Gastroduodenal ulceration detected endoscopically in cats: retrospective study of 61 patients.

OBJECTIVES: The aim of this study was to describe the endoscopic appearance of gastroduodenal ulcers (GDUs), and to assess the clinical, ultrasonographic and histological data, as well as long-term follow-up, in cats. METHODS: The medical record databases of five veterinary endoscopists were evaluated between January 2016 and 2020, in a retrospective study. Cats with at least one gastric or duodenal ulcer detected by endoscopic examination were included. All the medical records of the selected cats were reviewed and information was collected regarding breed, age, sex, neuter status, medical history, clinical signs, and ultrasonographic, endoscopic and histological findings. The cats were evaluated at 6, 12 and 18 months. RESULTS: Sixty-one cats with a median age of 9.0 years (range 2.0-16.0) were included in the study. The most common complaints were vomiting (n = 55; 90%) and hyporexia (n = 40; 66%); haematemesis was reported in 12 (20%) cats. Endoscopy showed GDUs in the following locations: gastric body in 28 cats (46%), antropyloric area in 34 cats (56%), fundus in 13 cats (21%) and duodenum in eight cats (13%). A single GDU was found in 42 cats (69%) and multiple GDUs were seen in 19 cats (31%). Histopathological evaluation revealed benign lesions in 33 (54%) cats and malignant lesions in 28 (46%; 24 high-grade lymphoma, one low-grade lymphoma and three carcinoma). High-grade lymphoma was detected only in the stomach. Cats diagnosed with malignant GDUs (median 10.5, range 4-16) were significantly older than cats with benign lesions (P = 0.002). CONCLUSIONS AND RELEVANCE: GDUs are common and were detected in 5.1% of cats undergoing an upper gastrointestinal endoscopy. The risk of a malignant ulcer increases proportionally with each year of increasing age. GDU location, number and morphological appearance do not provide any indication of the nature of the ulcer; however, duodenal ulcers are frequently benign. Endoscopic examination facilitates the early and minimally invasive detection of GDUs in cats.

The rare entity of cholocystocolonic fistula: a case report.

Cholocystocolonic fistulas (CCFs) represent a rare medical entity. Previous inflammatory processes in the abdomen, especially in the gallbladder and surgeries are all related to their appearance. There are not typical findings concerning the clinical image and the therapeutic approach varies between patients. Herein, we present a case of a 46-year-old patient, with a history of perforated duodenal ulcer, suffering from abdominal pain and diarrheas. A computed tomography (CT) demonstrated air inside the biliary system. A laparotomy was conducted to the patient and no complications had occurred. In addition, a review of literature regarding the clinical presentation and the therapeutic options for this disease are discussed in this manuscript in relation to our patient.

The clinical and endoscopic aspects of peptic ulcers secondary to the use of nonsteroidal anti-inflammatory drugs of various origins.

INTRODUCTION: currently, the non-steroid anti-inflammatory drugs constitute a veritable object of auto medication throughout the world. The goal of this study was to evaluate the endoscopic and clinical aspects of gastro-duodenal ulcer secondary to taking of non-steroid anti-inflammatory of various sources. METHODS: this was a cross-sectional study which was conducted between July 2016 and December 2017. All adult patients admitted to hospital for clinical symptoms suggestive of gastroduodenal involvement after taking anti-inflammatory drugs and having undergone upper digestive endoscopy were included in this study. Data analysis was done with Epi-info version 7 Software. RESULTS: a total of 114 patients were included, the mean age was 47.18±26 years with a male predominance (64.9%). Among the patients, only 1.75% had taken a non-steroid anti-inflammatory (NSAIDs) from pharmacy. The NSAIDs used were of different types: diclofenac, aceclofenac, aspirin and non-selective NSAIDs. For each drug used, more than half were derived from the streets. Clinically we noted: the dyspepsia (38.58%), hemorrhages (11.40%), the ulcerous syndrome (77.19%), haematemesis (19.29%), haematemesis associated with melena (37.71%), and the rectorrhagia in 6.14 of cases. The specific endoscopic lesions were bulbar ulcer (45.61%), gastric ulcers (20.17%), antral ulcerations (5.26%) and acute gastritis (9.64%), esophagitis (7.89%), esophageal varices (6.14%), and uncomplicated hiatal hernia in 7.01% of cases. CONCLUSION: the serious gastroduodenal lesions observed in this study and due to use of NSAIDs are mainly attributable to unauthorized molecules due to safety concerns. It would be necessary to conduct sensitization days at the community level and in each health facility.

