Update on endoscopic management of gastric outlet obstruction in children

Endoscopic balloon dilatation(EBD) and surgical intervention are two most common and effective treatments for gastric outlet obstruction. Correction of gastric outlet obstruction without the need for surgery is an issue that has been tried to be resolved in these decades; this management has developed with EBD, advanced treatments like local steroid injection, electrocauterization, and stent have been added recently. The most common causes of pediatric gastric outlet obstruction are idiopathic hypertrophic pyloric stenosis, peptic ulcer disease followed by the ingestion of caustic substances, stenosis secondary to surgical anastomosis; antral web, duplication cyst, ectopic pancreas, and other rare conditions. A complete clinical, radiological and endoscopic evaluation of the patient is required to make the diagnosis, with complimentary histopathologic studies. EBD are used in exceptional cases, some with advantages over surgical intervention depending on each patient in particular and on the characteristics and etiology of the gastric outlet obstruction. Local steroid injection and electrocauterization can augment the effect of EBD. The future of endoscopic treatment seems to be aimed at the use of endoscopic electrocauterization and balloon dilatations.     

Empirical treatment based on "typical" reflux symptoms is inappropriate in a population with a high prevalence of Helicobacter pylori infection

BACKGROUND: Empirical therapy or early endoscopy have been recommended as acceptable management options for GERD. The objective of this study was to determine whether diagnosis and empirical treatment based on reflux symptoms alone are appropriate as initial management for patients with gastroesophageal reflux. METHOD: Consecutive patients presenting with weekly reflux symptoms were evaluated with a structured questionnaire followed by endoscopy. Patients with dyspepsia as the predominant symptom, "alarm" symptoms (weight loss, dysphagia, or bleeding), history of peptic ulcer or gastric surgery, or recent nonsteroidal anti-inflammatory drugs intake were excluded. RESULTS: Four hundred sixty patients were studied: 82 (18%) were found to have peptic ulcer disease and 78 (95%) were infected with Helicobacter pylori. Concomitant erosive esophagitis was found in 26 (32%) of these patients with peptic ulcer disease. In the remaining 378 patients, 218 (58%) had erosive esophagitis and 1 had esophageal cancer. Among the 159 patients with no endoscopic lesion, 148 (93%) had relief of symptoms when treated with a proton pump inhibitor. Multivariate analysis showed that male gender (OR: 1.8, p = 0.03), age greater than 60 years (OR: 2.2, p = 0.01) and H pylori infection (OR: 3.6, p = 0.008) were significantly associated with a diagnosis of peptic ulcer disease. Coexisting dyspeptic symptom was not a predictor (p = 0.13) for peptic ulcer disease. CONCLUSIONS: In populations with a high prevalence of H pylori infection, a significant proportion of patients with GERD have concomitant peptic ulcer disease. Empirical treatment based on "typical" GERD symptoms alone may not be appropriate.     

Endoscopic balloon dilation for benign gastric outlet obstruction with or without Helicobacter pylori infection

BACKGROUND: Endoscopic balloon dilation has been used to treat patients with gastric outlet obstruction caused by peptic stricture. This study assessed the role of endoscopic balloon dilation in patients with gastric outlet obstruction with or without Helicobacter pylori infection. METHODS: Consecutive patients seen between January 1996 and September 2001 with benign gastric outlet obstruction (defined as stenosis preventing the passage of a 9-mm diameter endoscope, vomiting, succussion splash, and recent weight loss) were prospectively studied. Exclusion criteria were the following: refusal to undergo dilation, and gastric outlet obstruction because of malignancy. At endoscopy, antral biopsy specimens were obtained for histopathologic evaluation and for a rapid urease test for Helicobacter pylori infection. Patients then underwent dilation with through-the-scope balloons. After balloon dilation, patients with Helicobacter pylori infection were treated to eradicate the infection. RESULTS: Fifty-one patients (33 men, 18 women; median age 65 years; IQR 44-79 years) were studied; 33 consented to endoscopic balloon dilation. Symptom resolution occurred in 25 patients (14 Helicobacter pylori positive, 11 Helicobacter pylori negative). During a median follow-up of 24 months (IQR 16-40 months), 3 of 14 patients in the Helicobacter pylori positive group and 6 of 11 in the Helicobacter pylori negative group developed further ulcer complications (p=0.039). CONCLUSIONS: After endoscopic dilation for gastric outlet obstruction, eradication of Helicobacter pylori infection is associated with fewer ulcer complications.     

