Exploring the intersection: Peptic ulcers and hemolysis-Unraveling the complex relationship.

This paper investigates the intriguing relationship between peptic ulcers and hemolysis, 2 seemingly distinct medical conditions, aiming to unravel their potential interconnections and clinical implications. While traditionally studied in isolation, recent evidence has surfaced suggesting possible links and shared mechanisms between these conditions. This paper explores the underlying pathophysiological associations, shared risk factors, diagnostic challenges, management strategies, and implications for clinical practice and health policy. The interplay between peptic ulcers and hemolysis stems from shared inflammatory pathways, notably attributed to Helicobacter pylori infection in peptic ulcers, which might trigger systemic inflammatory responses contributing to hemolysis. Common risk factors including genetic predispositions, autoimmune disorders, and medication use (such as nonsteroidal anti-inflammatory drugs) are implicated in the development of both peptic ulcers and hemolytic conditions, suggesting a potential convergence of these disorders in affected individuals. Diagnostic considerations pose challenges, as overlapping symptoms and laboratory findings may complicate accurate differentiation between peptic ulcers and hemolysis. Recognizing the potential interplay between peptic ulcers and hemolysis holds significant implications for clinical practice and health policy. Streamlining diagnostic algorithms, fostering interdisciplinary collaborations, and developing tailored guidelines are pivotal in optimizing patient care. Continued research efforts, collaborative clinical approaches, and informed health policies are essential in advancing our understanding and enhancing patient care for individuals navigating the intersection of peptic ulcers and hemolysis.

Endoscopic Diagnosis, Grading, and Treatment of Bleeding Peptic Ulcer Disease.

Peptic ulcer bleeding is a major cause for hospital admissions and has a significant mortality. Endoscopic interventions reduce the risk of rebleeding in high-risk patients and several options are available including injection therapies, thermal therapies, mechanical clips, hemostatic sprays, and endoscopic suturing. Proton-pump inhibitors and Helicobacter pylori treatment are important adjuncts to endoscopic therapy. Endoscopic therapy is indicated in Forrest 1a, 1b, and 2a lesions. Patients with Forrest 2b lesions may do well with proton-pump inhibitor therapy alone but can also be managed by removal of the clot and targeting endoscopic therapy to the underlying lesion.

Nonsurgical risk factors for marginal ulcer following Roux-en-Y gastric bypass for obesity: a systematic review and meta-analysis of 14 cohort studies.

BACKGROUNDS: Marginal ulcer (MU) is a common complication of Roux-en-Y Gastric Bypass (RYGB). The primary goal of this meta-analysis was to identify potential risk factors for MU post-RYGB. METHODS: A comprehensive literature search was conducted on four databases (PubMed, Embase, Web of Science, and the Cochrane Library) to identify articles published from inception to 23 May 2023 that reported risk factors linked to ulcer occurrence post-RYGB. Hazard Ratio (HR) and Odds Ratio (OR) with respective 95% CI were calculated to estimate the impact of selected risk factors on MU. The risk factors were evaluated through multivariate analyses. The estimated risk factors were subjected to a random-effects model. Subgroup analysis based on study baseline characteristics and leave-one-out sensitivity analysis were also performed to investigate the potential sources of heterogeneity and assess the robustness of the findings. RESULT: Herein, 14 observational studies involving 77 250 patients were included. Diabetes, smoking, and steroid use were identified to be risk factors of MU, with pooled ORs of (1.812; 95% CI: 1.226-2.676; P =0.003), (3.491; 95% CI: 2.204-5.531; P< 0.001), and (2.804; 95% CI: 1.383-5.685; P =0.004), respectively. Other risk factors, such as alcohol consumption, male sex, and PPI use, were deemed not significant due to differences in data acquisition and effect estimates. CONCLUSION: Diabetes, smoking, and steroid use were identified as independent risk factors of MU. Enhancing awareness of these identified risk factors will lead to more effective preoperative prevention and targeted postoperative interventions for patients undergoing RYGB.

