The Evolutionary Profile of Patients Operated for Peptic Ulcer Perforation in Bujumbura

Background: The evolutionary profile of patients operated for peptic ulcer perforation in Bujumbura. Perforated peptic ulcer is a serious complication of peptic ulcer with potential risk of grave complications. Aim: To study the early morbidity and mortality of surgery for peptic ulcer perforation in Bujumbura City Hall hospitals: Kamenge University Hospital Center (CHUK), Kamenge Military Hospital (HMK) and Prince Louis Rwagasore Clinic (CPLR). Patients and methods: This is a retrospective, descriptive and analytical study carried out in the three hospitals of Bujumbura over a period of three years from January 1, 2020 to December 31, 2022. It involved 57 cases (n = 57) of peptic ulcer perforation. Results: The frequency of surgery for peptic ulcer perforation was 2.7% with a mean age of 43.6 years +/- 15.3 years and a male predominance with a sex ratio of 3.7. Eight percent of patients presented with shock, 24.5% were smokers, and 67.9% had taken non steroidal anti-inflammatory drugs. The mean hospital stay was 15.2 days with a standard deviation of 12.1. The morbidity rate was 30.2%, 32% were classified in grade IIIb of the Clavien-Dindo Surgical Complications Scale. There were 9 deaths (17%). Seven patients who underwent surgery and received late consultations died. Conclusion: Surgery for peptic ulcer perforation remains an intervention associated with a high rate of morbidity and mortality in Bujumbura. Surgery for peptic ulcer perforation remains a procedure associated with a high morbidity and mortality rate in Bujumbura. The time before consultation was the only factor associated with early morbidity and mortality of Surgery for peptic ulcer’s perforations.

Gastrointestinal contrast-enhanced ultrasonography for diagnosis and treatment of peptic ulcer in children

BACKGROUND The detection rate of peptic ulcer in children is improving,with development of diagnostic procedures.Gastroscopy is the gold standard for the diagnosis of peptic ulcer,but it is an invasive procedure.Gastrointestinal contrast-enhanced ultrasonography(CEUS)has the advantages of being painless,noninvasive,nonradioactive,easy to use,and safe.AIM To investigate the clinical value of CEUS for diagnosis and treatment of peptic ulcer in children.METHODS We investigated 43 children with digestive tract symptoms in our hospital from January 2021 to June 2022.All children were examined by routine ultrasound,gastrointestinal CEUS,and gastroscopy.The pathological results of gastroscopy were taken as the gold standard.Routine ultrasonography was performed before gastrointestinal CEUS.Conventional ultrasound showed the thickness of the gastroduodenal wall,gastric peristalsis,and the adjacent organs and tissues around the abdominal cavity.Gastrointestinal CEUS recorded the thickness of the gastroduodenal wall;the size,location and shape of the ulcer;gastric peristalsis;and adjacent organs and tissues around the abdominal cavity.The results of routine ultrasound and gastrointestinal ultrasound were compared with those of gastroscopy to evaluate the diagnostic results and coincidence rate of routine ultrasound and gastrointestinal CEUS.All children received informed consent from their guardians for CEUS.This study was reviewed and approved by the hospital medical ethics committee.RESULTS Among the 43 children,17(15 male,2 female)were diagnosed with peptic ulcer by gastroscopy.There were 26 children with nonpeptic ulcer.There were eight cases of peptic ulcer and 35 of nonpeptic ulcer diagnosed by conventional ultrasound.The diagnostic coincidence rate of peptic ulcer in children diagnosed by conventional ultrasound was 79.1%(34/43),which was significantly different from that of gastroscopy(P=0.033).It indicates that the coincidence rate of gastrointestinal contrast-enhanced ultrasound and gastroscope is low.Fifteen cases of peptic ulcer and 28 of nonpeptic ulcer were diagnosed by CEUS.The diagnostic coincidence rate of peptic ulcer in children was 95.3%(41/43).There was no significant difference between CEUS and gastroscopy(P=0.655).It indicates that the coincidence rate of gastrointestinal contrast-enhanced ultrasound and gastroscope is high.CONCLUSION Gastrointestinal CEUS has a high coincidence rate in the diagnosis of peptic ulcer in children,and can be used as a preliminary examination method.

