A Case of Postbulbar Duodenal Ulcer with Jaundice

Abstract: A 63-year-old man was hospitalized because of jaundice and anorexia. An upper gastrointestinal series and hypotonic duodenography revealed circumferential sclerosis and stenosis of the duodenal wall. Endoscopic examination disclosed an ulcer, the upper margin of which was located at the papilla of Vater. The papilla was situated in the base of the ulcer. Endoscopic retrograde cholangiopancreatography disclosed mild dilatation of the common bile, intrahepatic bile and pancreatic ducts, but with neither severe stenosis nor occlusion. Nevertheless, there was some degree of circumferential compression and mild stenosis of the terminal portions of the bile and pancreatic ducts, as potential causes of obstructive jaundice in this patient. Computed tomographic examination of the abdomen revealed a tumorous lesion at the duodenal bulb. Because malignancy in the duodenum could not be ruled out, a pancreatoduodenectomy was performed. Histopathological examination showed a postbulbar duodenal ulcer, associated with inflammation of the papillary orifice and fibrosis of the region near the papilla. There was no evidence of a tumorous lesion. In this case, a postbulbar duodenal ulcer may have caused obstructive jaundice.     

Combined laparoscopic and endoscopic treatment of perforated gastroduodenal ulcer using the ligamentum teres hepatis (LTH)

We propose a novel technique for laparoscopic treatment of perforated gastroduodenal ulcers. The principle of this procedure involves the closure of the perforated ulcer using the ligamentum teres hepatis (LTH). The LTH is cut near its umbilical end and then dissected up to the site of its hepatic insertion. The umbilical extremity of LTH is grasped with a Dormia noose passed through the ulcerated perforation via a gastroscope. Using the noose, the LTH is pulled through the ulcerated perforation until its volume fits and completely closes the perforation. This laparoscopic technique was performed in 15 patients (12 M, 3 F) with anterior perforated duodenal ulcer revealed within the previous 6 h. The procedure could not be performed in three cases: diameter of the perforation exceeding 1.5 cm (n=1), general purulent peritonitis (n=2). In the other 12 cases, closure of the ulcerated perforation with the LTH was realized without technical difficulty. The postoperative course was uncomplicated. The posttreatment comfort was excellent; the mean period of hospitalization was 10 days (range, 8–14 days). An endoscopic examination carried out following 5 weeks of anti-H2 treatment showed that cicatrization of the ulcer was good and that no pyloric stenosis remained. These initial results suggest that laparoscopic treatment of perforated gastroduodenal ulcer using the LTH is a simple procedure which can be performed with general assurance of success in patients whose perforated ulcers have occurred quite recently. As the laparoscopic procedure is less aggressive than a laparotomy, it enhances the postoperative comfort of patients and prevents the risk of parietal complications. Compared to laparoscopic endosuture this procedure is simple, effective, easier, and particularly adapted to large ulcerated perforation or when an ulcer's edges are tough or friable, tending to tear when knots are tied.Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Nashville, TN, USA, 18–19 April 1994.     

组胺H_2受体阻断剂对大鼠失血性应激反应时胃功能和溃疡指数的影响

用反射光谱法,研究了组胺H_2受体阻断剂Famotidine对急性失血大鼠胃粘膜血液量及血氧饱和度的影响。同时观察了胃液量和酸排出量的变化,并计量了溃疡指数。Famotidine(3mg/kg及8mg/kg,iv)对失血前大鼠胃粘膜血液量和血氧饱和度均未见有影响;对失血后胃粘膜血液量和血氧饱和度的降低有明显保护作用,对胃液量和酸排出量均有显著抑制作用,溃疡指数减小。     

The relationship between muscle kinetic parameters and kinematic variables in a complex movement

Summary Kinematic variables of the vertical jump (jumping height, jump phase durations and joint angles) were measured on 39 male physical education students. In addition, kinetic parameters of the hip and knee extensors, and of the plantar flexors (maxima voluntary force and its rate of development) were recorded on the same subjects, in isometric conditions. The results demonstrated significant positive correlations between kinetic parameters of the active muscle groups and jumping height (r=0.217−0.464). The dominant effect on these correlations was due to the knee extensors. Correlations between these parameters and the duration of the jump phases were much weaker. Correlation coefficients between kinetic parameters and limb angles in the lowest body position showed that fast force production in one muscle group was related to a significant decrease in the joint angles of distant body segments. Multiple correlation coefficients between leg extensor parameters and kinematic variables (ranging between 0.256 for the duration of the counter-movement phase and 0.616 for jump height) suggested that kinetic parameters could explain more than a quarter of the variability of this complex human movement. Therefore, the conclusion was drawn that an extended set of measurements of the relevant musculo-skeletal system parameters could predict a considerable amount of the variability of human movement. However, high correlation coefficients between the same kinetic parameters of different muscle groups suggest that not all active muscle groups have to be included in the measurements.     

