Obstructive Jaundice Due to Duodenal Ulcer Induced by Lenvatinib Therapy for Hepatocellular Carcinoma

An 82-year-old man with hepatocellular carcinoma presented with upper abdominal pain, vomiting, and jaundice. He had been taking a standard lenvatinib dose for three months. Although acute cholangitis was suggested, imaging studies failed to detect the biliary obstruction site. An endoscopic examination following discontinuation of lenvatinib and aspirin revealed multiple duodenal ulcers, one of which was formed on the ampulla of Vater and causing cholestasis. Endoscopic biliary drainage and antibiotics improved concomitant Enterobacter cloacae bacteremia. Ulcer healing was confirmed after rabeprazole was replaced with vonoprazan and misoprostol. Our case shows that lenvatinib can induce duodenal ulcers resulting in obstructive jaundice.     

Relapse of Duodenal Ulcer after Treatment with Trimipramine/Antacids or Cimetidine/Antacids

Ninety-three patients with duodenal ulcer were treated with trimipramine. 25 mg at night; Cimetidine. 400 mg at night; or cimetidine. 1000mg/day. In addition, all patients were given 20 ml antacids 1 and 3 h after meals. The healing rates after 6 weeks' treatment were 86%, 85%, and 100% in the three groups, respectively (differences not significant). After healing of the ulcers 88 of the patients were checked monthly during 1 year to study relapse rate. Endoscopy was performed on recurrence of symptoms suggesting relapse and after 6 and 12 months in all asymptomatic patients. Relapse was diagnosed in 64% of the patients in the trimipramine-treated group, in 48% in the 400 mg Cimetidine group, and in 54% in the 1000 mg Cimetidine group (differences not significant). The results suggest that ulcer recurrence is not commoner after treatment with a standard dose of Cimetidine than after a low dosage of Cimetidine or trimipramine.     

Doxepin in the Treatment of Duodenal Ulcer

In the double-blind study of 51 patients with duodenal ulcer the effect of doxepin and placebo was evaluated. Complete healing of the ulcer was found in 19 of 23 patients after 4 weeks of treatment with 50 mg doxepin (83%) and in 14 of 27 patients given placebo (52%) (p < 0.05). Two patients in the placebo group developed complications necessitating surgical intervention. No serious side effects were registered in the doxepin group.     

Prevention of Duodenal Ulcer Recurrence with Penicillin: A Double-Blind,Placebo-Controlled Trial

Eradication of Helicobacter pylori is associated with a reduced recurrence of duodenal ulcer (DU). The relationship between H. pylori and DU has been interpreted as causal, but the evidence has been criticized for methodologic reasons. To ascertain whether an antibiotic with no effect on epithelial-cell integrity prevents DU recurrence, we conducted a randomized double-blind trial of phenoxy-methylpenicillin (PEN), 2.4 twice daily, and placebo (PLA). Patients with an active DU and positive H. pylori culture from antral biopsy specimens were treated with 40 mg omeprazole daily for 4 weeks, but at week 2 they were allocated at random to PEN (85 patients) or PLA (85 patients) for up to 14 weeks. Those without recurrence during this treatment were followed up for another 6 months. Endoscopy and H. pylori culture were performed at the end of the treatment period and at the end of follow-up, and in between if ulcer symptoms recurred. During the treatment period the ulcer relapse rate was 5 of 58 (9%) in the PEN group and 34 of 68 (50%) in the PLA group (p < 0.0001, log-rank test), with 53% and 14%, respectively, of the patients in the two groups being H, pylori-negative. The relapse rate in the PEN group did not differ between H. pylori-negative and H. pylori-positive patients. The recurrence rate in the PEN group remained low for another 5 months but then approached the rate in the PLA group. The prevalence of H. pylori-negative patients at the end of follow-up was 20% in the PEN group and 10% in the PLA group. These data provide strong evidence that DU has a bacterial cause, with H. pylori as the likely agent.     

