Conducta ante la hemorragia digestiva alta por úlcera gastroduodenal en el anciano: consideraciones actuales / Behavior in face of a high digestive hemorrhage from gastroduodenal ulcer in elderly: current considerations

La hemorragia digestiva alta reviste singular importancia en el anciano porque es un evento que puede rápidamente poner en peligro la vida. En el adulto mayor, la alta incidencia de enfermedades osteomioarticulares y cardiovasculares asociadas, que además condicionan la ingestión de medicamentos como los antiinflamatorios no esteroideos y aspirina, y los hábitos tóxicos frecuentes en la tercera edad, como el consumo de alcohol, café y tabaco, constituyen factores que ejercen efecto ulcerógeno sobre la mucosa del tracto digestivo superior. La causa más común de hemorragia es la úlcera gastroduodenal. En la actualidad se considera de importancia capital la realización precoz de la endoscopia para el diagnóstico y tratamiento médico consecuente, y se limita la cirugía sólo para los ancianos en los cuales, por su estado general y la cuantía o persistencia del sangrado, no sea posible la realización de aquella, cuando fracase el tratamiento endoscópico, el farmacológico o ambos(AU)

High digestive hemorrhage has a peculiar significance in elderly because of it is an event putting quickly at risk the life. In elderly, the high incidence of associated osteomyoarticular and cardiovascular diseases that also fitting the drugs ingestion, e.g. the non-steroid anti-inflammatory and the aspirin and the toxic habits frequent in third age, since the alcohol, coffee and tobacco consumption are factors having an ulcerative effect on the high digestive tract mucosa. The commonest cause of hemorrhage is the gastric ulcer. At present time we considered as of supreme significance the early carrying out of the endoscopy for the consequent medical treatment and diagnosis limiting surgery only for elderlies, who due to its general status and the bleeding extent or persistence be impossible its carrying out when there is a failure of endoscopic and/or pharmacologic treatment(AU)

Comparison of Clinical Characteristics and Outcomes between Geriatric and Non-geriatric Patients in Peptic Ulcer Bleeding / 대한소화기학회지

BACKGROUND/AIMS: In geriatric patients with peptic ulcer, the use of NSAID and prevalence of chronic illness have been increased, but the Helicobacter pylori (H. pylori) infected portion decreased. The aim of this study was to evaluate the clinical characteristics and outcomes of geriatric patients (aged 65 or older) with peptic ulcer bleeding and compare with non-geriatric patients (less than 65 years old). METHODS: We conducted a retrospective study of 88 patients with peptic ulcer bleeding treated with therapeutic endoscopy from January 2006 to December 2006. We compared the clinical characteristics and outcomes of geriatric patients (n=34, 38.6%) with those of non-geriatric patients (n=54, 61.4%). RESULTS: Hypertension (52.9% vs. 24.1%), cardiovascular disease (35.3% vs. 13.0%), and chronic obstructive pulmonary disease (20.6% vs. 3.7%) were more prevalent in the geriatric group, compared with the non-geriatric group (p0.05). The amount of transfusion length of ICU stay, rebleeding rate, operation rate and mortality were not different between the two groups. The length of hospital stay in the geriatric patients was significantly longer than the non-geriatric group (12.3+/-10.6 vs. 7.2+/-5.9 days, p<0.05). In multiple regression analysis, old age was a significant risk factor for longer hospital stay (p<0.05). CONCLUSIONS: The geriatric patients with bleeding peptic ulcer had longer hospital stay than the non-geriatric patients in our study. The important emerging etiologies such as ulcerogenic drug and associated chronic illness should be checked and treated in these patients.

A Case of CD56+ Extranodal NK/T-cell Lymphoma, Nasal Type, Presenting as a Duodenal Ulcer Bleeding / 대한소화기학회지

Extranodal NK/T-cell lymphoma is a recently recognized distinct entity within the World Health Organization classification of lymphoid tumors. It is relatively prevalent in Asian and South American populations. It most commonly occurs in the nasal or paranasal areas and less frequently in the skin, the soft tissue, and the gastrointestinal tract. Among these, extranodal NK/T-cell lymphoma of the gastrointestinal tract has shown an aggressive clinical course. We report a case of CD56+ extranodal NK/T-cell lymphoma presenting as a duodenal ulcer bleeding. A 62-year-old male patient presented with melena and abdominal pain. Endoscopic examination of the upper gastrointestinal tract showed the duodenal ulcer covered by blood clot. Pathologic examination revealed the diffuse infiltration of atypical lymphocytes with an angiocentric growth pattern, which was positive for CD3, CD56, and granzyme. The patient showed rapid deteriorating clinical course and died on day 14 after admission. Thus, we report this case with the review of literatures.

