Endoscopic Hemostasis in Patients with Dieulafoy Ulcer

Abstract: Dieulafoy ulcer was defined based on endoscopic findings as an ulcer (1) of 10 mm or less in diameter, (2) of grade Ul-ll or less and (3) showing vascular protrusion in its floor. We evaluated the clinical background and endoscopic findings of Dieulafoy ulcer and studied the usefulness and problems of endoscopic hemostasis. Patients with Dieulafoy ulcer accounted for 8.7 % of 321 patients with diseases treated by endoscopic hemostasis excluding sclerotherapy. The patients were predominantly males, and their average age was 61 years. An association with other diseases was noted in 21 patients (75%). Therefore, more than 50 % of the patients were treated with NSAIDs such as aspirin. The most frequent site of this disease was the posterior wall of the upper gastric body. In particular, the ulcer was located in the superior duodenal angle. In six of the 28 patients, the ulcer and the exposed vessel were similar in size. Endoscopic hemostasis was successful in 25 patients (89%). Hemostasis was acheived by emergency surgery in two and by transcatheter arterial embolization (TAE) in one. No patient showed recurrence. Most Dieulafoy ulcers can be conservatively treated by endoscopic hemostasis. However, a few cases can not be managed conservatively and shock develops due to fatal massive bleeding. In such patients, the timing of TAE or surgery must be carefully considered.     

Development of a Submucosal Tumor-like Protrusion at the Site of a Gastric Ulcer during H2-Blocker Treatment—Report of a Case—

Abstract: We studied a patient with a gastric ulcer in which the entire ulcer protruded like a submucosal tumor. Candida albicans was observed in the biopsy specimen taken during treatment with cimetidine; the tumor disappeared after treatment with an antifungal agent, both topically and orally. The patient was a 68-year-old male who had undergone periodical endoscopic examinations of his upper digestive tract although he did not complain of any subjective symptoms. He was admitted to Suma Red Cross Hospital because examination revealed an active ulcer on the greater curvature of the fornix of the stomach. The patient was treated with 800mg/day of cimetidine. After ten days of treatment, endoscopic studies revealed the elevation of the entire ulcer, which grew into a mass resembling a submucosal tumor associated with a bridging fold. A biopsy of the periphery of the ulcer revealed the presence of Candida albicans in the tissue specimen. Endoscopic ultrasonography revealed a tear in the submucosa and an inflammatory picture that extended into the tunica muscularis. The patient was diagnosed as having a Candida-infected gastric ulcer. Concomitant use of topical and oral fungizon resulted in the protuberance settling; it was confirmed that the tumor mass completely disappeared and the ulcer healed after 58 days of treatment.     

Endoscopic Hemostasis in Hemorrhagic Gastric Ulcer—Effectiveness of the Hemoclipping,Ethanol Injections and Heat Probe—

Abstract: The hemostatic effects of hemoclipping, the pure ethanol local injection method and the heat probe methods on hemorrhagic gastric ulcers associated with exposed blood vessels, were compared. The locations of the ulcers and exposed blood vessles, as well as characteristics and the severity of the hemorrhage were discussed. The hemoclipping method was used on 59 patients, the pure ethanol local injection on 32 patients, and the heat probe methods on 26 patients. The hemoclipping and pure ethanol local injection methods were effective in all of the patients in whom the exposed blood vessels were present around the margin of ulcers. The efficacy rate was 91%, 92% and 92%, respectively, when exposed blood vessels were found at the base of the ulcer. The efficacy rate was 94%, 100% and 80% for the three hemostatic methods, respectively, when an oozing hemorrhage was present. The three methods had an efficacy rate of 100% when only blood clots were present. The efficacy rate for a spurting hemorrhage was 86%, 71% and 67%, respectively, for the three methods. The hemoclipping and pure ethanol local injection were effective in 100% of slight and moderate hemorrhage cases, while the heat probe method was effective in only 89% of moderate cases. The efficacy rate was 85%, 85% and 83%, respectively, for severe cases. Overall, the efficacy rate was 93% for the hemoclipping method, 94% for the pure ethanol local injection and 92% for the heat probe method, and there was no significant difference between the three methods with regard to the overall efficacy rate.     

