The recurrent bleeding risk of a Forrest IIc lesion at the second-look endoscopy can be indicated by high Rockall scores ≥ 6.

BACKGROUND: The Forrest classification is widely applied to guide endoscopic hemostasis for peptic ulcer bleeding. Accordingly, practice guidelines suggest medical treatment only for ulcer with a Forrest IIc lesion because it has low rebleeding risk even without endoscopic therapy, ranging from 0 to 13%. However, the risk ranges widely and it is unclear who is at risk of rebleeding with such a lesion. This study assessed whether the Rockall score, which evaluates patients holistically, could indicate the risk of recurrent bleeding among patients with a Forrest IIc lesion at the second-look endoscopy. METHODS: Patients who had peptic ulcer bleeding with Ia-IIb lesions received endoscopic hemostasis at the primary endoscopy, and they were enrolled if their Ia-IIb lesions had been fading to IIc at the second-look endoscopy after 48- to 72-h intravenous proton pump inhibitor (PPI) infusion. Primary outcomes were rebleeding during the 4th-14th day and 4th-28th day after the first bleeding episode. RESULTS: The prospective cohort study enrolled 140 patients, who were divided into a Rockall scores ≥ 6 group or a Rockall scores < 6 group. The rebleeding rates in the Rockall scores ≥ 6 group and the Rockall scores < 6 group during the 4th-14th day and the 4th-28th day were 13/70 (18.6%) versus 2/70 (2.9%), p = 0.003 and 17/70 (24.3%) versus 3/70 (4.3%), p = 0.001, respectively, based on an intention-to-treat analysis and 5/62 (8.1%) versus 0/68 (0%), p = 0.023 and 6/59 (10.2%) versus 0/67 (0%), p = 0.009, respectively, based on a per-protocol analysis. The Kaplan-Meier curves showed that the Rockall scores ≥ 6 group had a significantly lower cumulative rebleeding-free proportion than the Rockall scores < 6 group (p = 0.01). CONCLUSIONS: Combined Rockall scores ≥ 6 on arrival with a Forrest IIc lesion at the second-look endoscopy can identify patients at risk of recurrent peptic ulcer bleeding following initial endoscopic and intravenous PPI treatment. Trial registration Trial registration identifier: NCT01591083.

Osteopoikilosis: a major diagnostic problem solved by bone scintigraphy.

Osteopoikilosis (OPK) is a rare disease with an unknown etiology. Although a benign condition, it may lead to diagnostic problems when the patient undergoes diagnostic imaging of the skeletal system due to various reasons like malignancy. Herein, we report 2 cases with OPK causing difficulties in the final diagnosis of the cases which was resolved with the contribution of bone scintigraphy and clinical follow-up.

Encefalopatía de Wernicke tras duodenopancreatectomía cefálica / Wernicke's encephalopathy after cephalic pancreaticoduodenectomy

La encefalopatía de Wernicke (EW) es un trastorno neurológico agudo resultado del déficit de tiamina. Presentamos la aparición de dicho cuadro en un enfermo joven que es sometido a una duodenopancreatectomía cefálica ante una úlcera duodenal sangrante refractaria a tratamiento endoscópico y quirúrgico previo, precisando de una nutrición parenteral total, sin suplementos de tiamina(AU)

Wernicke’s encephalopathy is an acute neurological disorder resulting from thiamine deficiency. We report a case in a young patient who underwent a cephalic duodenopancreatectomy with a bleeding duodenal ulcer refractory to endoscopic and surgical treatment, requiring total parenteral nutrition, without thiamine supplementation(AU)

Randomized controlled trial of standard versus high-dose intravenous omeprazole after endoscopic therapy in high-risk patients with acute peptic ulcer bleeding.

BACKGROUND: Rebleeding from peptic ulcers is a major contributor to death. This study compared standard (40-mg intravenous infusion of omeprazole once daily for 3 days) and high-dose (80-mg bolus of omeprazole followed by 8-mg/h infusion for 72 h) in reducing the rebleeding rate (primary endpoint), need for surgery, duration of hospital stay and mortality in patients with peptic ulcer bleeding after successful endoscopic therapy. METHODS: This was a single-institution prospective randomized controlled study based on a postulated therapeutic equivalence of the two treatments. All patients who had successful endoscopic haemostasis of a bleeding peptic ulcer (Forrest classification Ia, Ib, IIa or IIb) were recruited. Informed consent was obtained and patients were randomized to receive standard- or high-dose infusions of intravenous omeprazole. RESULTS: Two (3 per cent) of 61 patients in the high-dose group and ten (16 per cent) of 61 in the standard-dose group exhibited rebleeding, a difference of - 13 (95 per cent confidence interval - 25 to - 2) per cent. The upper limit of the one-sided confidence interval exceeded a predefined equivalence absolute difference of 16 per cent. Equivalence of standard- and high-dose omeprazole in preventing rebleeding was not demonstrated. CONCLUSION: Intravenous standard-dose omeprazole was inferior to high-dose omeprazole in preventing rebleeding after endoscopic haemostasis for peptic ulcer bleeding. REGISTRATION NUMBER: NCT00519519 (http://www.clinicaltrials.gov).

