Unusual case of retroperitoneal hematoma and duodenal ulcerative bleeding after nephrectomy: Case report.

RATIONALE: Retroperitoneal hematomas are relatively common in patients undergoing nephrectomy. Herein, we report an unusual case involving a giant retroperitoneal hematoma and subsequent duodenal ulcerative bleeding following a radical nephrectomy. PATIENT CONCERNS: A 77-year-old woman was admitted to our hospital for lower back pain, and she had severe right hydronephrosis and a urinary tract infection. DIAGNOSES: The patient was diagnosed and confirmed as high-grade urothelial carcinoma. INTERVENTIONS: After ineffective conservative treatments, a right radical nephrectomy and ureteral stump resection were performed. The patient received proton pump inhibitors to prevent stress ulcer formation and bleeding. On the first day post-surgery, she had normal gastrointestinal (GI) endoscopy findings. On the second day post-surgery, abdominal computed tomography revealed a retroperitoneal hematoma. Notably, 14 days post-surgery, massive GI bleeding occurred, and GI endoscopy identified an almost perforated ulcer in the bulbar and descending duodenum. OUTCOMES: The patient died on day 15 after surgery. LESSONS: Duodenal ulceration and bleeding might occur following a retroperitoneal hematoma in patients treated with nephrectomy. Timely intervention may prevent duodenal ulcers and complications, and thus could be a promising life-saving intercession.

Peptic ulcer characteristics in oral opium and non-opium user patients with upper gastrointestinal bleeding.

BACKGROUND/AIMS: Upper gastrointestinal bleeding (UGIB) is a frequent medical issue. The primary risk factors for bleeding peptic ulcers are Helicobacter pylori infection and non-steroidal anti-inflammatory drugs. The association between acute gastric/duodenal ulcer and opium use has been previously proposed; however, there is no available data on endoscopic findings of patients with acute UGIB who use opium. MATERIALS AND METHODS: In the present descriptive cross-sectional study, endoscopic data of 50 consecutive patients with oral opium use and 50 consecutive patients without any opium use who were admitted for UGIB were recorded. The size (5-10 mm, 11-20 mm, or more than 20 mm), number (single, double, or multiple), and location of the ulcers (esophagus, gastric corpus including the fundus and body, antrum, angulus, or duodenum) were examined by endoscopy in both groups. RESULTS: Three or more ulcers were observed in 46% and 16% of patients with oral opium use and without opium use, respectively (P-value = 0.001). The rate of giant ulcers (> 20 mm) was significantly higher in patients who used oral opium (40% vs. 12%; P-value = 0.007). Esophageal ulcers were also more common in oral opium users (30%) than non-users (8%) with UGIB (P-value = 0.01). Nevertheless, the location of the ulcers between the two groups generally was not statistically different. CONCLUSIONS: This study has demonstrated that multiple, large peptic ulcers in GIB are potential complications of oral opium use. This could aid the needed modifications in the treatment protocol for these patients.

Successful endoscopic combined with endovascular haemostasis of a ruptured pseudoaneurysm of the duodenal bulb: A case report.

Pseudoaneurysms are uncommon but their rupture and bleeding can lead to serious complications and be fatal. We present here a case of a man in his late 70s who was transferred to our hospital with persistent gastrointestinal bleeding. One month prior to his admission, he had undergone surgery for a fracture to his left knee. Endoscopic examination found pulsating blood vessels on a duodenal ulcer, which suddenly ruptured and caused significant bleeding. Immediate endoscopic haemostasis was administered and the bleeding decreased. Considering the high rate of rebleeding that may occur with a pseudoaneurysm, the patient underwent interventional radiology that culminated in a diagnosis of a pseudoaneurysm originating from gastroduodenal artery (GDA); successful embolization was achieved. Tests showed that the patient had Helicobacter pylori infection. We hypothesised that the H. pylori infection had led to the occurrence of the duodenal bulb ulcer, and the patient's left knee fracture and surgery a month previously had contributed to this predisposition for a pseudoaneurysm.

Decision-Utility Analysis of Empiric Treatment Versus Test and Treat Strategies for Helicobacter pylori in Patients With Duodenal Ulcer.

