The etiological and pathogenetic characteristics of duodenal peptic ulcer in adolescents

Studied by endoscopy were 100 adolescents with diagnosed duodenal ulcer, as were 100 essentially healthy subjects and 90 ones of the same age presenting with primary chronic gastroduodenitis together with 60 adults who had duodenal ulcer. The following items were etiologic risk factors for duodenal ulcer, if combined, in the above adolescent series: Frequent episodes nervous of tension, hereditary predisposition and helicobacteriosis. In juveniles with duodenal ulcer, secretion and motility of the stomach appeared to be subjected to changes to a higher degree than it was in adult subjects with duodenal ulcer, while functions of the psychovegetative and immune systems were found to be less changeable in the former. In adolescents presenting with duodenal ulcer and primary chronic gastroduodenitis, the etiologic risk factors and pathogenetic changes were found out to be identical.     

Small intestinal sarcoidosis with massive hemorrhage: report of a case

Sarcoidosis of the small intestine is a rarely described complication of systemic sarcoidosis. Although bleeding from sarcoidosis of the esophagus, stomach, and colon has been reported, massive bleeding from this condition in the small intestine has not been previously described. We present here the first case of hemorrhage from a jejunal sarcoid lesion that was unsuspected and undiagnosed until laparotomy with resection was performed. As with most pathologic conditions of the small intestine, preoperative diagnosis is difficult. Furthermore, the refractory nature of bleeding from this lesion made resection necessary in this patient, suggesting the need for similar therapy in other affected patients.     

Comparative results of surgical treatment for perforating and bleeding pyloroduodenal ulcers

Results of treatment of 1309 patients with perforated and bleeding pyloroduodenal ulcers for 20-years period have been analysed. Resection of the stomach performed in 85 cases resulted in high postoperative lethality which made up in bleeding ulcers 14.8%. Drainage operations of the stomach with excision or suturing of ulcer combined with bilateral truncal vagotomy was performed in 60 patients, postoperative lethality rate being 8.4%. 128 patients underwent selective proximal vagotomy together with pyloro- and duodenoplasty, lethality rate being 1.6%. Combined vagotomy (posterior truncal and anterior sero-muscular) with excision of ulcer, transversal pyloroplasty and duodenoplasty was carried out in 1036 patients (postoperative lethality--2.4%). Excellent and good functional results were achieved in 79.6% of the patients.     

Sonographically guided intravascular biopsy of an intraluminal mass in the inferior vena cava

In a 48-year-old Japanese man there was an uncontrollable and recurrent bleeding from a gastric ulcer and laparoscopic surgery was done. Two cannulae were placed in the gastric cavity through the abdominal wall and suture ligation of the bleeding vessel at the posterior wall of the stomach was done under video-visual control with endoscopic guidance. The bleeding ceased, complications were nil, and he remains well. This article reports on surgery done to repair uncontrollable, recurrent bleeding from a gastric ulcer. Two cannulae were placed in the gastric cavity through the abdominal wall and suture of the vessel at the posterior wall of the stomach was done with videovisual control and endoscopic guidance. This approach is concluded to have supplied minimal-access surgery, cost effectiveness, early discharge, less pain, and doctor-patient satisfaction.     

Technetium pertechnetate scintigraphy in an ileal duplication of the stomach and duodenum

We report a patient with ileal duplication of the stomach and duodenum that presented with gastrointestinal bleeding. The scan appearance of the duplicated stomach in both shape and temporal course of activity bore a striking resemblance to the patient's homotopic stomach.     

The evolution of surgery for extrahepatic portal hypertension

30 years' experience of elective surgical treatment of 600 patients with extrahepatic portal hypertension is summarized. Insufficient effectiveness of splenectomy in bleeding from varicose veins (VV) of the stomach and the esophagus (40% of relapses) is shown as well as frequent development (25%) of asplenic hemorrhagic thrombocytopenia. Partial esophagogastrectomy also has failed initial hopes due to severe agastric anemia which developed in 49.6% patients and relapses of erosion and ulcerogenous hemorrhage from the gastric stump (30%). Introduction of microsurgical methods, contemporary suturing material, usage of the jugular vein's segment for performing H-shape anastomoses enabled in the last decade to carry out porto-caval shunt using distal segments of superior mesenteric vein with diameter 5-9 mm and thus to increase the number of radical operations to thoroughly rehabilitate the patients, and to decrease postoperative mortality rate from 11.1% to 0.7% as well. Vascular anastomoses were not feasible, the operation of choice may be suturing of VV of the esophagus and the stomach with subsequent endoscopic sclerosis formation.     

