Use of omeprazole in the management of giant duodenal ulcer: results of a prospective study.

BACKGROUND: Giant duodenal ulcer (GDU) is generally thought to require surgical intervention. Proton pump inhibitors have beneficial effects in peptic ulcer disease, but their role in GDU disease is unknown. We examined the use of omeprazole in GDU management. METHODS: Twenty-eight patients were diagnosed with GDU. One patient required immediate operative intervention. The remaining 27 were placed on omeprazole (40 mg daily). When ulcer healing was documented by endoscopy, the patients were placed on oral histamine-2 receptor antagonist therapy. RESULTS: Of the 28 study patients, 20 (71.4%) did not require operative intervention, and 8 (28.6%) required operation for ulcer complications. Of the 15 patients with adherent clot or a visible vessel at initial endoscopy, 7 (46.7%) required operative intervention, as compared with 1 (7.7%) of the 13 patients without a visible vessel or adherent clot. This difference was statistically significant (P < .05). Twenty-three patients underwent antral biopsy and/or enzyme-linked immunosorbent assay for Helicobacter pylori, and 9 (39.1%) had a positive result. CONCLUSIONS: Omeprazole is effective in the treatment of GDU disease. An adherent clot or a visible vessel at endoscopy indicates a higher likelihood of complications requiring operation. The relatively low H pylori infection rate, as compared with other peptic ulcer disease, may indicate a different pathophysiology in GDU.

Arterial oxygen saturation during emergency esophagogastroduodenoscopy. The effects of nasal oxygen.

Cardiopulmonary events account for many of the serious gastrointestinal endoscopy complications. Pulse oximetry monitoring detects hypoxemia to allow prevention of complications. Alternatively, prophylaxis by continuous nasal oxygen during the procedure may offset any tendency toward oxygen desaturation. We monitored patients with major upper gastrointestinal hemorrhage by pulse oximetry during emergency upper endoscopy on room air or while receiving supplemental nasal oxygen (2 l/min). Desaturation (SpO2 < 90%) occurred in 80% of patients undergoing emergency procedures on room air but in only 25% of those receiving supplemental oxygen. For comparison, patients without significant cardiac or pulmonary disease undergoing elective procedures were studied on room air and desaturation only occurred in 29%. Thus, arterial oxygen desaturation as measured by pulse oximetry occurs more often during emergency than elective endoscopy. Supplemental oxygen decreases desaturation during emergency endoscopy but does not abolish it. We recommend that supplemental oxygen be used during emergency endoscopy to decrease desaturation, but it should not substitute for patient monitoring.

Pancreatitis in patients with end-stage renal disease.

In a population of 716 patients with end-stage renal disease (ESRD), 46 patients (6.4%) were identified as having pancreatitis. Pancreatitis was significantly more common in those with alcohol abuse, systemic lupus erythematosus (SLE), and polycystic kidney disease. It was not significantly associated with hyperlipidemia, biliary tract disease, or hypercalcemia. Acute pancreatitis occurring before the patient developed ESRD was mainly alcohol-related and did not appear to be a significant risk factor for future episodes of pancreatitis during dialysis. Chronic calcific pancreatitis diagnosed before ESRD was almost invariably due to alcohol abuse, and tended to be a marker for recurrent acute exacerbation after development of ESRD, whether alcohol consumption continued or not. Pancreatitis occurring for the first time after ESRD in patients on dialysis was generally benign, and was usually accompanied by an uneventful recovery and few recurrent episodes. However, a significant elevation of the calcium x phosphate product was observed in these patients, occurring in about half the patients without any known precipitating factor. After kidney transplantation, the development of pancreatitis was associated with higher morbidity and mortality. Chronic calcific pancreatitis diagnosed after ESRD occurred only in patients with SLE; reported here for the first time, it may be a manifestation of long-standing disease, chronic steroid therapy, or both.

Limitations of percutaneous endoscopic jejunostomy.

