Úlcera duodenal benigna con penetración en cabeza de páncreas, con obstrucción de la vía biliar / Benign duodenal ulcer penetrating into pancreas, with obstruction of common bile duct

Resumen Objetivo: Reportamos un caso clínico con presentación atípica de una úlcera duodenal benigna que simula el cuadro clínico y radiológico de una neoplasia de páncreas. Materiales y Método: Presentamos el caso de un varón de 83 años que debuta con un cuadro clínico de astenia e ictericia mucocutánea. En estudio de imagen se identifica una masa en cabeza pancreática. En estudio endoscópico se observa úlcera duodenal benigna penetrada a cabeza de páncreas que condiciona obstrucción de vía biliar. Discusión y Conclusiones: El manejo de estos pacientes suele ser quirúrgico porque desarrollan un deterioro asociado a sepsis o perforación. Si la situación clínica lo permite se puede intentar un tratamiento conservador. En nuestro caso el paciente precisó un mes de hospitalización con antibioticoterapia intravenosa de amplio espectro, reposo alimentario, nutrición parenteral y tratamiento con inhibidores de la bomba de protones (IBP) para la resolución del cuadro. La penetración o fistulización a la cabeza del páncreas es una complicación grave e infrecuente de la enfermedad ulcerosa péptica. Su manejo puede ser conservador en casos seleccionados donde no exista perforación de la úlcera a la cavidad peritoneal, ni exista deterioro séptico ni hemodinámico.

Aim: To report an atypical presentation of a benign duodenal ulcer that simulates pancreatic neoplasia. Materials and Method: A case of a 83 years old male patient with astenia and jaundice due to a benign duodenal ulcer penetrating into the pancreas with obstruction of common bile duct. Imagining study identified a pancreatic head mass. The patient required one month admission, receiving broad-spectrum antibiotics, parenteral nutrition and intravenous proton pump inhibitors. Discussion and Conclusion: Due to frequent complications associated to this condition, such as haemodynamic failure, sepsis or free peritoneal perforation, surgery is the main treatment. However, in mild cases, as in our patient, conservative management can be considered. Penetration or fistulization to the head of the pancreas is a rare and serious complication of peptic ulcer disease. Its management can be conservative in selected cases where there is no perforation of the ulcer into the peritoneal cavity, nor septic or hemodynamic deterioration.

Hemorragia digestiva por úlcera duodenal pós-bypass gástrico em estômago excluso: abordagem endoscópica transgástrica por laparoscopia / Gastrointestinal bleeding by duodenal ulcer after gastric bypass in excluded stomach: endoscopic transgastric approach by laparoscopy

O Bypass Gástrico é uma das cirurgias bariátricas mais realizadas no Brasil e no mundo. Com o aumento exponencial da utilização desta técnica cirúrgica, complicações a longo prazo podem ocorrer. Nesse contexto, é necessário um bom conhecimento pós-operatório, principalmente em relação à fisiopatologia gastrointestinal destes pacientes. Uma complicação rara, porém, extremamente grave, é a úlcera duodenal sangrante. Uma razão para isto é o difícil acesso ao estômago excluso e ao duodeno através da endoscopia digestiva alta. Este relato demonstra uma úlcera duodenal sangrante em paciente pós-operatório de bypass gástrico laparoscópico.

Gastric bypass in Roux-Y is the most common bariatric surgery in Brazil and the world. With the exponential increase of this surgical technique, complications can occur. In this context, is required a great knowledge postoperatively, especially in relation to gastrointestinal pathophysiology of these patients. A rare complication, however, extremely severe, is a duodenal ulcer bleeding. One account for this is the difficult to access excluded stomach and the duodenum through the endoscopy. This case report shows a duodenal ulcer bleeding in a patient postoperative laparoscopic gastric bypass.

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.