Role of second look endoscopy in endoscopic submucosal dissection and peptic ulcer bleeding:Meta-analysis of randomized controlled trials

BACKGROUND Second-look endoscopy(SLE)to prevent recurrent bleeding in patients with peptic ulcer disease(PUD)and those undergoing endoscopic submucosal dissection(ESD)is routinely being performed.Conflicting evidence exists regarding efficacy,risk,benefit,and cost-effectiveness.AIM To identify the role and effectiveness of SLE in ESD and PUD,associated rebleeding and PUD-related outcomes like mortality,hospital length of stay,need for endoscopic or surgical intervention and blood transfusions.METHODS A systematic review of literature databases PubMed,Cochrane,and Embase was conducted from inception to January 5,2023.Randomized controlled trials that compared patients with SLE to those who did not have SLE or evaluated the role of prophylactic hemostasis during SLE compared to other conservative interventions were included.The study was conducted per PRISMA guidelines,and the protocol was registered in PROSPERO(ID CRD42023427555:).RevMan was used to perform meta-analysis,and Mantel-Haenszel Odds ratio(OR)were generated using random effect models.RESULTS A total of twelve studies with 2687 patients were included in our systematic review and meta-analysis,of which 1074 patients underwent SLE after ESD and 1613 patients underwent SLE after PUD-related bleeding.In ESD,the rates of rebleeding were 7%in the SLE group compared to 4.4%in the non-SLE group with OR 1.65,95%confidence intervals(CI)of 0.96 to 2.85;P=0.07,whereas it was 11%in the SLE group compared to 13%in the non-SLE group with OR 0.895%CI:0.50 to 1.29;P=0.36.The mean difference in the blood transfusion rates in the SLE and no SLE group in PUD was OR 0.01,95%CI:-0.22 to 0.25;P=0.91.In SLE vs non-SLE groups with PUD,the OR for Endoscopic intervention was 0.29,95%CI:0.08 to 1.00;P=0.05 while it was OR 2.03,95%CI:0.95 to 4.33;P=0.07,for surgical intervention.The mean difference in the hospital length of stay was-3.57 d between the SLE and no SLE groups in PUD with 95%CI:-7.84 to 0.69;P=0.10,denoting an average of approximately 3 fewer days of hospital stay among patients with PUD who underwent SLE.For mortality between SLE and non-SLE groups in PUD,the OR was 0.88,95%CI:0.45 to 1.72;P=0.70.CONCLUSION SLE does not confer any benefit in preventing ESD and PUD-associated rebleeding.SLE also does not provide any significant improvement in mortality,need for interventions,or blood transfusions in PUD patients.SLE decreases the hospital length of stay on average by 3.5 d in PUD patients.

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 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.pylorirelated 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.

Peptic ulcer disease in non-alcoholic fatty liver disease hospitalizations:A new challenge on the horizon in the United States

BACKGROUND Peptic ulcer disease(PUD)is frequently seen in patients with liver cirrhosis.However,current literature lacks data on PUD in non-alcoholic fatty liver disease(NAFLD)hospitalizations.AIM To identify trends and clinical outcomes of PUD in NAFLD hospitalizations in the United States.METHODS The National Inpatient Sample was utilized to identify all adult(≥18 years old)NAFLD hospitalizations with PUD in the United States from 2009-2019.Hospitalization trends and outcomes were highlighted.Furthermore,a control group of adult PUD hospitalizations without NAFLD was also identified for a comparative analysis to assess the influence of NAFLD on PUD.RESULTS The total number of NAFLD hospitalizations with PUD increased from 3745 in 2009 to 3805 in 2019.We noted an increase in the mean age for the study population from 56 years in 2009 to 63 years in 2019(P<0.001).Racial differences were also prevalent as NAFLD hospitalizations with PUD increased for Whites and Hispanics,while a decline was observed for Blacks and Asians.The all-cause inpatient mortality for NAFLD hospitalizations with PUD increased from 2%in 2009 to 5%in 2019(P<0.001).However,rates of Helicobacter pylori(H.pylori)infection and upper endoscopy decreased from 5%in 2009 to 1%in 2019(P<0.001)and from 60%in 2009 to 19%in 2019(P<0.001),respectively.Interestingly,despite a significantly higher comorbidity burden,we observed lower inpatient mortality(2%vs 3%,P=0.0004),mean length of stay(LOS)(11.6 vs 12.1 d,P<0.001),and mean total healthcare cost(THC)($178598 vs$184727,P<0.001)for NAFLD hospitalizations with PUD compared to non-NAFLD PUD hospitalizations.Perforation of the gastrointestinal tract,coagulopathy,alcohol abuse,malnutrition,and fluid and electrolyte disorders were identified to be independent predictors of inpatient mortality for NAFLD hospitalizations with PUD.CONCLUSION Inpatient mortality for NAFLD hospitalizations with PUD increased for the study period.However,there was a significant decline in the rates of H.pylori infection and upper endoscopy for NAFLD hospitalizations with PUD.After a comparative analysis,NAFLD hospitalizations with PUD had lower inpatient mortality,mean LOS,and mean THC compared to the non-NAFLD cohort.