Primary hypertrophic pyloric stenosis in the adult: a case report.

A 66-year-old male was admitted with a two-month history of vomiting and weight loss. Endoscopy showed a pyloric obstruction and the patient underwent subtotal gastrectomy with gastro- jejunostomy. The histopathological study of the specimen revealed primary hypertrophic pyloric stenosis without any evidence of duodenal peptic disease. In the adult, this is a rare cause of gastric outlet obstruction of unknown etiology. It is usually recognized by histopathological examination of the specimen after a gastric resection performed to treat gastric outlet obstruction syndrome. However, some endoscopic and radiological signs, such as the cervix sign, or elongation of the pyloric channel, may give clues about the presence of the disease preoperatively. In symptomatic cases, surgery is the preferred treatment modality.     

Selective outpatient management of upper gastrointestinal bleeding in the elderly

OBJECTIVE: We sought to determine whether elderly patients with upper gastrointestinal bleeding can be safely managed as outpatients. We were also interested in determining the etiology of bleeding peptic ulcer disease in this population. METHODS: Eighty-four patients (65 yr of age and older) were studied during a 23-month period. Urgent outpatient endoscopy was performed and clinical as well as endoscopic criteria were applied to determine the need for hospital admission. Patients with endoscopic findings that indicated a low risk for rebleeding were not admitted if they lacked one major or three minor predefined clinical criteria. All enrollees were followed after discharge from the clinic or hospital for 4 wk with hematocrit determination and clinical assessments. The main outcome measures were the number of patients who met our predefined clinical and endoscopic criteria for outpatient versus inpatient care and the differences in the rebleeding rates in these two groups. RESULTS: Twenty-four (29%) patients were treated as outpatients; none rebled. In contrast, seven (12%) of the 60 inpatients had one or more rebleeding episodes (p = 0.002). Bleeding from peptic ulcer disease was associated with use of nonsteroidal antiinflammatory medications in 81% of patients. CONCLUSIONS: Selective outpatient management of elderly patients with upper gastrointestinal bleeding can be done safely and has the potential to lead to reduced health care expenditures. Over-the-counter nonsteroidal antiinflammatory drugs are the most frequent cause of bleeding peptic ulcer disease in this population.     

Benign gastric outlet obstruction--spectrum and management

Intrinsic or extrinsic obstruction of the pyloric channel or duodenum either by benign or malignant diseases leads to gastric outlet obstruction. With improvement in science and technology, the spectrum of gastric outlet obstruction has changed from peptic ulcer disease to corrosives and malignant diseases. Newer investigations like computerized tomography and endoscopy have supplemented the previous clinical tests like saline load test and barium series. Improvised treatment modalities like endoscopic balloon dilatation and endoscopic incision have circumvented the use of surgery which was the gold standard for management of gastric outlet obstruction. Newer modalities like biodegradable stents have an upcoming role in the management.     

The association of Helicobacter pylori infection and nonsteroidal anti-inflammatory drugs in peptic ulcer disease.