Die klinische Relevanz der Sonographie in der Akutdiagnostik perforierter Gastroduodenalulcera

Zusammenfassung Anhand einer prospektiven, auslesefreien Serie von 22 Patienten mit perforierten Ulcera im Gastroduodenalbereich verweisen wir auf die begrenzte diagnostische Aussagekraft einfacher anamnestischer, klinischer und radiologischer Daten. Lediglich bei acht Patienten (36%) ergaben sich wesentliche Indizien aus Krankengeschichte und Aufnahmebefund. Bei 16 Patienten (73%) verriet die Thoraxübersichtsaufnahme durch Nachweis einer subphrenischen Luftsichel eine Perforation im Magen-Darm-Trakt. Die Ultraschalluntersuchung wird als bedeutungsvolle Ergänzungsmethode vor allem in der diagnostischen Abklärung radiologisch negativer Ulcusperforationen vorgestellt und diskutiert. Dabei werden die sonographisch faßbare flüssigkeitsbedingte Magendistension sowie das Magenwandödem als unspezifische Kriterien gewertet. Der Objektivierung einer pathologischen Magenkokarde kommt bei gleichzeitigem Nachweis freier Luft und/oder extraluminärer Ingesta sowie freier echoloser Transsudatflüssigkeit pathognomonische Beweiskraft zu. Selbige Ultraschallkriterien erlaubten im einschlägigen Krankengut bei 16 Patienten (73%) eine definitive Diagnose und erfaßte 4 Patienten mit negativem Röntgen. Die kombinierte Analyse radiologischer und sonographischer Befunde führte somit bei 20 Patienten (91 %) unverzüglich zur korrekten Diagnose.

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Perforated peptic ulcer: Diagnosis and assessment by sonography

Summary In a prospective unselected series of 22 patients with perforated gastroduodenal ulcers the diagnostic efficacy of clinical and radiologic data was modest. In eight patients only (36%), clinical data yielded sufficient evidence; in 16 patients (73%), plain X-ray demonstrated subphrenic gas. Sonography was proven to be a major advance, especially rewarding in the diagnosis of perforations with negative plain X-ray. Gastric distention and stomach wall edema are unspecifc sonographic criteria, whereas objectivation of a pathologic stomach cockade in the presence of free gas, extraluminary ingesta or echofree fluid in the peritoneal cavity are pathognomonic data. These criteria yielded a definite diagnosis in 16 patients (73%) including four patients with negative X-ray. The combined analysis of radiologic and sonographic findings yielded an immediate correct diagnosis in 20 patients (91%).

     

Marjolin’s ulcer of the forearm from 30-year-neglection of external fixator

BackgroundMarjolin’s ulcers are a rare form of malignancy that present at regions exposed to chronic infection. They present with a clinical triad of nodularity, induration, and ulceration greater than 3 months.Case reportWe present herein, an extremely rare case of Marjolin’s ulcer of the forearm, secondary to osteomyelitis, resulting from a 30-year neglection of external fixator used to treat a war injury of the forearm.DiscussionMarjolin’s ulcers are classically encountered in lower extremities at sites of burns, trauma or complicated wounds. In the upper extremity however, they are seldom mentioned in literature. The presence of risk factors raise the suspicion of the disease.ConclusionMarjolin’s ulcer is rare sequelae of chronic wound infection. Patients often present after a latency period with exacerbated pain, discharge, and exophytic mass. This disease should be suspected in every case of chronic ulcer, where histological studies of the lesion must be conducted to exclude or confirm the diagnosis.     

Häufigkeit pathologischer Veränderungen des oberen Gastrointestinaltraktes bei Patienten vor Herzoperationen

Resümee Schwerwiegende gastroduodenale Erkrankungen sind bei fast der Hälfte aller Patienten, die sich einer Operation am offenen Herzen unterziehen müssen, auch bei Fehlen von Symptomen nachweisbar. Das erhebliche Überwiegen von Magenläsionen spricht dafür, daß die arteriosklerotisch bedingte Perfusionsminderung der Schleimhaut die entscheidende Ursache hierfür ist. Routinemäßige präoperative Ösophago-Gastro-Duodenoskopien können die nicht unerhebliche durch gastrointestinale Komplikationen bedingte postoperative Mortalität senken helfen.