Evaluación posoperatoria de los pacientes con úlcera perforada / Postoperative evaluation of patients operated on perforated gastro-duodenal ulcer

Introducción: la úlcera péptica gastroduodenal constituye después de la hemorragia la complicación ulcerosa más frecuente y la más grave de todas. Ocurre entre el 2 y 5 porciento de los pacientes con enfermedad ulcerosa y sus síntomas son provocados por la acción del jugo gástrico derramado en la cavidad abdominal. Objetivo: valorar la evolución de los pacientes operados de urgencia con el diagnóstico de úlcera gastroduodenal perforada. Métodos: se realizó un estudio observacional descriptivo con carácter prospectivo en el periodo comprendido entre enero del 2005 y diciembre del 2011. El universo estuvo constituido por todos los pacientes intervenidos quirúrgicamente por úlcera gastroduodenal perforada en el servicio de Cirugía General del Hospital General Docente Enrique Cabrera durante ese período. Los datos fueron transferidos a una planilla de recolección de datos que posteriormente fue procesada y analizada en el Microsoft Office Excel 2007. Los resultados se expresaron en tablas y gráficos, y solo se usaron técnicas de estadística descriptiva; distribuciones de frecuencia absolutas y relativas para las variables cuantitativas y media aritmética para las cuantitativas. Resultados: el grupo de edad predominante fue de mayores de 60 años con 42,4 porciento. El sexo masculino fue el de mayor incidencia con un 88 porciento. La asociación tabaco más café y solo tabaco constituyeron los hábitos tóxicos más frecuentes con 23,1 porciento cada uno. El dolor abdominal estuvo presente en el 100 porciento de los pacientes. La radiografía de tórax con el paciente de pie fue el estudio complementario más utilizado para corroborar la sospecha diagnóstica. En el 77 porciento de los pacientes se evidenció el neumoperitoneo radiológico. La úlcera duodenal fue la localización más frecuente (19 pacientes). En 15 pacientes (57,7 por ciento) se realizó la sutura y epiploplastia como tratamiento de urgencia. La complicación postoperatoria más frecuente fue la dehiscencia de la herida quirúrgica. Un paciente falleció en el postoperatorio con diagnóstico de bronconeumonía. Conclusiones: los pacientes mayores de 60 años de edad y del sexo masculino constituyeron el mayor número con el diagnóstico de úlcera gastroduodenal perforada. La localización más frecuente de la úlcera fue en el duodeno. La sutura y epiploplastia fue el proceder más utilizado como tratamiento. La dehiscencia de la sutura fue la complicación que más se observó en la serie(AU)

Introduction: Perforated peptic gastroduodenal ulcer represents the most frequent and serious complication after hemorrhage. It occurred in 2 to 5 percent of patients diagnosed as peptic ulcer and the main symptoms are caused by the gastroduodenal content spilled over the peritoneal cavity. Objective: To assess the recovery of patients operated on from perforated gastroduodenal ulcer at emergency setting. Methods: Prospective, observational and descriptive study carried out from January 2005 through December 2011. The universe of study was all the patients operated on from perforated gastroduodenal ulcer in Enrique Cabrera general teaching hospital's general surgery service in this period. Data were collected in forms, which were processed and analyzed by using Microsoft Office Excel 2007. The results were provided in tables and graphs; summary statistics, absolute and relative distribution for quantitative variables and arithmetic median for the quantitative ones were the statistical techniques used. Results: Men over 60 years old were the main group of patients with this pathology( 42.2 percent). The highest incidence rate was found in males (88 percent).Toxic habits like coffee plus cigar, and coffee alone were the most frequent, accounting for 23.1 percent each. All the patients complained of acute epigastric pain. Chest Rx on standing position was the most used study to confirm the suspected diagnosis. Radiological pneumoperitoneum was evident in 77 percent of patients. Duodenal ulcer was the main location of perforation (19 patients). Suture and epiploplasty were performed as emergency treatment in 15 patients (57.7 percent). Surgical wound dehiscence was the most common complication. One patient died from bronchopneumonia during the postoperative phase. Conclusions: Patients aged over 60 and males represented the highest number with diagnosis of perforated gastroduodenal ulcer. The most frequent location was duodenum. Epipoplasty and suture were the main therapeutic methods. Suture dehiscence was the most observed complication in this group(AU)