BACKGROUND AND AIM: Peptic ulcer disease (PUD) affects 10% of the world population. Helicobacter pylori infection and the use of a nonsteroidal anti-inflammatory drug (NSAID) are the principal factors associated with PUD. The aim of the present study was to evaluate a cohort of patients with PUD and determine the association between H pylori infection and NSAID use. PATIENTS AND METHODS: The medical charts of patients with endoscopic diagnosis of PUD were retrospectively reviewed from September 2002 to August 2003. Patients were divided into three groups according to ulcer etiology: H pylori infection (group 1); NSAID use (group 2); and combined H pylori infection and NSAID use (group 3). RESULTS: One hundred two patients were evaluated: 36 men (35.3%) and 66 women (64.7%). Forty patients had H pylori infection, 43 had used NSAIDs and 15 had combined H pylori infection and NSAID use; four patients with ulcers secondary to malignancy were excluded. The frequency of women was significantly higher in group 2 (P=0.01). The mean age of patients in group 1 was significantly lower than in the other two groups (P=0.003). PUD developed earlier in group 3 than in group 2 (5.0+/-4.7 months versus 1.4+/-2.1 months, respectively, P=0.018). Thirty-two patients (32.7%) had bleeding peptic ulcer. Group 2 had a higher risk of bleeding peptic ulcer than the other two groups (P=0.001). CONCLUSIONS: The development of PUD was observed earlier in the combined H pylori and NSAID group than in patients with only NSAID use. This suggests a synergic effect between the two risks factors in the development of PUD.     

Videolaparoscopy gastrectomy for complicated peptic ulcer: technique and case report

Since the introduction of H2 receptor antagonists and inhibitors of the acid pump, the indications for the surgical management of peptic disease have decreased significantly. However some patients presenting bleeding, perforation, gastric outlet obstruction and intractable peptic ulcer still need surgical treatment. The first laparoscopic Billroth II gastrectomy was performed in 1992. To date, laparoscopic gastrectomy has been performed by a small number of surgeons around the world. The aim of this study was to present a case of totally laparoscopic Billroth II gastrectomy and to describe an alternative technique using endoscopic stapling devices. We present a case of a 48-year-old man, complaining of severe epigastralgia, who had a 20-year history of peptic ulcer. Gastroscopy had revealed a duodenal ulcer and a deformity of the bulbus. A diagnosis of intractable peptic ulcer was made, and the patient underwent laparoscopic Billroth II gastrectomy with side-to-side intracorporeal gastrojejunostomy using endoscopic stapling devices. On postoperative day 1, he was able to walk. On postoperative day 3, he started on a clear liquid diet and was discharged on postoperative day 6. During his postoperative recovery, the patient experienced little pain and did not request narcotic analgesia. Laparoscopic gastric resection is an alternative to open procedure in well selected cases.     

Observations on peptic ulcer in Shan Dong, China

The study consisted of 10 994 inpatients with peptic ulcer in Shan Dong province. The ratio of duodenal to gastric ulcer was 1.59 : 1. The ratio of males to females was 6.8 : 1 for duodenal ulcer and 4.6 : 1 for gastric ulcer. The highest incidence was in adolescence and young adults and the presentation occurred more commonly in winter. A study of blood groups revealed that there was no relationship between blood group and duodenal or gastric ulcer. The majority (71.9%) of patients with peptic ulcer had complications of upper gastrointestinal bleeding, perforation or gastric outlet obstruction. Bleeding and obstruction were equally common in gastric and duodenal ulcer, but perforation was more common in gastric ulcer.     

Duodenal tuberculosis presenting as gastric outlet obstruction: A case report

Gastric outlet obstruction is commonly associated with malignancies and peptic ulcer disease. However, when no malignancy is seen and the patient is nonresponsive to conventional peptic ulcer treatment, other etiologies need to be explored. We report a case of gastric outlet obstruction due to duodenal tuberculosis. The patient is a 31 year old male who presented with 1 year history of recurrent epigastric pain and an a cute episode of vom iting. Endoscopy revealed duodenal stricture. Computed tomography scan showed pyloro antral thickening. The patient was referred to the surgery service and underwent an exp lor atory laparotomy and gastrojejunostomy. A duodenal mass and calcified lymph nodes were noted on exploration and biopsy revealed a tuberculous origin. The patient was started on anti-tuberculosis medications and had impro ved on discharge. Gastroduodenal tuber culosis is rare and pyloric stenosis resulting from tuber culosis is even rarer. This, however, should be consid ered in patien ts who come from areas where the dise ase is endemic.     