[Gastrocolic fistula - a rare cause of cachexia and polyneuropathy]. / Gastrokolische Fistel als seltene Ursache von Kachexie und Polyneuropathie.

Gastrocolic fistula is a rare clinical disorder which in the past most often occurred after gastric surgery or carcinoma of the gastrointestinal tract. However, during the last decade an increasing number of cases after benign gastric ulcers have been described. Most common symptoms have been weight loss, abdominal pain, diarrhea and copremesis. A 49-year-old cachectic patient presented with a 2-year history of abdominal discomfort and diarrhea. He reported a weight loss of 32 kg during this period and was finally unable to move because of exhaustion. Furthermore, he suffered of burning paresthesia of the legs and the abdomen. His medical history included a Billroth II operation because of recurrent ulcer disease in 1987. Barium enema revealed a gastrocolic fistula which caused small bowel bacterial overgrowth with villous atrophy and malabsorption and development of polyneuropathy. The fistula was surgically resected, and postoperatively, the patient improved and regained his weight. Gastrocolic fistula is a rare cause of diarrhea and should be considered in clinical practice. Barium enema is superior to endoscopy in detecting gastrocolic fistula.

Postgastrectomy polyneuropathy with thiamine deficiency.

OBJECTIVE: Polyneuropathy has been reported after gastrectomy performed to treat various lesions. Although thiamine deficiency is a possible cause of this neuropathy, the pathogenesis still remains to be clarified. Seventeen patients with peripheral neuropathy with thiamine deficiency after gastrectomy are described. METHODS: Seventeen patients with polyneuropathy after gastrectomy accompanied by thiamine deficiency were selected. Patients were restricted to those with total or subtotal gastric resection to treat ulcer or neoplasm. Patients who had undergone operations to treat morbid obesity were excluded. RESULTS: Intervals between the operation and onset of neuropathy varied from 2 months to 39 years. Most patients did not seem malnourished. Serum concentrations of B vitamins other than thiamine were nearly normal. Symmetric motor-sensory polyneuropathy, predominantly involving the lower limbs, had progressed over intervals varying from 3 days to 8 years. Relative degrees of motor and sensory impairment also varied extensively. Some cases that progressed rapidly mimicked Guillain-Barré syndrome. Electrophysiological and pathological findings were those of axonal neuropathy. Substantial functional recovery from polyneuropathy was seen in most patients by 3 to 6 months after initiating thiamine supplementation. Motor recovery was better than sensory recovery. CONCLUSIONS: Various symptoms were seen in patients with postgastrectomy neuropathy. Thiamine deficiency should be considered in the differential diagnosis of motor-sensory polyneuropathy after gastrectomy.

Operations for peptic ulcer disease: paradigm lost.

Over the past several decades, the pharmacologic and endoscopic treatment of peptic ulcer disease (PUD) has dramatically improved. To determine the effects of these and other changes on the operative management of PUD, we reviewed our surgical experience with gastroduodenal ulcers over the past 20 years. A computerized surgical database was used to analyze the frequencies of all operations for PUD performed in two training hospitals during four consecutive 5-year intervals beginning in 1980. Operative rates for both intractable and complicated PUD were compared with those for other general surgical procedures and operations for gastric malignancy. In the first 5-year period (1980 to 1984), a yearly average of 70 upper gastrointestinal operations were performed. This experience included 36 operations for intractability, 15 for hemorrhage, 12 for perforation, and seven for obstruction. During the same time span, 13 resections were performed annually for gastric malignancy. By the most recent 5-year interval (1994 to 1999), the total number of upper gastrointestinal operations had declined by 80% (14 cases), although the number of operations for gastric cancer had changed only slightly. Operations decreased most markedly for patients with intractability, but the prevalence of operations for bleeding, obstruction, and perforation was also decreased. We conclude that improved pharmacologic and endoscopic approaches have progressively curtailed the use of operative therapy for PUD. Elective surgery is now rarely indicated, and emergency operations are much less common. This changed paradigm poses new challenges for training and suggests different approaches for practice.