Assessing peptic ulcer risk with the HAMPROW score in the general Chinese population.

The timely identification of individuals at high risk for peptic ulcers (PUs) is vital in preventing gastrointestinal bleeding after antiplatelet therapy. This study was designed to determine PU risk factors and develop a risk assessment model for PU detection in the general Chinese population. In a prospective dataset, clinical data from individuals undergoing gastroscopic evaluation between April 2019 and May 2022 were recorded. PUs were defined as mucosal defects exceeding 5 mm confirmed via gastroscopy. Participants were categorized into development (April 2019 to April 2021) and validation (May 2021 to May 2022) sets based on chronological order. LASSO-derived logistic regression analysis was employed to create a score, which was further validated via temporal validation. A total of 902 patients were ultimately enrolled, 204 (22.6%) of whom had PUs based on endoscopic findings. In the development cohort (n = 631), seven independent risk factors emerged: male sex (OR = 2.35, P = 0.002), white blood cell (WBC) count (OR = 1.16, P = 0.010), red blood cell (RBC) count (OR = 0.49, P < 0.001), globulin level (OR = 0.92, P = 0.004), albumin level (OR = 0.94, P = 0.020), pepsinogen I (PGI) level (OR = 1.01, P < 0.001), and positive Helicobacter pylori (HP) antibody (OR = 2.50, P < 0.001). Using these factors, a nomogram (HAMPROW score [hazard ratio (HP) antibody, albumin, male, PGI, RBC, globulin, and WBC]) was developed for individual PU prediction. The ability of the HAMPROW score to predict survival was confirmed with AUCs of 0.854 (95% CI 0.816-0.891) and 0.833 (95% CI 0.771-0.895) in the development and validation sets, respectively. In conclusion, the HAMPROW score can be used to screen for PUs effectively in the general Chinese population, facilitating personalized early detection of high risk of gastrointestinal bleeding before antiplatelet therapy.

The Helicobacter pylori cag pathogenicity island as a determinant of gastric cancer risk.

Helicobacter pylori strains can be broadly classified into two groups based on whether they contain or lack a chromosomal region known as the cag pathogenicity island (cag PAI). Colonization of the human stomach with cag PAI-positive strains is associated with an increased risk of gastric cancer and peptic ulcer disease, compared to colonization with cag PAI-negative strains. The cag PAI encodes a secreted effector protein (CagA) and components of a type IV secretion system (Cag T4SS) that delivers CagA and non-protein substrates into host cells. Animal model experiments indicate that CagA and the Cag T4SS stimulate a gastric mucosal inflammatory response and contribute to the development of gastric cancer. In this review, we discuss recent studies defining structural and functional features of CagA and the Cag T4SS and mechanisms by which H. pylori strains containing the cag PAI promote the development of gastric cancer and peptic ulcer disease.

The efficacy and safety of fexuprazan in treating erosive esophagitis: a phase III, randomized, double-blind, multicenter study.

BACKGROUND AND AIM: Fexuprazan is a novel potassium-competitive acid blocker (P-CAB). This study aimed to explore the noninferior efficacy and safety of fexuprazan to esomeprazole in treating erosive esophagitis (EE). METHODS: This was a phase III, randomized, double-blind multicenter study. Patients with endoscopically confirmed EE were randomized to receive fexuprazan 40 mg or esomeprazole 40 mg once a daily for 4-8 weeks. The healing rates of EE, symptom response, GERD-health-related quality life (GERD-HRQL), and treatment-emergent adverse events (TEAEs) were compared between fexuprazan group and esomeprazole group. RESULTS: A total of 332 subjects were included in full analysis set (FAS) and 311 in per-protocol set (PPS). The healing rates of fexuprazan and esomeprazole groups at 8 weeks were 88.5% (146/165) and 89.0% (145/163), respectively, in FAS and 97.3% (145/149) and 97.9% (143/146), respectively, in PPS. Noninferiority of fexuprazan compared with esomeprazole according to EE healing rates at 8 weeks was demonstrated in both FAS and PPS analysis. No significant difference was found between groups in EE healing rates at 4 weeks, symptom responses, and changes of GERD-HRQL. The incidence of drug-related AEs was 19.4% (32/165) in fexuprazan arm and 19.6% (32/163) in esomeprazole arm. CONCLUSION: This study demonstrated noninferior efficacy of fexuprazan to esomeprazole in treating EE. The incidence of TEAEs was similar between fexuprazan and esomeprazole. Trial registration number NCT05813561.