OBJECTIVES: The optimal strategy of Helicobacter pylori eradication in patients with duodenal ulcer is unclear. In this study, we aimed to compare the utility and the ulcer recurrence rate using the empiric treatment versus the test and treat strategies in patients with uncomplicated duodenal ulcer. METHODS: A decision-utility analysis was performed using a decision tree. The empiric treatment strategy was compared with the test and treat strategy. The probabilities of recurrent ulcers were determined and utilities of the 2 strategies were compared using the quality-adjusted life-year (QALY). Sensitivity analysis was performed to evaluate for model robustness. RESULTS: The probability of recurrent ulcer with the empiric strategy was 10.5%. The probabilities of recurrent ulcer with the test and treat strategy were 12.6%, 14.7%, 16.8%, and 17.9% based on 95%, 90%, 85%, and 80% sensitivity for histopathology, respectively. At the 95% estimate for the sensitivity of histopathology, the empiric strategy was associated with greater QALY compared with the test and treat strategy, 0.9875 versus 0.9853. The empiric treatment strategy was associated with greater QALY at extreme values for the estimates in our model. CONCLUSIONS: The empiric treatment strategy is associated with 2.1% to 7.4% lower recurrence rate for a range of test sensitivity between 95% and 80%, and results in greater QALY compared with the test and treat strategy.

Infectious pathogens and risk of esophageal, gastric and duodenal cancers and ulcers in China: A case-cohort study.

Infection by certain pathogens is associated with cancer development. We conducted a case-cohort study of ~2500 incident cases of esophageal, gastric and duodenal cancer, and gastric and duodenal ulcer and a randomly selected subcohort of ~2000 individuals within the China Kadoorie Biobank study of >0.5 million adults. We used a bead-based multiplex serology assay to measure antibodies against 19 pathogens (total 43 antigens) in baseline plasma samples. Associations between pathogens and antigen-specific antibodies with risks of site-specific cancers and ulcers were assessed using Cox regression fitted using the Prentice pseudo-partial likelihood. Seroprevalence varied for different pathogens, from 0.7% for Hepatitis C virus (HCV) to 99.8% for Epstein-Barr virus (EBV) in the subcohort. Compared to participants seronegative for the corresponding pathogen, Helicobacter pylori seropositivity was associated with a higher risk of non-cardia (adjusted hazard ratio [HR] 2.73 [95% CI: 2.09-3.58]) and cardia (1.67 [1.18-2.38]) gastric cancer and duodenal ulcer (2.71 [1.79-4.08]). HCV was associated with a higher risk of duodenal cancer (6.23 [1.52-25.62]) and Hepatitis B virus was associated with higher risk of duodenal ulcer (1.46 [1.04-2.05]). There were some associations of antibodies again some herpesviruses and human papillomaviruses with risks of gastrointestinal cancers and ulcers but these should be interpreted with caution. This first study of multiple pathogens with risk of gastrointestinal cancers and ulcers demonstrated that several pathogens are associated with risks of gastrointestinal cancers and ulcers. This will inform future investigations into the role of infection in the etiology of these diseases.

Management of post-ERCP duodenal perforations: experience at Hospital Juárez de México.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) is an endoscopic study in which the duodenum is observed laterally, and the bile duct is instrumented. There are several indications and complications in the procedure. OBJECTIVE: To determine the incidence of duodenal perforations, using the Stapfer classification in the Hospital Juárez de Mexico over a period of 5 years, as well as the management implemented in such cases. METHOD: The study was carried out at the Hospital Juárez de Mexico of the Ministry of Health. All patients who underwent ERCP between January 1, 2017, to May 30, 2022 were included. RESULTS: 485 ERCP were performed in the study period. Incidence of 1.6% post-ERCP duodenal perforation. The average age of the subjects 56.37 years. In-hospital stay of post-ERCP perforations averaged 9.37 days. The time of the endoscopic study at the time of the surgical procedure is 10 h on average. CONCLUSIONS: Post-ERCP duodenal perforation is a complication that occurs with a low incidence, it tends to increase the number of days of in-hospital stay and increases morbimortality of patients; therefore, it is important to be always alert.