Gastric Acid Secretion in Patients with Duodenal Ulcer

Augmented histamine tests were performed in 349 patients with duodenal ulcers verified by operation, of whom 268 were men between 16 and 84 years of age, and 81 were women between 12 and 78 years; all were citizens of Copenhagen. In the men the mean peak acid output was 44 mEq H⁺ per hour, ranging from 16.8 to 111.4 mEq. The mean acid output in women was 32.3 mEq H⁺ per hour, ranging from 13.7 to 74.4 mEq. In men with duodenal ulcer a statistically significant correlation between age and peak acid output is clearly demonstrable, the acid output decreasing by 5 mEq H⁺ per hour for each ten years’ increase of age. In women, the acid output falls about two mEq H⁺ per hour per decade, although the statistical significance of this finding is not certain.     

The Acetylator Phenotypes of Duodenal Ulcer Patients

Rats deficient in pantothenic acid have diminished acetylating powers due to a lack of coenzyme A, and they develop hypersecretion of gastric acid and duodenal ulcers. Human beings are genetically constituted as either rapid or slow acetylators due to a polymorphism of the enzyme acetyl transferase.

A population of duodenal ulcer subjects studied has a normal incidence of slow acetylators, suggesting that this phenotype is not more liable to develop the disease. Other possible ways in which the acetylation polymorphism might be related to duodenal ulcer are discussed.     

十二指肠球部溃疡患者高胃泌素血症与幽门螺杆菌相关性的研究

本文报告我院１９９０年４月～１９９２年１０月期间经胃镜确诊的２６４例十二指肠球部溃疡患者胃窦部幽门螺杆菌检测和血清胃泌素测定结果。结果显示ＨＰ检出率球溃组高达８０．３％（２１２／２６４），与对照组２９．６３％（１６／５４）有显著差异（Ｐ＜０．００５）。ＨＰ阳性球溃组血清胃泌素水平１０３．０３±７２．４３（ｎｇ／Ｌ），较对照组６３．３３±３９．０４（ｎｇ／Ｌ）和ＨＰ阴性球溃组７４．３２±４９．７２（ｎｇ／Ｌ）明显增高（Ｐ均＜０．００５）。随访３８例治疗后ＨＰ阳性球溃患者，２６例溃疡愈合且ＨＰ转阴者血清胃泌素为７８．３２±４２５６（ｎｇ／Ｌ），较前明显下降（Ｐ＜０．０１）。表明球溃患者高胃泌素血症与ＨＰ感染有一定相关性。     

Seven-Year Follow-up of Patients with Duodenal Ulcer Disease

Kayser L, M0ller B, Harting K, Rune SJ. Seven-year follow-up of patients with duodenal ulcer disease. Scand J Gastroenterol 1994;29:684-687.

Background: The activity of duodenal ulcer disease varies not only between patients but also from time to time within patients, and earlier studies have concluded that the disease 'burns out' in many cases. It was the aim of this study to examine duodenal ulcer disease activity over a long period, to determine whether the degree of activity is stable within the individual patient. Methods; A cohort of 145 patients with a first-time duodenal ulcer diagnosed in our department between 1980 and 1985 were followed up for 7 years. The patients' self-reported use of acid-inhibitory drugs was taken as a measure of disease activity. Results: Twenty-eight per cent of the patients had no or minimal ulcer symptoms during the 7 years after healing of the index ulcer, whereas 13% had maximal activity with frequent or continuous use of acid-inhibitory drugs every year or ulcer surgery. A total of 11 patients were operated on because of severe ulcer symptoms or complications to the ulcer disease. The disease activity during the first 2 years after diagnosis did not change much during the following 5 years in most of the patients. Conclusions: The course of duodenal ulcer disease during the first 2 years after diagnosis was a predictor of the long-term prognosis with a predictive value of approximately 70%, which may be considered satisfactory for decision-making in some clinical situations.     