Medical therapy has similar hemostatic efficacy with endoscopic treatment for PUB patients with adherent clot (FIIb ulcers).

BACKGROUND: Currently, there is no clear consensus on whether medical treatment or endoscopic treatment should be used for peptic ulcer bleeding patients with adherent clot. The aim of this study is to investigate the hemostatic effects of medical treatment, single endoscopic treatment, and combination endoscopic treatment for peptic ulcer bleeding (PUB) patients with adherent clot. METHODS: We retrospectively analyzed PUB patients with adherent clot who underwent endoscopic examination or treatment in our center from March 2014 to January 2023 and received intravenous administration of proton pump inhibitors. Patients were divided into medical treatment (MT) group, single endoscopic treatment (ST) group, and combined endoscopic treatment (CT) group. Subsequently, inverse probability of treatment weighting (IPTW) was performed to calculate the rebleeding rate. RESULTS: A total of 605 eligible patients were included in this study. After IPTW, the rebleeding rate in the MT group on days 3, 7, 14, and 30 were 13.3 (7.3), 14.2 (7.8), 14.5 (7.9), and 14.5 (7.9), respectively; the rebleeding rates in the ST group were 17.4 (5.1), 20.8 (6.1), 20.8 (6.1), and 20.8 (6.1), respectively; the rebleeding rates in the CT group were 0.4 (0.9), 1.7 (3.3), 2.3 (4.5), and 2.3 (4.5), respectively. Although the rebleeding rate in the medical treatment group was higher, there was no significant difference among the three groups on days 3, 7, 14, and 30 (P = 0.132, 0.442, 0.552, and 0.552). CONCLUSIONS: Medical therapy has similar hemostatic efficacy with endoscopic treatment for PUB patients with adherent clot (FIIb ulcers). However, for patients with more risk factors and access to well-equipped endoscopy centers, endoscopic treatment may be considered. The choice of treatment approach should be based on the individual conditions of the patient, as well as other factors such as medical resources available.

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.

Diagnostic utility of CT angiography compared with endoscopy in patients with acute GI hemorrhage.

BACKGROUND AND AIMS: Because it is minimally invasive, CT angiography (CTA) has emerged as an attractive diagnostic tool for investigation of acute GI hemorrhage. METHODS: This study examined patients with acute GI bleeding who underwent CTA. RESULTS: CTA was the initial diagnostic examination in 177 patients, identifying upper and lower GI bleeding lesions in 16 and 27 patients, respectively. In 103 patients with an initial negative CTA, 78 had endoscopy (32 EGD and 46 colonoscopy/flexible sigmoidoscopy), of whom 52 (67%) had a bleeding lesion identified, including 23 with a high-risk bleeding lesion requiring therapy. Peptic ulcer disease and diverticular bleeding were the most commonly identified bleeding lesions. With endoscopy as a criterion standard, the sensitivity of CTA for the detection of a source of GI bleeding was 20%. CONCLUSIONS: CTA has very poor sensitivity for identification of a GI bleeding source or lesion, suggesting that CTA should not be used as an initial diagnostic test.

Factors influencing re-bleeding after trans-arterial embolization for endoscopically unmanageable peptic ulcer bleeding.