ANTECEDENTES: La colangiopancreatografía retrógrada endoscópica (CPRE) es un estudio endoscópico en el cual se observa lateralmente el duodeno y se instrumenta la vía biliar. Existen diversas indicaciones y complicaciones en el procedimiento. OBJETIVO: Determinar la incidencia de perforaciones duodenales utilizando la clasificación Stapfer para ubicación anatómica en el Hospital Juárez de México en un periodo de 5 años, así como el manejo implementado en dichos casos. MÉTODO: El estudio se realizó en el Hospital Juárez de México de la Secretaría de Salud. Se incluyeron todos los pacientes sometidos a CPRE entre el 1 de enero de 2017 y el 30 de mayo de 2022. RESULTADOS: Se realizaron 485 CPRE en el periodo de estudio. Hubo una incidencia del 1.6% de perforación duodenal post-CPRE. El promedio de edad de los sujetos fue de 56.37 años. La estancia hospitalaria de los pacientes con perforación post-CPRE fue en promedio de 9.37 días. El tiempo del estudio endoscópico al momento de realizar el procedimiento quirúrgico fue de 10 h en promedio. CONCLUSIONES: La perforación duodenal post-CPRE es una complicación que ocurre con una baja incidencia, suele aumentar los días de estancia intrahospitalaria y aumenta la morbimortalidad de los pacientes, y por ello es importante estar siempre alerta.

Rare Cause of Gastrointestinal Bleeding: A Case Report of Pancreatic Arteriovenous Malformation.

BACKGROUND Arteriovenous malformation is an unusual cause of gastrointestinal bleeding, particularly in the pancreas. A definitive treatment strategy is not yet established. CASE REPORT We present the case of a 37-year-old man with underlying hypertension and no significant family history who presented with a 3-month history of intermittent epigastric pains and unintentional weight loss of 5 kg in 2 months. The upper endoscopy showed a large duodenal ulcer, which was uncontrolled with a standard dose of proton pump inhibitors. An abdominal computed tomography scan with contrast was indicated and revealed an enhanced mass of 2.5×3.5×4 cm in size, located on the second and third parts of the duodenum and head of the pancreas, indicating an arteriovenous malformation. On day 10 of hospitalization, the patient suddenly had melena and a drop of hemoglobin level to 5.6 g/dL; angiography intervention was successful to control the bleeding. However, gastrointestinal bleeding recurred after 2 weeks, and the patient successfully underwent a Whipple procedure. CONCLUSIONS The diagnosis and therapeutic management of arteriovenous malformations are uniquely challenging; therefore, pancreatic arteriovenous malformations should be listed on the differential diagnosis, particularly in those cases with non-healing and large duodenal ulcers. Otherwise, early imaging modalities should be performed to confirm the diagnosis. In particular, angiography can temporarily control bleeding before proceeding with more definitive therapy.

East Asian-specific and cross-ancestry genome-wide meta-analyses provide mechanistic insights into peptic ulcer disease.

Peptic ulcer disease (PUD) refers to acid-induced injury of the digestive tract, occurring mainly in the stomach (gastric ulcer (GU)) or duodenum (duodenal ulcer (DU)). In the present study, we conducted a large-scale, cross-ancestry meta-analysis of PUD combining genome-wide association studies with Japanese and European studies (52,032 cases and 905,344 controls), and discovered 25 new loci highly concordant across ancestries. An examination of GU and DU genetic architecture demonstrated that GUs shared the same risk loci as DUs, although with smaller genetic effect sizes and higher polygenicity than DUs, indicating higher heterogeneity of GUs. Helicobacter pylori (HP)-stratified analysis found an HP-related host genetic locus. Integrative analyses using bulk and single-cell transcriptome profiles highlighted the genetic factors of PUD being enriched in the highly expressed genes in stomach tissues, especially in somatostatin-producing D cells. Our results provide genetic evidence that gastrointestinal cell differentiations and hormone regulations are critical in PUD etiology.

