.5%; P=0.021), gastritis (reduction to 13.5% vs 39.1%; P = 0.024), and duodenitis (reduction to 0% vs 8.7%; P=0.327) were observed in the Syferol-IHP and Pylorest vs placebo and Pylorest groups, respectively. Adverse events (RR=0.971, 95% CI=0.46–2.04, P=0.937) and laboratory parameters were not significantly different pre- and posttherapies (P>0.05, for both groups).

Conclusion

Although both treatment arms were equally safe, co-administration of Syferol-IHP and triple therapy is more efficacious than triple therapy alone for treating PUD. Pan African Clinical trial registry identifier number is PACTR201606001665364.

Helicobacter pylori and nonmalignant upper gastrointestinal diseases

The review of the most important recent publications concerning the relation of Helicobacter pylori with peptic ulcer disease (PUD), noninvestigated and functional dyspepsia, and gastroesophageal reflux disease (GERD) is presented. H. pylori remains the main etiopathogenetic factor in complicated and uncomplicated PUD. Nevertheless, the role of nonsteroidal anti-inflammatory drugs (NSAIDs) and aspirin is increasing. The novel data did not confirm that PUD caused by NSAIDs and aspirin is less symptomatic. The role of glucocorticoids, immunosuppressants, and antidepressants seems to be of some importance. Although the involvement of H. pylori in functional dyspepsia is controversial, several data support the importance of H. pylori-induced gastritis in the pathogenesis of dyspeptic symptoms. Recent interventional studies have reported that H. pylori eradication improves dyspepsia mainly in areas with a high prevalence of this bacterium. Novel data regarding the relation of gastrointestinal peptides, ghrelin and obestatin, with H. pylori infection are also presented. Intriguing findings support the involvement of the gastric microbiota in the causation of chronic functional dyspepsia. Finally, some data concerning negative, positive, or neutral associations of H. pylori with gastroesophageal reflux disease (GERD) were published. In this context, today there is no evidence indicating that H. pylori eradication could worsen the symptoms or the course of GERD.