BACKGROUND/AIMS: Acute peptic ulcer bleeding is the most common cause of non-variceal upper gastrointestinal bleeding (NVUGIB). Endoscopic hemostasis is the standard treatment. However, various conditions complicate endoscopic hemostasis. Transarterial visceral embolization (TAE) may be helpful as a rescue therapy. This study aimed to investigate the factors associated with rebleeding after TAE. METHODS: We retrospectively investigated the records of 156 patients treated with TAE between January 2007 and December 2021. Rebleeding was defined as the presence of melena, hematemesis, or hematochezia, with a fall (>2.0 g/dl) in hemoglobin level or shock after TAE. The primary outcomes were rebleeding rate and 30-day mortality. RESULTS: Seventy patients with peptic ulcer bleeding were selected, and rebleeding within a month after TAE occurred in 15 patients (21.4%). Among the patients included in rebleeding group, significant increases were observed in the prevalence of thrombocytopenia (73.3% vs. 16.4%, p<.001) and ulcers >1 cm (93.3% vs 54.5%, p = .014). The mean AIMS65 (albumin, international normalized ratio, mental status, systolic blood pressure, age >65 years) score (2.3 vs 1.4, p = .009) was significantly higher in the rebleeding group. Multivariate logistic analysis revealed that thrombocytopenia (odds ratio 31.92, 95% confidence interval 6.24-270.6, p<.001) and larger ulcer size (odds ratio 27.19, 95% confidence interval 3.27-677.7, p=.010) significantly increased the risk of rebleeding after TAE. CONCLUSION: TAE was effective in the treatment of patients with high-risk peptic ulcer bleeding. AIMS65 score was a significant predictor of rebleeding after TAE, and thrombocytopenia and larger ulcer size increased the risk of rebleeding after TAE.

A pilot study of non-invasive diagnostic tools to detect Helicobacter pylori infection and peptic ulcer disease.

Helicobacter pylori (H. pylori) infection can lead to various digestive system diseases, making accurate diagnosis crucial. However, not all available tests are equally non-invasive and sensitive. This study aimed to compare the efficacy of non-invasive and invasive diagnostic tools for H. pylori infection and assess their correlation with esophagogastroduodenoscopic (EGD) findings. The study utilized the Campylobacter-Like Organism (CLO) test, serum anti-HP IgG blood test, and C-13-urea breath test (UBT) to diagnose H. pylori infection. A total of 100 patients with peptic ulcer symptoms, including 45 males and 55 females, were recruited for the study. Symptomatic patients between the ages of 20-70, eligible for EGD examination, were enrolled. Each diagnostic test and any combination of two positive tests were considered the reference standard and compared against the other diagnostic methods. Additionally, the relationship between these diagnostic tests and EGD findings was evaluated. Among the participants, 74.0% were diagnosed with peptic ulcer disease through EGD. The UBT demonstrated the highest Youden's index, ranging from 58 to 100%, against all the non-invasive tests. The IgG blood test displayed the highest sensitivity at 100%, with a specificity of 60-70%. On the other hand, the CLO test exhibited the highest specificity at 100% and a sensitivity of 50-85%. Furthermore, only the CLO test showed a significant association with esophageal ulcers (p-value = 0.01). The IgG blood test holds promise as a primary screening tool due to its exceptional sensitivity. While the UBT is relatively expensive, its non-invasive nature and high sensitivity and specificity make it a potential standalone diagnostic test for H. pylori infection. Moreover, the noteworthy negative correlation between the CLO test and esophageal ulcers provides evidence of the differing effects of H. pylori infection on antral-predominant and corpus-predominant gastritis.

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.

Comparison and validation of the Japanese score and other scoring systems in patients with peptic ulcer bleeding: A retrospective study.