Thirty-six patients at the University of Kentucky Medical Center underwent percutaneous endoscopic jejunostomy placement between January 1 and December 31, 1989. We retrospectively reviewed their charts for indications and complications of the procedure. Experience and outcome with the initial placement of the percutaneous jejunostomy tube was evaluated. Primary diagnoses at the time of insertion included central nervous system disorders (28), ventilator dependence (5), cancer (2), and gastroparesis (1). The follow-up period ranged from 2 to 131 days (median 16 days). Tube dysfunction or dislodgment occurred in 31% of patients. Other complications included pulmonary aspiration (11%) and bleeding at the insertion site (3%). The 30-day mortality rate was 19% with all but one death caused by the severity of the underlying primary illness. It is concluded that problems with the currently performed technique of percutaneous endoscopic jejunostomy, along with tube-related problems, seriously limit the usefulness of this technique. Improvements in technology, along with routine postprocedure radiographs to allow early detection of malpositioned jejunostomy tubes, may improve the outcome of this procedure. Newer techniques that have a higher success of distal small intestinal placement need to be evaluated.

A multicenter, double-blind, randomized, placebo-controlled comparison of nocturnal roxatidine in the treatment of active duodenal ulcer disease. Multicenter Roxatidine Cooperative Study Group.

This multicenter randomized, double-blind, 4-wk study compared the new H2-receptor antagonistic roxatidine (R) to placebo (P) for treatment of endoscopically diagnosed active duodenal ulcer disease. Subjects were evaluated after 2 and 4 wk of treatment. Those whose ulcer was unhealed at 2 wk received 2 more weeks of treatment before final evaluation. Ulcer healing (endoscopically determined) with roxatidine was more effective than placebo at both wk 0-2 (R = 33.9%, P = 21.9%, p = 0.018) and wk 2-4 (R = 68.2%, P = 29.7%, p less than 0.001), with an overall 4-wk effectiveness of 78.9% compared to 44.8% (p less than 0.001). At the end of treatment, average maximum ulcer diameter diminished 83% in R and 50% in P (p less than 0.001). Roxatidine was also more effective than placebo in decreasing abdominal pain (p less than 0.001), decreasing the number of antacid tablets taken for pain relief (p less than 0.001), improving dyspeptic symptoms (p less than 0.001), and permitting return to a normal routine for subjects with previous illness-imposed restrictions on work and/or other daily activities. The profile of laboratory values and adverse experiences demonstrated roxatidine to be safe and well-tolerated. The efficacy of roxatidine as evaluated by the healing rate of duodenal ulcer and reduction in abdominal pain emphasize its value as an addition to the family of H2-receptor antagonists.

Lipid responses of hypercholesterolemic men to oat-bran and wheat-bran intake.

The hypocholesterolemic effects of oat bran (OB) have been recently challenged. To carefully document the hypocholesterolemic effects of OB, 20 hypercholesterolemic men admitted to a metabolic ward were randomly allocated to either OB or wheat bran (WB) for 21 d after a 7-d control-diet period. Control and treatment diets were designed to be identical in energy content and nutrients, differing only in the amount of soluble fiber. After 21 d, OB significantly decreased total cholesterol by 12.8% (P less than 0.001), low-density-lipoprotein cholesterol by 12.1% (P less than 0.004), and apolipoprotein B-100 by 13.7% (P less than 0.001) whereas WB had no significant effect. High-density-lipoprotein cholesterol and apolipoprotein A-I did not change significantly in either group. Serum triglycerides decreased by 10% in both groups but the decrease was only significant (P less than 0.04) in WB subjects. OB but not WB significantly reduced total cholesterol and other atherogenic lipoprotein fractions independent of other dietary changes.

Gaucher's disease complicated by bleeding esophageal varices and colonic infiltration by Gaucher cells.

We report a 10-yr-old child with Gaucher's disease who developed upper gastrointestinal bleeding from esophageal varices, as well as hemorrhage from a colonic polyp infiltrated with Gaucher cells. Both the varices and polyp were treated endoscopically, and the outcome was successful. Although gastrointestinal hemorrhage due to portal hypertension is considered a rare complication of Gaucher's disease, colonic infiltration with Gaucher cells has not been recognized previously.