Retrospective Study Efficacy of pantoprazole plus perforation repair for peptic ulcer and its effect on the stress response

BACKGROUND Peptic ulcer(PU)is an abnormal phenomenon in which there is rupture of the mucosa of the digestive tract,which not only affects patients'normal life but also causes an economic burden due to its high medical costs.AIM To investigate the efficacy of pantoprazole(PPZ)plus perforation repair in patients with PU and its effect on the stress response.METHODS The study subjects were 108 PU patients admitted between July 2018 and July 2022,including 58 patients receiving PPZ plus perforation repair[research group(RG)]and 50 patients given simple perforation repair[control group(CG)].The efficacy,somatostatin(SS)concentration,stress reaction[malondialdehyde(MDA),lipid peroxide(LPO)],inflammatory indices[tumor necrosis factor(TNF)-α,C-reactive protein(CRP),interleukin(IL)-1β],recurrence,and complications(perforation,hemorrhage,and pyloric obstruction)were compared.RESULTS The overall response rate was higher in the RG than in the CG.Patients in the RG and IL-1β were significantly reduced to lower levels than those in the CG.Lower recurrence and complication rates were identified in the RG group.CONCLUSION Therefore,PPZ plus perforation repair is conducive to enhancing treatment outcomes in PU patients,reducing oxidative stress injury and excessive inflammatory reactions,and contributing to low recurrence and complication rates.

Low serum albumin may predict poor efficacy in patients with perforated peptic ulcer treated nonoperatively

BACKGROUND Nonoperative management(NOM)is a promising therapeutic modality for patients with perforated peptic ulcer(PPU).However,the risk factors for poor efficacy and adverse events of NOM are a concern.AIM To investigate the factors predictive of poor efficacy and adverse events in patients with PPU treated by NOM.METHODS This retrospective case-control study enrolled 272 patients who were diagnosed with PPU and initially managed nonoperatively from January 2014 to December 2018.Of these 272 patients,50 converted to emergency surgery due to a lack of improvement(surgical group)and 222 patients were included in the NOM group.The clinical data of these patients were collected.Baseline patient characteristics and adverse outcomes were compared between the two groups.Logistic regression analysis and receiver operating characteristic curve analyses were conducted to investigate the factors predictive of poor efficacy of NOM and adverse outcomes in patients with PPU.RESULTS Adverse outcomes were observed in 71 patients(32.0%).Multivariate analyses revealed that low serum albumin level was an independent predictor for poor efficacy of NOM and adverse outcomes in patients with PPU.CONCLUSION Low serum albumin level may be used as an indicator to help predict the poor efficacy of NOM and adverse outcomes,and can be used for risk stratification in patients with PPU.

Risk factors and therapeutic response in Chinese patients with peptic ulcer disease

AIM:To assess the risk factors and the eff icacy of medications of patients with gastric and duodenal ulcers among Chinese patients in Taiwan.METHODS:Patients with peptic ulcers,diagnosed by upper endoscopy,were retrospectively collected between January 2008 and December 2008.The differences were compared.RESULTS:Among all 448 cases,254(56.6%) and 194(43.4%) patients had gastric ulcers and duodenal ulcers respectively.Patients with gastric ulcers were younger than those with duodenal ulcers.Although more men existed,there was a female predominance in middle-aged cases.Patients with duodenal ulcers had a higher rate of Helicobacter pylori(H.pylori) infection(62.4% vs 43.3%,P = 0.001),and those with gastric ulcers owned a significantly higher amount of aspirin and nonsteroidal anti-inflammatory drug(NSAID) use(7.5% vs 1.5%,6.7% vs 2.1%,P = 0.001).Tobacco smoking and alcohol drinking had no different impact between these two groups.Proton-pump inhibitors and H2-receptor antagonists(H2RA) were effective,but significantly less so in cases with duodenal ulcers receiving H2RAs,or in those with H.pylori infection and a history of NSAID use.CONCLUSION:Patients with gastric ulcers had lower H.pylori infection but more aspirin or NSAID use.Antisecretory therapy was ineffective in gastric ulcers underwent H2RA treatment,and cases combined H.pylori infection and NSAID use.

Scoring systems for peptic ulcer bleeding: which one to use?