Invasive Group G Streptococcal Infection Complicated by Posterior Reversible Encephalopathy Syndrome: A Case Report.

BACKGROUND Group G streptococcus (GGS) infection is reported to have invasive pathogenicity similar to that of group A streptococcus (GAS) infection, causing a strong systemic inflammatory response with bacteremia and various complications. Herein, we report a case of posterior reversible encephalopathy syndrome (PRES) as a rare complication of a GGS infection. CASE REPORT An 89-year-old Japanese man presented to our hospital with gastrointestinal bleeding and shoulder pain. Close examination revealed a refractory duodenal ulcer (DU) with disseminated intravascular coagulation and soft tissue infection of the right arm, which was found to be caused by GGS. A hemorrhagic tendency due to disseminated intravascular coagulation made it difficult to achieve hemostasis, leading to repeated blood transfusions. Although remission of both the DU and infection was achieved with treatment, impairment of swallowing function and vision subsequently appeared. Magnetic resonance imaging revealed hyperintense lesions with elevated apparent diffusion coefficient (ADC) values on T2-weighted imaging (T2WI), fluid-attenuated inversion recovery (FLAIR), and diffusion-weighted imaging (DWI). The patient was diagnosed with PRES, which did not improve even after discharge on day 118. CONCLUSIONS GGS infection developed with refractory duodenal ulcer bleeding, resulting in PRES with irreversible sequelae. The occurrence of PRES, which may be a rare complication of GGS infection, should be considered when central nervous system manifestations are observed in case of invasive streptococcal infection with a systemic inflammatory response.

Duodenal ulcer bleeding from a branch of the middle colic artery: A case report.

RATIONALE: Duodenal ulcer bleeding is a potentially life-threatening condition commonly caused by the erosion of the duodenal arteries. PATIENT CONCERNS: A 55-year-old male was referred to our hospital with abdominal pain for the past 3 days. Contrast-enhanced computed tomography of the abdomen revealed wall thickening in the descending part of the duodenum and a cystic lesion (27 × 19 mm) contiguous with the duodenum, with an accumulation of fluid. An esophagogastroduodenoscopy showed the significantly stenotic duodenum, which prevented passage of the endoscope and evaluation of the main lesion. Based on these findings, duodenal ulcer perforation and concomitant abscess formation were suspected. Two days after admission, he had massive hematochezia with bloody drainage from the nasogastric tube. DIAGNOSES: Emergency angiography revealed duodenal ulcer bleeding from the gastroduodenal artery and the branch artery of the inferior pancreaticoduodenal artery and middle colic artery (MCA). INTERVENTIONS: The patient was treated with transcatheter arterial embolization (TAE) of the gastroduodenal artery, the branch vessel of the inferior pancreaticoduodenal artery, and the main trunk of the MCA. OUTCOMES: Hemostasis was achieved with TAE. The patient recovered uneventfully and undergone a gastro-jejunal bypass surgery for the duodenal stenosis 2 weeks after TAE. He was discharged without any abnormal complaints on postoperative day 12. LESSONS: We have experienced a rare case of duodenal ulcer bleeding from a branch of the MCA. In patients with refractory upper gastrointestinal bleeding, careful evaluation of bleeding sites is recommended considering unexpected culprit vessels.

Concurrent laparoscopic highly selective vagotomy with closure of duodenal ulcer perforations show good clinical results as primary repair alone.

OBJECTIVE: To compare clinical and operative results between laparoscopic primary repair (LPR) alone and LPR with highly selective vagotomy (LPR-HSV) in patients with duodenal ulcer perforation. METHODS: Clinical data from patients who underwent either LPR or LPR-HSV by resecting both sides of the neurovascular bundle using an ultrasonic or bipolar electrosurgical device for duodenal ulcer perforations, between 2010 and 2020, were retrospectively collected. Between-group differences in continuous and categorical variables were statistically analysed. RESULTS: Data from 184 patients (mean age, 49.6 years), who underwent either LPR (n = 132) or LPR-HSV (n = 52) were included. The mean operation time was significantly longer in the LPR-HSV group (116.5 ± 39.8 min) than in the LPR group (91.2 ± 33.3 min). Hospital stay was significantly shorter in the LPR-HSV group (8.6 ± 2.6 days) versus the LPR group (11.3 ± 7.1 days). The mean postoperative day of starting soft fluid diet was also significantly shorter in the LPR-HSV group (4.5 ± 1.4 days) than in the LPR group (5.6 ± 4 days). No between-group difference in morbidity rate was observed. The learning curve of the HSV procedure showed a stable procedure time after 10 operations. CONCLUSIONS: LPR with HSV may be a safe and feasible procedure for selective cases who are at high risk for ulcer recurrence.

