A large perforated gastric ulcer due to cocaine use.

Juxtapyloric perforation is one of the most common digestive tract complications associated with cocaine use. We present the case of an habitual user of cocaine who goes to the Emergency Department due to epigastric pain due and intolerance of days of evolution. An endoscopic finding of a large antral ulcer with an ischemic appearance; in which it is not possible to show pylorus.

[Perforated peptic ulcer: is the form of methamphetamine known as "crystal meth" a new risk factor?]. / Úlcera péptica perforada: ¿es la forma de la metanfetamina conocida como "cristal" un nuevo factor de riesgo?

BACKGROUND: The emergence of new synthetic drugs related to peptic ulcer perforation has been reported. Recently an increase in the use of inhaled methamphetamine has been observed and we have described an association of frequent use with peptic disease symptomatology and perforation. AIMS: To determine whether methamphetamine use is a factor related to peptic acid disease and perforation and to establish its demographic variables. MATERIAL AND METHODS: A retrospective, comparative, descriptive, and observational study was carried out through the evaluation of medical records of patients admitted to the Surgery Service with perforated ulcer, within the time frame of January 2002 to March 2005. A descriptive analysis was carried out, along with the Z test, odds ratio, confidence interval, p value and the Student's t test. RESULTS: Forty-two patients were divided into 2 groups: methamphetamine users (n=25) and nonusers (n=17). There was a statistically significant difference in relation to age, which was lower in the methamphetamine user group (38,7 years vs 58,88 years, p=0.0001). In addition, there was a trend in the user group to develop peptic ulcer perforation at earlier ages compared with the nonuser group (p=0.0001). There were no statistically significant differences between the two groups in regard to clinical presentation. CONCLUSIONS: Methamphetamine use is related to ulcer perforation in age groups of younger patients when compared with nonuser patients.

Double Peptic Ulcer Perforation due to Cumulative Effects of Post-surgery Stress and NSAIDs: A Rare Event in Surgical Practice.

Peptic ulcer disease affects a large number of people around the world. Complications occur in 10-20% of patients and perforation develops in 2-14% of the cases. It can either be in the pyloric part of the stomach or in the first part of duodenum. Helicobacter pylori infection and nonsteroidal anti-inflammatory drugs (NSAIDs) abuse and smoking are noted to be the most common risk factors in developing countries. Other risk factors are steroid abuse, post-surgery stress, burns and Zollinger-Ellison syndrome. Although small perforations can be treated conservatively but Graham patch repair is the treatment of choice. Double peptic ulcer perforation is a rare event with only a few cases reported worldwide. This patient presented with double peptic ulcer perforation in emergency due to post-surgery stress. She had cesarean section 10 days earlier with delayed recovery. Key Words: Peptic ulcer disease, Perforation, Graham patch repair, Cesarean section.

Duodenal Ulcer Perforation after Activated Charcoal Treatment.

Activated charcoal, having the capacity to absorb substances with its porous surface, has been used in intoxication treatment for nearly 200 years. Although live-saving, occasionally, it can lead to complications. Because of the risk of perforation during activated charcoal therapy, the integrity of the gastrointestinal tract should be checked after the procedure. In this case report, a 27-year patient, who received activated charcoal therapy after diclofenac intoxication developed duodenal ulcer perforation and charcoal peritonitis. The present case constitutes the first report of duodenal ulcer perforation after activated charcoal therapy. It should be remembered that activated charcoal, which is widely used in intoxication treatment, may cause gastrointestinal system perforation, peritonitis, adhesion, abscess formation, organ loss within the abdomen, and prolonged hospitalization. Key Words: Activated charcoal, Intoxication, Duodenal ulcer perforation.

[Cocaine-related gastric perforation]. / Kokain-assoziierte Magenperforation.

Since the 1980s the abuse of cocaine has been -associated with gastroduodenal perforations in the United States. Here, we report the case of a 28-year-old man who came to our hospital with severe abdominal pain after smoking cocaine. Physical examination revealed generalised abdominal guarding. His X-ray did not show any free intraperitoneal air. However, there was a slightly elevated white blood cell count. Upon laparoscopic exploration of the abdomen, the -patient was found to have a generalised peritonitis secondary to a perforation of the prepyloric anterior wall. The operative procedure consisted of ulcer excision and primary closure with a pyloroplasty as well as an extensive abdominal irrigation after laparotomy.

