Hiatal hernia with cameron ulcers and erosions

Cameron lesions are seen in 5.2% of patients with hiatal hernias who undergo EGD examinations. The prevalence of Cameron lesions seems to be dependent on the size of the hernia sac, with an increased prevalence the larger the hernia sac. In about two thirds of the cases, multiple Cameron lesions are noted rather than a solitary erosion or ulcer. Historically, Cameron lesions present clinically with chronic GI bleeding and associated iron deficiency anemia. With increased awareness of the existence of this lesion, however, it is now more frequently seen as an incidental finding during EGD. Cameron lesions can also present as acute upper GI bleeding, occasionally life-threatening, in up to one third of cases. Therefore, Cameron lesions should be considered in any patient in whom a hiatal hernia is noted during endoscopic examination. Concomitant acid-peptic diseases are seen in a majority of individuals, especially reflux esophagitis and its complications. Mechanical trauma, ischemia, and acid mucosal injury may play a role in the pathogenesis of Cameron lesions. The choice of therapy of Cameron lesions, medical or surgical, should be individualized for each patient. Of those patients who were treated with a spectrum of medical therapy and who have had long-term follow-up, about one third have had a recurrence of the lesion and 17% (8/48) have developed complications, most commonly either acute upper GI bleeding (6.3%) or persistent and recurrent iron deficiency anemia (8.3%).     

Quantitative assessment of mast cells in recurrent aphthous ulcers (RAU)

Previous studies on the frequency of mast cells (MCs) in recurrent aphthous ulcers (RAU) have yielded conflicting results. Monoclonal antibodies specific for tryptase (AA1) and anti-IgE (polyclonal antibody) were used to identify density and distribution of MCs in an immunohistochemical study of RAU (n=15), induced oral traumatic ulcers (TUs) (n=9), and control clinically healthy oral mucosa (n=15). Results were quantified by means of a VIDAS image analyzer. In all sections studied, IgE-positive cells showed similar frequency and distribution to tryptase-positive MCs. In RAU lesions, numerous tryptase-positive MCs were found in the sub-epithelial lamina propria, but MC numbers in the epithelium were low and present only in some RAU biopsies. MCs were also more numerous in RAU-inflammatory infiltrates (118+/-31 cells/mm2) than those seen in TU-inflammatory infiltrates (75+/-18 cells/mm2, P<0.001). MC activation/degranulation, as judged by diffuse extracellular tryptase staining, was a common feature within RAU-inflammatory infiltrates and at RAU-inflammatory infiltrates-connective tissue interfaces, which were often associated with connective tissue disruption. MC counts in the RAU connective tissue, lateral to the inflammatory infiltrates, were significantly greater than in the connective tissue of TUs and of control biopsies (124+/-36 vs 73+/-13 vs 69+/-21 cells/mm2, respectively; P<0.001). Overall, MCs were significantly increased in aphthae (116+/-26 cells/mm2) compared with TU lesions (72+/-11 cells/mm2, P<0.001) and controls (71+/-16 cells/mm2, P<0.001). In conclusion, MC numbers are increased in a typical topographical pattern, and the local MCs show signs of activation/degranulation suggesting active involvement of this cell type in RAU pathogenesis.     

Duodenal erosions and ulcers in patients with pancreatobiliary obstruction

The authors compared in a controlled clinical study two groups of patients after a first renal transplantation treated by triple drug immunosuppressive therapy. In a group of 31 patients the triple combination comprised Sandimmune Neoral. In the control group there were 30 patients who received Sandimmune. No differences were found between the two groups as regards the effectiveness of this treatment and the authors did not confirm a lower incidence of rejections described in patients treated with Sandimmune Neoral. They confirmed, however, a lower interindividual variability of Cy-A levels assessed specifically in patients treated with Sandimmune Neoral.     