The role of laparoscopy in the treatment of perforated gastro-duodenal ulcers / Laparoszkópia helye a gastro-duodenális fekélyperforációk ellátásában

Introduction: The incidence of peptic ulcer disease decreased due to proton pump inhibitors and Helicobacter pylori eradication. Bleeding from peptic ulcer decreased, as well, although perforation did not decrease and it is permanently between 2­10%. This is a potential surgical emergency, the mortality can reach up to 25% and the morbidity 50%, respectively. Urgent surgical intervention in the right time can improve the results. Aim: To compare the morbidity, mortality, the length of hospital stay and duration of operating time in open and laparoscopic repair of perforated peptic ulcer. Results: A cohort of 55 patients were operated on with perforated peptic ulcer from 01.01.2017 to 30.06.2019 31 open (51.36%) and 24 laparoscopic (43.63%) operations were performed from which 4 (16.6%) needed conversion to open approach. The average age of 23 men and 8 women were 56.3 and 70.3 years respectively in the open operations group, while 13 men and 11 women with average age of 49.7 and 53.7 years was in the laparoscopic operations group. Within 30 days the number of complications were 5 in the open and 2 in the laparoscopic group (p = 0.45). The average duration of operation was 51.95 minutes (30­85) in the open and 63.41 minutes (25­110) in the laparoscopic group (p = 0.13). 6 from the open group with average age of 74.3 years and 2 from the laparoscopic group with average age of 68.5 years died within 30 days (p = 0.44). The average length of stay was 7.13 (5­16) days in the open and 6.19 (4­13) days in the laparoscopic group (p = 0.24). The average size of the perforation was 7.4 mm (3­20) in the open and 5.3 mm (3­10) in the laparoscopic group (p = 0.14). Free air was seen in the abdominal cavity in 25 cases (80%) of the open and in 11 cases (54%) of the laparoscopic group. Conclusion: Early diagnosis, prompt supportive care and antibiotic treatment and urgent surgical intervention are essential to improve outcomes. The standard operation is the simple suture with pedicled omental flap which can be performed by either open or laparoscopic surgical repair. Laparoscopic method spreads slowly, the learning curve is longer and it needs more expertise but the morbidity is lower than that of the open surgery. The morbidity does not increase after conversion according to the literature so if there is no contraindication and there is enough expertise it should be suggested as the first choice.

Eosinophilic Gastroenteritis-associated Duodenal Ulcer Successfully Treated with Crushed Budesonide.

Eosinophilic gastroenteritis (EGE)-associated duodenal ulcer is rare and its endoscopic and pathological features remain poorly described. A 15-year-old boy was referred to our hospital for further examination and treatment of duodenal ulcer. Esophagogastroduodenoscopy (EGD) revealed two A2-stage duodenal ulcers on the duodenal bulb. A biopsy revealed marked infiltration of eosinophils, suggestive of EGE-associated duodenal ulcers. Thus, treatment with crushed budesonide (9 mg/day) was started. EGD revealed healing of the duodenal ulcers seven months after treatment. To our knowledge, this is the first report describing EGE-associated duodenal ulcer successfully treated with crushed budesonide.

Perforation of anastomotic peptic ulcer following pancreaticoduodenectomy: a report of three cases.