Transgastric endoluminal laparoscopic resection of a duodenal polyp

Transgastric endoluminal surgery is a laparoscopic procedure used to treat gastric lesions such as polyps and carcinoma in situ. This approach can also be used to treat proximal duodenal problems such as bleeding and polyps. Our case was a young patient with bleeding from a benign duodenal polyp, localized 3 cm from the papilla of Vater. Two trocars were introduced by laparoscopy into the stomach. Guided by the flexible gastroscope, the polyp (a 6-cm Brunner's benign hamartoma) was resected by means of the endostaplers. Transgastric endoluminal surgery can be used to extirpate benign lesions in the proximal duodenum. The use of a flexible gastroscope can be very useful because of its adaptability to the anatomy.     

Retained myoma after laparoscopic supracervical hysterectomy with morcellation

Leiomyoblastomas account for a small percentage of smooth muscle tumors of the stomach. Intraperitoneal bleeding is an unusual and unexpected presenting sign. We herein present a 43-year-old woman who was urgently operated on due to signs of collapse. A large hemorrhagic mass measuring 25 x 18 x 15 cm was found arising from the greater curvature of the stomach. A histologic examination demonstrated rounded and spindle cells, and rare mitoses were also seen. Although the number of mitoses was small, the lesion was nevertheless felt to be consistent with malignant leiomyoblastoma because of its large size. Three years later the patient is doing well with no evidence of tumor recurrence. We conclude that intraperitoneal bleeding due to leiomyoblastoma of the gastrointestinal tract is an extremely rare phenomenon and has been described only in a few reports, and only one other previous case presented with signs of collapse.     

The comparison of postoperative multiple organ failure with arterial disease to that with gastrointestinal cancer]

The clinical features of 22 postoperative multiple organ failure (MOF) patients, comprised of 8 with arterial disease (A-MOF) and 14 with gastrointestinal cancer (G-MOF), were investigated. Differences in the operative time, blood loss, and mortality were not significant. The initial organ impaired was the lungs in 78.6% of G-MOF patients and the heart or kidneys in all A-MOF patients. Infection developed in over 80% of both groups. In many A-MOF patients, the pneumonia or septicemia developed secondary to organ failure, while intraabdominal infection triggered respiratory failure in many G-MOF patients. Our organisms in infected specimens and their antibiotic sensitivities was valuable for the early administration of effective antibiotics. Upper gastrointestinal tract bleeding was important in the prognosis of both groups and occurred more frequently in A-MOF than in G-MOF patients. Consumption coagulopathy in A-MOF patients and DIC induced by infection in G-MOF patients mainly caused such bleeding. Preoperative administration of heparin was effective in improving coagulopathy. Furthermore, measurement of intramural pH with tonometer in the stomach and gastric irrigation with oxygenated perfluorochemicals were effective in the prediction and prevention of gastrointestinal bleeding.     

Hemorrhage from acute ulcers of gastric mucosa

The work analyses the results of management of 429 patients with acute erosive-ulcerative gastritis in a specialized department. The most frequent causes are duodeno- or enterogastric reflux (24.7%), abuse of alcohol (23.6%), medication with mucosa irritating drugs (22.5%). Particular attention is drawn to gastritis of a reflux character which is dangerous not only because of recurrent bleeding but also because of the possibility of structural reorganization of the gastric mucosa leading to development of carcinoma. Attention is focused on the errors in nonoperative and surgical treatment and the need for taking into consideration the etiopathogenesis of acute ulcers. In ulcerations of a reflux character it is recommended that after bleeding is arrested by conservative measures, an operation for removal of the reflux is performed in a planned order. In the other cases, in emergency situations, deep stitching of the erosions with vagotomy and pyloroplasty must be resorted to. The author considers acute ulcers of the stomach to be a precancer marker and believes it necessary to register all patients for regular medical control.     