Peptic ulcer disease in the elderly.

Peptic ulcer disease in the elderly poses challenges to the physician distinct from those encountered in younger individuals. Factors predisposing to the more aggressive natural history of peptic ulcer disease in the elderly are examined. These are of great importance in considering diagnostic investigations, the choice of therapeutic agents, and the management of complications. Despite advances in operative technique and care, surgery, particularly when emergent, is attended by a high mortality in this group. The utility of diagnostic and therapeutic endoscopy is discussed, and strategies for short and longer term medical treatment are presented.

Right ventricular thrombosis after peritoneovenous shunt: nonoperative treatment with successful outcome.

Complications of peritoneovenous shunt for intractable ascites include a high propensity to malfunction, facilitation of infection, and the induction of coagulopathies. Right heart thrombosis is a rarely encountered adverse effect, the management of which has not yet been defined. We report a patient with an extensive right heart thrombus in the setting of a blocked peritoneovenous shunt that was discovered incidentally and treated expectantly with subsequent complete resolution and satisfactory outcome.

Pancreatic function testing. Methods to identify exocrine insufficiency.

The diagnosis of chronic pancreatitis is ideally established by an appropriate clinical history and confirmatory radiologic imaging. However, in cases where imaging results are normal or equivocal, pancreatic function testing is necessary. Direct (intubation) tests are generally accepted as the best methods for study of pancreatic exocrine capacity, but indirect tests, which are well tolerated and generally simple to perform, are gaining interest. Their shortcoming is that they are too insensitive to reliably differentiate patients with early exocrine dysfunction (ie, before malabsorption has occurred) from controls. Sensitivity is not improved by combining two or more studies. However, several modified tests (eg, two-stage paraaminobenzoic acid test, pancreolauryl test) have improved specificity and are able to distinguish pancreatic from other causes of steatorrhea. Their reproducibility in individual cases is of value in sequential studies and in patients with established pancreatic exocrine deficiency to seek evidence of improvement or deterioration in function and to determine patient compliance with replacement therapy.

Fatal amiodarone hepatoxicity.

The antiarrhythmic agent amiodarone is associated with numerous adverse effects, but clinically significant liver disease is rare. A patient is described who presented with muscle weakness, hepatomegaly, and ascites following 28 months of amiodarone usage. His condition deteriorated despite discontinuation of amiodarone therapy. A postmortem liver biopsy demonstrated necrosis, fibrosis, hyalin, and phospholipid-laden lysosomal lamellar bodies. Resolution of hepatic dysfunction may not necessarily occur on withdrawal of amiodarone if irreversible damage is already established. We speculate as to the reasons for the reportedly low incidence of overt liver disease, and suggest that hepatic enzyme levels, as well as other indicators of hepatic function, such as the serum albumin concentration, be monitored indefinitely in all patients while taking amiodarone.

Peptic ulcer disease in the elderly.

The elderly are a growing minority; they comprise approximately 12% of the population but consume an increasing proportion of health care resources. Disease in the aged is unique in many ways, demanding special attention and study. This is particularly evident with regard to peptic ulceration, which is a more serious disorder in the elderly than in younger individuals, often presenting in an atypical manner and having a greater propensity to complications. Management traditionally tends to be conservative, enthusiasm often being tempered by the presence of frailty and associated disease. Despite technologic and pharmacologic advances, the elderly continue to account for a disproportionate number of deaths from this disorder. This paper will review the peculiarities of peptic ulcer disease of the elderly and examine currently emerging trends which may influence evolving management policies.

Immunoproliferative small-intestinal disease: clinical features and outcome in 30 cases.