Decreasing incidence of peptic ulcer complications after the introduction of the proton pump inhibitors, a study of the Swedish population from 1974-2002.

BACKGROUND: Despite a decreasing incidence of peptic ulcer disease, most previous studies report a stabile incidence of ulcer complications. We wanted to investigate the incidence of peptic ulcer complications in Sweden before and after the introduction of the proton pump inhibitors (PPI) in 1988 and compare these data to the sales of non-steroid anti-inflammatory drugs (NSAID) and acetylsalicylic acid (ASA). METHODS: All cases of gastric and duodenal ulcer complications diagnosed in Sweden from 1974 to 2002 were identified using the National hospital discharge register. Information on sales of ASA/NSAID was obtained from the National prescription survey. RESULTS: When comparing the time-periods before and after 1988 we found a significantly lower incidence of peptic ulcer complications during the later period for both sexes (p < 0.001). Incidence rates varied from 1.5 to 7.8/100000 inhabitants/year regarding perforated peptic ulcers and from 5.2 to 40.2 regarding peptic ulcer bleeding. The number of sold daily dosages of prescribed NSAID/ASA tripled from 1975 to 2002. The number of prescribed sales to women was higher than to males. Sales of low-dose ASA also increased. The total volume of NSAID and ASA, i.e. over the counter sale and sold on prescription, increased by 28% during the same period. CONCLUSION: When comparing the periods before and after the introduction of the proton pump inhibitors we found a significant decrease in the incidence of peptic ulcer complications in the Swedish population after 1988 when PPI were introduced on the market. The cause of this decrease is most likely multifactorial, including smoking habits, NSAID consumption, prevalence of Helicobacter pylori and the introduction of PPI. Sales of prescribed NSAID/ASA increased, especially in middle-aged and elderly women. This fact seems to have had little effect on the incidence of peptic ulcer complications.

Scalable collaborative targeted learning for high-dimensional data.

Robust inference of a low-dimensional parameter in a large semi-parametric model relies on external estimators of infinite-dimensional features of the distribution of the data. Typically, only one of the latter is optimized for the sake of constructing a well-behaved estimator of the low-dimensional parameter of interest. Optimizing more than one of them for the sake of achieving a better bias-variance trade-off in the estimation of the parameter of interest is the core idea driving the general template of the collaborative targeted minimum loss-based estimation procedure. The original instantiation of the collaborative targeted minimum loss-based estimation template can be presented as a greedy forward stepwise collaborative targeted minimum loss-based estimation algorithm. It does not scale well when the number p of covariates increases drastically. This motivates the introduction of a novel instantiation of the collaborative targeted minimum loss-based estimation template where the covariates are pre-ordered. Its time complexity is O(p) as opposed to the original O(p2) , a remarkable gain. We propose two pre-ordering strategies and suggest a rule of thumb to develop other meaningful strategies. Because it is usually unclear a priori which pre-ordering strategy to choose, we also introduce another instantiation called SL-C-TMLE algorithm that enables the data-driven choice of the better pre-ordering strategy given the problem at hand. Its time complexity is O(p) as well. The computational burden and relative performance of these algorithms were compared in simulation studies involving fully synthetic data or partially synthetic data based on a real world large electronic health database; and in analyses of three real, large electronic health databases. In all analyses involving electronic health databases, the greedy collaborative targeted minimum loss-based estimation algorithm is unacceptably slow. Simulation studies seem to indicate that our scalable collaborative targeted minimum loss-based estimation and SL-C-TMLE algorithms work well. All C-TMLEs are publicly available in a Julia software package.

Seven cases of gastric perforation in Roux-en-Y gastric bypass patients: what lessons can we learn?

BACKGROUND: Patients undergoing Roux-en-Y gastric bypass for the resolution of morbid obesity have significant medical sequelae related to their weight. One of the most common comorbid conditions is joint pain requiring the use of non-steroidal anti-inflammatory medications (NSAIDs). In addition to NSAIDs, patients may engage in behaviors such as smoking and alcohol misuse that increase the risk of long-term postoperative complications to include gastric perforation. METHODS: Data on 1,690 patients undergoing gastric bypass surgery were collected prospectively and reviewed retrospectively. RESULTS: We identified seven patients who presented to an emergency room and subsequently required emergent surgical intervention for repair of gastric perforation. Six of the seven cases involved use or abuse of NSAIDs. CONCLUSION: Important characteristics were identified including the use of NSAIDs, alcohol use, and non-compliance with routine long-term postoperative follow-up. Identifying those patients at high risk may decrease the incidence of this potentially life-threatening complication.