AIM To compare the Glasgow-Blatchford score(GBS), Rockall score(RS) and Baylor bleeding score(BBS) in predicting clinical outcomes and need for interventions in patients with bleeding peptic ulcers. METHODS Between January 2008 and December 2013, 1012consecutive patients admitted with peptic ulcer bleeding(PUB) were prospectively followed. The pre-endoscopic RS, BBS and GBS, as well as the post-endoscopic diagnostic scores(RS and BBS) were calculated for all patients according to their urgent upper endoscopy findings. Area under the receiver-operating characteristics(AUROC) curves were calculated for the prediction of lethal outcome, rebleeding, needs for blood transfusion and/or surgical intervention, and the optimal cutoff values were evaluated.RESULTS PUB accounted for 41.9% of all upper gastrointestinal tract bleeding, 5.2% patients died and 5.4% patients underwent surgery. By comparing the AUROC curves of the aforementioned pre-endoscopic scores, the RS best predicted lethal outcome(AUROC 0.82 vs 0.67 vs0.63, respectively), but the GBS best predicted need for hospital-based intervention or 30-d mortality(AUROC0.84 vs 0.57 vs 0.64), rebleeding(AUROC 0.75 vs 0.61 vs 0.53), need for blood transfusion(AUROC 0.83 vs0.63 vs 0.58) and surgical intervention(0.82 vs 0.63 vs 0.52) The post-endoscopic RS was also better than the post-endoscopic BBS in predicting lethal outcome(AUROC 0.82 vs 0.69, respectively).CONCLUSION The RS is the best predictor of mortality and the GBS is the best predictor of rebleeding, need for blood transfusion and/or surgical intervention in patients with PUB. There is no one 'perfect score' and we suggest that these two tests be used concomitantly.

GC/MS-based differential metabolic profiling of human peptic ulcer disease to study Helicobacter pylori-induced metabolic perturbations

Helicobacter pylori infection has been significantly linked to Peptic Ulcer Disease and Gastric Cancer.Metabolomic fingerprinting may offer a principal way of early diagnosis and to understand the molecular mechanism of H.pylori-induced pathogenicity.The rationale of the study is to explore the underlying distinct metabolic mechanisms of H.pylori-induced PUD and to identify potential biomarkers for disease diagnosis and associated risks using Gas chromatography/mass spectrometry.GC/MS-based analytical method was used to compare metabolic profiles of healthy controls(N=20)and peptic ulcer patients(N=45).Acquired metabolomic data were analyzed by constructing a diagnostic model using principal component analysis and a non-parametric two-tailed paired Wilcoxon analysis to identify disease-specific metabolic biomarkers.A total of 75 low-molecular-weight endogenous metabolites were detected during comparative metabolomic analysis of PUD vs.healthy gut tissues,among which 16 metabolites are being proposed to be diagnostic markers of Human PUD.Perturbations related to amino acids,carbohydrates,fatty acids,organic acids,and sterol metabolism were significantly revealed during this differential metabolomic profiling.Results convincingly suggest that metabolic profiles can contribute immensely in early diagnosis of the disease and understanding molecular mechanisms of disease progression for predicting novel drug targets for prophylactic and anaphylactic measures.

Peptic Ulcer Disease in CHUYO

Background: Prevalence of Peptic Ulcer Disease (PUD) is decreasing in developed countries since the use of the treatments for eradication of Helicobacter pylori. Objectives: To revalue the sociodemographic, clinical and evolutionary aspects of the PUD among hospitalized patients in CHUYO. Methodology: This prospective study is related to 65 files of patients hospitalized in hepato-gastroenterology and general surgical services of the CHUYO between March 1st and August 31st, 2015. Results: Hospital utilization rate was 6.59%. The average age of patients was 40.6 years with extremes of 17 and 80 years. The sex ratio was 9.8. The location of the ulcer was 69.23% in stomach. A notion of taking aggressive gastrointestinal products was found in 62 patients (95.4%). The clinical picture was represented by diffuse abdominal pain (76.92%), peritoneal irritation syndrome (64.61%) and epigastric pain (56.92%), anemia (23.07%). Gastric perforations (64.61%) and gastrointestinal bleeding (12.30%) were the main complications. Consumption of non-steroidal anti-inflammatory drugs (NSAIDs) was found in 81.5% of cases. The management was medical and/or surgical with an overall mortality rate of 7.7%. Conclusion: The PUD rate decreased from 10.12% to 6.59% in 5 years. The complications are dominated by stomach perforations. They are relative increase and seem related to NSAIDs. Better management of this disease requires awareness of the population to self-medication.