The Prevalence of Barrett's Esophagus and the Comparison of Barrett's Esophagus with Cardiac Intestinal Metaplasia in the Health Screening at a Secondary Care Hospital / 대한소화기학회지

BACKGROUND/AIMS: The purpose of this study was to estimate the prevalence of Barrett's esophagus (BE) and its association with reflux esophagitis (RE) and peptic ulcer disease detected by free charge endoscopy which was covered by the National Health Insurance at a secondary care hospital, and to compare the results of the biopsy of BE with that of cardiac intestinal metaplasia (CIM). METHODS: A total of 4,002 patients underwent endoscopy from March 2010 to December 2012. BE was diagnosed if there was histologically proven specialized intestinal metaplasia, and CIM was diagnosed if intestinal metaplasia was accompanied with chronic gastritis. RESULTS: Four hundred twenty four patients underwent endoscopic biopsy, and the prevalence of BE was 1.0% (42/4,002). The mean age and the proportion of males in BE were significantly higher than those of the rest of study population, and BE had slight tendency related to RE than the rest of study population. CIM was observed in 34 patients and BE and CIM showed similar results, regarding age, sex and association with RE. The mean length of endoscopic Barrett's mucosa of BE group was 9.2+/-5.1 mm, and it was similar to that of CIM. CONCLUSIONS: The prevalence of BE in the secondary care hospital was not low, and old age and male sex were significantly associated with BE. Because BE was observed in about 10% of biopsied patients and CIM was observed in a similar percentage with BE, the precise targeted biopsy is warranted and the biopsy method should be reestablished through the large prospective study of multiple secondary care hospitals.

Complicações gastrintestinais em usuários de cocaína/crack: revisão da literatura / Gastrointestinal complications among users of cocaine / crack-a literature review

O consumo de cocaína/crack atinge todos os extratos sociais e grande parcela da população, principalmente os jovens. Esse abuso leva à ampla gama de complicações sistêmicas. No trato gastrintestinal, pode se expressar por manifestações como perfuração gastroduodenal aguda, colite isquêmica, infarto, isquemia intestinal e, raramente, hemorragia maciça. Seu mecanismo fisiopatológico parece ser o vasoespasmo ou vasoconstrição, que pode levar à isquemia, inclusive com necrose transmural. É importante a atenção e vigilância para o abuso de cocaína/crack ao deparar com paciente com dor abdominal inexplicável. (AU)

Cocaine/crack have being consumed by a large portion of the population especially by youth and reaching all social levels. This abuse leads to a wide range of systemic complications. In the gastrointestinal tract, the drug can lead to manifestations such as acute gastroduodenal perforation, ischemic colitis, infarction, intestinal ischemia and, rarely, massive hemorrhage. The most accepted pathophysiological mechanism is vasospasm or vasoconstriction which can lead to ischemia, including transmural necrosis. It is important that physicians to be aware and search recent history of abuse of crack / cocaine when faced with a patient with unexplained abdominal pain. (AU)