Elevation of the Ulcer Base in Cases Treated with an H2-Blocker —Difference between an Elevated Type of Gastric Ulcer Scar and a White Elevated Lesion—

Abstract: A white elevated lesion (WEL) was noted in 7 out of 227 ulcer patients treated with an H₂-blocker. These were compared with eight patients with an elevated type of gastric ulcer scars The elevated type of gastric ulcer scar (ES) is an elevated lesion covered with regenerating epithelium, showing no whitish exudate, and is foveolar hyperplasia in the histological picture of biopsy. The period prior to the formation of an elevated lesion was as short as 4 weeks on average, and the formed elevated lesion retained the elevated from for as long as several months to several years. The WEL is an elevated lesion covered with whitish exudate, and shows granulation in the histological picture of biopsy. The period prior to the formation of an elevated lesion was as short as 3 weeks on average, and the formed elevated lesion became flattened in a relatively short period of several weeks to several months. From the above results the ES and the WEL are different in the clinical course, morphology and the histological picture, and considered to be of a different quality.     

Gastric Ulcer and Risk of Cancer

Abstract In 1976, 121 patients with benign gastric ulcer and 13 with gastric carcinoma were diagnosed in our department by endoscopy, cytology and directed biopsies. At a 5-year follow-up, 78 of these patients were re-examined with endoscopy and biopsies. None had developed gastric cancer during the observation time. Of the 78 patients who underwent endoscopy, 16 had gastric ulcer, 2 duodenal ulcer and 27 atrophic gastritis, including 3 with moderate dysplasia of the gastric mucosa. The patients with ulcer had remarkably few symptoms. Only few data are available concerning the postulated link between gastric ulcer disease and gastric malignancy. The cancer-ex-ulcere hypothesis seems to be a medical dogma. However, well planned prospective studies with endoscopic follow-up of gastric ulcers are needed to elucidate the question properly     

杜氏病的诊断及治疗

对我院10年来收治的15例杜氏病（Dieulafoy disease）进行回顾性分析。结果显示11例内镜下治疗成功止血,3例行DSA治疗,1例手术治疗。急诊内镜检查是杜氏病主要的诊断手段,内镜下治疗是目前杜氏病首选的治疗方法。     

A CASE OF EARLY GASTRIC CANCER ACCOMPANIED BY DIEULAFOY ULCER IN A YOUNG WOMAN

A case of early gastric carcinoma accompanied by Dieulafoy ulcer is presented. The patient, a 26‐year‐old female, visited our emergency room with chief complaints of massive hematemesis and tarry stool. The initial endoscopic examination revealed a superficial depressed lesion with a faded color accompanied by a tiny ulcer with converging folds at the anterior wall of the middle gastric body. Although no active bleeding vessel was found at that time, the patient was admitted to our hospital for further check‐ups and treatment. On the 6th hospital day, she developed massive hematemesis resulting in shock. Urgent endoscopy, this time, disclosed an exposed bleeding vessel at the small ulcer floor previously mentioned, and endoscopic hemostasis was achieved. Since, however, a biopsy at initial examination from the surrounding depressed area proved carcinoma, a partial distal gastrectomy was subsequently carried out. Histological examination of the resected specimen confirmed the diagnosis of carcinoma limited to the mucosa and submucosa along with findings consistent with Dieulafoy ulcer. This is a rare case of combination of early cancer and Dieulafoy ulcer particularly in such a young patient. A review of the literature is also presented.     

