Algunas especificidades sobre la mortalidad asociada a la hemorragia por enfermedad ulcerosa péptica gastroduodenal / Some specificities on mortality associated with hemorrhage due to gastroduodenal peptic ulcerous disease

En la actualidad constituye un verdadero problema científico la diversidad de criterios sobre las características epidemiológicas, clínicas y quirúrgicas de la hemorragia digestiva alta no varicosa, debido a sus altas tasas de letalidad y mortalidad, por cuanto resulta de gran importancia identificar los factores pronósticos de complicaciones y decesos, inherentes a esta entidad clínica, a fin de elaborar un protocolo de actuación y buenas prácticas, una vez reconocidas las condiciones modificables que disminuyan el número de fallecimientos por esta causa, sobre todo en la población envejecida como grupo vulnerable, de donde se derivaría la trascendencia de su impacto médico social. Todo ello justifica la necesidad de profundizar en los principales aspectos cognoscitivos relacionados con este tema, puesto que solo contando con equipos de trabajo altamente especializados, podrá elevarse la calidad asistencial y, con esa premisa, el índice de supervivencia de quienes presenten ese tipo de sangrado por enfermedad ácido péptica.

At present the diversity of criteria on the epidemiological, clinical and surgical characteristics of the high digestive hemorrhage non varicose constitutes a true scientific problem, due to their high lethality and mortality rates, so that it is of great importance to identify the complications prognosis factors and death, inherent to this clinical entity, in order to elaborate a performance protocol and good practices, once the modifiable conditions which decrease the number of deaths due to this cause are recognized, mainly in the aged population as vulnerable group, from where the transcendency of its social medical impact would be derived . All this justifies the necessity to deepen in the main cognitive aspects related to this topic, since just having highly specialized working teams, it will be able to rise the assistance quality and, with that premise, the survival index of those who suffer from that type of bleedding caused by acid peptic disease.

Úlcera de estresse no paciente queimado / Stress ulcer in burned patients

A úlcera de estresse pode ocorrer, dentre outras situações, nas queimaduras graves (de Curling), em que a mortalidade é bastante elevada. Contribuem para a formação dessa úlcera a isquemia de mucosa, a presença do ácido e a difusão de ureia no estômago, bem como a acidose grave e a deficiência de energia diferencial na célula mucosa. Este é um relato de caso de um paciente queimado grave, etilista crônico, sem comorbidades, que desenvolveu uma úlcera duodenal perfurada no terceiro dia de internação hospitalar. Pacientes queimados apresentam redução da perfusão esplâncnica, que torna a mucosa intestinal isquêmica, seguido de lesão e hemorragia. Tal cadeia de eventos normalmente ocorre em 72 horas. Alguns estudos demonstraram que o uso profilático de bloqueadores H2 reduziu a incidência da referida úlcera para 0,9%. Outros evidenciam que os inibidores de bomba de prótons são ainda mais eficazes em aumentar e manter o pH. Preconiza-se que esses doentes devem receber 40 mg de omeprazol intervaladas de 6 horas no primeiro dia, seguidas de 20 mg por dia nos dias seguintes. Novos métodos de profilaxia contra a úlcera de Curling devem ser estudados a fim de reduzir a morbimortalidade desta doença.

Besides other medical situations, stress ulcer may occur in patients with severeburns (Curling’s ulcer) whose mortality rate is expressively high. Factors such as mucosal ischemia, the presence of acid and urea diffusion in the stomach contribute to ulceration, as well as severe acidosis and differential energy deficiency in mucosal cell. This is a case report of a severe burned patient with chronic alcoholism and no comorbidities who developed a perforated duodenal ulcer on the third day of hospitalization. Splanchnic hypoperfusion presented by burned patients leads to ischemia of the bowel mucosa resulting in injury and hemorrhage. Such chain of events usually develops in 72 hours. In some studies, the prophylactic use of H2 blockers was able to reduce the incidence of that ulcer to around 0.9%. In others, the proton-pump inhibitors are more effective in increasing and maintaining the pH level. It´s recommended that these patients should receive 40 mg of omeprazole every 6 hours during the first day and 20 mg per day from the second day on. New prophylactic methods against the Curling ulcer should be studied in order to decrease morbidity and mortality rates of this disease.

The Influence of Diabetes Mellitus on Short-Term Outcomes of Patients with Bleeding Peptic Ulcers

PURPOSE: Little information is available on the influence of diabetes mellitus on the short-term clinical outcomes of patients with bleeding peptic ulcers. The aim of this study is to investigate whether diabetes mellitus influences the short-term clinical outcomes of patients with bleeding peptic ulcers using a Japanese national administrative database. MATERIALS AND METHODS: A total of 4863 patients treated by endoscopic hemostasis on admission for bleeding peptic ulcers were referred to 586 participating hospitals in Japan. We collected their data to compare the risk-adjusted length of stay (LOS) and in-hospital mortality of patients with and without diabetes mellitus within 30 days. Patients were divided into two groups: patients with diabetes mellitus (n=434) and patients without diabetes mellitus (n=4429). RESULTS: Mean LOS in patients with diabetes mellitus was significantly longer than those without diabetes mellitus (15.8 days vs. 12.5 days, p<0.001). Also, higher in-hospital mortality within 30 days was observed in patients with diabetes mellitus compared with those without diabetes mellitus (2.7% vs. 1.1%, p=0.004). Multiple linear regression analysis revealed that diabetes mellitus was significantly associated with an increase in risk-adjusted LOS. The standardized coefficient was 0.036 days (p=0.01). Furthermore, the analysis revealed that diabetes mellitus significantly increased the risk of in-hospital mortality within 30 days (odds ratio=2.285, 95% CI=1.161-4.497, p=0.017). CONCLUSION: This study demonstrated that presence of diabetes mellitus significantly influences the short-term clinical outcomes of patients with bleeding peptic ulcers.