[A patient with vitamin E deficient, myopathy presenting with amyotrophy].

We report a 61-year-old man with vitamin E deficiency, presenting with, myopathy as an only clinical symptom. In 1997, at 59 years of age, he noted mild proxymal-muscle weakness and atrophy in the four extremities, nine years after he received a Billroth II partial gastrectomy for a gastric ulcer. His muscle weakness slowly exacerbated, and he was admitted to our hospital in 1999. On admission, neurological examination confirmed mild proximal-muscle weakness and atrophy in the four extremities. Intelligence, cranial nerves, coordination, sensation and tendon reflexes were all normal. Laboratory examination showed normochromic anemia (Hb 9.9 g/dl, Ht 30.9%, MCV 97.5 fl, MCHC 31.2 pg), hypoproteinemia (5.0 g/dl), and hypocholesterolemia (107 mg/dl). The levels of serum CK, lactate and pyruvate were normal. The serum vitamin E level was markedly reduced (0.17 mg/dl; normal 0.75-1.41). Cerebrospinal fluid was normal. Nerve conduction, sensory evoked potentials (SEP), electromyography (EMG), head CT and electroencephalography (EEG) were all normal. Muscle biopsy from the right deltoid muscle showed both mild myogenic and neurogenic changes. Remarkably, type 1 muscle fiber predominance and granular accumulation of autofluorescent lipofuscin granules in the muscle fibers were found. These pathological findings were compatible with those of vitamin E-deficient myopathy. Thus, he was diagnosed as having vitamin E-deficient myopathy, which was confirmed by apparent effective supplementation of vitamin E. Interestingly, our present case did not show any other neurological manifestations such as deep sensory disturbance, sensory ataxia or polyneuropathy. A long-term workload due to hard physical labor and smoking in our patient may have accelerated oxidative muscle damage, resulting in amyotrophy mainly due to vitamin E deficient myopathy.

Auricular-plaster therapy plus acupuncture at zusanli for postoperative recovery of intestinal function.

In order to relieve the abdominal distension and other discomforts due to gastrointestinal dysfunction after abdominal operations, the patients were treated by auricular-plaster therapy plus acupuncture at Zusanli (ST 36). 12 (92.4%) of the 13 cases in the treatment group showed recovery of normal peristalsis within 72 hours after operations, while that in 13 cases of the control group was 46.1%, indicating that auricular-plaster therapy plus acupuncture at Zusanli (ST 36) may promote postoperative recovery of the intestinal function.

[Giant benign gastric ulcer penetrating into the liver, pancreas and mesocolon]. / Ulcera gastrica gigante benigna penetrante nel fegato, nel pancreas e nel mesocolon.

Penetration of the liver, pancreas and transverse mesocolon by a giant benign gastric ulcer is relatively uncommon, and literature contains a few reports of this complication. The preoperative histological diagnosis may be difficult or impossible. A 63-year-old female patient with a history of seven months of lack of appetite, asthenia, epigastric pain, a remarkable weight decrease, presenting at physical examination a large, smooth margins, not pulsating, quite fixed abdominal mass, is reported. Echography confirmed the presence of a mass of approximately 14 x 19 cm, with solid and liquid content. Biopsy showed inflammatory elements and cellular detriti. Barium enema showed that the mass compressed the descendent colon, which appeared dislocated. Tumor markers (CEA, CA 19-9, alpha-fetoprotein) where in the normal range. Endoscopy showed a giant angular ulcer whose bottom was represented by necrotic material (after the definitive histological examination it proved to be hepatic tissue). At TC scan of the abdomen, a remarkable thickening of the gastric wall was present. At surgery the stomach appeared increased in volume, with remarkably thickened walls, tenaciously sticking to II and III hepatic segments, to the pancreas and transverse mesocolon. A total gastrectomy was performed because of the depth of the ulcer penetration and the extension of the alteration of the gastric wall, even if the giant gastric ulcer, in the literature, is more frequently benign than malignant.

[The importance of electrogastrography in clinical practice]. / Znachennia elektrohastrohrafiï v klinichnii praktytsi.