Ulcer Recurrence after Parietal Cell Vagotomy for Duodenal Ulcer

The object of the study was to identify individual high-risk patients with regard to ulcer recurrence after parietal cell vagotomy for duodenal ulcer. The study comprises a multivariate analysis of 14 variables (age, sex, duration of symptoms, site of ulcer, pre- and post-operative acid secretion) for 37 patients with and 111 patients without recurrence 5–11 years after parietal cell vagotomy for duodenal ulcer. The data were analyzed using a supervised pattern recognition technique, SIMCA (Soft Independent Modeling of Class Analogy), which analyzes complex data as geometrical elements in a multidimensional space. We found no statistical difference between the patients with and without ulcer recurrence. Thus, no predictive value for the selection of patients liable to develop recurrent ulcer after parietal cell vagotomy was contained in the variables generally registered in current surgery.     

An Ulcer in the Gastric Tube Used for Esophageal Replacement after Esophagectomy — Report of a Case

Abstract: We report a patient with an asymptomatic recurrent peptic ulcer occurring in the gastric tube after reconstruction for esophagectomy with a long follow-up. The patient is an 82-year-old male, who had undergone an esophagectomy for cancer, and a gastric tube was used for esophageal replacement at the age of 77 years. A follow-up study using endoscopic examination revealed an active peptic ulcer in the gastric tube one year after the operation, ulcer scar formation 9 weeks after H2 receptor antagonist medication, and recurrence of the ulcer about 3 years after quitting the medication. The recurrent active ulcer has disappeared after re-administration of H2 receptor antagonist. Helicobacter pylori has not been detected, although eradication has not been per formed. It is suggested that high acidity might play a part in the pathogenesis of ulcer formation despite the vagotomy. Since a peptic ulcer in the gastric tube can potentially cause serious complications including perforation and hemorrhage, we have to bear in mind not only recurrence of the cancer but also gastric tube ulceration in the follow-up survey after esophagectomy, to facilitate early detection of ulcer and effective treat ment. (Dig Endosc 1999:11: 62–65)     

Giant Fungal Gastric Ulcer in an Immunocompetent Individual

Candida infection of gastrointestinal tract is frequent in immunocompromised patients and rare in an otherwise healthy person in whom no permissive factor is present. Herein is a case report on 25-year-old woman, 2 months postpartum, with fungal gastric ulcer with invasion leading to fungemia. She developed fever and anemia. Gastric biopsy and blood culture both showed growth of Candida albicans. The patient responded well to parenteral amphotericin B. This supports the hypothesis of invasion of Candida from gastric ulcer into blood.     

Gastric Ulcer Relapse

Abstract: In this review we found that the rate of gastric ulcer relapse reached near! 70% over a 13 year period and was nearly 10% after one year from when they reache the white scar stage. A H2-RA or proton pump inhibiter had a high relapse rate the reason being the fragile re-epithelization of the scar³⁾⁴⁾. Factors involved in gastric ulcer relapse are considered to be the fragile re-epithelization of the ulcer, disturbance c blood flow due to fibrosis underneath the ulcer scar, and etiological factors such a smoking and so on. Endoscopic findings of the ulcer scar can statistically suggest th gastric ulcer relapse rate. The main cause of peptic ulcers, especially duodenal ulce relapse, is strongly related to Helicobacter pylori infection. The causes of gastric ulcer relapse are very complicated and variegated. H. pylori infection contributes to les gastric ulcer relapse than duodenal ulcer relapse. To prevent gastric ulcer relapse, therefore, one should consider the eradication c H. pylori, the endoscopic features of the ulcer scar and etiological factors.     

Gastric Emptying of a Liquid Meal in Health and Duodenal Ulcer Disease

In the present investigation an extension of the method of George was used, which allows the rate of emptying of the gastric content (GC) to be assessed. The aim of the study was to find out whether there is any difference in gastric emptying rate of a liquid meal of 750 ml 10% glucose (glucose monohydrate, mol. wt. 198) between healthy subjects and duodenal ulcer patients (DU). The straight numerical volume of GC, the logarithm and the square root of GC were related to time, and these functions were compared. The correlation coefficient for the regression line for these functions showed that data both for healthy subjects and DU gave a better fit to the GC/time and ?GC/time relationship than to a semi-logarithmic function, when the starting point at time zero was excluded. Regardless of the type of transformation of the basic data, there was no difference between healthy controls and DU as regards the regression coefficient, indicating that from 20 min after the installation of the test volume the GC is decreasing at the same rate in the two groups. When the straight numerical volume of GC was used, there was a significant difference in the extrapolated Y-intercept for the regression lines between healthy subjects and the DU, indicating an increased initial emptying in the DU patients. This was further confirmed when the volume emptied during consecutive 20-min periods was estimated. Furthermore, there was a shorter emptying time in patients with duodenal ulcer than in healthy controls.     