Endoscopic treatment of major bleeding from advanced gastroduodenal malignant lesions

OBJECTIVE: To summarize the results of endoscopic therapy for acute hemorrhage from gastroduodenal malignant lesions. DESIGN: The 3-year experience (1989 through 1991) of a specialized gastrointestinal (GI) bleeding team in the endoscopic treatment of acute upper GI bleeding from gastroduodenal malignant tumors was retrospectively reviewed. MATERIAL AND METHODS: Of 1,083 consecutive patients with acute major upper GI hemorrhage, 21 (1.9%) were found to have advanced tumors of the stomach and duodenum, 15 of whom received endoscopic therapy. In this study group of 15 patients, the tumors were gastric in 11 and duodenal in 4. Endoscopic treatment consisted of injection of epinephrine, heater probe coagulation, neodymium:yttrium-aluminum-garnet laser coagulation, or injection of sodium tetradecyl sulfate. RESULTS: Initial endoscopic hemostasis was achieved in 10 of the 15 patients (67%); however, bleeding recurred in 8 of 10 (80%), and all 5 in whom endoscopic hemostasis was not achieved continued to bleed. Mean transfusion requirements for the 30 days before and the 30 days after the first endoscopic treatment were 7.6 and 6.4 units of packed erythrocytes, respectively (P > 0.10). Five major procedure-related complications occurred, two of which were fatal. The median duration of survival after the first endoscopic treatment was 39 days (range, 1 to 1,414). CONCLUSION: In patients with major bleeding from advanced gastroduodenal malignant lesions, endoscopic therapy seems to provide limited benefit.     

Natural honey prevents ischaemia-reperfusion-induced gastric mucosal lesions and increased vascular permeability in rats

OBJECTIVE: It has been proposed that natural honey may contain a 'sucralfate-like' substance. Recent studies have shown that sucralfate affords protection against ischaemia-reperfusion-induced injuries in the rat stomach. Therefore, the effect of honey was studied on ischaemia-reperfusion-induced gastric lesions, intraluminal bleeding, vascular permeability and non-protein sulphhydryls (NP-SH) in the rat stomach. METHODS: Rats were subjected to 30 min of gastric ischaemia in the presence of 100 mM HCl and reperfusion period of 60 min. Intraluminal bleeding was assessed macroscopically and the gastric lesions were graded microscopically under an inverted microscope. Vascular permeability was quantified by measuring spectrophotometrically the extravasated Evans blue dye in the stomach. NP-SH levels were measured spectrophotometrically. A luminol-dependent chemiluminescence method was used to assess antioxidant effects of honey in vitro. RESULTS: There were significantly more gastric lesions, more severe intraluminal bleeding, more leakage of Evans blue and depletion of NP-SH during the reperfusion period as compared to controls. Pre-treatment with honey (0.078-0.625 g/kg, orally) or dimethyl sulphoxide (0.02-0.08 g/kg, intraperitoneally) 30 min before the ischaemia-reperfusion dose-dependently reduced the gastric lesions and intraluminal bleeding and decreased the vascular permeability. Furthermore, honey reversed the ischaemia-reperfusion-induced depletion of NP-SH levels and inhibited the luminol-dependent chemiluminescence induced in a cell-free xanthine-xanthine oxidase system. CONCLUSION: These results suggest that gastric protection by honey may be a result of its antioxidant effect. It is suggested that this property of honey may be due to the presence of a 'sucralfate-like' substance.     

A case of esophageal cancer required jejunal reconstruction because of a gastric ulcer scar

Recently, with increase of number of esophagectomy for esophageal cancer, the cases having the lesion in the organs for esophageal substitute have been increasing. The case of esophageal cancer, required reconstruction using the pedicled jejunum, because of impaired submucosal blood perfusion of the stomach caused by a ulcer scar, was reported. The patient was a 72-year-old female, with the ulcerative and infiltrative cancer lesion in the anterior wall of the mid-thoracic esophagus. Barium swallow revealed shortening of the lesser curvature and indentation of the greater curvature of the stomach. Endoscopy showed the lesion occupying anterior two thirds of the esophageal wall circumferentialy from 30 to 34 cm from the incisor tooth. The lineal scar of ulcer on the lesser curvature of the body of the stomach was also found. Following esophagectomy through right thoracotomy, the stomach was mobilized for reconstruction by dividing left gastric artery and short gastric artery, but the stomach oral to the ulcer scar became ischemic and bleeding was not found at the tip of the stomach. Therefore, reconstruction was performed using the pedicled jejunum through antesternal route. The gastric cardia is rich in the vascular network in the submucosal layer. The ulcer or ulcer scar of this region can cause ischemia in the tip of the gastric tube for esophageal substitute. Care should be taken to detect the ulcer lesion at the stomach preoperatively. In the case with the ulcer lesion blood supply to the tip of the gastric tube should be critically evaluated.     

