1. 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

2. Background 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.

3. 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

4. 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

5. 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.

6. 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.

7. 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

8. 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

9. 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

10. Results A 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)

11. Drug consumption

12. Symptoms

13. Biliary reflux in patients with gastric resection

14. Incidence of H. pylori infection in patients with gastric resection

15. Endoscopic findings

16. Risk factors for ulcer Patients with PUD (n=10) Patients with no endoscopic lesions (n=26) p n(%) Gastrotoxic medication8 (80%)10 (38,4%)0,048 H. pylori infection1(1%)5 (19,2%)NS Biliary reflux9 (90%)15 (57,6%)NS Premalignant histological lesions (gastric atrophy/intestinal metaplasia) 3 (30%)5 (19,2%) NS Male gender8 (80%)17 (65,3%)NS Bile reflux7 (70%) 28 (50%)NS

17. 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.

18. Thank you for your attention!