Dieulafoy病19例诊治分析

目的探讨Dieulafoy病的发病情况、临床特征、诊断与治疗。方法收集我院1996年~2008年7月间收治的上消化道出血病人1 470例,对其中检出的19例Dieulafoy病病例的临床特征、内镜下表现及治疗方法进行回顾性分析。结果Dieulafoy病约占上消化道出血的1.3%,19例Dieulafoy病中,病灶位于胃底5例,胃体10例,胃窦部2例,贲门部1例,十二指肠球部1例,其中17例均于胃镜下可直接见破裂血管,有10例可见活动性出血。病灶直径1.0~3.0 mm。于内镜下行病灶黏膜下局部注射5%鱼甘油酸钠,1例因再出血予手术治疗。结论Dieulafoy病是上消化道大出血的少见而重要的病因,该病诊断主要依靠胃镜检查,通过内镜早期诊断和治疗可以取得很好的疗效。     

Gastric Ulcer Healing with Ranitidine and Cimetidine

A single-blind study of 339 patients in 19 centres compared the efficacy and tolerance of ranitidine in treating endoscopically confirmed gastric ulcers. Ranitidine (150 mg twice daily) was compared with cimetidine (1 g daily in divided doses) over 4 weeks, followed by a second 4-week treatment for any patient whose ulcer was not healed. In 292 patients who completed the study, endoscopy showed healing in 69% of patients receiving ranitidine and 59% receiving cimetidine after 4 weeks, and 90% and 88%, respectively, by 8 weeks. These results were not significantly different, and, similarly, healing rates for different ulcer sites did not differ. There were no serious adverse drug reactions during the study. Ranitidine is an effective and safe treatment for healing gastric ulcers, with a tendency to produce a faster healing rate than cimetidine during the first 4 weeks of treatment.     

Duodenogastric Bile Reflux in Patients with Gastric Ulcer

The duodenogastric bile reflux rate in 33 patients with gastric ulcer is compared with the rates in 33 non-ulcer patients. Duodenogastric bile reflux was measured by a non-invasive isotope method using ^99mTc-diethyliminodiacetic acid. Reflux occurred significantly oftener in the ulcer patients (27 of 33) than in the non-ulcer patients (14 of 33) (p < 0.01) but did not differ significantly in quantity between these two groups. The results suggest that the magnitude of bile reflux cannot be used to distinguish between ulcer patients and non-ulcer patients.     

Lysolecithin and Glyceroglucolipids in Gastric Secretion of Patients with Gastric and Duodenal Ulcer

Basal and pentagastrin-stimulated gastric secretions, collected (at 15-min intervals for 1 h) from six duodenal ulcer and six gastric ulcer patients, were analyzed for their content of lecithin, lysolecithin, and glyceroglucolipids. Whereas the glycero-glucolipid concentrations and the molar ratios of lysolecithin to lecithin (2.5:1) in basal and stimulated secretions from patients with duodenal and gastric ulcer were similar, significant (p < 0.01) differences were noted between these two groups with regard to the lysolecithin contents. The basal secretions of patients with duodenal ulcer contained about 4.5-fold less (204 μmol/l) of lysolecithin than those from patients with gastric ulcer (932 μmol/l). After pentagastrin stimulation, the lysolecithin concentrations in the secretion from duodenal ulcer patients rose slightly (to 212 μmol/l), whereas a twofold decrease (to 440 μmol/l) in lysolecithin was observed in the secretion from patients with gastric ulcer. Statistically significant correlation between concentrations of lysolecithin and glyceroglucolipids was only observed in basal (r = 0.85, p < 0.05) and stimulated (r = 0.93, p < 0.01) secretions from patients with gastric ulcer. It is concluded that high concentrations of lysolecithin in the secretion of gastric ulcer patients results in the weakening of the gastric mucosal barrier by depleting its glyceroglucolipid component.     