Emergency operations for bleeding duodenal ulcer: a simple option to consider: Case report

We report a 46 years-old man who had severe bleeding from a posterior duodenal ulcer [DU] that was diagnosed but could not be treated endoscopically in another health facility. He went into shock as he was being admitted to the casualty at Khartoum North Teaching Hospital [KNTH]. His haemoglobin [Hb] dropped to five gram/dl. He required resuscitation and transfusion of six units of blood overnight. Emergency surgery was performed. Over sewing [OS] of the ulcer was done and the stenosed first part of duodenum was closed transversely [pyloroplasty]. No acid-reducing procedure [ARP] was done. The patient received anti- helicobacter therapy via the intravenous route preoperatively and continued postoperatively. This was later given orally after he started taking by mouth. He made an uneventful recovery with no recurrence of bleeding and was discharged home one week latter. Endoscopy was done at KNTH six weeks later. This showed complete healing of the ulcer with no evidence of Helicobacter pylori in the biopsies taken. We found simple OS of the bleeding DU together with anti-helicobacter therapy safe, efficient, and not associated with re-bleeding. We discuss the rationale of this simple treatment. We propose the need for a randomized controlled study comparing it with acid-reducing procedure [ARP] as options in the surgical treatment of bleeding DU

Massive Gastric Ulcer Bleeding in a Healthy Full Term Infant / 대한소화기학회지

Gastric ulcer bleeding in neonatal period, mainly in preterm newborn babies or in neonates treated in intensive care units, is relatively frequent, However the occurrence of significant gastric ulcer bleeding in healthy full term infants is unusual. We experienced a case of massive upper gastrointestinal (GI) bleeding in a 3-day-old healthy full term infant. Endoscopic examination confirmed the presence of gastric ulcerations. Treatment was initiated with transfusion and histamine 2 receptor antagonist, and the clinical signs resolved. Mother's serum antibody to Helicobacter pylori (H. pylori) was positive. We collected stool of the patient including other 17 infants in the intensive care unit. A highly sensitive semi-nested PCR for H. pylori DNA was performed, but all infants including the patient revealed negative. H. pylori infection is not related with upper GI bleeding in healthy full term infants. In conclusion, the diagnosis of upper GI bleeding in infant can be easily made by means of pediatric endoscopy, which is a simple and a well tolerated examination.

The effect of blood on rapid urease test for Helicobacter pylori detection: an in vitro study.

The sensitivity of rapid urease test (RUT) for detecting Helicobacter pylori (H. pylori) is limited in patients presented with bleeding peptic ulcers. Blood contents are potentially responsible for the lack of sensitivity of RUT in patients with upper gastrointestinal bleeding. This study was designed to determine the efficacy of RUT in detecting H. pylori when exposed to the patients' own blood at varying durations. Four gastric antral biopsy specimens were collected from dyspeptic patients who underwent gastroscopic examination. The first specimen was immediately placed into the urea broth as the control group. The second, third and fourth specimens were immersed in the patients' own blood for one, two and four hours respectively before testing for the RUT. The results of these RUT were compared to those of the control group. Gastric antral biopsy specimens tested with the RUT of twenty patients were evaluated in this study. The 1-hour RUT and 2-hour RUT was not significantly different in sensitivity (92.31% vs 100%: p>0.05, 84.62% vs 100%: p>0.05 respectively) and accuracy (95.0% vs 100%: p>0.05, 90.0% vs 100%: p>0.05 respectively) compared to the unexposed blood RUT for H. pylori diagnosis. However, the study demonstrated that the 4-hour RUT had significantly lower sensitivity (53.85% vs 100%: p<0.05) and accuracy (70.00% vs 100%: p<0.05) than that of the unexposed blood RUT for H. pylori diagnosis. It is concluded that exposure of gastric biopsy specimens to their own blood for four hours significantly decreased the sensitivity of the biopsy rapid urease test for H. pylori detection.