Management of Peptic Ulcer Bleeding Refractory to Endoscopic Treatment

Background: Before the advent of transcatheter arterial embolization (TAE), emergency surgery was the only choice for patients with peptic ulcer bleeding refractory to endoscopic therapy. This study compared the effectiveness of TAE and surgery in patients with peptic ulcer bleeding refractory to endoscopic hemostasis. Materials and Methods: This was a retrospective analysis of 116 patients with peptic ulcer bleeding refractory to endoscopic treatment at our institution. Eighty-three cases were treated with surgery, and 33 cases were managed with TAE. Clinical outcomes were evaluated. Results: There were no differences between groups with respect to the mortality rate (p > 0.05), length of hospital stay, or medical diseases related to mortality. The TAE group exhibited a significantly higher rebleeding rate (p < 0.05). Rebleeding predominantly occurred in patients with type Ia peptic ulcers (Forrest classification) irrespective of the treatment approach. The rebleeding rates in such patents were 30.2% and 56.3% in the surgery and TAE groups, respectively. Patients with rebleeding after further therapy showed high mortality rates (68.6%). The rebleeding rate was not significantly different between the subgroups of patients with type Ia lesions, although there was a higher mortality rate in the TAE group (27.9% vs. 75%, p = 0.001). Conclusions: TAE may be the first-choice therapy for patients with peptic ulcer bleeding refractory to endoscopic treatment, whereas emergency surgery may be used as an alternative in patients with type Ia bleeding at institutions with no 24-hour radiology service or when no experienced radiologist is available.

Impact of epinephrine volume on further bleeding due to high-risk peptic ulcer disease in the combination therapy era

BACKGROUND In monotherapy studies for bleeding peptic ulcers,large volumes of epinephrine were associated with a reduction in rebleeding.However,the impact of epinephrine volume in patients treated with combination endoscopic therapy remains unclear.AIM To assess whether epinephrine volume was associated with bleeding outcomes in individuals who also received endoscopic thermal therapy and/or clipping.METHODS Data from 132 patients with Forrest class Ia,Ib,and IIa peptic ulcers were reviewed.The primary outcome was further bleeding at 7 d;secondary outcomes included further bleeding at 30 d,need for additional therapeutic interventions,post-endoscopy blood transfusions,and 30-day mortality.Logistic and linear regression and Cox proportional hazards analyses were performed.RESULTS There was no association between epinephrine volume and all primary and secondary outcomes in multivariable analyses.Increased odds for further bleeding at 7 d occurred in patients with elevated creatinine values(aOR 1.96,95%CI 1.30-3.20;P<0.01)or hypotension requiring vasopressors(aOR 6.34,95%CI 1.87-25.52;P<0.01).Both factors were also associated with all secondary outcomes.CONCLUSION Epinephrine maintains an important role in the management of bleeding ulcers,but large volumes up to a range of 10-20 mL are not associated with improved bleeding outcomes among individuals receiving combination endoscopic therapy.Further bleeding is primarily associated with patient factors that likely cannot be overcome by increased volumes of epinephrine.However,in carefully-selected cases where ulcer location or size pose therapeutic challenges or when additional modalities are unavailable,it is conceivable that increased volumes of epinephrine may still be beneficial.

Distinctive aspects of peptic ulcer disease,Dieulafoy'slesion,and Mallory-Weiss syndrome in patients withadvanced alcoholic liver disease or cirrhosis

AIM:To systematically review the data on distinctive aspects of peptic ulcer disease(PUD),Dieulafoy’s lesion(DL),and Mallory-Weiss syndrome(MWS)in patients with advanced alcoholic liver disease(a ALD),including alcoholic hepatitis or alcoholic cirrhosis.METHODS:Computerized literature search performed via Pub Med using the following medical subject heading terms and keywords:"alcoholic liver disease","alcoholic hepatitis","alcoholic cirrhosis","cirrhosis","liver disease","upper gastrointestinal bleeding","nonvariceal upper gastrointestinal bleeding","PUD",‘‘DL’’,‘‘Mallory-Weiss tear",and"MWS’’.RESULTS:While the majority of acute gastrointestinal(GI)bleeding with a ALD is related to portal hypertension,about 30%-40%of acute GI bleeding in patients with a ALD is unrelated to portal hypertension.Such bleeding constitutes an important complication of a ALD because of its frequency,severity,and associated mortality.Patients with cirrhosis have a markedly increased risk of PUD,which further increases with the progression of cirrhosis.Patients with cirrhosis or a ALD and peptic ulcer bleeding(PUB)have worse clinical outcomes than other patients with PUB,including uncontrolled bleeding,rebleeding,and mortality.Alcohol consumption,nonsteroidal anti-inflammatory drug use,and portal hypertension may have a pathogenic role in the development of PUD in patients with a ALD.Limited data suggest that Helicobacter pylori does not play a significant role in the pathogenesis of PUD in most cirrhotic patients.The frequency of bleeding from DL appears to be increased in patients with a ALD.DL may be associated with an especially high mortality in these patients.MWS is strongly associated with heavy alcohol consumption from binge drinking or chronic alcoholism,and is associated with a ALD.Patients with a ALD have more severe MWS bleeding and are more likely to rebleed when compared to non-cirrhotics.Preendoscopic management of acute GI bleeding in patients with a ALD unrelated to portal hypertension is similar to the management of a ALD patients with GI bleeding from portal hypertension,because clinical distinction before endoscopy is difficult.Most patients require intensive care unit admission and attention to avoid over-transfusion,to correct electrolyte abnormalities and coagulopathies,and to administer antibiotic prophylaxis.Alcoholics should receive thiamine and be closely monitored for symptoms of alcohol withdrawal.Prompt endoscopy,after initial resuscitation,is essential to diagnose and appropriately treat these patients.Generally,the same endoscopic hemostatic techniques are used in patients bleeding from PUD,DL,or MWS in patients with a ALD as in the general population.CONCLUSION:Nonvariceal upper GI bleeding in patients with a ALD has clinically important differences from that in the general population without a ALD,including:more frequent and more severe bleeding from PUD,DL,or MWS.