Changes were analyzed in electrogastrogrammes (EGG) of 135 patients who had underwent a surgical treatment for gastric and duodenal ulcer. Time of restoration of bioelectrical activity of the stomach was determined, with diagnostic and prognostic value of EGG during the process of rehabilitation being shown. Changes in EGG were studied in 92 patients with acute appendicitis. Efficiency of the above procedure was established with respect to obtaining supplementary objective data of informative value on the course of the pathological process in the abdominal cavity, which fact permits the prognostication of the different complications development. Transcutaneous electrostimulation of the stomach was shown to be helpful in gastroenterological patients as was intracavitary pneumomassage.

[2-Component silicone compounds in the emergency surgery of gastrointestinal hemorrhages]. / Dvukhkomponentnye silikonovye kompozitsii v neotlozhnoi khirurgii zheludochno-kishechnykh krovotechenii.

Based upon their clinico-experimental investigations the authors prove advantages of the two-component silicon compositions over oil preparations for the arrest of gastro-intestinal bleedings. Such compositions are recommended for patients whose treatment by traditional methods of hemostasis proved to be ineffective due to some causes which is often observed in elderly and senile patients.

[Effects of transcutaneous electrostimulation on motor function of the stomach after abdominal surgery]. / Vplyv cherezshkirnoï elektrostymuliatsiï na rukhovu funktsiiu shlunka pislia vykonannia abdominal'noï operatsiï.

While examining of 35 patients it was revealed that transcutaneous gastric electrostimulation application may influence the frequency and amplitude of gastric contractions, its tone and hydrogen ions secretion. Gastric electrostimulation efficacy was noted in 83.3% of patients after cholecystectomy conduction and in 58.3%--after laparotomy, conducted for peritonitis.

[A study of subtotal gastrectomy under the acupuncture combined with epidural anesthesia of small dosage].

Forty-eight cases with benign gastric diseases were operated using acupuncture at Zusanli (ST 36) and Neiguan (PC 6) combined with epidural anesthesia of small dosage (group A, 39 cases), and simple epidural anesthesia of small dosage (group B, 9 cases). The results show that the effect in the group A is better than that in the group B. Namely, the analgesia is stronger, the tractive reaction of internal organs is lighter, the abdominal muscles are more relaxed, the dosage of anesthetic is much smaller and the physiological disturbance is less in the group A.

[Peptic ulcer localized in the stomach: conservative therapy or surgical treatment?]. / Iazvennaia bolezn' s lokalizatsiei v zheludke--konservativnaia terapiia ili khirurgicheskoe lechenie?

Most authors advocate surgery for peptic ulcer because of the high frequency of malignancy of the ulcers. The literature data and personal observations provide evidence, however, that true malignant degeneration of the ulcer is a quite rare complication of the disease. Of greater importance in examination of the patients is differential diagnosis between benign ulcers and the infiltrative-ulcerous form of gastric ulcer which may take the "mask" of a benign ulcer in the early stages. Patients with an uncomplicated form of peptic gastric ulcer must be given nonoperative treatment. An operation should be considered only in formation of poorly cicatrizing ulcers with due regard for the poor efficacy of their nonoperative management.

[The rehabilitative treatment of patients following gastric resection at the hospital stage]. / Vosstanovitel'noe lechenie bol'nykh posle rezektsii zheludka na gospital'nom étape.

To diminish the frequency of postoperative pulmonary complications following gastric resection and stay in hospital, a complex of preventive and therapeutic measures has been designed and tested in 165 patients. The complex involves early exercise, aerosol therapy, vibratory massage, heparin electrophoresis of the chest. Clinicophysiological data on respiratory function, pulmonary circulation, hemocoagulation support the effectiveness of the rehabilitation in patients after gastric resection.

[Electroacupuncture stimulation in the treatment of postoperative disorders of the motor-evacuatory function of the stomach and intestines]. / Elektroakupunkturnaia stimuliatsiia v lechenii posleoperatsionnykh narushenii motorno-évakuatsionnoi funktsii zheludka i kishechnika.

One hundred and eight patients with gastric ulcer subjected to planned and urgent surgery have been treated for postoperative gastric atonia and intestinal paresis using electroacupuncture stimulation (EAPS). The treatment was effective in 85% of cases, with the efficacy confirmed by clinical results and gastroenterologic findings. EAPS promoted a decrease in the initially high blood levels of cortisol, aldosterone and histamine, an increase in serotonin and a reduction in gastric juice histamine levels, which were indicative of the analgetic and antihistamine EAPS effect and attenuation of parasympathetic activity. EAPS introduction into a complex of postoperative rehabilitation procedures led to reduction of drug doses or total drug replacement, early activation of surgical patients and prompt recovery of normal gastrointestinal evacuation.