BACKGROUND: Perforation of a marginal peptic ulcer after pancreaticoduodenectomy (PD) can lead to severe conditions, although its clinical features have not been well reported. In this article, we present three cases of marginal peptic ulcer perforation after PD that we experienced in our institute and attempt to clarify its appropriate treatment and prevention. CASE PRESENTATION: Marginal ulcer perforation confirmed with computed tomography and/or surgical exploration occurred in 3 (1.8%) of 163 consecutive patients who underwent PD (including 160 patients who underwent a total or subtotal stomach-preserving procedure) at our institution. The three patients (one man and two women) had a median age of 77 (65-79) years. Two of these patients had a medical history of duodenal peptic ulcer. All three patients had biliary neoplasms. Two of the patients underwent subtotal stomach-preserving PD with antro-jejunal anastomosis, and the other patient underwent pylorus-preserving PD with duodenal jejunostomy. The perforation occurred with a sudden and severe onset of abdominal pain 34, 94, and 1204 days, respectively, after the PDs. At the time of the perforation, all of the patients had been withdrawn from postoperative prophylactic antipeptic ulcer agents, with the cessation periods ranging from 12 to 1008 days. In addition, all the patients were in fasting conditions for 1 to 13 days just before the perforation. Surgical treatment with direct suturing of the perforated ulcer was performed for two patients, while conservative therapy was performed for one patient. Their primary treatment courses were satisfactory. Chronic antisecretory agent therapy was prescribed for 562, 271, and 2370 days, respectively, from marginal ulcer perforation, and no ulcer recurrence was noted in any of the patients. CONCLUSIONS: Lack of antisecretory therapy and fasting were considered an essential cause of marginal peptic ulcer perforation after PD. In addition, unlike the native duodenum, the jejunal limb used for reconstruction to a preserved stomach may be at increased risk of ulceration. Chronic permanent administration of antisecretory agents and fasting avoidance are desirable for patients who have undergone stomach-preserving PD to prevent marginal ulcer perforation.

Distribution of duodenal tuft cells is altered in pediatric patients with acute and chronic enteropathy.

Clinical interest into the function of tuft cells in human intestine has increased in recent years. However, no quantitative study has examined intestinal tuft cells in pathological specimens from patients. This study quantified tuft cell density by using a recently identified marker, specific for tyrosine phosphorylation (pY1798) of girdin (also known as CCDC88A or GIV) in the duodenum of pediatric patients. Deidentified sections with pathological diagnosis of acute duodenitis, ulcer, or celiac disease, and age-matched normal control were analyzed under double-blind conditions. Immunostaining for pY1798-girdin demonstrated the distinct shape of tuft cells with and filopodia-like basolateral membrane structure and a small apical area, which densely expressed gamma-actin. As compared to normal tissues, the specimens diagnosed as celiac disease and duodenal ulcer had significantly fewer tuft cell numbers. In contrast, acute duodenitis showed varied population of tuft cells. The mucosa with severe inflammation showed lower tuft cell numbers than the specimens with none to mild inflammation. These results suggest that loss of tuft cells may be involved in prolonged inflammation in the duodenal mucosa and disrupted mucosal integrity. pY1798-girdin and gamma-actin are useful markers for investigating the distribution and morphologies of human intestinal tuft cells under healthy and pathological conditions.

Prevalence of Helicobacter pylori infection rate in heterotopic gastric mucosa in histological analysis of duodenal specimens from patients with duodenal ulcer.

Heterotopic gastric mucosa in the duodenal bulb is a rare congenital disorder with varied clinical presentations. The mechanism of formation of a duodenal ulcer is failure of balance of the attack factor and the defense factor, which is the same as the mechanism of formation of a gastric ulcer. However, the true etiology of the duodenal ulcer remains unknown. Gastric mucosa can secrete gastric juice which injures itself, but the duodenal mucosa does not contain cells secreting a digestive enzyme. We assume that duodenal ulcers are caused by the presence of heterotopic gastric mucosa that can secrete gastric acid. This study was designed to assess the prevalence and associations of heterotopic gastric mucosa in duodenal ulcers. The present study included 137 patients who underwent biopsy or resection of duodenal ulcer. We detected gastric foveolar metaplasia due to inflammation from a heterotopic gastric mucosa using immunohistochemical staining. Heterotopic gastric mucosa consists of foveolar epithelium (MUC5AC-positive) and fundic gland (H⁺K⁺ ATPase-positive parietal cells, pepsinogen I-positive chief cells and MUC6-positive mucous neck cells), whereas gastric metaplasia is composed of foveolar epithelium without fundic glands. These specimens were stained with toluidine blue for detection of Helicobacter pylori infection. Among the 137 patients with duodenal ulcer, 76 cases (55%) had heterotopic gastric mucosa in the obtained specimens, and Helicobacter pylori was found in 45 cases (59%,45/76) among those with heterotopic gastric mucosa. Our results suggest that heterotopic gastric mucosa was strongly associated with concurrent duodenal ulcer.

[The 471st case: duodenal ulcer, mucor infection, and elevated IgG(4)].