Diagnostic Strategy in Suspected Duodenal Ulcer Disease

Abstract. In a questionnaire study of 89 Danish gastroenterologists the current diagnostic strategy in patients suspected of having duodenal ulcer disease was elucidated. A case summary concerning a patient with upper abdominal pain was presented. It was assumed that the patient had had a double-contrast barium meal examination or an upper gastrointestinal endoscopy performed. If the X-ray had revealed a deformity of the duodenal bulb, 30% of the gastroenterologists would offer the patient specific medical treatment (H₂-blocking agent etc.), but a significantly higher number of gastroenterologists, 45%, (p<0.05) would offer specific medical treatment if a deformity was revealed at endoscopy. There was also a significant difference (p<0.01) between those who would offer specific treatment if X-ray (84%) or if endoscopy (100%) had revealed an ulcer. Considerable variation was found among experts in their decisions on the basis of X-ray and endoscopy in patients with suspected duodenal ulcer disease. Gastroenterologists generally rely more on endoscopic than on radiographic findings.     

Antacids in the Treatment of Duodenal Ulcer

ABSTRACT Fifty patients with endoscopically proven pyloric-prepyloric ulcers (PU/PPU) and 50 with duodenal ulcers (DU) completed a six-week double-blind clinical trial initially comprising 124 patients. The antacid-treated patients received 10 ml of an antacid suspension seven times a day (buffering 367.5 mmol acid). Healing rate after three weeks of treatment was 74% in the antacid and 42% in the placebo group (p<0.01). After six weeks the corresponding figures were 96 and 68% (p<0.001). Regarding the PU/PPU and DU subgroups we found significant differences compared to placebo in the PU/PPU group only. Antacids caused a significantly faster and more perceptible pain relief than placebo. We found no significant correlation between ulcer healing and smoking habits. Regression analyses showed that, besides antacids, ulcer size and peak acid output influenced the healing rate significantly.     

A Case of Duodenal Duplication

Abstract: Duplication of the duodenum is extremely rare. Including the present case, duodenal duplication in adults has been reported in only 20 cases in Japan. All previously reported cases underwent open surgery, and endoscopic resection has not previously been reported. In this report, we describe a patient in whom a duodenal duplication was endoscopically resectable, demonstrating the usefulness of endoscopic resection for the treatment of this malformation.     

血浆胃动素水平与十二指肠球部溃疡发生与愈合的关系

本文用放免法测定了３３例十二指肠球部溃疡及３５例慢性胃炎患者血浆胃动素水平，同时检测胃粘膜ＨＰ感染情况及胃液ｐＨ值，并对其中１９例十二指肠球部溃疡患者进行抗ＨＰ二联治疗（得乐冲剂＋甲硝唑片）共６周，观察ＨＰ转阴后胃动素变化，结果表明十二指肠球部溃疡患者血浆胃动素显著高于慢性胃炎患者，分别为４４７．２３±９８．４ｎｇ／Ｌ及３５３．５±１００．２ｎｇ／Ｌ（Ｐ＜０．０１），１７例溃疡愈合者血浆胃动素显著下降，与慢性胃炎愈合者无显著性差异（Ｐ＞０．０５），而２例溃疡未愈者血浆胃动素仍持续升高，相关分析显示十二指肠球部溃疡患者血浆胃动素升高与ＨＰ感染及胃液ｐＨ值无关。本文认为十二指肠球部溃疡患者血浆胃动素升高可能是一种继发性改变，其临床意义尚有待进一步阐明。     

