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The ulcer of gastric stump: a case-control study
Coordinators: Author: Roxana Spac
Dr.Anca Negovan
Drd. Monica Pantea Co-author: Dr Nina Sincu
Andreea Stoica
Adrian Stoica
Gavriela Radoiu
Background
Introduction
The need to perform gastrectomy in patients with peptic ulcer disease (PUD) has decreased since the discovery of Helicobacter pylori (H. pylori) and development of proton pump inhibitors (PPI), even among a population with high prevalence of H. pylori infection
Antisecretory drugs (especially PPI) are used to treat the majority of patients with ulcer disease
Nowadays, the main indicator for partial gastrectomy is failure of medical management of PUD, early detection of gastric cancer and bariatric surgery.
Chung W, et al. World J Gastroenterol 2012 July 7; 18(25): 3260-3266.
Background
The main reason for endoscopic follow-up in patients with gastrectomy is the risk for gastric stump cancer
Marginal ulcers are defined as ulceration around anastomosis following gastrectomy. It has been reported that the incidence of marginal ulcers varies from 0.6% to 16%
Although the etiology of marginal ulcers remains obscure, several mechanisms have been postulated (alkaline reflux, H. pylori infection, etc.)
Sacks BC, et al. Incidence of marginal ulcers and the use of absorbable anastomotic sutures in laparoscopic Roux-en-Y gastric bypass. Surg Obes Relat Dis 2006; 2: 11-16
Background
Until now, there are no convincing results, and the exact link between H. pylori and the development of marginal ulcers is unclear.
The role of gastrotoxic medication and bile reflux in ulcer occurrence on gastric stump has not been extensively studied
Objective
To study the effects of biliary reflux, H. pylori infection and use of gastrotoxic medication (non-steroidal anti-inflammatory drugs, NSAID, antiplatelet therapy) in ulcer occurrence among patients with partial gastric resection performed for peptic ulcer disease.
Materials and methods:
A consecutive series of patients with gastric resection for PUD, who underwent endoscopic examination between 2012-2014 for dyspeptic symptoms, were retrospectively analyzed.
We applied an interview and medical records of patients were studied in order to determine drug exposure and the presence of other diseases.
In all the patients enrolled we performed upper digestive endoscopy and at least two biopsies were taken and analyzed.
Materials and methods:
Biopsy specimens were fixed in formalin, embedded in paraffin and examined with hematoxylin-eosin staining, improved toluidine-blue staining and Giemsa staining
H. pylori infection was considered negative if H. pylori were absent from all biopsy sites and positive if at least one of histology tests was positive
The degree of mucosal inflammation, activity of H. pylori infection, glandular atrophy, intestinal metaplasia were classified into 4 grades according to the Updated Sydney System
Data collection:
age and gender
patients current and previous medical records
history of gastrointestinal diseases
digestive symptoms
current medication
upper digestive endoscopy findings
gastric biopsies
Inclusion criteria:
-patients with gastric resections for PUD, with upper digestive endoscopy between 2012-2014 irrespective of symptomatology
Exclusion criteria:
-patients with esophageal and gastric tumors detected on endoscopy.
-patients with severe medical associated condition (cirrhosis, congestive heart failure, etc.)
-patients with PPI therapy
ResultsA number of 58 patients (44 male, 14 female) with
gastric resection were included in our study
We compare demographical and clinical characteristics and risk factors for ulcer occurrence in the studied group ( n= 10 patients with ulcers) and in the control group (patients with no endoscopic lesions n=26)
Drug consumption
46%
35%
8%
6% 5%
No drugsAntiplatelet drugAnticoagulant drugNSAIDCorticosteroid drug
Symptoms
47%
7%
2%
9%2%
3%
2%
29%PainHeartburnNauseaFlatulenceHematemesisMelenaRegurgitationAsimptomatic
Biliary reflux in patients with gastric resection
Refl +, 32, (55%)
Relf -, 26, (45%)
Refl +Relf -
Incidence of H. pylori infection in patients with gastric resection
9, (16%)
49, (84%)
H pylori +H pylori -
Endoscopic findings
44%
11%
2%
26%
18%No lesionsEsophagitisPolypsErosive gastri-tisGastric ulcer
Risk factors for ulcer
Patients with PUD
(n=10)
Patients with no endoscopic lesions
(n=26)
p
n(%) n(%)
Gastrotoxic medication
8 (80%) 10 (38,4%) 0,048
H. pylori infection 1(1%) 5 (19,2%) NS
Biliary reflux 9 (90%) 15 (57,6%) NS
Premalignant histological lesions (gastric atrophy/intestinal metaplasia)
3 (30%) 5 (19,2%) NS
Male gender 8 (80%) 17 (65,3%) NS
Bile reflux 7 (70%) 28 (50%) NS
Conclusions:
Gastrotoxic medication (NSAIDs and antiplatelet drug consumption) was the most important risk factor for ulcer in patients with partial gastrectomy.
The frequency of H. pylori infection was lower in patients with partial gastrectomy and it is not correlated with ulcer on endoscopy
Biliary reflux does not seem to influence the ulcer occurrence in gastric stump in our population.
Thank you for your attention!