Acute upper gastrointestinal bleeding (UGIB) is one of the most urgent medical conditions, with peptic ulcer bleeding (PUB) accounting for most gastrointestinal bleeding cases. The Japanese scoring system was developed to predict the probability of intervention in patients with UGIB, and it is more effective than other scoring systems, according to several studies. This study aimed to verify whether the Japanese scoring system is better than other scoring systems in predicting the probability of intervention when limited to PUB in patients with UGIB. We enrolled patients who presented with symptoms of UGIB and were diagnosed with peptic ulcers using endoscopy. The performances of the scoring systems in predicting patient outcomes were validated and compared using the receiver-operating characteristic curve analysis. Additionally, we used the chi-square test, Fisher exact test, and the t test to analyze the association between the patients characteristics and clinical outcomes. Of the 1228 patients diagnosed with peptic ulcers, 90.6% underwent endoscopy. rebleeding occurred in 12.5% of the patients, and 2.5% of the patients died within 30 days. The Japanese score was the most effective in predicting the need for endoscopic intervention for PUB. Sex, systolic blood pressure, hematemesis, syncope, blood urea nitrogen level, and the American Society of Anesthesiologists score were predictive factors for the probability of endoscopic intervention in patients with PUB. The Japanese score is an effective predictor of the probability of endoscopic intervention in patients with PUB.

Endoscopic Versus Conservative Therapy for Bleeding Peptic Ulcer with Adherent Clot: A Comprehensive Systematic Review and Meta-Analysis.

INTRODUCTION: Peptic ulcers with adherent clots are associated with a high-risk of rebleeding and mortality. However, the optimal management of bleeding ulcers with adherent clots remains unclear. We conducted this systematic review and meta-analysis to compare endoscopic therapy and conservative therapy to manage bleeding ulcers with adherent clots. METHODS: We systematically searched PubMed, Embase, and Web of Science databases through October 2022 to include all studies comparing the endoscopic and conservative therapeutic approaches for bleeding ulcers with adherent clots. Our primary outcome was rebleeding (overall and 30-day). The secondary outcomes were mortality (overall and 30-day), need for surgery, and length of hospital stay (LOS). The random-effects model was used to calculate the pooled odds ratios (OR) and mean differences (MD) with the corresponding confidence intervals (CI) for proportional and continuous variables, respectively. RESULTS: Eleven studies (9 RCTs) with 833 patients (431 received endoscopic therapy vs. 402 received conservative therapy) were included. Overall, endoscopic therapy was associated with lower overall rebleeding (OR 0.41, 95% CI 0.22-0.79, P = 0.007), 30-day rebleeding (OR 0.43, 95% CI 0.21-0.89, P = 0.002), overall mortality (OR 0.47, 95% CI 0.23-0.95, P = 0.04), 30-day mortality (OR 0.43, 95% CI 0.21-0.89, P = 0.002), need for surgery (OR 0.44, 95% CI 0.21-0.95, P = 0.04), and LOS (MD - 3.17 days, 95% CI - 4.14, - 2.19, P < 0.00001). However, subgroup analysis of randomized controlled trials (RCTs) showed no significant difference in overall mortality (OR 0.78, 95% CI 0.24-2.52, P = 0.68) between the two strategies, with numerically lower but statistically non-significant rates of overall rebleeding (7.2% vs. 18.5%, respectively; OR 0.42, 95% CI 0.17-1.05, P = 0.06), statistically lower rate of need for surgery (OR 0.28, 95% CI 0.08-0.96, P = 0.04) with endoscopic therapy compared to conservative therapy. CONCLUSIONS: Our meta-analysis demonstrates that endoscopic therapy was overall associated with lower rates of rebleeding (overall and 30-day), mortality (overall and 30-day), need for surgery, and LOS, compared to conservative therapy for the management of bleeding ulcers with adherent clots. However, subgroup analysis of RCTs showed that endoscopic therapy was associated with numerically lower but statistically non-significant rates of overall rebleeding and a statistically lower rate of need for surgery compared to conservative therapy with similar overall mortality rates. Combined treatment with thermal therapy and injection therapy was the most effective treatment modality in reducing rebleeding risk. Further large-scale RCTs are needed to validate our findings.