Mucor infection is rarely reported in non-immunocompromised population, especially in isolated gastrointestinal tracts. IgG(4)-related diseases (IgG(4)-RD) have been recognized in recent years, but secondary causes of IgG(4) elevation should be differentiated. We reported a young man with duodenal mass and ulcer and high serum IgG(4) level. Histological biopsy of the mass revealed positive mucor mycelium and infiltration of IgG(4) positive plasma cells. Serum IgG(4) decreased to normal range after surgical resection and systemic antifungal treatment. This case suggests that isolated mucor mycosis infection can develop in the digestive tract and mimics as IgG(4)-related disease.

STW 5 is effective against nonsteroidal anti-inflammatory drugs induced gastro-duodenal lesions in rats.

BACKGROUND: Proton pump inhibitors are often used to prevent gastro-intestinal lesions induced by nonsteroidal anti-inflammatory drugs. However, they are not always effective against both gastric and duodenal lesions and their use is not devoid of side effects. AIM: To explore the mechanisms mediating the clinical efficacy of STW 5 in gastro-duodenal lesions induced by nonsteroidal anti-inflammatory drugs (NSAIDs), exemplified here by diclofenac, in a comparison to omeprazole. METHODS: Gastro-duodenal lesions were induced in rats by oral administration of diclofenac (5 mg/kg) for 6 successive days. One group was given concurrently STW 5 (5 mL/kg) while another was given omeprazole (20 mg/kg). A day later, animals were sacrificed, stomach and duodenum excised and divided into 2 segments: One for histological examination and one for measuring inflammatory mediators (tumor necrosis factor α, interleukins-1ß and 10), oxidative stress enzyme (heme oxygenase-1) and apoptosis regulator (B-cell lymphoma 2). RESULTS: Diclofenac caused overt histological damage in both tissues, associated with parallel changes in all parameters measured. STW 5 and omeprazole effectively prevented these changes, but STW 5 superseded omeprazole in protecting against histological damage, particularly in the duodenum. CONCLUSION: The findings support the therapeutic usefulness of STW 5 and its superiority over omeprazole as adjuvant therapy to NSAIDs to protect against their possible gastro-duodenal side effects.

PECULIARITIES OF ACID PRODUCTION AND PATHOGENESIS OF PYLORIC AND PREPYLORIC GASTRIC ULCER COMPLICATIONS.

The purpose of the study was to identify the pathogenesis features of prepiloric and pyloric ulcers and to establish the cause of resistance to conservative therapy and the tendency to complicated course of type III ulcers according to H.D. Johnson. A comparative analysis of acid production was carried out in 150 patents with duodenal ulcer (n-80) and peptic ulcer of type III according to H.D. Johnson classification (n-70). We revealed a definite individual rhythm of daily intragastric acidity with a maximum rise at night in patients with duodenal ulcer. The paper explores the peculiarities of digestive juice secretion depending on ulcerative substratum localization. The pathogenetic validity of the use of antisecretory drugs for duodenal ulcer treatment and the need to further improve the algorithm for pyloric and prepyloric ulcer therapy are shown. For pyloric and prepiloric ulcers characteristic specific morphological changes in the muscle layer of the wall of the antrum, leading to the motor-evacuation disorders and promoting duodenogastric reflux - dystrophy myocytes circular muscle layer vacuolation of the cytoplasm, edema and hypertrophy ganglia intermuscular plexus, hemorrhages in the muscle sheath, violation of muscle bundles.

Endoscopic features, pathological correlates and possible origin of foveolar gastric metaplasia presenting as a duodenal polyp.

It has recently been shown that duodenal foveolar gastric metaplasia (FGM) sometimes presents as a polyp. The mechanism by which FGM develops into a polypoid lesion is unknown and it is unclear whether this form of FGM is indistinguishable from other polypoid lesions or whether endoscopists do not recognize it because they are unfamiliar with it. We identified and retrieved archival cases of FGM endoscopically suspicious for adenomatous polyp and examined their pathological, clinical and endoscopic features. Endoscopic features of the 13 identified FGMs presenting as polyps were heterogeneous and overlapping with those of adenomatous polyps. FGM was frequently associated with mucosal and submucosal Brunner's glands, but defining and recognizing hyperplasia of these glands remains difficult. Other pathological features could not explain the development of a polypoid lesion. The endoscopic features of FGM polyps are non-specific, overlapping with those of adenomatous polyps. FGM polyps probably acquire their polypoid aspect due to association with Brunner's gland hyperplasia (BGH), which also arises due to chronic inflammation and damage. Because BGH is ill-defined and difficult to recognize, while FGM is diagnosed easily, this type of polypoid lesions has until now only been recognized based on the presence of FGM, although FGM is most likely a secondary phenomenon and not the primary cause of the polyp.