effect of ramadan fasting on duedenal ulcer perforation

Fasting during the month of Ramadan is one of the five holy pillars in the Islamic faith and is an important annual ritual practiced by all Muslims. This involves fasting from dawn to dusk, followed by a break of fast at designated times. The length of fasting varies from ten to 19 hours, depending on the season in which the fasting month of Ramadan falls and the geographical locations. 1st to evaluate the relation between Ramadan fasting and duodenal ulcer perforations and 2nd to asses the risk factors of this complications. This is a prospective study in Baghdad Teaching Hospital - Medical City . Data from 231 consecutive patients with perforated duodenal ulcer from the period of October 2007 to December 2010 were collected and analyzed and all the patients were managed surgically after resuscitation in emergency unit. [96/231, 41.6%] of patients with perforated duodenal ulcer during Ramadan vs. [135/231, 58.4%] during the rest of the years. [96/490, 19.5%] of patients with perforated duodenal ulcer from the total number of all patients with acute abdomeninal surgeries during Ramadan. 43% of patients smoking and 47% of patients had a previous history of acid peptic disease in Ramadan. 54% of patients were in between [20 to 40] years age group and the male to female ratio was 6 :1 . 15% patients of perforated duodenal ulcer had history of regular use of non steroidal anti inflammatory drugs.. Erect chest x-ray demonstrated gas under the diaphragm in 86% . Only 2 patients had a previous surgery of duodenal ulcer perforation. This study suggests that the incidence of duodenal ulcer perforation is relatively high in Ramadan among the people, who are fasting and have predisposing factors [smoking, history of acid peptic disease, non steroidal anti-inflammatory drugs] and need special precaution during this month

A Case of Superior Mesenteric Venous Thrombosis Due to Protein C Deficiency in a Patient with Duodenal Ulcer Bleeding / 대한소화기학회지

Mesenteric venous thrombosis is a clinically very rare disease, and may cause bowel infarction and gangrene. Difficulty in the dignosis the disease due to its non-specific symptoms and low prevalence can cause a clinically fatal situation. Mesenteric venous thrombosis may be caused by both congenital and acquired factors, and protein C deficiency, which is a very rare genetic disorder, is one of many causes of mesenteric thrombosis. The authors experienced a case of mesenteric venous thrombosis caused by protein C deficiency in a patient with duodenal ulcer bleeding, so here we report a case together with literature review.

Primary Antibiotic Resistance of Helicobacter pylori Strains and Eradication Rate according to Gastroduodenal Disease in Korea / 대한소화기학회지

BACKGROUND/AIMS: This study was performed to evaluate whether the prevalence rates of primary antibiotic resistance in Helicobacter pylori (H. pylori) isolates and the eradication rate of H. pylori could be different between cancer and non-cancer patients. METHODS: H. pylori were isolated from gastric mucosal biopsy specimens obtained from 269 Koreans, who did not have any eradication therapy history and were diagnosed as one of the following diseases; chronic gastritis, benign gastric ulcer, duodenal ulcer or gastric cancer. The susceptibilities of the H. pylori isolates to amoxicillin, clarithromycin, metronidazole, tetracycline, azithromycin, ciprofloxacin, levofloxacin and moxifloxacin were examined with the agar dilution method. In addition, eradication rate of H. pylori was evaluated. RESULTS: There was no significant difference in the primary antibiotic resistance to above eight antibiotics among chronic gastritis, peptic ulcer disease and gastric cancer. Furthermore there was no difference of antibiotic resistance between cancer and non-cancer patients, and there was no difference of eradication rate of H. pylori according to disease. CONCLUSIONS: Primary antibiotic resistance and H. pylori eradication rate were not different between cancer and non-cancer patients.

Bleeding duodenal ulcer after Roux-en-Y gastric bypass surgery: the value of laparoscopic gastroduodenoscopy

Roux-en-Y gastric bypass is a common surgical procedure used to treat patients with morbid obesity. One of the rare, but potentially fatal complications of gastric bypass is upper gastrointestinal bleeding, which can pose diagnostic and therapeutic dilemmas. This report describes a 39-year-old male with morbid obesity who underwent a Roux-en-Y gastric bypass. Three months postoperatively, he sustained repeated and severe upper attacks of upper gastrointestinal bleeding. He received multiple blood transfusions, and had repeated upper and lower endoscopies with no diagnostic yield. Finally, he underwent laparoscopic endoscopy which revealed a bleeding duodenal ulcer. About 5 ml of saline with adrenaline was injected, followed by electrocoagulation to seal the overlying cleft and blood vessel. He was also treated with a course of a proton pump inhibitor and given treatment for H pylori eradication with no further attacks of bleeding. Taking in consideration the difficulties in accessing the bypassed stomach endoscopically, laparoscopic endoscopy is a feasible and valuable diagnostic and therapeutic procedure in patients who had gastric bypass

Upper gastrointestinal bleeding in children in southern Iran.