Perforated peptic ulcer and short-term mortality among tramadol users.

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT: * Use of nonsteroidal anti-inflammatory drugs (NSAIDs) is a strong risk and prognostic factor for peptic ulcer perforation, and alternative analgesics are needed for high-risk patients. * Pain management guidelines propose tramadol as a treatment option for mild-to-moderate pain in patients at high risk of gastrointestinal side-effects, including peptic ulcer disease. * Tramadol may mask symptoms of peptic ulcer complications, yet tramadol's effect on peptic ulcer prognosis is unknown. WHAT THIS STUDY ADDS: * In this population-based study of 1271 patients hospitalized with peptic ulcer perforation, tramadol appeared to increase mortality at least as much as NSAIDs. * Among users of tramadol, alone or in combination with NSAIDs, adjusted 30-day mortality rate ratios were 2.02 [95% confidence interval (CI) 1.17, 3.48] and 1.32 (95% CI 0.89, 1.95), compared with patients who used neither tramadol nor NSAIDs. AIM: Use of nonsteroidal anti-inflammatory drugs (NSAIDs) increases risk and worsens prognosis for patients with complicated peptic ulcer disease. Therefore, patients who are at high risk of peptic ulcer often use tramadol instead of NSAIDs. Tramadol's effect on peptic ulcer prognosis is unknown. The aim was to examine mortality in the 30 days following hospitalization for perforated peptic ulcer among tramadol and NSAID users compared with non-users. METHODS: The study was based on data on reimbursed prescriptions and hospital discharge diagnoses for the 1993-2004 period, extracted from population-based healthcare databases. All patients with a first-time diagnosis of perforated peptic ulcer were identified, excluding those with previous ulcer diagnoses or antiulcer drug use. Cox regression was used to estimate 30-day mortality rate ratios for tramadol and NSAID users compared with non-users, adjusting for use of other drugs and comorbidity. RESULTS: Of 1271 patients with perforated peptic ulcers included in the study, 2.4% used tramadol only, 38.9% used NSAIDs and 7.9% used both. Thirty-day mortality was 28.7% overall and 48.4% among users of tramadol alone. Compared with the 645 patients who used neither tramadol nor NSAIDs, the adjusted mortality rate in the 30 days following hospitalization was 2.02-fold [95% confidence interval (CI) 1.17, 3.48] higher for the 31 'tramadol only' users, 1.41-fold (95% CI 1.12, 1.78) higher for the 495 NSAID users and 1.32-fold (95% CI 0.89, 1.95) higher for the 100 patients who used both drugs. CONCLUSION: Among patients hospitalized for perforated peptic ulcer, tramadol appears to increase mortality at a level comparable to NSAIDs.

Introduction of newer selective cyclo-oxygenase-2 inhibitors and rates of hospitalization with bleeding and perforated peptic ulcer.

BACKGROUND: Limited data exist on the impact of the introduction of newer selective cyclo-oxygenase-2 inhibitors into clinical practice in 1999 on overall non-steroidal anti-inflammatory drug use and hospitalization rates of complicated peptic ulcer disease at the population level. AIM: To examine these issues, we conducted a population-based study in western Denmark, within a population of 1.2 million. METHODS: All patients with perforated (n = 1488) or bleeding peptic ulcer (n = 6017) between 1996 and 2004 were identified in hospital discharge registries. We computed standardized annual hospitalization rates and hospitalization rate ratios using Poisson regression. Data on annual number of prescriptions for non-steroidal anti-inflammatory drugs were obtained through population-based prescription databases. Results Introduction of newer selective cyclo-oxygenase-2 inhibitors was followed by a 44% increase in the annual number of prescriptions for non-steroidal anti-inflammatory drugs--almost entirely due to increased use of newer selective cyclo-oxygenase-2 inhibitors. Annual standardized hospitalization rates for bleeding peptic ulcer remained stable. Standardized hospitalization rates for perforated peptic ulcer decreased from 17 per 100,000 person-years in 1996 to 12 per 100,000 person-years in 2004 (HRR 0.71; 95% CI: 0.57-0.88). Conclusion Introduction of newer selective cyclo-oxygenase-2 inhibitors was followed by substantial increase in overall non-steroidal anti-inflammatory drug use and coincided with stable and decreasing hospitalization rates for bleeding and perforated peptic ulcer, respectively.