胃舒散联合呋喃唑酮和阿莫西林根除幽门螺杆菌阳性十二指肠溃疡及抗复发疗效观察

目的 :观察胃舒散、呋喃唑酮和阿莫西林对幽门螺杆菌 (Hp)阳性十二指肠溃疡 (DU)的疗效及根除Hp对溃疡复发的影响。方法 :73例 Hp阳性 DU患者随机分为两组 :三联组 4 1例 ,服用胃舒散 2 .0 g,呋喃唑酮 0 .1g,阿莫西林 0 .5 g,各 3次 /d ,2周后再继服胃舒散 4周。雷尼替丁组 32例 ,服用雷尼替丁 0 .15 g,3次 /d,共 6周。治疗前后均记录胃痛症状 ,内镜观察溃疡情况 ,并进行 2年随访。Hp检测采用 Warthin- Starry银染色法 ,1 4C-尿素呼气试验或快速尿素酶试验 ,2项阳性为 Hp感染 ,阴性为 Hp根除。结果 :6周治疗结束后 ,两组溃疡愈合率均为10 0 %。三联组临床症状缓解率、副反应发生率为 97.6 %和 18.8% ,雷尼替丁组为 93.8%和 9.4 % (均 P >0 .0 5 )。三联组 Hp根除率 (92 .7% )显著高于雷尼替丁组 (0 % ,P <0 .0 1)。 Hp根除的 38例中 ,1年及 2年溃疡复发率为(5 .3% ,10 .5 % )均显著低于 Hp持续感染者 (2 8.1% ,4 6 .9% ,P <0 .0 1)。结论 :以胃舒散为主的三联疗法具有疗效高、副作用少、溃疡复发率低的优点 ,是一种根除 Hp的较好方案。     

三联疗法治疗HP相关性出血性十二指肠溃疡的远期疗效观察

目的：观察三联疗法根除幽门螺杆菌（ＨＰ）,预防溃疡复发与再出血的远期疗效。方法：选择有ＨＰ感染的出血性十二指肠溃疡患者５８ 例,随机分为两组。治疗组３６ 例,用丽珠得乐冲剂、呋喃唑酮片剂、泰胃美片治疗２周;对照组２２例,单用泰胃美片治疗２周。疗程结束后,两组患者均再用泰胃美治疗２ 周,总疗程结束后４ 周及每半年复查胃镜和ＨＰ,定期随访２ 年。结果：治疗组和对照组溃疡愈合率分别为１００％ 和８１．８％ ,ＨＰ根除率分别为８０．５％ 和９．１％ 。随访２ 年后,治疗组溃疡复发率为１３．９％ ,再出血率为５．５％ ,对照组溃疡复发率为９０．９％ ,再出血率为４５．４％ ,两组溃疡复发率与再出血率比较有显著性差异（ Ｐ＜ ０．０５）。结论：三联疗法具有较好的根除ＨＰ、明显减少溃疡复发和再出血发生的作用,具有较好的远期疗效     

梗阻性黄疸与消化性溃疡

研究234例梗阻性黄疸和209例非黄疸病人的消化性溃疡发病情况.结果黄疸组42例(17.9%),而对照组仅5例(2.4%)发现胃或十二指肠溃疡.十二指肠溃疡发病率两组有显著差别,而胃溃疡则两组发生率无明显差别.黄疸持续的时间对溃疡的发生无明显影响.胆总管阻塞者溃疡发生率高,而胆总管以上部位阻塞者溃疡发生率与对照组无明显差异.本研究进一步证实了胃酸在十二指肠溃疡形成中的重要作用.     

Risk Factors For Duodenal Ulcer Recurrence: Three-year Follow-up during Famotidine Maintenance Therapy

The recurrence-free rate and factors related to recurrence after healing were investigated in duodenal ulcer patients on H₂-blocker maintenance therapy with famotidine. Famotidine maintenance therapy (20 or 40 mg once a day before bedtime) was performed in 488 evaluable patients after endoscopically-proven healing of ulcers (S₁ or S₂). The cumulative recurrence-free rates were 81.1%, 65.1% and 58.2%, respectively, after one, two and three years of maintenance therapy. Among various background factors, those which have been suggested to be closely associated with ulcer recurrence were compared on the basis of their relation to the recurrence-free rate. These factors included a past history of duodenal ulcer, smoking, alcohol use, bulbar deformation, the endoscopic stage of ulcer healing, concomitant drugs and compliance with famotidine therapy. Recurrence correlated most significantly with a past history of duodenal ulcer and with compliance. Compliance was categorized as excellent, good, fair or poor. The recurrence-free rate was significantly lower in patients with excellent compliance than in any other compliance group. A famotidine dose of 40 mg/day (the standard dose), versus the half dose of 20 mg/day, produced no significant difference in the cumulative recurrence-free rate and it was therefore suggested that 20 mg/day of famotidine is comparable to 40 mg/day in its preventive effect on duodenal ulcer recurrence. In addition, because recurrence was more common in patients who had previously experienced recurrence, a past history of ulcer was suggested to be a significant risk factor for ulcer recurrence.     