Upper-gastrointestinal bleeding secondary to peptic ulcer disease:Incidence and outcomes

AIM:To evaluate the incidence,surgery,mortality,and readmission of upper gastrointestinal bleeding(UGIB)secondary to peptic ulcer disease(PUD).METHODS:Administrative databases identified all hospitalizations for UGIB secondary to PUD in Alberta,Canada from 2004 to 2010(n=7079)using the International Classification of Diseases Codes(ICD-10).A subset of the data was validated using endoscopy reports.Positive predictive value and sensitivity with 95%confidence intervals(CI)were calculated.Incidence of UGIB secondary to PUD was calculated.Logistic regression was used to evaluate surgery,in-hospital mortality,and 30-d readmission to hospital with recurrent UGIB secondary to PUD.Co-variants accounted for in our logistic regression model included:age,sex,area of residence(i.e.,urban vs rural),number of Charlson comorbidities,presence of perforated PUD,undergoing upper endoscopy,year of admission,and interventional radiological attempt at controlling bleeding.A subgroup analysis(n=6356)compared outcomes of patients with gastric ulcers to those with duodenal ulcers.Adjusted estimates are presented as odds ratios(OR)with95%CI.RESULTS:The positive predictive value and sensitivity of ICD-10 coding for UGIB secondary to PUD were85.2%(95%CI:80.2%-90.2%)and 77.1%(95%CI:69.1%-85.2%),respectively.The annual incidence between 2004 and 2010 ranged from 35.4 to 41.2 per100000.Overall risk of surgery,in-hospital mortality,and 30-d readmission to hospital for UGIB secondary to PUD were 4.3%,8.5%,and 4.7%,respectively.Interventional radiology to control bleeding was performed in 0.6%of patients and 76%of these patients avoided surgical intervention.Thirty-day readmission significantly increased from 3.1%in 2004 to 5.2%in 2010(OR=1.07;95%CI:1.01-1.14).Rural residents(OR rural vs urban:2.35;95%CI:1.83-3.01)and older individuals(OR≥65 vs<65:1.57;95%CI:1.21-2.04)were at higher odds of being readmitted to hospital.Patients with duodenal ulcers had higher odds of dying(OR=1.27;95%CI:1.05-1.53),requiring surgery(OR=1.73;95%CI:1.34-2.23),and being readmitted to hospital(OR=1.54;95%CI:1.19-1.99)when compared to gastric ulcers.CONCLUSION:UGIB secondary to PUD,particularly duodenal ulcers,was associated with significant morbidity and mortality.Early readmissions increased over time and occurred more commonly in rural areas.

Clinical characteristics of Helicobacter pylori-negative drugnegative peptic ulcer bleeding