Objective. To find out whether the causes of upper GI bleeding in our center in a developing country differed from developed countries. Methods. Children presenting to our center with upper GI bleeding from March 2002 to March 2007, were retrospectively evaluated. Informations were retrieved from patient’s history and physical examination and results of upper GI endoscopy regarding etiology of bleeding, managements, use of medications which might predispose patient to bleeding, and the mortality rate. Results. From 118 children (67 boys; with age of 7.7±4.7 yrs) who underwent upper GI endoscopies, 50% presented with hematemesis, 14% had melena and 36% had both. The most common causes of upper GI bleeding among all patients were gastric erosions (28%), esophageal varices (16%), duodenal erosions (10%), gastric ulcer (8.5%), Mallory Weiss syndrome tear (7.8%), duodenal ulcer (6.8%), esophagitis (1.7%) and duodenal ulcer with gastric ulcer (0.8%). The causes of bleeding could not be ascertained in 20.5% of cases. No significant pre-medication or procedure related complications were observed. Endoscopic therapy was performed in 13.5% of patients. In 14.4% of patients, there was a history of consumption of medications predisposing them to upper GI bleeding. Two deaths occurred (1.7%) too. Conclusion. The findings in the present study showed that half of upper GI bleedings in pediatric patients from south of Iran, were due to gastric and duodenal erosions and ulcers. This study concludes that the causes of upper GI bleeding in children in our center of a developing country, are not different from those in developed ones.

Primary closure of perforated peptic duodenal ulcer

To find out the morbidity and mortality of primary closure of perforated peptic duodenal ulcer with an omental patch. An observational descriptive study, from February 2003 to January 2006. This study is carried out in Surgical units of People's Medical College Hospital Nawabshah on 92 patients of perforated duodenal ulcer were included in this study with male to female ratio 8:1. The age varies between 26-45 year with peak age incidence 35 years. The perforation closed primarily with vicryl-0 and supported with omental patch. Peritoneal lavage performed and drain kept in all cases. All patients were investigated for H. pylon and treated with eradication therapy in infected cases. Follow up carried out with upper G.I. Endoscopy at 6 weeks, and then six monthly for two years. Out of 92 cases, only 5 cases had recurrence within two years and wound infection remained the major post operative complication seen in 20% and chest infection in 15% of cases. No mortality seen in this study. Omental patch repair as primary closure of perforated peptic duodenal ulcer is effective surgical treatment with excellent results. The eradication therapy for H. pylon is adequate and comparable with definitive surgical treatment for peptic ulcer

A Case of Intramural Duodenal Hematoma Accompanied by Acute Pancreatitis Following Endoscopic Hemostasis for Duodenal Ulcer Bleeding / 대한소화기학회지

Intramural duodenal hematoma is an uncommon condition, which usually develops after blunt abdominal trauma. It is also reported as a complication of anticoagulant therapy, blood dyscrasia, pancreatic disease, and diagnostic and therapeutic endoscopy. The typical clinical pictures of intramural duodenal hematoma consist of upper abdominal pain, vomiting, fever, and hematochezia, and it is rarely accompanied by intestinal obstruction, peritonitis, and pancreatitis as its complication. We report a case of intramural duodenal hematoma extended to peritoneal cavity, and accompanied by acute pancreatitis following therapeutic endoscopy for duodenal ulcer bleeding in a 32-year-old man who was on maintenance of anti-coagulation therapy after valvular heart surgery.

Gastrointestinal bleeding in a toddler secondary to chronic renal failure and hyper-gastrinemia.

A 3-year-old girl with H. pylori negative duodenal ulcer with hypergastrinemia secondary to chronic renal failure presenting with upper gastrointestinal bleed as the cardinal manifestation is unusual in toddlers and the case is presented for its rarity.