Duodenal tuberculosis with a choledocho-duodenal fistula

A 22-year-old man visited our hospital (National Cancer Center Hospital East) complaining of fatigue and anorexia. A laboratory investigation demonstrated a biochemical 'picture' of obstructive jaundice. An abdominal CT showed a low density mass in the retropancreatic area with multiple enlarged periportal lymph nodes. Upper gastrointestinal endoscopy revealed active ulceration on the dorsal wall of the descending part of the duodenum, and histopathology of the biopsy specimen revealed an ulcer with reactive inflammatory cell infiltration; no tumor cells were detected. The possibility of neoplasm had been ruled out by the use of CT and angiography. The jaundice recovered spontaneously and the abdominal mass gradually decreased in size. Endoscopic retrograde pancreatography showed no evidence of pancreatic disease; however, endoscopic retrograde cholangiography showed a choledocho-duodenal fistula. This patient showed hypersensitivity against the tuberculin skin test and Mycobacterium tuberculosis was successfully detected in gastric juice by using a polymerase chain reaction method and culture. Biopsy samples obtained from the duodenal ulcer at the second upper gastrointestinal endoscopy showed chronic inflammation with an epithelioid granuloma, suggesting tuberculosis. We thus diagnosed this case as a duodenal tuberculosis with a choledocho-duodenal fistula. To the best of our knowledge, there has been no report available of duodenal tuberculosis being the cause of a choledocho-duodenal fistula.     

A Case of Groove Pancreatitis with Duodenal Stenosis

A 58‐year‐old man presented with a 2‐month history of nausea and vomiting. Blood levels of hepatic enzymes and pancreatitis markers were slightly elevated. Hypotonic duodenographic and endoscopic examinations revealed stenosis encircling the descending duodenum. A computed tomography (CT) scan showed inflammatory changes in the head of the pancreas and thickening of the duodenal wall. Magnetic resonance cholangiography demonstrated stenosis of the intrapancreatic segment of the common bile duct and diffuse dilatation of the main pancreatic duct, without irregularity. At laparotomy, microscopic examination of a needle biopsy specimen of the head of pancreas revealed no evidence of malignancy. Distal gastrectomy with Billroth II anastomosis was performed. Microscopically, fibrous thickening of the duodenal wall, serositis and hyperplasia of Brunner's glands were found. The presence of duodenal stenosis due to segmental pancreatitis, referred to as groove pancreatitis, was confirmed. The elevated blood levels of pancreatitis markers returned to the normal range 8 months after the operation. Ultrasonic echography and abdominal CT also revealed a marked reduction in dilatation of the extrahepatic bile duct and the main pancreatic duct. In patients suspected of having pancreatic carcinoma or regional pancreatitis, groove pancreatitis should be included in the differential diagnosis.     

Pancreatic Arteriovenous Malformation Associated with Duodenal Ulcer and H.Pylori Infection

Summary Pancreatic arteriovenous malformation (PAVM) is a rare condition that may cause duodenal ulcer. A 36-yr-old man with PAVM associated with duodenal ulcer and H.Pylori infection is described. The patient had recurrent episode of upper abdominal pain despite healed ulcer and H.Pylori eradication. The preoperative diagnosis was confirmed by computed tomography and the patient was treated with a pancreatoduodenectomy. Histological examination of the resected pancreas revealed a pancreatic arteriovenous malformation involving the adjacent duodenal wall.