AIM:To investigate the clinical characteristics and outcomes of idiopathic Helicobacter pylori(H.pylori)-negative and drug-negative]peptic ulcer bleeding(PUB).METHODS:A consecutive series of patients who experienced PUB between 2006 and 2012 was retrospectively analyzed.A total of 232 patients were enrolled in this study.The patients were divided into four groups according to the etiologies of PUB:idiopathic,H.pylori-associated,drug-induced and combined(H.pylori-associated and drug-induced)types.We compared the clinical characteristics and outcomes between the groups.When the silver stain or rapid urease tests were H.pylori-negative,we obtained an additional biopsy specimen by endoscopic re-examination and performed an H.pylori antibody test 6-8 wk after the initial endoscopic examination.For a diagnosis of idiopathic PUB,a negative result of an H.pylori antibody test was confirmed.In all cases,re-bleeding was confirmed by endoscopic examination.For the risk assessment,the Blatchford and the Rockall scores were calculated for all patients.RESULTS:For PUB,the frequency of H.pylori infection was 59.5%(138/232),whereas the frequency of idiopathic cases was 8.6%(20/232).When idiopathic PUB was compared to H.pylori-associated PUB,the idiopathic PUB group showed a higher rate of rebleeding after initial hemostasis during the hospital stay(30%vs 7.4%,P = 0.02).When idiopathic PUB was compared to drug-induced PUB,the patients in the idiopathic PUB group showed a higher rate of rebleeding after initial hemostasis upon admission(30%vs 2.7%,P < 0.01).When drug-induced PUB was compared to H.pylori-associated PUB,the patients in the drug-induced PUB were older(68.49 ± 14.76 years vs 47.83 ± 15.15 years,P< 0.01) and showed a higher proportion of gastric ulcer(77%vs 49%,P < 0.01).However,the Blatchford and the Rockall scores were not significantly different between the two groups.Among the patients who experienced drug-induced PUB,no significant differences were found with respect to clinical characteristics,irrespective of H.pylori infection.CONCLUSION:Idiopathic PUB has unique clinical characteristics such as re-bleeding after initial hemostasis upon admission.Therefore,these patients need to undergo close surveillance upon admission.

Optimal initiation of Helicobacter pylori eradication in patients with peptic ulcer bleeding

AIM:To evaluate when Helicobacter pylori(H.pylori)eradication therapy(ET)should be started in patients with peptic ulcer bleeding(PUB).METHODS:Clinical data concerning adults hospitalizedwith PUB were retrospectively collected and analyzed.Age,sex,type and stage of peptic ulcer,whether endoscopic therapy was performed or not,methods of H.pylori detection,duration of hospitalization,and specialty of the attending physician were investigated.Factors influencing the confirmation of H.pylori infection prior to discharge were determined using multiple logistic regression analysis.The H.pylori eradication rates of patients who received ET during hospitalization and those who commenced ET as outpatients were compared.RESULTS:A total of 232 patients with PUB were evaluated for H.pylori infection by histology and/or rapid urease testing.Of these patients,53.7%(127/232)had confirmed results of H.pylori infection prior to discharge.In multivariate analysis,duration of hospitalization and ulcer stage were factors independently influencing whether H.pylori infection was confirmed before or after discharge.Among the patients discharged before confirmation of H.pylori infection,13.3%(14/105)were lost to follow-up.Among the patients found to be H.pylori-positive after discharge,41.4%(12/29)did not receive ET.There was no significant difference in the H.pylori eradication rate between patients who received ET during hospitalization a n d t h o s e w h o c o m m e n c e d E T a s o u t p a t i e n t s[intention-to-treat:68.8%(53/77)vs 60%(12/20),P=0.594;per-protocol:82.8%(53/64)vs 80%(12/15),P=0.723].CONCLUSION:Because many patients with PUB who were discharged before H.pylori infection status was confirmed lost an opportunity to receive ET,we should confirm H.pylori infection and start ET prior to discharge.

Small bowel ulcerative lesions are common in elderly NSAIDs users with peptic ulcer bleeding

AIM: To determine the frequency of small bowel ulcerative lesions in patients with peptic ulcer and define the significance of those lesions. METHODS: In our prospective study, 60 consecutive elderly patients with upper gastrointestinal bleeding from a peptic ulceration(cases) and 60 matched patients with a non-bleeding peptic ulcer(controls) underwent small bowel capsule endoscopy, after a negative colonoscopy(compulsory in our institution). Controls were evaluated for non-bleeding indications. Known or suspected chronic inflammatory conditions and medication that could harm the gut were excluded. During capsule endoscopy, small bowel ulcerative lesions were counted thoroughly and classified according to Graham classification. Other small bowellesions were also recorded. Peptic ulcer bleeding was controlled endoscopically, when adequate, proton pump inhibitors were started in both cases and controls, and Helicobacter pylori eradicated whenever present. Both cases and controls were followed up for a year. In case of bleeding recurrence upper gastrointestinal endoscopy was repeated and whenever it remained unexplained it was followed by repeat colonoscopy and capsule endoscopy.RESULTS: Forty(67%) cases and 18(30%) controls presented small bowel erosions(P = 0.0001), while 22(37%) cases and 4(8%) controls presented small bowel ulcers(P < 0.0001). Among non-steroidal antiinflammatory drug(NSAID) consumers, 39(95%) cases and 17(33%) controls presented small bowel erosions(P < 0.0001), while 22(55%) cases and 4(10%) controls presented small bowel ulcers(P < 0.0001). Small bowel ulcerative lesions were infrequent among patients not consuming NSAIDs. Mean entry hemoglobin was 9.3(SD = 1.4) g/d L in cases with small bowel ulcerative lesions and 10.5(SD = 1.3) g/dL in those without(P = 0.002). Cases with small bowel ulcers necessitate more units of packed red blood cells. During their hospitalization, 6(27%) cases with small bowel ulcers presented bleeding recurrence most possibly attributed to small bowel ulcers, nevertheless 30-d mortality was zero. Presence of chronic obstructive lung disease and diabetes was related with unexplained recurrence of hemorrhage in logistic regression analysis, while absence of small bowel ulcers was protective(relative risk 0.13, P = 0.05).CONCLUSION: Among NSAID consumers, more bleeders than non-bleeders with peptic ulcers present small bowel ulcers; lesions related to more severe bleeding and unexplained episodes of bleeding recurrence.