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Pathological changes in the upper gastrointestinal tract in patients awaiting open heart surgery

Summary While waiting for open heart surgery, in 153 patients (104 male, 49 female, 22–76 years of age) without gastrointestinal symptoms and/or history esophago-gastro-duodenoscopy was performed. 124 patients suffered from coronary heart disease, 29 from valvular defect, aneurysm of the sinus of Valsalva or tumor of the heart.In 47.1% endoscopy revealed serious abnormal findings: in 16.3% gastric ulcer, in 20.9% erosive gastritis, duodenal ulcer and erosive duodenitis in 5.2%, respectively, 1 case of gastric carcinoma, 2 of large polyps and 3 of reflux esophagitis of higher degree (totally 3.9%).In patients with coronary artery disease, the relation of erosive and ulcerous gastric lesions as compared with those of duodenal origin was 41, in patients with other cardiac diseases it was 21, respectively (p<0,001).Compared with a normal population, the incidence of pathological gastric findings was 54-fold higher in our patients, and 1.7-fold concerning duodenal lesions, respectively (p<0.001).51 patients on acethylsalicylic acid (160 mg/ die) showed pathologic findings in 41.2%, and 96 patients without ulcer-inducing therapy in 51%. Thus, low-dose Aspirin does not seem to have serious gastric side effects.The results of the study stress the necessity of routinely performed endoscopy of the upper gastrointestinal tract in patients awaiting open heart surgery. This will lead to a lower incidence of serious gastrointestinal complications postoperatively, which are known to have a high mortality.

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Abkürzungen ASS Azetylsalizylsäure - J. Jahre - GI-Trakt Gastrointestinaltrakt     

豚鼠应激性胃溃疡模型的制作与验证的实验研究

该实验首次应用豚鼠水浸拘束法制作应激性胃溃疡的模型,从胃溃疡指数、应激前后胃电活动的变化、胃粘膜病理改变等方面观察应激性胃溃疡的发生、发展过程。该实验模型易制作,重复性好,适合应用于应激性胃溃疡的实验研究。     

Accuracy of a rapid 10-minute carbon-14 urea breath test for the diagnosis of Helicobacter pylori-associated peptic ulcer disease

Urease in the human gastric mucosa is a marker for infection with Helicobacter pylori (HP), an organism which is associated with peptic ulcer disease. To detect gastric urease, we examined 184 patients (144 males, 40 females; mean age: 49.8±15.6 years) with suspected peptic ulcer disease. Fasting patients were given orally 5 Ci of carbon-14 labelled urea. From each patient only one breath sample was collected in hyamine at 10 min. The amount of ¹⁴C collected at 10 min was expressed as follows: [(DPM/mmol CO₂ collected)/(DPM administered)] × 100 × body weight (kg). The presence of HP colonization was determined by examination of multiple endoscopic prepyloric antral biopsy specimens subjected to culture or a rapid urease test. For the purpose of this study, HP-positive patients were defined as those with characteristic bacteria as indicated by a positive result of either the culture or the rapid urease test; HP-negative patients were defined as those with negative findings on both the culture and the rapid urease test. Of the 184 cases, 99 (53.8%) were positive for HP infection, and 85 (46.2%), negative. The sensitivity and specificity of the rapid 10 min ¹⁴C-urea breath test for the diagnosis of HP-associated peptic ulcer disease were evaluated by a receiver operating characteristic (ROC) curve with a variable cut-off value from 1.5 to 4.5. When a cut-off value of 1.5 was selected, the sensitivity was 100% and the specificity, 83.5%; when a cut-off value of 4.5 was selected, the sensitivity was 54.5% and the specificity, 97.6%. Correspondence to: Chia-Hung Kao     

Greffe Intertibio-péronière dans le Traitement des Pseudarthroses Fistuleuses Diaphysaires de Jambe

Résumé Les auteurs présentent une série de 30 pseudarthroses fistuleuses de jambe traitées par greffe intertibiopéronière, revues avec un recul allant de 3 à 9 ans.La voie d'abord utilisée pour la greffe est le plus souvent rétropéronière; dans 14 cas l'immobilisation a été réalisée par un plâtre et dans 16 cas par un fixateur externe (chez 9 malades, l'opération a été réalisée après mise en place du fixateur). 28 guérisons sont constatées (25 rapides en 3 à 8 mois, 3 plus lentes) et 2 échecs.Les auteurs insistent sur l'intérêt de la voie rétropéronière qui permet le plus souvent de rester à distance des parties molles «septiques» et du fixateur externe comme moyen de contention.L'indication de cette méthode concerne surtout les pseudarthroses infectées anciennes avec des extrémités osseuses atrophiques ou en cas de perte de substance osseuse. Dans les autres cas, la décortication de Judet est plus simple et permet d'obtenir d'excellents résultats.

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Intertibio-peroneal graft in the treatment of infected non-united legs

Summary The authors present a series of 30 cases of fistular non united fractures of the leg treated by interosseous bone graft. Survey was performed from 3 to 9 years.In most cases, the surgical approach is made behind the fibula; in 14 cases, immobilization by means of a plaster cast and in 16 cases by means of external fixation (in 9 cases, external fixation bar + screws was realised first).Healing occured in 28 cases (quick in 25 cases, i.e. within 3–8 months, slow in 3 cases) and 2 failures.The authors emphasize the value of the posterior (retrofibular) approach, which avoids the distal septic soft areas, and of the bar-screws device.The procedure is mostly relevant in old infected non united fractures, with atrophic bony extremities or with boneloss.In the other cases, Judet's procedure is more simple and allows excellent results.