Diagnosis method of Helicobacter pylori infection in bleeding peptic ulcer.

Peptic ulcer lesions are the most frequent cause of upper gastrointestinal bleeding and are responsible for more than 50 per cent of cases. Several etiologic factors of peptic ulcer are known, the principle one being Helicobacter pylori (H. pylori). Recent studies indicate that H. pylori eradication is associated with the marked reduction in rebleeding rate. In peptic ulcer bleeding which requires surgical intervention, knowledge H. pylori status may help to determine the choice of procedure (simple sewing in H. pylori positive patients vs full-blown ulcer surgery in H. pylori negative patients). We suggest to use the invasive combination of histology and biopsy-rapid urease test in stable bleeding peptic ulcer patients without coagulopathy for H. pylori diagnosis. Cases with positive result do not need further investigation for H. pylori diagnosis. If negative, the serology test was suggested to confirm the absence of H. pylori. However, in unstable patients, the serology test seem to effectively detect H. pylori infection.

Ulceras gástricas sangrantes y hepatitis aguda: dos reacciones adversas simultáneas por nimesulida en un caso / Bleeding gastric ulcers and acute hepatitis: 2 simultaneous adverse reactions due to nimesulide in 1 patient

A 66 year-old obese woman with arthrosis, self-medicated with oral nimesulide, 200 mg daily. After 6 weeks she developed nausea, jaundice and dark urine. Two weeks later she had recurrent hematemesis and was hospitalized. Besides obesity and anemia her physical examination was unremarkable. An upper GI endoscopy revealed 3 acute gastric ulcers and a 4th one in the pyloric channel. Abdominal ultrasonogram showed a slightly enlarged liver with diffuse reduction in ecogenicity; the gallbladder and biliary tract were normal. Blood tests demonstrated a conjugated hyperbilirubinemia (maximal total value: 18,4 mg/dl), ALAT 960 U/l, ASAT 850 U/l, GGT 420 U/l, alkaline phosphatases mildly elevated, pro-time 49 percent and albumin 2.7 mg/dl. Serum markers for hepatitis A, B and C viruses were negative. ANA, AMA, anti-SmA, were negative. Ceruloplasmin was normal. A liver biopsy showed bridging necrosis and other signs of acute toxic liver damage. Gastric ulcers healed after conventional treatment and hepatitis subsided after 2 months leaving no signs of chronic liver damage. The diagnosis of toxic hepatitis due to nimesulide was supported by the time-course of drug usage, sex, age, absence of other causes of liver disease, a compatible liver biopsy and the improvement after drug withdrawal. Peptic ulcers or toxic hepatitis have been previously described as independent adverse reactions in patients taking nimesulide or other NSAIDs but their simultaneous occurrence in a single patient is a unique event that deserves to be reported

Hemorragia aguda de tubo digestivo alto: diagnóstico endoscópico y manejo quirúrgico / Endoscopic diagnosis and surgical treatment of upper gastrointestinal acute haemorrhage

Se estudiaron 142 pacientes del servicio de urgencias del Hospital Regional 1o. de Octubre I.S.S.S.T.E. con diagnóstico de hemorragia aguda de tubo digestivo alto, del 1o. de marzo de 1998 al 28 de febrero de 1999; fueron 99 hombres y 43 mujeres con edad promedio de 62.2 años, analizamos: tabaquismo, alcoholismo y la ingesta de anti-inflamatorios no esteroides (AINES) y las causas de reingreso hospitalario. La etiología más frecuente fue la gastritis (29 por ciento), úlcera duodenal (25 por ciento), úlcera gástrica (23 por ciento), várices esofágicas (6 por ciento), esofagitis (50 por ciento), cáncer gástrico (4 por ciento), úlceras esofágicas (2 por ciento), duodenitis (2 por ciento), Mallory-Weiss (1 por ciento), úlcera marginal (0.7 por ciento). Se realizó cirugía de urgencia en el 51 por ciento de los casos. Se requirió de mayor número de procedimientos quirúrgicos para la úlcera duodenal (43 por ciento), úlcera gástrica (30 por ciento), várices esofágicas (13 por ciento), cáncer gástrico (8 por ciento), esofagitis (3 por ciento). Los procedimientos más empleados fueron la escleroterapia (22 por ciento), vagotomía con piloroplastía (14 por ciento), gastrectomía subtotal (11 por ciento), sutura y ligadura (8 por ciento), vagotomía con piloroplastía laparoscópica (3 por ciento). La quirúrgica, eventración. La mortalidad observada fue del 8.4 por ciento, el choque hipovolémico y las alteraciones cardiopulmonares fueron las más frecuentes.