Is the new potent acid-inhibitory drug vonoprazan effective for healing idiopathic peptic ulcers? A multicenter observational study in Akita Prefecture, Japan.

BACKGROUND: The incidence of peptic ulcers unrelated to H. pylori infection and non-steroidal anti-inflammatory drugs (NSAIDs), termed idiopathic peptic ulcers (IPUs), has increased worldwide. We recently reported that IPUs were refractory to proton pump inhibitor (PPI) treatment. Vonoprazan, which was recently developed in Japan, has shown a more potent acid-inhibitory effect than ordinary PPIs. In the present study, we compared the healing rates among peptic ulcers of different etiologies following treatment with vonoprazan. METHOD: A multicenter observational study was performed at six participating hospitals in Akita Prefecture, Japan. Consecutive patients who had endoscopically confirmed gastro-duodenal ulcers were enrolled between August 2016 and March 2018. For each patient, the Helicobacter pylori infection status and NSAID use, including aspirin, were checked, and 20 mg vonoprazan was administered for 6 weeks for duodenal ulcers and 8 weeks for gastric ulcers. The healing status was checked by endoscopy at the end of vonoprazan treatment. Patients were divided into four subgroups according to the H. pylori status and NSAID usage. RESULTS: The proportion of IPUs was 18.2%. A total of 162 patients completed the study protocol. The healing rate of IPUs was marginally lower than that of simple H. pylori-associated ulcers (81.2% vs. 93.5%, P = 0.05). Similarly, the healing rate of NSAID-related ulcers, irrespective of concomitant H. pylori infection, was significantly lower than that of simple H. pylori-associated ulcers. CONCLUSIONS: Six- or 8-week vonoprazan treatment still seems to be insufficient for healing IPUs. Longer-term vonoprazan or another treatment option may be required to heal potentially refractory peptic ulcers.

Rare case of a giant duodenal ulcer penetrating the pancreas during antiangiogenic treatment.

We report a case of a patient with renal cell carcinoma on pazopanib, who presented with severe upper gastrointestinal bleeding. Endoscopy showed a giant bulbar ulcer with a visible vessel of 4 mm. Due to unavailability of surgical rescue backup, large calibre vessel treatment was delayed. Endoscopy was repeated after 48 hours and showed a reduction in the vessel diameter. Endoscopic adrenalin injection and electrocoagulation were performed. However, the vessel increased in size and became pulsatile. The patient was operated, confirming a giant bulbar ulcer penetrating the pancreas with active bleeding from the gastroduodenal artery. Pazopanib therapy was suspended, and the patient is asymptomatic. Antiangiogenic treatment has been associated with gastrointestinal bleeding, perforation and fistulisation. Although we cannot confirm the causal association between the penetrating ulcer and pazopanib, the absence of Helicobacter pylori infection or non-steroidal anti-inflammatory drugs, and the reported cases of gastrointestinal bleeding during these therapies favour a possible association.

The Value of Confocal Laser Endoscopy in Assessing the Quality of Duodenal Ulcer Healing.