Multiple indomethacin-induced jejunal ulcerations with perforation: a case report with histology.

Gastric and duodenal inflammation and ulceration are well-known complications of nonsteroidal anti-inflammatory (NSAID) usage. However, small bowel ulceration and perforation secondary to NSAID use is uncommon and has rarely been reported in the literature. We describe a perforated jejunal ulcer that developed in a patient using indomethacin for treatment of ankylosing spondylitis. We performed a literature review of NSAID-induced small bowel injury and compared the histology of NSAID-related injury with more familiar causes of small bowel perforation.

[Nonsteroidal anti-inflammatory agents--choice between disturbances of gastrointestinal tract and cardiovascular toxicity]. / Nesteroidiniai vaistai nuo uzdegimo--pasirinkimas tarp zalingo poveikio virskinimo traktui bei galimo sirdies ir kraujagysliu pazeidimo.

Nonsteroidal anti-inflammatory agents are used more than 100 years. Most of them can cause undesirable effects on gastrointestinal tract: ulceration, bleeding and perforation of stomach and duodenum. Gastrointestinal toxicity is diminished when selective cyclooxygenase-2 inhibitors are used. However, recent clinical trials have showed that the use of cyclooxygenase-2 inhibitors increases the risk of cardiovascular event and cerebrovascular accident. According to the data such risk may be high using also nonselective nonsteroidal anti-inflammatory agents, however, it is lesser. Incidence rates of the cardiovascular events and cerebrovascular accidents increase due to activated thrombotic activity. Nonsteroidal anti-inflammatory agents are very useful in the management of rheumatic diseases and as pain relievers. Choosing appropriate nonsteroidal anti-inflammatory agent it is essential to consider the risk of gastrointestinal as well cardiovascular damage.

[Gastropleural fistula due to perforated gastric ulcer].

A 65-year-old woman, who had been taking non-steroidal anti-inflammatory drugs (NSAIDs), prednisolone and methotrexate for rheumatiod arthritis, was admitted to our hospital with a sudden onset of left-back and chest pain and breathlessness. A chest radiograph and computed tomography revealed a left-side pneumothorax and pleural effusion. Chest tube was inserted for drainage and the fluid was formed to contain food residuum. Contrast radiography demonstrated escape of soluble contrast medium into the left pleural space. A thoracotomy and transdiaphragmatic revealed a gastropleural fistula. It was repaired and the gastric origin was resected. Pathologic evaluation revealed evidence of chronic peptic ulceration, but no malignant change. Gastropleural fistula due to peptic ulcer without esophageal herniation, malignancy, or traumatic injury is extremely unusual. The cause of the focal adhesion of the gastric ulcer and diaphragm, fistula formation was not certain but was probably related to the ingestion of NSAIDs in combination with prednisolone and other immunosuppressive agents. Although gastropleural fistula is rare, the prognosis in such patients related to early diagnosis and surgical intervention, emphasizing the importance of including this condition when making a differential diagnosis.

Comparison of lumiracoxib with naproxen and ibuprofen in the Therapeutic Arthritis Research and Gastrointestinal Event Trial (TARGET), reduction in ulcer complications: randomised controlled trial.