Current status of management of benign bleeding peptic ulcer in Al-Gamhouria Teaching Hospital, Aden, Yemen

We aimed to explore and analyze current status of bleeding peptic ulcers in surgical patients. The study was carried out at the Surgical Department of Al-Gamhouria Teaching Hospital, Aden-Yemen. It was divided into 2 parts. Group [A] patients, admitted with bleeding peptic ulcers during the period May 1998 to April 2003, were retrospectively evaluated, and the prospective group [B] that included patients admitted during the period May 2003 to April 2006. One hundred and twenty patients were enrolled in the study; 75% were in group [A] and 25% in [B]. Men were [103] and women [17], with a ratio of [6.1:1]. Overall mean age was 43.4 years [ranging 17 to 70 years] with 23 patients [19.17%] over 60 years. Endoscopic activity within the first 24 hours in group [A] was [55.56%] and zero in [B]. Ratio of bleeding duodenal to gastric ulcers was [2:1]. Bleeding was massive and /or recurred in [32.5%] of patients, with transfusion of 3-9 units of blood [mean - 5.38]. Surgery was performed only in the retrospective group - in [11.11%]. Hospital stay time was for group [A] and [B] 17.5 and 9 days respectively. Overall death rate was [8.33%]; it was less in group [A] than [B] - [6.67%] and [13.3%] respectively. In patients treated only conservatively, death rates in [A] and [B] were [7.5%] and [13.3%] respectively. Nevertheless, death rates were statistically not significant. Overall outlook was quite alarming. Lack of good administration, limited resources, and lack of necessary equipments played the major role in improper management of these patients. To improve the situation, it is recommended to prepare guidelines and establish a well equipped and well functioning endoscopy unit

Lesäo péptica hemorrágica : avaliaçäo de resultados com aplicaçäo de um score / Peptic hemorrhage lesion: evaluation of results with application score

O presente trabalho consiste de estudo retrospectivo na avaliaçäo de resultados com aplicaçäo de um score, utilizado na clínica cirúrgica do HUSF, nas lesöes pépticas hemorrágicas. O score desenvolvido e publicado por Pimpl et al. Auxilia no prognóstico, índice de mortalidade e na comparaçäo dos pacientes e resultados, cotejando com doentes e resultados obtidos em outros serviços - facilitando estudos multicêntricos. A esclerose endoscópica deve ser enfatizada como método hemostático provisório nas lesöes pépticas hemorrágicas, para obtençäo de melhores resultados

Hemorragia digestiva alta: cirugía de urgencia / Upper gastrointestinal bleeding: surgical emergency

El uso de modernos bloqueantes de la secreción gástrica ha modificado poco la incidencia de complicaciones en la enfermedad ulcerosa gastroduodenal. En este trabajo, se analizan 1154 pacientes internados por hemorragia digestiva alta; el 93,7 por ciento eran portadores de úlcera gástrica, o duodenal, o recidivante. Se excluyó el sangrado por várices. Se utilizó la clasificación de Forrest modificada para determinar la posibilidad de sangrado considerándola útil. Noventa pacientes debieron ser operados sangrando, observándose una mortalidad del 34 por ciento y morbilidad del 66 por ciento. Este grupo de pacientes debe considerarse de alto riesgo. Los antecedentes clínicos pre-sangrado, shock en el momento del ingreso, y hemorragia complicando el post-operatorio, fueron factores significativos para el pronóstico. Debe realizarse un esfuerzo para evitar intervenciones en agudo. En este sentido, la hemostasia por vía endoscópica o la embolización endovascular, pueden reducir el número de operaciones de urgencia

Hemorragia digestiva alta masiva por úlcera péptica / Upper gastrointestinal tract hemorrhage in peptic ulcer

Se analiza una serie de 108 pacientes intervenidos en plena hemorragia por úlcera péptica en 7 años. El diagnóstico preoperatorio se precisó en 68% de los casos. La mortalidad global fue del 23,1% siendo 3 a 5 veces superior en los mayores de 60 años. El porcentaje global de resangrado alcanzó al 20,3%, siendo superior en los casos de úlcera gástrica tratados mediante procedimientos no resectivos. Se recomienda cirugía precoz en los mayores de 60 años, con patología asociada y en los que requieran más de 500 ml de sangre cada 6 horas para mantener los signos vitales estables. La resección gástrica es de elección en la úlcera gástrica sangrante. La sutura asociada a vagotomía y piloroplastía tiene un rendimiento similar a la resección con vagotomía en los casos de úlcera duodenal