Factor XIIIa-positive dendrocytes are increased in number and size in recurrent aphthous ulcers (RAU)

The factor XIIIa-positive (FXIIIa+) cell is a potent antigen-presenting cell, which has been described as increasing in numbers in various chronic inflammatory conditions. The purpose of this study was to investigate the distribution and frequency of FXIIIa+ cells in acute recurrent aphthous ulcer (RAU) lesions compared with induced traumatic ulcer (TU) lesions and with clinically healthy oral mucosa. Samples were labeled with polyclonal rabbit anti-human FXIIIa antibodies in avidin-biotin-peroxidase complex (ABC) staining. Most of the FXIIIa-immunoreactive cells in TUs and normal mucosa were spindle-shaped, whereas a relatively large, dendritic-like cell was predominant in RAU lesions. FXIIIa+ cells were quite frequent within mononuclear cell-rich inflammatory cell infiltrates and in perivascular areas in RAU lesions. In contrast, FXIIIa+ cells were not found in mucosal epithelium or in the neutrophil-rich areas. RAU mononuclear cell-rich inflammatory cell infiltrates appeared to have greater numbers of positively stained cells than the TU-inflammatory cell infiltrates (199 +/- 67 vs 110 +/- 31 cells/mm2, P < 0.001). Overall, FXIIIa+ dendrocytes were increased in numbers, and apparently also in size, in RAU lesions (274 +/- 68/mm2) as compared to controls (177 +/- 74/mm2, P < 0.01), and to TU lesions (183 +/- 50 mm2, P < 0.01). Interestingly, relatively high numbers of FXIIIa+ dendrocytes were also found in deep connective tissue in RAU sections compared with TUs (281 +/- 80 vs 166 +/- 57, P < 0.01). The characteristic changes in the size and shape of individual FXIIIa+ cells, their typical distribution and increase in frequency in RAU lesions indicate active involvement in the local pathogenic mechanisms. Localization to perivascular areas/inflammatory cell infiltrates would be compatible with a role in antigen presentation.     

Genetically obese (ob/ob) mice are predisposed to gastric stress ulcers.

In Exp I, 20 adult male genetically obese (ob/ob) mice and 20 lean littermate controls were food deprived and subsequently physically restrained at normal room temperatures. Obese Ss became hypothermic and developed gastric stress ulcers. Lean Ss maintained normal body temperatures and did not form gastric ulcers. In Exp II, 5 male obese and 4 lean littermates were used to test the effects of noradrenaline (NA) during restraint, and 5 obese and 5 lean mice were used to test the effects of NA alone. It was expected that in lean, but not in obese, Ss that NA would induce an increase in O? consumption beyond that induced by initial restraint. O? consumption was measured during food deprivation and restraint. Obese and lean Ss had parallel metabolic responses, with obese Ss using significantly less O? at all times. The predisposition to formation of gastric ulcers is a new phenotypic expression of the ob/ob genotype. The pathogenesis of this susceptibility appears to be related to a genetic disturbance in heat production. (14 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The effect of sodium lauryl sulfate on recurrent aphthous ulcers: a clinical study

This study measured the incidence of recurrent aphthous ulcers during the use of dentifrices with and without sodium lauryl sulfate (SLS). A single-blind, crossover design was used. A statistically significant reduction in recurrent aphthous ulcers was observed during 2 months' use of SLS-free dentifrice compared to 2 months' use of the SLS-containing dentifrice. These results support the results of an earlier independent study, and suggest that use of an SLS-free dentifrice should be considered for individuals suffering from recurrent aphthous ulcers.     

Expression of laminin 5, fibronectin, and epithelium-associated integrins in recurrent aphthous ulcers