BACKGROUND: Cyclo-oxygenase 2 (COX2)-selective inhibitors should reduce ulcer complications compared with non-selective non-steroidal anti-inflammatory drugs, but evidence is limited, and the possibility that these inhibitors increase cardiovascular events has been raised. The Therapeutic Arthritis Research and Gastrointestinal Event Trial (TARGET) aimed to assess gastrointestinal and cardiovascular safety of the COX2 inhibitor lumiracoxib compared with two non-steroidal anti-inflammatory drugs, naproxen and ibuprofen. METHODS: 18325 patients age 50 years or older with osteoarthritis were randomised to lumiracoxib 400 mg once daily (n=9156), naproxen 500 mg twice daily (4754), or ibuprofen 800 mg three times daily (4415) for 52 weeks, in two substudies of identical design (lumiracoxib vs ibuprofen or naproxen). Randomisation was stratified for low-dose aspirin use and age. The primary endpoint was the difference in time-to-event distribution of upper gastrointestinal ulcer complications (bleeding, perforation, or obstruction); analysis was by modified intention to treat. The principle measure of adverse cardiovascular events was the Antiplatelet Trialists' Collaboration endpoint (myocardial infarction, stroke, or cardiovascular death); this analysis was intention to treat. FINDINGS: 81 (0.44%) patients did not start treatment and 7120 (39%) did not complete the study. In patients not taking aspirin, the cumulative 1-year incidence of ulcer complications was 1.09% (95% CI 0.82-1.36) with non-steroidal anti-inflammatory drugs (64 events) versus 0.25% (95% CI 0.12-0.39) with lumiracoxib (14 events; hazard ratio 0.21 [95% CI 0.12-0.37], p<0.0001). Reductions in ulcer complications were also significant in the overall population (0.34 [0.22-0.52], p<0.0001) but not in those taking aspirin (0.79 [0.40-1.55], p=0.4876). In the overall population, 0.55% (50/9127) of those on non-steroidal anti-inflammatory drugs and 0.65% (59/9117) of those on lumiracoxib reached the cardiovascular endpoint (1.14 [0.78-1.66], p=0.5074). INTERPRETATION: Lumiracoxib showed a three to four-fold reduction in ulcer complications compared with non-steroidal anti-inflammatory drugs without an increase in the rate of serious cardiovascular events, suggesting that lumiracoxib is an appropriate treatment for patients with osteoarthritis.

Association between nonsteroidal anti-inflammatory drugs and upper gastrointestinal tract bleeding/perforation: an overview of epidemiologic studies published in the 1990s.

BACKGROUND: In the last decades, studies have estimated the upper gastrointestinal tract bleeding/perforation (UGIB) risk associated with individual nonsteroidal anti-inflammatory drugs (NSAIDs). Later analyses have also included the effect of patterns of NSAID use, risk factors for UGIB, and modifiers of NSAID effect. METHODS: Systematic review of case-control and cohort studies on serious gastrointestinal tract complications and nonaspirin NSAIDs published between 1990 and 1999 using MEDLINE. Eighteen original studies were selected according to predefined criteria. Two researchers extracted the data independently. Pooled relative risk estimates were calculated according to subject and exposure characteristics. Heterogeneity of effects was tested and reasons for heterogeneity were considered. RESULTS: Advanced age, history of peptic ulcer disease, and being male were risk factors for UGIB. Nonsteroidal anti-inflammatory drug users with advanced age or a history of peptic ulcer had the highest absolute risks. The pooled relative risk of UGIB after exposure to NSAIDs was 3.8 (95% confidence interval, 3.6-4.1). The increased risk was maintained during treatment and returned to baseline once treatment was stopped. A clear dose response was observed. There was some variation in risk between individual NSAIDs, though these differences were markedly attenuated when comparable daily doses were considered. CONCLUSIONS: The elderly and patients with a history of peptic ulcer could benefit the most from a reduction in NSAID gastrotoxicity. Whenever possible, physicians may wish to recommend lower doses to reduce the UGIB risk associated with all individual NSAIDs, especially in the subgroup of patients with the greatest background risk.

Gastrointestinal injury from NSAID therapy. How to reduce the risk of complications.

Use of nonsteroidal anti-inflammatory drugs (NSAIDs) and low-dose aspirin is accompanied by risk of upper and lower gastrointestinal (GI) complications, some of which can be serious or even fatal. Management strategies to reduce this risk include gastroprotective pharmacotherapy, use of safer NSAIDs, and eradication of Helicobacter pylori infection. In this article, Dr Lanas summarizes the GI risks associated with NSAID and low-dose aspirin therapy and weighs the efficacy of current risk management strategies.

Double peptic perforation: Report of a rare case.

Perforation peritonitis is the most common surgery performed in an emergency. Upper gastrointestinal tract perforation is more common than lower gastrointestinal perforation. Multiple peptic perforations in an individual are a relatively rare entity, with fewer than 10 cases reported in the literature. The factor that contributes the most for the occurrence of multiple peptic perforations is analgesic and steroid abuse. Herein, we report a rare case of double peptic perforation in a middle-aged man with history of analgesic use for 18 months.