Surgical management of combined perforated and bleeding duodenal ulcer

Peptic ulcer is one of the most frequent diseases of the alimentary tract, while mortality from perforated peptic ulcer still remains high. We conducted this retrospective study to determine the adverse operative risk factors for perforated hemorrhagic peptic ulcers in Shiraz, southern Iran. 896 patients with peptic ulcer were enrolled. A questionnaire was used to collect the data on age, gender, site of ulcer, presentation, endoscopic findings, type of peptic ulcer complications, method of treatment, surgical procedure, and results of the treatment. Complicated duodenal ulcer was 15% in period I, and 11.5% in period II [P>SD of the age of +/- 0.05]. The mean 11 years. The age of the patients with perforated duodenal the patients was 42.7 8.6 years. Perforation with 12.5 and in hemorrhagic patients 37.4 +/- ulcer was 48 hemorrhagic duodenal ulcer in the first period was 1.2% and in second period, 0.2%. In the second period, simple closure was done in 29 [74%] patients, and in perforated DU cases, conservative management was done in 23 [56%] patients. Although the number of complicated duodenal ulcer cases increased from period I to period II, complications of duodenal ulcer [Kissing disease] significantly decreased

Pattern of change in the frequency of Helicobacter pylori with perforated duodenal ulcer

Peptic ulcers were believed to be caused by stress, dietary factors, and gastric acid, but the link between H. pylori and peptic ulcers was identified in 1983. To see the frequency of Helicobacter pylori infection in patients with perforated duodenal ulcer and advise eradication therapy in these patients. This cross sectional study was conducted in Surgical Unit Hayatabad Medical Complex, Peshawar, during January 2007-June 2008. A total of 50 cases were included in the study. All cases presenting to our unit with acute perforated duodenal ulcer were recruited. After resuscitation and baseline investigations, all underwent emergency laparotomy via upper midline incision, after thorough peritoneal lavage, the perforation margins were freshened and closed over an omental patch. Serum from every patient was tested for H. pylori and accordingly managed. Out of the 50 cases, 45 were males, and 5 were females. Age ranged from 20- 80 years old. All patients underwent emergency laparotomy. Postoperatively, all were started on PPI treatment and serum testing for H. pylori was done. Thirty-four [68%] turned out positive and 16 [32%] were found to be negative for H. pylori. There is still a high frequency of H. pylori infection in patients with perforated duodenal ulcer. But comparing these results with the various data available, there is a significant decline in H pylori positive perforated duodenal ulcer patients

[Laparoscopic treatment of duodenal ulcer feasibility and results: about 160 cases]

The objective of this study is to evaluate the feasibility, efficacy and safety of laparoscopic repair for perforated duodenal ulcer. One hundred and sixty patients were treated by coelioscopic procedure for a perforated duodenal ulcer. The procedure consists of a suture of perforated ulcer associated with a peritoneal lavage. A medical treatment of Helicobacter pylori associated with an inhibitor of the protons pump was conducted. The coelioscopic procedure permitted to confirm the diagnostic of perforated duodenal ulcer in all cases. A simple suture of the ulcer was done in 155 cases. The conversion was compulsory in 5 cases, because of difficulties of the peritoneal lavage in 2 cases, a bleeding associated with perforation of the ulcer in one case and associated stenosis in 2 cases. Mean duration was 90 min [extremes 50 - 120 min]. Complications occur in 3.1%. There were post - operative peritonitis in 3 cases and duodenal fistulae in 2 cases. All patients were reviewed at 16 months. A recurrence, either clinical or endoscopic occured in 4 cases because of no adhesion to medical treatment. Coelioscopic treatment of perforated duodenal ulcer is a safe and efficacy method. It permits to avoid potential septic and parietal complications of laparotomy. The actual efficacy of medical treatment mustn't allow place to the radical treatment of ulcerous illness