Bleeding due to successive duodenal and rectal ulcers in an 81-year-old patient with severe COVID-19: a case report.

BACKGROUND: In the early stages of the coronavirus disease 2019 (COVID-19) outbreak, the most widely recognised symptoms of the disease were fever, cough, shortness of breath, myalgia, and fatigue. However, in addition to these symptoms, COVID-19 can cause systemic symptoms outside the lungs. Older patients with severe COVID-19 often require admission to the intensive care unit (ICU). Acute rectal ulcer bleeding, characterised by painless, profuse haematochezia, caused by solitary or multiple rectal ulcers, is one of the main causes of severe haematochezia in patients with COVID-19 in the ICU. However, recurrent duodenal ulcer bleeding followed by rectal ulcer bleeding has not previously been reported in older patients during ICU treatment for severe COVID-19. CASES PRESENTATION: Herein, we report the case of an 81-year-old woman admitted to the emergency department due to severe COVID-19 and transferred to the ICU 2 days later for treatment. During treatment in the ICU, the patient developed recurrent duodenal ulcer bleeding and underwent endoscopic electrocoagulation haemostasis and gastroduodenal artery embolisation. However, the night after the final haemostatic operation, due to rectal ulcer bleeding, the patient discharged bloody stools intermittently, which was effectively controlled using endoscopic electrocoagulation, topical medication, blood transfusion, and haemostatic drugs. CONCLUSIONS: To the best of our knowledge, this is the first report of duodenal ulcer bleeding followed by rectal ulcer bleeding in an older patient with severe COVID-19 infection. This report creates awareness for clinicians about the multiple and complex gastrointestinal symptoms that may occur during COVID-19 treatment.

The use of magnet-controlled capsule endoscopy as the initial diagnostic tool in patients with acute upper gastrointestinal bleeding.

BACKGROUND: The latest magnet-controlled capsule endoscopy (MCCE) system can examine the water-distended stomach, duodenum, and the small bowel. We assessed the use of MCCE as the first diagnostic tool in patients with acute upper gastrointestinal bleeding (AUGIB). METHODS: This was a prospective cohort study that enrolled patients admitted with AUGIB from two teaching hospitals. Patients underwent MCCE as the initial diagnostic modality. Our primary endpoint was the diagnostic yield of MCCE. The subsequent care of these patients was guided by MCCE findings. RESULTS: Of 100 enrolled patients, 99 (mean age 54 years, 70.7% men) with a median Glasgow-Blatchford score of 6 (IQR 3-9) underwent MCCE. In three patients, MCCE found active bleeding (two duodenal ulcers and Dieulafoy's lesion). The overall diagnostic yield of MCCE was 95.8% (92 lesions in 96 patients); five in the esophagus (Mallory Weiss tears 2, varices 1, and esophagitis 2), 51 in the stomach (gastric erosions 26, gastric ulcers 14, cancer 3, GIST 3, gastric polyps 3, antral vascular ectasia 1,angiodysplasia 1), 32 in the duodenum (ulcers 28, erosions 3, polyp 1), and four in the small bowel (ulcers 2, an erosion with a nonbleeding vessel 1, Meckel's diverticulum 1). Fifty-two (52.5%) patients were discharged without endoscopy. Forty-five (45.5%) patients underwent inpatient esophagogastroduodenoscopy (EGD), which found an antral ulcer and six duodenal ulcers in addition. CONCLUSIONS: In stable patients with AUGIB, MCCE can be used as a diagnostic tool. EGD should follow in patients with an inadequate view of the duodenum.