Laparoscopy-assisted devascularization of the lower esophagus and upper stomach in the management of gastric varices

Devascularization of the lower esophagus and the upper stomach is one method of treating patients with clinically significant gastric varices. We describe a new method of laparoscopically-assisted devascularization which has been applied in seven patients with esophagogastric varices. Three of the seven patients had an episode of gastric variceal bleeding, and the remaining four had moderate to large gastric varices with red color signs. The operative procedure was carried out without pneumoperitoneum by using an ordinary forceps and laparoscopic instruments through a small skin incision (3-5 cm); the abdominal wall was elevated with a U-shaped retractor. The operative field was obtained by laparoscopic and direct vision illuminated by laparoscopic light. The procedure time ranged from 100 to 180 minutes with minimal blood loss (70-320 g). No complications were encountered. All patients could be discharged within one week; postoperative pain was minimal and all patients returned to work early. Follow-up (mean 11.4 months) showed no recurrence of gastric varices although, due to an incomplete procedure in two cases, two patients were treated additionally by endoscopic injection of histoacryl.     

Gastrointestinal hemorrhage in patients with systemic sclerosis and CREST syndrome

OBJECTIVES: Systemic sclerosis (SSc) and calcinosis, Raynaud's phenomenon, esophageal disease, sclerodactyly, telangiectasia (CREST) syndrome present distinctive microvasculature lesions that are thought to be responsible for tissue damage and disease progression. Involvement of the gastrointestinal tract may lead to the occurrence of profuse hemorrhage. We performed a study to assess the incidence and characteristics of gastrointestinal hemorrhage in a large group of patients with SSc and CREST syndrome. METHODS: We reviewed the medical records of 144 patients with SSc/CREST seen at our institution during the period 1985-1996. Endoscopic findings and clinical data were correlated. Data are expressed as means +/- SD. RESULTS: Twenty-two of 144 (15.2%) patients had at least one episode of gastrointestinal hemorrhage (16 women, 6 men; mean age, 59.4 +/- 17.6 yr). Eight patients (8/22; 36%) had multiple episodes and four (4/22; 18%) required chronic transfusion therapy. Mucosal telangiectasias were the most common cause of bleeding (9/22; 40.9%), followed by peptic ulcer disease (7/22; 31.8%) and erosive gastritis (3/22; 13.6%). Bleeding telangiectasias occurred in the entire gastrointestinal tract, including oral cavity (n = 1), esophagus (n = 1), stomach (n = 3), duodenum (n = 1), ileum (n = 1), cecum (n = 2), and colon (n = 2). Mortality was 22.7% in patients with gastrointestinal bleeding, compared with 7.3% in patients without bleeding. CONCLUSIONS: Patients with SSc/CREST syndrome are at risk of developing severe gastrointestinal hemorrhage. This complication is associated with frequent hospitalization, blood transfusions, and increased mortality. Mucosal telangiectasias are the most common source of bleeding. Appropriate endoscopic intervention is recommended in evaluating and preventing bleeding in patients with SSc/CREST.     

Ticlopidine, diarrhea and lymphocytic colitis

Perforation into the heart is a rare ulcer complication in a hiatal hernia. Because of the massive bleeding, medical help is often in vain. The case of a 73-year-old patient reported by our department confirms this. Endoscopic treatment was not possible because of the extraordinary amount of blood in the stomach, and the high intraoperative blood loss was lethal. If gastric ulcers occur in upper regions of the stomach, the possibility of the presence of an paraesophageal hernia and elective surgical treatment must be considered.     

Surgical treatment of paraesophageal hiatal hernia with total intrathoracic volvulus of the stomach

From 1971 to 1993, we operated 44 patients, 34 females and 10 males with a paraoesophageal hernia in which the entire stomach entered the thorax. Mean age of the patients was 70 years. Seventeen patients underwent emergency surgery for strangulated hernia leading to complete ghastric occlusion, gastric bleeding or necrosis (3 cases). Only 2 patients had a past history of gastro-oesophageal reflux. The following techniques were used: abdominal access in all cases, saccular resection, closure of the widened hiatus or of a left sided hernial hiatus, anterior gastropexy suturing the greater curvature to the abdominal on the left. Several patients were in precarious clinical situations and had to be treated under local or regional anaesthesia alone. Two patients had partial necrosis of the stomach and were treated by partial gastropexy. There were no deaths or major complications. Incomplete recurrence was noted in one patient 2 years after the initial procedure. In conclusion: 1) abdominal access is much preferable; 2) an antireflux procedure is only indicated when the patients have signs of gastro-oesophageal reflux; 3) most complications are not due to the hernia itself but to gastric volvulus. Consequently, simple reduction of the hernia followed by anterior gastroplexy under local anaesthesia can give excellent results in patients in precarious clinical situations and argues against major operation with general anaesthesia; 4) due to the gravity of paraesophageal hernia, a surgical solution is required as soon as diagnosis has been confirmed.     