老年消化性溃疡112例病因和临床特点分析

目的 探讨老年消化性溃疡的发病病因、临床表现及内镜特点.方法 收集我院2012年1月～2013年12月住院的消化性溃疡患者273例,将其分为老年组和中青年组,对两组患者的病因、临床表现、内镜特征进行比较.结果 幽门螺杆菌（HP）感染并非老年消化性溃疡的主要病因,老年患者非甾体抗炎药（NSAID）溃疡发病率明显增加,是老年患者的重要病因.老年消化性溃疡多以呕血、黑便为临床首发症状,并发幽门梗阻、癌变的机率高于中青年组.老年组胃溃疡发病率高于中青年组,且巨大溃疡发生率较中青年组多见.结论 老年消化性溃疡临床症状不典型,因同时合并多种基础疾病而增加了复发率及病死率.应了解老年消化性溃疡的发病特点、临床特征及内镜表现,并进行针对性的治疗.     

Idiopathic non-hypertrophic pyloric stenosis in an infant successfully treated via endoscopic approach

Non-peptic, non-hypertrophic pyloric stenosis has rarely been reported in pediatric literature. Endoscopic pyloric balloon dilation has been shown to be a safe procedure in treating gastric outlet obstruction in older children and adults. Partial gastric outlet obstruction (GOO) was diagnosed in an infant by history and confirmed by an upper gastrointestinal series (UGI). Abdominal ultrasonography and computed tomography scan excluded idiopathic hypertrophic pyloric stenosis, abdominal tumors, gastrointestinal and hepato-biliary-pancreatic anomalies. Endoscopic findings showed a pinhole-sized pylorus and did not indicate peptic ulcer disease, Helicobacter pylori infection, antral web, or evidence of allergic and inflammatory bowel diseases. Three sessions of a step-wise endoscopic pyloric balloon dilation were conducted under general anesthesia and a fluoroscopy at two week intervals using catheter balloons (Boston Scientific Microvasive^®, MA, USA) of increasing diameters. Repeat UGI after the first session revealed normal gastrointestinal transit and no intestinal obstruction. The patient tolerated solid food without any gastrointestinal symptoms since the first session. The endoscope was able to be passed through the pylorus after the last session. Although the etiology of GOO in this infant is unclear (proposed mechanisms are herein discussed), endoscopic pyloric balloon dilation was a safe procedure for treating this young infant with non-peptic, non-hypertrophic pyloric stenosis and should be considered as an initial approach before pyloroplasty in such presentations.     

Ulcer recurrence after gastric surgery: is helicobacter pylori the culprit?

Objectives: Helicobacter pylori is the most important cause of recurrent peptic ulcer disease. However, its role in ulcer recurrence after peptic ulcer surgery is unclear. We aimed at studying the prevalence and distribution of H. pylori in patients who had undergone peptic ulcer surgery, and any association between H. pylori infection and ulcer recurrence in these patients.
Methods: Patients with previous vagotomy or partial gastrectomy presenting with dyspepsia or ulcer bleeding were recruited. Ulcer recurrence was documented by endoscopy. Biopsy specimens were taken from the gastric remnant and gastroenteric anastomosis in patients with previous partial gastrectomy, or from the antrum and corpus in vagotomized patients. H. pylori infection was detected by either a positive rapid urease test or the presence of the bacteria on histology.
Results: Ninety-three patients were studied; 73 patients (78%) had partial gastrectomy and 20 (22%) had vagotomy with drainage. H. pylori infection was documented in 36 patients (49%) in the gastrectomy group and in 13 (65%) in the vagotomy group. Thirty-six patients in the gastrectomy group had recurrent ulcers and 15 (42%) of them had H. pylori infection. Twelve patients in the vagotomy group had recurrent ulcers and eight (67%) of them were H. pylori positive. The prevalence of H. pylori infection did not differ between patients with or without ulcer recurrence.
Conclusion: H. pylori infection cannot account for ulcer recurrence after peptic ulcer surgery.     