Clinical and endoscopic aspects in the evolution of patients with bleeding peptic ulcer: a cohort study

BACKGROUND: Bleeding ulcers are a major problem in public health and represent approximately half of all the cases of upper gastrointestinal hemorrhage in the United States. This study aims to determine the prognostic value of factors such as clinical history, laboratory and endoscopic findings in the occurrence of new episodes of bleeding in patients who have upper gastrointestinal hemorrhage caused by gastric or duodenal peptic ulcer. METHODS: A cohort study with 94 patients was designed to investigate prognostic factors to the occurrence of new episodes of bleeding. RESULTS: From the 94 patients studied, 88 did not present a new bleeding episode in the 7 days following hospital admission. The incidence of rebleeding was significantly higher in those patients with hemoglobin < 6 g/dL at the admission (P = 0.03, RR = 6.2). The localization of the ulcers in bulb was positively associated to rebleeding (P = 0.003). The rebleeding group needed a greater number of units transfunded (P = 0.03) and the time of hospitalization was longer than the time of the hemostasia group (P = 0.0349). CONCLUSIONS: The identification of patients with risk of death by bleeding peptic ulcer remains as a challenge, once few factors are capable of predicting the severity of the evolution. The identification of such factors will alow the choice of the better therapeutic conduct improving the diagnosis and decreasing the rate of rebleeding and the mortality

Avaliação prognóstica de pacientes com hemorragia digestiva alta por úlcera péptica baseada em espectos clínicos e endoscópicos / Gastrointestinal hemorrhage prognosis due to peptic ulcer based on clinical and endoscopic findings

Os autores fazem uma revisão sobre a hemorragia digestiva alta induzida por úlcera péptica, abordando a fisiopatologia, aspectos clínicos, achados endoscópicos e medidas terapêuticas, ressaltando o manejo endoscópico e a correlação prognóstica entre os aspectos clínicos e endoscópicos

Ulcera gástrica péptica crônica hemorrágica: resultados obtidos com tratamento cirúrgico e após terapêutica medicamentosa / Bleeding chronic peptic ulcer: results obtained with early operation and after medical treatment

Säo estudados sessenta doentes portadores de UGPCH, que, após exame endoscópico, foram divididos em dois grupos. No grupo I (36 doentes), administrou-se cimetidine e/ou antiácido com intuito de coibir a hemorragia e praticar a operaçäo fora da fase aguda do sangramento. No grupo II (24 doentes), logo após exame endoscópico, os pacientes foram encaminhados para tratamento cirúrgico. Pôde-se observar que a necessidade de sangue, o índice de complicaçöes pós-operatórias, o tempo de hospitalizaçäo e a mortalidade foram maiores nos doentes do grupo I. Em virtude de nossos resultados, julgamos recomendável que doentes portadores de UGPCH sejam encaminhados para operaçäo em caráter imediato ao invés de serem submetidos a prévio tratamento conservador com administraçäo de climetidine e/ou antiácido

Ulcera péptica e tratamento cirúrgico: indicaçöes / Peptic ulcer and surgical treatment: indications

Atualmente a grande maioria das úlceras pépticas sao tratadas com sucesso através de tratamento clínico. Entretanto, existem situaçoes em que o tratamento cirúrgico torna-se necessário e indicado. O presente trabalho tem como objetivo revisar as indicaçoes de tratamento cirúrgico para as úlceras pépticas, abrangendo suas principais manifestaçoes clínicas, investigaçoes diagnósticas e procedimentos cirúrgicos preferenciais.