Experience with 30 patients with immunoproliferative small intestinal disease followed prospectively between 1971 and 1986 is described. All presented with malabsorption or growth retardation and had similar clinical, biochemical, and radiological features, irrespective of the presence of lymphoma or immunological abnormality. Alpha-chain disease protein was detected in 4 of the 11 patients who had a non-lymphomatous, predominantly plasmacytic infiltration of the small bowel; and in 5 of the 19 cases with diffuse intestinal lymphoma. The importance of exploratory laparotomy to include full-thickness intestinal biopsy in patients who have a benign infiltrate on peroral biopsy is demonstrated by the finding of lymphoma in operative specimens in 9 of 15 patients with mature, lymphoplasmacytic cells, and 5 of 8 patients with atypical, lymphoplasmacytic cells. The majority of patients with fully established benign disease, even those elaborating alpha-chain disease protein, appeared to have a good prognosis. No patient with immunoproliferative small intestinal disease developed immunologically demonstrated alpha-chain disease or frank lymphoma, when this was not found initially at explorative laparotomy.

Nocturnal dosage regimen of sucralfate in maintenance treatment of gastric ulcer.

Sixty-six patients with recently healed gastric ulcers were entered into a double-blind, placebo-controlled, six-month maintenance trial to determine whether sucralfate 2 g at night reduces the liability to recurrent ulceration. Thirty-three patients were randomly assigned to treatment with sucralfate and 33 were assigned to placebo. Endoscopy was performed at the time of entry into the study and at 24 weeks, or earlier if clinical relapse occurred during this period. Of the patients available for analysis, endoscopic recurrences were found in eight of the 29 patients (28 percent) randomly assigned to sucralfate and in 15 of the 27 patients (56 percent) assigned to placebo. Eight of the recurrences noted at 24 weeks were asymptomatic and, of these, five were in the placebo-treated group. The cumulative relapse rate at 24 weeks was significantly lower in the sucralfate-treated group (p less than 0.05), and the Cox-Mantel text showed a significant difference between the cumulative relapse curves of the two treatment groups over the 24-week period (p less than 0.05). The results indicate that a single maintenance dose of sucralfate 2 g at night reduces the relapse rate in patients with recently healed gastric ulceration.

Annular pancreas associated with diffuse chronic pancreatitis.

A patient with longstanding diabetes and renal failure presented with painless vomiting due to duodenal obstruction was found to have an annular pancreas. Initial operative evaluation, later pathologically confirmed, demonstrated involvement of not only the annulus, but also the entire gland by diffuse atrophic chronic pancreatitis. We speculate on the possible influence of the underlying diabetes and renal disease on the pathogenesis of the unusual generalized chronic inflammatory changes and the precipitation of duodenal obstruction in this patient.

The role of pancreatic function testing in the 1980s.

The recent advent of non-invasive imaging techniques and tubeless pancreatic function tests has revolutionised the investigation of patients with suspected chronic pancreatic disease. The current diagnostic role of the conventional pancreatic function test is evaluated and the practical usefulness of alternative modalities is reviewed.

A comparison of sucralfate dosage schedule in duodenal ulcer healing. Two grams twice a day versus one gram four times a day.

The conventional dosage schedule for sucralfate is 1 g 4 i.d., but a dose of 2 g 2 i.d. may be equally effective in duodenal ulcer healing. We compared the efficacy of these two regimens in duodenal ulcer healing. Seventy-seven patients with endoscopically proven duodenal ulceration were entered into a double-blind, controlled study and randomized to treatment with sucralfate 2 g 2 i.d. (on waking and at bedtime) or 1 g 4 i.d. (1/2 h before meals and at bedtime). The patients were endoscoped before entry into the study, after 4 weeks, and after 8 weeks if unhealed at 4 weeks. Of the patients considered suitable for analysis at 4 weeks, 79% (26/33) of those taking 2 g 2 i.d. had healed ulcers in comparison to 72% (23/32) of those taking 1 g 4 i.d. After 8 weeks, cumulative healing rates were 85% (28/33) and 80% (24/30), respectively. The results suggest that the more convenient dosage schedule of 2 g 2 i.d. is as effective as the 1 g 4 i.d. regimen in the short-term treatment of duodenal ulcer.