Bulbar and post-bulbar duodenal ulcers: characteristics based on location.

OBJECTIVES: Most research on duodenal ulcers has focused on bulbar ulcers; details on post-bulbar ulcers remain largely unknown. This study was conducted to determine the characteristics of patients with post-bulbar duodenal ulcers depending on their location. METHODS AND MATERIALS: We conducted a retrospective study of hospitalized patients newly diagnosed with duodenal ulcers on endoscopy at a tertiary referral center in Japan between April 2004 and March 2019. Five hundred fifty-one patients diagnosed with duodenal ulcers were extracted for analysis. RESULTS: Ulcers were observed only in the bulbus in 383 cases, only in the post-bulbar duodenum in 82 cases, and were co-existing in both areas in 86 cases. The Bulbar group had less comorbidities and was more likely to have atrophic gastritis, while the Post-bulbar and Co-existing groups were more likely to be admitted for non-gastrointestinal conditions. Regular acid suppressant use was more common in the post-bulbar group than in the Bulbar group. Bulbar ulcers were associated with a shorter length of stay relative to post-bulbar and co-existing ulcers, but ulcer location was not an independent predictor of length of stay. Patients with co-existing bulbar and post-bulbar ulcers have characteristics similar to those with post-bulbar ulcers alone. CONCLUSION: Patients with post-bulbar ulcers and those with co-existing bulbar and post-bulbar ulcers have different characteristics and outcomes relative to patients with bulbar ulcers.

Duodenal ulcer perforation and its consequences.

Duodenal ulcer perforation, a frequent surgical emergency, needs simple closure with indirect Graham's Omentopexy which is effective with excellent results in majority of cases despite patients' late presentation. The objective of the study was to determine the frequency of postoperative complications of perforated duodenal ulcer, conducted in the Surgery Department, Jinnah Postgraduate Medical Centre, Karachi, from March 20, 2018 to September 20, 2018. The study was a descriptive case series of 108 patients of both genders with perforated duodenal ulcer > 1 week old with ASA score I & II. Patients with trauma and comorbidities were excluded. The patients underwent laparotomy and peritoneal toilet, and after noting the site of perforation indirect Graham's Omentopexy was performed. Complications like duodenal fistula, peritonitis, and paralytic ileus, and patient's death within 10 days of surgery were noted. Age ranged from 18 to 50 years with mean age of 35.027±5.13 years, mean weight 71.120±12.77 kg, mean height 1.541 ±0.09 metres, mean BMI 29.975±4.99 kg/m2, and the mean duration of complaint was 4.194±1.30 weeks. Male predominance in 75 (69.4%) patients. Duodenal fistula was seen in 10 (9.3%) patients, peritonitis 12 (11.1%), paralytic ileus 14 (13%) and mortality was in 11 (10.2%) patients.

Pancreas-sparing partial duodenectomy as an alternative to emergency pancreaticoduodenectomy for a major duodenal perforation: a case report.

A 71-year-old woman underwent endoscopic submucosal dissection for early duodenal cancer at the second portion of the duodenum and developed acute peritonitis due to delayed duodenal perforation. Emergency laparotomy was performed. A huge perforation formed at the descending duodenum without ampulla involvement. Pancreas-sparing partial duodenectomy (PPD) with gastrojejunostomy was performed (250 min operative time) with 50 mL of intraoperative blood loss. She required intensive care for 3 days and was discharged on postoperative day 21 with no severe complications. Emergency treatment for a major duodenal injury or perforation remains challenging because of high morbidity and mortality. An appropriate treatment should be considered according to the nature of the defect. Although PPD is an acceptable procedure for patients with a duodenal neoplasm, its use in emergency surgery is rarely reported. PPD is more reliable than primary repair or anastomosis using a jejunal wall, and less invasive than pancreaticoduodenectomy, for emergency treatment. We performed PPD in this patient because the duodenal perforation was too large to reconstruct and did not involve the ampulla. PPD can be a safe and feasible alternative surgical procedure to pancreaticoduodenectomy for a major duodenal perforation, especially in patients with a duodenal perforation that does not involve the ampulla.