Injection of fibrin tissue adhesive versus laser photocoagulation in the treatment of high-risk bleeding peptic ulcers: a controlled randomized study

BACKGROUND AND STUDY AIMS: A controlled and randomized multicenter study was carried out in order to compare the efficacy of fibrin sealant and Nd:YAG laser photocoagulation in patients with high-risk arterial bleeding from peptic ulcers of the stomach and the small intestine. PATIENTS AND METHODS: In four teaching hospitals, 53 patients presenting with either active arterial ulcer bleeding (Forrest class 1 a) or a large visible vessel in the ulcer base (diameter over 2 mm, Forrest class 2 a) were treated with infiltration of epinephrine 1: 10,000 followed by the injection of fibrin tissue adhesive (n = 28), or with epinephrine plus laser photocoagulation (n = 25). Permanent hemostasis for at least seven days served as the principal end point; rebleeding, emergency surgery, and hospital mortality served as further end points. RESULTS: There were no significant differences between the study groups in terms of age, risk factors, initial hemoglobin values, number of patients showing signs of hemodynamic impairment, ulcer size and localization, or bleeding activity. Primary hemostasis was achieved in all patients. Rebleeding rates were seven of 28 and four of 25 among the patients treated with fibrin sealant and laser coagulation, respectively (not significant). There were no significant differences regarding the rates of ultimate hemostasis (24 of 28 vs. 24 of 25), emergency surgery (four of 28 vs. one of 25), or hospital mortality (0 vs. two of 25). No complications occurred with either form of treatment. Patients who had a visible vessel in the ulcer floor at the first control endoscopy had a significantly higher incidence of rebleeding, regardless of the type of endoscopic therapy. CONCLUSIONS: We conclude that both the injection of fibrin tissue adhesive and laser photocoagulation are effective methods of treating high-risk arterial peptic ulcer bleeding. As the number of high-risk patients necessary to reach significance are difficult to recruit within a reasonable period even in a multicenter study, a new meta-analysis of all studies now available should be considered.     

Treatment of hemorrhage of the digestive system with amine alpha-adrenergic stimulants

Noradrenaline was administered through the stomach or peritoneum in thirty patients of the Raza Hospital of the I.M.S.S. in an attempt to control severe gastro-intestinal bleeding as described by Dr. H. H. Le Veen. In 84% of the cases this was accomplished with an average elapsed time of 82 minutes. The method proved to be effective of various etiologies except in those cases in which an important size artery was involved. There were no side effects.     

Congestive gastropathy in liver cirrhosis

Congestive gastropathy has emerged as a new nosological entity that can be included among the complications of advanced liver cirrhosis. It has been defined as the macroscopic changes of gastric mucosa occurring in portal hypertension that are associated with vascular mucosal and submucosal dilatation and ectasia without significant inflammatory changes. The pathogenesis of congestive gastropathy has not been completely cleared up. Many epidemiological and clinical studies and some tests on animals lead most Authors to think that the cause of this disease is a chronic increase of pressure in the portal vascular system. However the involvement of humoral factors cannot be excluded as, for example, the presence of high plasma levels of gastrin and histamine or a decrease of E2 prostaglandin in the gastric mucosa. The macroscopic lesions typical of congestive gastropathy can be seen through endoscopy. Up to now mosaic-like pattern, red points, cherry-red and black-brown spots and erosions have been observed. These changes are prominent in the area near the gastric body and cardias, but can be present in all parts of the stomach. The frequently reported spontaneous bleeding corresponding to cherry-red spots make the presence of these lesions to be considered a sign of severe congestive gastropathy. The prevalence of congestive gastropathy in cirrhotic patients is between 30% and 70%. This condition is more frequent in patients with large esophageal varices and severe liver disease and in patients submitted to endoscopic variceal sclerotherapy. Congestive gastropathy is a frequent cause of acute and chronic bleeding: 10-20% of gastrointestinal bleeding episodes occurring in cirrhotic patients are caused by this condition and about 30% of cirrhotics with portal hypertension will have one or more acute bleeding in a four year follow-up. The percentage of subjects with chronic hemorrhage in the same period can reach 90%. At the moment is not possible to suggest a therapy able to prevent or cure the acute or chronic bleeding associated with congestive gastropathy. beta-blockers seem to be a promising treatment. However, further and larger clinical trials are necessary to settle definitively their efficacy.