Ideology of Helicobacter pylori prevalence in peptic ulcer disease in an inner-city minority population

GOALS AND BACKGROUND: The prevalence of Helicobacter pylori infection among patients with peptic ulcer disease has been reported to range from 61 to 94%. Recent studies show a reduction in the prevalence of H. pylori infection in patients with peptic ulcer disease. This study was conducted to determine the prevalence of H. pylori infection in peptic ulcer disease in an inner-city hospital in Washington, DC. METHODS: Medical records of all patients who had undergone upper gastrointestinal endoscopy from July 1997 through June 1999 were reviewed. All patients who had gastric ulcer and/or duodenal ulcer on upper gastrointestinal endoscopy were studied. Demographic characteristics, history of nonsteroidal antiinflammatory drug ingestion, alcohol consumption, and associated diseases were studied. H. pylori was considered to be present if CLOtest and/or histopathology were positive for H. pylori. Patients with negative pathology for H. pylori or negative pathology and CLOtest were considered negative for H. pylori. RESULTS: One-hundred fifty-six patients were found to have gastric and/or duodenal ulcers. Fifty-one ulcer patients did not meet the inclusion criteria and were excluded. Among the 105 patients who were included in the study, gastric ulcers were found in 48 patients (45.7%), duodenal ulcers were found in 46 patients (43.8%), and both gastric and duodenal ulcers were found in 11 patients (10.5%). H. pylori was present in 66.7% of gastric ulcer patients and in 69.5% of duodenal ulcer patients. Antral histology and CLOtest were in agreement 96% of the time. CONCLUSIONS: At the District of Columbia General Hospital, an inner-city hospital serving predominantly an African-American community, the prevalence of H. pylori in ulcer patients compares similarly to other more recent studies that have found a decreased prevalence of this bacterial infection in ulcer patients. This suggests that the treatment of H. pylori in minority patients is reducing the proportion of ulcers due to this bacterium, as has been seen with the majority population.     

Efferent limb of gastrojejunostomy obstruction by a whole okra phytobezoar: Case report and brief review

A phytobezoar is one of the intraluminal causes of gastric outlet obstruction,especially in patients with previous gastric surgery and/or gastric motility disorders.Before the proton pump inhibitor era,vagotomy,pyloroplasty,gastrectomy and gastrojejunostomy were commonly performed procedures in peptic ulcer patients.One of the sequelae of gastrojejunostomy is phytobezoar formation.However,a bezoar causing gastric outlet obstruction is rare even with giant gastric bezoars.We report a rare case of gastric outlet obstruction due to a phytobezoar obstructing the efferent limb of the gastrojejunostomy site.This phytobezoar which consisted of a whole piece of okra(lady finger vegetable) was successfully removed by endoscopic snare.To the best of our knowledge,this is the first case of okra bezoar-related gastrojejunostomy efferent limb obstruction reported in the literature.     

Changing pattern of peptic ulcer in India. An endoscopic study of 1,188 ulcer patients.

Earlier studies have described a profile of peptic ulcer different in developing and developed countries. In a prospective endoscopic study in India over 5 years and 8 months involving 5,948 patients with upper gastrointestinal symptoms, we detected peptic ulcers in 1,188. There were 920 patients with duodenal ulcer (DU), 185 with gastric ulcer (GU), and 83 with combinations of the two. The male to female ratio was 4.2:1. About half the ulcers were in patients age greater than or equal to 40 years. Of the 223 (18.7%) patients with peptic ulcer complications, gastrointestinal bleeding was the most common (12.7%) and gastric outlet obstruction was less common (6.2%). Endoscopic evidence of duodenal bulb deformity was seen in 74.4% of DU patients. A comparison of these results with data from previous Indian studies suggests a changing trend of peptic ulcer with respect to age and sex distribution, the ratio between DU and GU, and complications of peptic ulcer. The profile of peptic ulcer in north India today is similar to that seen in Western countries four to five decades ago. We discuss possible factors responsible for this change.     