Recurrent aphthous ulceration (RAU) is characterized by an ulcerated lesion that persists longer than traumatic ulcers of similar size. This delayed healing phase of the lesion was investigated for extracellular matrix components and matrix receptors (integrins). The hypothesis tested was that aphthous ulcers may lack key extracellular matrix components, or their receptors, that are necessary for the migration of marginal keratinocytes from the ulcer edge. We immunocytochemically stained biopsy specimens of RAUs and non-involved mucosal specimens from HIV+ and non-infected individuals to investigate the presence and distribution of molecules reported to be associated with reepithelialization of mucosal and cutaneous wounds. Fibronectin, laminin type 5 (kalinin), and integrin subunits beta 1, beta 4, alpha 6, and alpha v were consistently found at the margins of RAU, as they are in traumatic ulcers. The alpha 5 and beta 6 subunits were not always present. We also found alpha v in the intact stratified squamous epithelium adjacent to ulcers. Immunohistochemical stains showed distruption in the deposition of laminin 5 and an apparent lack of fibronectin at the edges of some ulcers. Although these tissue results do not determine which integrin subunits are paired with each other, they do show some alterations in their expression in RAU. Absence of one or more of these molecules at the migrating front may contribute to delayed epithelial regeneration. It is likely that the absence or inappropriate expression of keratinocyte integrins or their extracellular matrix receptors occurs after the causative factors (currently unknown) of the lesion are gone. The reason for the altered expression of these molecules may be related to the secretory products (including lymphokines and proteinases) of the lymphocytic infiltrate.     

Double pyloroplasty and vagotomy for gastric ulcers

A group of 31 patients with a variety of gastric ulcers were treated by vagotomy, biopsy, oversewing of bleeding points and a wide double pyloroplasty. On patient, a quadriplegic with multiple stress ulcers, rebled and had to undergo resection. He died a month later of progressive respiratory problems. A second quadriplegic died a month after a bleeding episode from myelitis and encephalitis resulting from a gunshot wound of the neck. He had no rebleeding. A third patient died two years after a gastric operation as a result of bronchial carcinoma. He had no recurrence of the ulcer problem. The remaining 28 patients were observed from six months to five years, an average of two and one-half years. There were no recurrences and only minimal untoward symptoms. It would appear that, for this period of observation, vagotomy with double pyloroplasty offers good treatment for patients with benign gastric ulcers.     

History of perforated duodenal and gastric ulcers

Perforated peptic ulcer as a disease entity has been known since 167 BC. Surgical and nonsurgical treatment strategies for perforated peptic ulcer disease were not developed until the latter half of the nineteenth century. The history of the gradual evolution of the various forms of treatment adopted for the conditions over the last century and a half is described.     

Multiple gastric carcinoid, its diagnosis in gastric polyposis (author's transl)

Carcinoid of the stomach, hormonally inactive, is diagnosed with MDP, gastroscopy and biopsy. Solitary carcinoids are treated with excision in toto with immediate histology of the edges. Multiple gastric carcinoids require gastrectomy.     

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.     

Laparoscopic surgery of perforated duodenal and gastric ulcers

During the period of 13 months, the authors have operated on seven patients with perforated gastroduodenal ulcers. All surgeries were completely performed by the laparoscopic method. The laparoscopic suture of perforated ulcers was performed with lavage and only in one case it involved omentoplasty. The healing process was free of any complications in all patients. The advantage of laparoscopic operations of perforated ulcers resides in fast convalescence and in the fast restoration of working abilities. This method is appropriate in cases when the surgeon performing laparoscopic surgeries has sufficient experience in coincidence with the treatment of perforated ulcers.     

Defensive burying and stress gastric erosions in alcohol-preferring AA and alcohol-avoiding ANA rats

The aim of this study was to investigate differences in shock-prod induced defensive burying and vulnerability to stress gastric ulcerations in two lines of rats selectively bred for alcohol-preference (AA) and alcohol-avoidance (ANA). Alcohol-na?ve animals from the AA and ANA lines were tested in the shock-prod defensive burying test and (after an interval of approximately 2 months) in a 75 min water-immersion stress ulceration-inducing procedure. The AA rats showed longer latencies (327.5 s) for burying after shock-prod compared with the ANA animals (128.0 s). Furthermore, the ANA rats developed more stomach ulcerations (12.35 mm) compared with the AA rats (1.30 mm). Animals also differed based on whether they had been tested for defensive burying or not, with the tested animals showing less ulceration development than the control group. We hypothesize that the difference between AA and ANA rats is controlled by some common biochemical mechanism. One likely candidate is the dopaminergic system, which is involved in both the motivational effects of alcohol, as well as anxiety and stomach ulceration. In addition, the alcohol-preferring strain seems to be less fearful and generally may be less sensitive to aversive stimuli, be it shock prod, the aversive properties of alcohol, or water immersion stress.     