Hemorragia digestiva por ulcera péptica / Digestive bleeding in Peptic Ulcer

Quarenta e sete pacientes com sangramento do trato digestivo alto por úlcera péptica foram revisados. A relaçäo homem/mulher foi 3:2 com uma idade média de 38 a 55 anos, respectivamente. Vinte pacientes apresentavam úlceras gástricas, vinte e cinco duodenais e dois casos de úlceras combinadas. Houve recidiva da hemorragia em 26 pacientes, 15 com úlceras gástricas e 11 duodenais. Em 17 casos de úlceras com 2 cm. ou mais de diâmetro apenas uma näo sangrou. A mortalidade foi de 6,3 por cento. os achados endoscópicos sugerem evoluçäo do paciente e poderiam ser usados como critérios objetivos na decisäo de operar ou näo estes pacientes

Hemorragia gastrointestinal alta: experiencia de 30 años en el hospital central militar / Upper gastrointestinal bleeding: 30 years experience in the Hospital Central Militar

Se analizan y comparan resultados en cuanto a la epidemiología y la mortalidad de 1417 casos de hemorragia gastrointestinal alta (HGIA) en el Hospital Central Militar de México de 1960 a 1990. El estudio se divide en décadas: A) 1960-1970, 465 casos; B) 1970-1980, 535 casos, C) 1980-1990, 417 casos. Se señalan las diferencias en cuanto a recursos diagnósticos y terapéuticas en cada una. La HGIA predomina en el sexo masculino, con tendencia a aumentar en el femenino. La mayoría de los casos se presentan entre la 6a y 7a década de la vida. La serie gastroduodenal pierde valor como elemento cierto del diagnóstico. El recurso de elección es la panendoscopía que se realiza en todos los casos y aporta información en el 90 por ciento de los mismos. La angiografía diagnóstica y terapéutica es muy efeciva pero tiene sus indicaciones precisas. La gastritis como causa de HGIA ha aumentado: 12 por ciento A), 25 por ciento B), 38 por ciento C). La úlcera péptica duodenal como causa ha disminuido 40 por ciento A), 35 por cieno B), 23 por ciento C). Las várices esofágicas: 15 por ciento A), 22 por ciento B), 13 por ciento C). En 7 por ciento A), 8 por ciento B) y 10 por ciento C) no puede determinarse la causa exacta. Han aumentado los sangrados ligeros 20 por ciento A), 35 por ciento B), 48 por ciento C); y han disminuido los masivos: 40 por ciento A), 35 por ciento B), 20 por ciento C). La mortalidad de los sangrados moderados y de los ligeros cayó a 0 por ciento desde 1980. La mortalidad en los masivos ha disminuido 60 por ciento A), 40 por ciento B), 40 por ciento C) pero aún es muy importante. Independientemente de la causa, la mortalidad es del 10 por ciento.

Ulcus péptico en recién nacidos: diagnóstico por endoscopia y tratamiento con cimetidina / Peptic ulcer in newborn infants: endoscopic diagnosis and treatment with cimetidine

Entre marzo 1984-mayo 1985, se atendieron en el Departamento de Pediatría del Hospital Universitario "Antonio María Pineda", Barquisimeto, cinco Recién Nacidos con ulcus péptico; 3 del sexo femenino y 2 del sexo masculino, a término adecuados para la edad gestacional, con peso promedio al nacer de 3.330 gr. Había antecedentes de stress perinatal en todos. En cuatro casos hubo manifestaciones clínicas antes de las 48 horas y en un caso a los 9 días. En todos se determinaron valores de Hemoglobina, hematócrito, tiempo de protrombina, tiempo de tromboplastina y recuento de plaquetas. Al comprobarse normalidade de estos valores se practicó esofagogastroduodenoscopia, sin anestesia previa y se comprobó el diagnóstico de ulcus péptico. A todos los pacientes se les administró Cimetidina: 10-20 mg/kg/día, endovenosa durante 7 días y luego oral hasta completar un mes. La endoscopia de control se realizó a los 7 y 30 días de iniciado el tratamiento y reveló desaparición del sangramiento, de los signos de inflamación y cicatrización de las lesiones. Todos los niños han sido colocados en un plan de seguimiento y hasta la fecha no se han detectado problemas hepáticos o trastornos en el comportamiento