Relationship between gastric mucosal hemodynamics and gastric motility

Continuous measurement of gastric mucosal hemodynamics (the index of mucosal hemoglobin concentration, the index of oxygen saturation and blood flow) in rats showed oscillatory changes. The mechanism of the oscillations was investigated using a probe specially designed for simultaneous measurement of hemodynamics and intragastric pressure. A hemodynamics-measuring probe for either reflectance spectrophotometry or laser-Doppler flowmetry was tied to a pressure microtransducer, inserted through an incision in the forestomach, and brought into gentle contact with the corpus mucosa. Synchronous oscillatory changes (4-6 cycles/min) in hemodynamics and motility were observed in the resting state (mean blood pressure: 120 mmHg). During moderate hemorrhagic hypotension (mean: 81 mmHg), oscillations in the hemodynamics increased in both amplitude and frequency, while motility remained constant. Oscillations in the hemodynamics were also affected by fluctuations in blood pressure and by topical application of norepinephrine to the corpus serosa. In water-immersion restraint rats, changes in the oscillations in the hemodynamics and motility were virtually synchronous; frequency decreased and amplitude increased. These findings suggest that oscillatory changes in gastric mucosal hemodynamics are regulated not only by gastric motility but also by arteriolar vasomotion of the gastric wall.     

消化性溃疡病证关系探讨

本文通过对消化性溃疡病理因素、溃疡大小、部位，分期、有无活动性炎症等与溃疡病表现证型的关系探讨，以及证型与证微观定量指标的关系探讨，指出同一种溃疡病之所以表现为不同证型，关键可能在于内环境状态的差异，肝胃不和证、脾气虚证、肝郁脾虚证内环境状态的差别，或许是其不同临床表现的内在根源。     

Epidemiological Aspects of Peptic Ulcer Disease on the Faroe Islands: An Interim Report

A prospective epidemiological study was carried out from 1981 to 1983 to determine the incidence of peptic ulcer on the Faroe Islands. The annual incidence of first-time-diagnosed peptic ulcer was on the average 3.3 per 1000 inhabitants aged 15 years and older. No significant changes in incidence were observed during the 3-year period. The male to female ratio of peptic ulcer was 2.1:1. The annual incidences of duodenal and gastric ulcer were 2.3 per 1000 and 1.0 per 1000, respectively. The duodenal to gastric ulcer ratio was approximately 2:1 in both male and female patients. The incidence of peptic ulcer observed in the Faroe Islands is very high compared with other countries. The incidence of duodenal ulcer is of the same high magnitude as observed in Scotland, whereas the incidence of gastric ulcer is twice as high as generally found in Western countries and in accordance with the rates found in Arctic areas.     

Effect of Ranitidine on the Content of Glyceroglucolipids in Gastric Secretion of Patients with Gastric and Duodenal Ulcer

The glyceroglucolipids content of basal and pentagastrin-stimulated gastric secretion was measured in male patients with gastric (12) and duodenal (12) ulcer. Six patients in each group received twice daily for a period of 4 weeks 150 mg of ranitidine, whereas the other patients received placebo. The glyceroglucolipids output in the basal secretion of patients with gastric and duodenal ulcer before treatment was similar and increased 2.7-fold after pentagastrin stimulation. In all patients treated with ranitidine, the mean output of glyceroglucolipids after pentagastrin stimulation increased from 1.38 to 2.05 μmol/h (P < 0.05). This increase, however, was more pronounced in the duodenal ulcer group than in the gastric ulcer patients. No change in glyceroglucolipids output was noted in the patients treated with placebo. The ratio of glyceroglucolipids to HCl increased significantly (P < 0.02) only in the ranitidine-treated patients.