Therapeutic indications in hemorrhaging duodenal and gastric ulcers

Ulcer complications including bleeding and perforation were increasingly observed during the last decade due to the greater life expectancy and the increased NSAID consumption. The unchanging mortality rate, which has been around 6-10% for several decades, could be explained by the fact that age and the prevalence of concurrent illness are important predictors of death. Rebleeding which is also an independent prognostic factor can be predicted by the presence of hypovolemic shock and of endoscopic stigmata such as active bleeding or a visible vessel. Endoscopic hemostatic therapy, specially injection therapy which is the most widely used method, has become the treatment of choice. It has been proven to significantly reduce rates of further bleeding, surgery and mortality. Surgical intervention is indicated in cases of immediate or secondary failure of endoscopic therapy (20%) and should not be delayed in high-risk patients. Once hemostasis has been achieved therapeutic goals are to heal the ulcer and to prevent the occurrence of further complications including bleeding and also perforation.     

Acute erosions of the gastric mucosa in burned rats: effect of sucralfate

Endometriosis remains a significant cause of pain and ill health for women and is a significant factor in reducing quality of life for women. The ability of desquamated endometrium to attach and implant within the peritoneal cavity is dependent upon its ability to establish and maintain an adequate blood supply. New vascularization is therefore a key part in the progression of endometriosis. Increased angiogenic activity is present in the peritoneal cavity of patients who suffer from the disease and more recently the potent angiogenic growth factor VEGF has been shown to be increased in the peritoneal fluid in patients with this disease. Whilst the desquamated endometrium itself under the influence of hypoxia further to retrograde menstruation is a likely rich source of VEGF, activated peritoneal fluid macrophages and infiltrating macrophages are also a rich source of this angiogenic growth factor. Surprisingly, steroidal regulation of macrophage expression of VEGF also appears to be a feature of this disease.     

Phosphatidylcholine-associated aspirin accelerates healing of gastric ulcers in rats

In this double-blind study, we administered lumbar epidural bupivacaine or bupivacaine plus verapamil to investigate the possible role of the calcium channel blocker, verapamil, in postoperative pain. One hundred patients (ASA physical class I or II) scheduled for lower abdominal surgery were randomly assigned to one of four groups. Group 1 received 10 mL of 0.5% epidural bupivacaine injected 15 min before incision, followed by 10 mL of epidural normal saline 30 min after incision. Group 2 received 10 mL of epidural normal saline injected before incision, followed by 10 mL of 0.5% epidural bupivacaine 30 min after incision. Group 3 received 10 mL of 0.5% epidural bupivacaine plus 5 mg of verapamil injected before incision, followed by 10 mL of epidural normal saline 30 min after incision. Group 4 received the same drugs as Group 3, in the reverse order. Pain and mood numeric rating scores, sedation scores, Prince Henry scores, patient-controlled cumulative postoperative analgesic consumption, and the incidence of side effects were assessed 2, 6, 12, 24, and 48 h after the operation in each group. Cumulative postoperative analgesic consumption in Groups 3 and 4 was significantly lower (P < 0.05) than that in Groups 1 and 2 24 and 48 h after surgery. There were no differences in the pain, mood, and sedation scores and the incidence of side effects among the four groups. We conclude that epidural verapamil decreases postoperative pain, possibly by interfering with normal sensory processing and by preventing the establishment of central sensitization. Implications: Calcium plays an important role in pain physiology at the spinal cord level. We examined the effect of bupivacaine plus verapamil (calcium channel blocker) and of bupivacaine alone. We demonstrated that the combination, administered epidurally, resulted in less postoperative analgesic consumption than bupivacaine alone.