BACKGROUND AND OBJECTIVE: Confocal laser endomicroscopy (CLE) is a novel endoscopic technique that can image cells and subcellular layers of the gastric mucosa in vivo. We aimed to investigate the value of CLE in assessing the quality of ulcer healing (QOUH) and preliminarily establish evaluation criteria. MATERIALS AND METHODS: Patients with duodenal ulcers were enrolled. After duodenal ulcer healing, we compared the value of CLE and white light endoscopy (WLE) in assessing the QOUH by using the histopathological diagnosis as the gold standard. At the same time, immunohistochemistry was performed to examine the expressions of transforming growth factor ß1 (TGF-ß1) and fibroblast growth factor 2 (FGF-2) in normal and scar tissues. RESULTS: In assessing the QOUH classified as poor, good, and excellent by the pathological classification, the sensitivity of WLE was 57.14%, 50%, and 47.06%, the specificity was 87.80%, 52.38%, and 81.58%, and the accuracy was 80.00%, 50.91%, and 70.91%, respectively. Meanwhile, the sensitivity of CLE was 73.33%, 85.19%, and 92.31%, the specificity was 95%, 85.71%, and 92.86%, and the accuracy was 89.09%, 85.45%, and 92.73%, respectively. The κ value for the correlation with pathological diagnosis grade was 0.38 for WLE vs. 0.74 for CLE. The assessment of the QOUH in the CLE image classification showed great improvement compared with that in the WLE image classification. The image classification of CLE was not associated with the immunohistochemical expression of TGF-ß1 or FGF-2 according the Spearman rank correlation (P > 0.05). CONCLUSION: Compared with WLE, CLE has a higher value in assessing the QOUH. Lasers Surg. Med. © 2019 Wiley Periodicals, Inc.

Clinicopathological features of duodenal bulb biopsies and their relationship with upper gastrointestinal diseases.

AIM: To assess the prevalence of the lesions in duodenal bulb mucosa and the relationship between duodenal lesions and upper gastrointestinal diseases, including helicobacter pylori infection. METHODS: Clinical, endoscopic and pathological data of the cases with duodenal bulb and gastric mucosal biopsy from January 2005 to May 2017 were analyzed retrospectively. RESULTS: A total of 3540 patients were enrolled. The biopsy from protuberant lesions with endoscopic morphology are mostly duodenal gastric heterotopia or adenoma. The biopsy from duodenal ulcers are often observed in inflammatory changes and gastric metaplasia. Patients with gastric heterotopia had a significantly lower prevalence of chronic atrophic gastritis, intestinal metaplasia, and gastric ulcer; and much higher prevalence of gastroesophageal reflux disease and gastric fundic polyps. Patients with gastric metaplasia had been positively associated with gastroesophageal reflux disease, and negatively associated with gastric fundic polyps. There were positive correlation between helicobacter pylori infection and duodenal active inflammation, Brunner gland hyperplasia, gastric metaplasia and duodenal ulcer. However, Patients with gastric heterotopia in bulb had been negatively associated with helicobacter pylori infection. CONCLUSIONS: The mucosa lesions in duodenal bulb were associated with concurrent gastric fundic gland polyps, gastroesophageal reflux disease, duodenal ulcer, and helicobacter pylori infection.

Ilaprazole Compared With Rabeprazole in the Treatment of Duodenal Ulcer: A Randomized, Double-blind, Active-controlled, Multicenter Study.

GOALS: The main goal of this study was to explore the dose-effect relationship of ilaprazole. BACKGROUND: Ilaprazole is a kind of benzimidazole proton-pump inhibitor, which was confirmed efficacious and safe in treatment of duodenal ulcer (DU). However, the dose-effect relationship of ilaprazole was not clear. STUDY: This was a double-blind, parallel, randomized study. Patients aged above 18 years with at least one endoscopically confirmed active nonmalignant DU were treated with rabeprazole 10 mg or ilaprazole 10 mg/5 mg for 4 weeks. Healing of ulcer was determined by its resolution from active to scarring stage. Symptoms relief was evaluated using a graded score. Safety and tolerability were evaluated on basis of clinical assessments. RESULTS: A total of 390 patients completed the study finally. Ulcers were successfully healed in 75.38%, 77.86%, and 83.72% of patients after 4-week treatment with rabeprazole 10 mg, ilaprazole 5 mg, and ilaprazole 10 mg, respectively. The 4-week healing rate difference between rabeprazole 10 mg and ilaprazole 5 mg was 2.48% (95% confidence interval: -7.79% to 12.74%) leading to accept the noninferiority hypothesis. Logistic regression model suggested that ilaprazole 10 mg was superior to ilaprazole 5 mg at week 2 (odds ratio, 1.92; 95% confidence interval: 1.02, 3.59; P=0.04). Most patients (80%) became asymptomatic after treatment. At the dosages administered, the 3 drug groups exhibited similar efficacy and a similar safety profile. CONCLUSIONS: Ilaprazole 5 mg is not inferior to rabeprazole 10 mg in treating DU, and a dose-effect relationship have been revealed between 5 mg and 10 mg of ilaprazole.