Is the AIM65 score useful in predicting outcomes in peptic ulcer bleeding?

AIM:To evaluate the applicability of AIMS65 scores in predicting outcomes of peptic ulcer bleeding.METHODS:This was a retrospective study in a single center between January 2006 and December 2011.We enrolled 522 patients with upper gastrointestinal haemorrhage who visited the emergency room.Highrisk patients were regarded as those who had rebleeding within 30 d from the first endoscopy as well as those who died within 30 d of visiting the Emergency room.A total of 149 patients with peptic ulcer bleeding were analysed,and the AIMS65 score was used to retrospectively predict the high-risk patients.RESULTS:A total of 149 patients with peptic ulcer bleeding were analysed.The poor outcome group comprised 28 patients[male:23(82.1%)vs female:5(10.7%)]while the good outcome group included 121patients[male:93(76.9%)vs female:28(23.1%)].The mean age in each group was not significantly different.The mean serum albumin levels in the poor outcome group were slightly lower than those in the good outcome group(P=0.072).For the prediction of poor outcome,the AIMS65 score had a sensitivity of35.5%(95%CI:27.0-44.8)and a specificity of 82.1%(95%CI:63.1-93.9)at a score of 0.The AIMS65 score was insufficient for predicting outcomes in peptic ulcer bleeding(area under curve=0.571;95%CI:0.49-0.65).CONCLUSION:The AIMS65 score may therefore not be suitable for predicting clinical outcomes in peptic ulcer bleeding.Low albumin levels may be a risk factor associated with high mortality in peptic ulcer bleeding.

High rate of Helicobacter pylori reinfection in Lithuanianpeptic ulcer patients

AIM: To evaluate the frequency of Helicobacter pylori(H. pylori) reinfection in peptic ulcer patients during 9 years after H. pylori eradication.METHODS: We invited 117 peptic ulcer patients in whom eradication of H. pylori was confirmed 1 year after eradication treatment both by histology and by rapid urease test. In total, 57 patients were available for the study procedures: 34(59.6%) male, 23(40.4%) female; mean age 52.3 ± 13.0 years. There were 45(78.9%) patients with duodenal ulcer and 12(21.1%) with gastric ulcer. H. pylori was diagnosed by a rapid urease test and histology if endoscopy was performed. If endoscopy was refused, H. pylori was diagnosed by the C14-urea breath test and serology. H. pylori was established if at least one of the tests was positive.RESULTS: The mean follow-up was 8.9 ± 1.0 years(range, 6-12). H. pylori was established in 15 patients. In 2 H. pylori-negative patients, H. pylori was established during the follow-up period and eradicated. Therefore, we consider that reinfection occurred in 17 patients. In the per protocol analysis, reinfection was established in 17 of 57(29.8%; 95%CI: 19.2-42.2) patients during the follow-up period. The annual rate of infection was 3.36%. If all non-responders were considered H. pylori-negative, reinfection would be 14.5%(17/117), the annual ratebeing 1.63%. The mean age of patients with reinfection was 51.8 ± 14.0 years, and without reinfection was 52.5 ± 13.0 years, P > 0.05; the mean body mass index of patients with reinfection was 27.2 ± 4.1 kg/m2, and without reinfection was 25.7 ± 4.2 kg/m2, P > 0.05. There were no differences in the reinfection rates according the location of the peptic ulcer, the eradication regimen used, and smoking status.CONCLUSION: The reinfection rate of H. pylori is relatively high in Lithuania and probably related to the high prevalence of H. pylori, what may reflect differences in the socioeconomic status between Western and Eastern European countries.