Management of peptic ulcer disease not related to Helicobacter pylori or NSAIDs

Helicobacter pylori (H. pylori) infection is widely accepted as the most important factor in the pathogenesis of duodenal ulcer. However, in parallel with more effective eradication of H. pylori, the prevalence of H. pylori is changing, and H. pylori-negative peptic ulcer disease appears to be increasing. When making a diagnosis of H. pylori-negative peptic ulcer disease, it is essential to avoid misclassification because of inaccurate diagnosis. In addition, secondary causes may need to be excluded with appropriate investigations. In the absence of H. pylori, nonsteroidal anti-inflammatory drug usage is the most common cause of peptic ulcer; surreptitious nonsteroidal anti-inflammatory drug usage is a cause of unexplained ulcer disease in up to 60% of patients. Hypersecretory syndromes such as Zollinger-Ellison syndrome, although rare, need to be excluded. Once all known etiological factors are excluded, there remains a group of patients with so-called "idiopathic ulcers." The interplay of etiological factors in the pathogenesis of idiopathic peptic ulcer disease is poorly defined but may include a genetic predisposition, altered acid secretion, rapid gastric emptying, defective mucosal defense mechanisms, psychological stress, and smoking. The management of idiopathic peptic ulcers is not defined; they appear to be more resistant to standard therapy, can be associated with more frequent complications, and those that relapse may require long-term maintenance therapy.     

The value of alarm features in identifying organic causes of dyspepsia.

The unaided clinical diagnosis of dyspepsia is of limited value in separating functional dyspepsia from clinically relevant organic causes of dyspepsia (gastric and esophageal malignancies, peptic ulcer disease and complicated esophagitis). The identification of one or more alarm features, such as weight loss, dysphagia, signs of gastrointestinal bleeding, an abdominal mass or age over 45 years may help identify patients with a higher risk of organic disease. This review summarizes the frequency of alarm symptoms in dyspeptic patients in different settings (such as the community, primary care and specialist clinics). The prevalence of alarm features in patients diagnosed with upper gastrointestinal malignancy or peptic ulcer disease is described. The probability of diagnosing clinically relevant upper gastrointestinal disease in patients presenting with alarm features and other risk factors is discussed. Alarm features such as age, significant weight loss, use of nonsteroidal anti-inflammatory drugs, signs of bleeding and dysphagia may help stratify dyspeptic patients and help optimize the use of endoscopy resources.     

Effect of treatment of Helicobacter pylori infection on the long-term recurrence of gastric or duodenal ulcer. A randomized, controlled study.

OBJECTIVE: To determine the effect of treating Helicobacter pylori infection on the recurrence of gastric and duodenal ulcer disease. DESIGN: Follow-up of up to 2 years in patients with healed ulcers who had participated in randomized, controlled trials. SETTING: A Veterans Affairs hospital. PARTICIPANTS: A total of 109 patients infected with H. pylori who had a recently healed duodenal (83 patients) or gastric ulcer (26 patients) as confirmed by endoscopy. INTERVENTION: Patients received ranitidine, 300 mg, or ranitidine plus triple therapy. Triple therapy consisted of tetracycline, 2 g; metronidazole, 750 mg; and bismuth subsalicylate, 5 or 8 tablets (151 mg bismuth per tablet) and was administered for the first 2 weeks of treatment; ranitidine therapy was continued until the ulcer had healed or 16 weeks had elapsed. After ulcer healing, no maintenance antiulcer therapy was given. MEASUREMENTS: Endoscopy to assess ulcer recurrence was done at 3-month intervals or when a patient developed symptoms, for a maximum of 2 years. RESULTS: The probability of recurrence for patients who received triple therapy plus ranitidine was significantly lower than that for patients who received ranitidine alone: for patients with duodenal ulcer, 12% (95% CI, 1% to 24%) compared with 95% (CI, 84% to 100%); for patients with gastric ulcer, 13% (CI, 4% to 31%) compared with 74% (44% to 100%). Fifty percent of patients who received ranitidine alone for healing of duodenal or gastric ulcer had a relapse within 12 weeks of healing. Ulcer recurrence in the triple therapy group was related to the failure to eradicate H. pylori and to the use of nonsteroidal anti-inflammatory drugs. CONCLUSIONS: Eradication of H. pylori infection markedly changes the natural history of peptic ulcer in patients with duodenal or gastric ulcer. Most peptic ulcers associated with H. pylori infection are curable.