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68-Year-Old Man With Peptic Ulcer and Diarrhea

1997; Elsevier BV; Volume: 72; Issue: 9 Linguagem: Inglês

10.4065/72.9.879

1942-5546

Afonso Ribeiro, John R. Cangemi,

Potassium and Related Disorders

A 68-year-old man was admitted for evaluation of an 18-month history of progressive, severe diarrhea (10 to 20 watery bowel movements daily, including nocturnal episodes), which resulted in weight loss of 22.7 kg. The stools were described as watery with no blood, no oily material, and no foul smell. Associated complaints were abdominal cramping, severe urgency, and occasional fecal incontinence. Ingestion of food aggravated his symptoms and caused associated vague epigastric discomfort. His past medical history was remarkable for a perforated duodenal ulcer 24 years earlier, treated with a Billroth II anastomosis. Six years before the current assessment, an anastomotic ulcer necessitated revision of his previous Billroth II operation. Two years after that procedure, two parathyroid adenomas were removed. The patient denied use of any medication, including nonsteroidal anti-inflammatory drugs (NSAIDs). He consumed 1 pint of alcohol daily and had a 90-pack-year history of tobacco use. On physical examination, the patient appeared chronically ill with considerable muscle wasting. His pulse rate was 120 beats/min, systolic blood pressure was 70 mm Hg, and body temperature was 37°C. The heart and lung examinations were unremarkable. No masses and no hepatosplenomegaly were present, and no tenderness was noted on abdominal examination. The rectal examination showed normal findings. Examination of the extremities revealed 3+ peripheral edema to the midcalf. Results of initial laboratory studies revealed the following: hemoglobin 11.0 g/dL., platelets 232 × 109/L, prothrombin time 12.4 seconds, calcium 8.3 mg/dL., albumin 1.9 g/dL, normal results of liver tests, cholesterol 66 mg/dL, triglycerides 92 mg/dL, potassium 4.7 mEq/L, sodium 132 mEq/L, creatinine 0.6 mg/dL., and normal urinalysis. Esophagogastroduodenoscopy (EGD) was performed and showed changes from a prior Billroth II anastomosis and a large anastomotic ulcer, from which a biopsy specimen was obtained. 1.Which one of the following is the least likely cause of recurrent ulcer in this patient? a.Gastric cancerb.Gastric bezoarc.Incomplete vagotomyd.Antral G-cell hyperplasiae.Retained antrum syndrome EGD not only establishes the diagnosis but also may disclose the cause of the recurrent ulcer. The presence of an ulcer on the gastric side should alert one to the possibility of a malignant lesion. Patients who underwent partial gastrectomy more than 20 to 25 years ago may have a risk for gastric cancer that is fourfold to fivefold that in the general population. The risk begins to increase even 10 to 15 years after the initial operation.1Tersmette AC Giardiello FM Tytgat GN Offerhaus GJ Carcino-genesis after remote peptic ulcer surgery: the long-term prognosis of partial gastrectomy.Scand J Gastroenterol Suppl. 1995; 212: 96-99Crossref PubMed Scopus (35) Google Scholar Because the EGD did not reveal a bezoar in our patient, it is the least likely cause of the ulcer. It is easily identified on EGD and consists of concretions of foreign material (hair, vegetable fiber, medications) that either cause no symptoms or lead to a variety of complaints: early satiety, anorexia, nausea, vomiting, or bloating. In some patients, symptoms do not resolve after bezoars are removed; this result suggests that the symptoms may relate more to an underlying gastric motility disorder. Bezoars do not cause diarrhea as seen in our patient. Incomplete vagotomy is among the most common causes of postoperative recurrent ulcer. For assessment of this possibility, several tests have been used, including Congo red staining of the proximal gastric mucosa; if vagotomy is incomplete, the fundic mucosa will stain black.2Thirlby RC Postoperative recurrent ulcer.Gastroenterol Clin North Am. 1994 Jun; 23: 295-311PubMed Google Scholar Antral G-cell hyperplasia (pseudo-Zollinger-Ellison syndrome) and retained antrum are exceedingly rare causes of recurrent ulcer, but their presence cannot be ruled out on endoscopy. Both conditions will cause mildly increased serum gastrin on a secretin test (less than 100 pg/mL) and a substantial increase in response to a standard high-protein meal test. Patients with antral Gcell hyperplasia have an increased density or efficacy of antral G cells, which augments net secretion of gastrin. In contrast, patients with retained antrum after a Billroth II procedure have unrestrained gastrin secretion because the retained segment is not exposed to gastric acid; thus, the negative feedback loop is not activated.2Thirlby RC Postoperative recurrent ulcer.Gastroenterol Clin North Am. 1994 Jun; 23: 295-311PubMed Google Scholar Radionuclide scanning with technetium pertechnetate may have a role in detection of retained antral cuffs.3Cortot A Fleming CR Brown ML Go VL Malagelada JR Isolated retained antrum diagnosis by gastrin challenge tests and radioscintillation scanning.Dig Dis Sei. 1981; 26: 748-751Crossref PubMed Scopus (4) Google Scholar In all patients with recurrent ulcers, surreptitious use of aspirin or over-the-counter NSAIDs and Helicobacter pylori infection should be ruled out before other investigations are undertaken. The biopsy specimen from our patient was negative for cancer. Although most of the foregoing diagnostic possibilities can lead to ulcer recurrence, none of them should cause the degree of chronic diarrhea and protein malnutrition seen in our patient. Because of persistent diarrhea and malnutrition, no oral intake was allowed, and total parenteral nutrition was begun. 2.Which one of the following is the most likely cause of diarrhea in this patient? a.Bacterial overgrowthb.Zollinger-Ellison syndromec.Chronic pancreatitisd.Efferent loop syndromee.Dumping syndrome Although the overall rate of ulcer recurrence after a Billroth II operation is approximately 1 %, patients can still experience considerable morbidity over the years. The presence of a blind loop of bowel and decreased acid secretion in patients with a Billroth II anastomosis lead to an increased risk of bacterial overgrowth, which results in malabsorption and diarrhea.4Toskes PP Donaldson Jr, RM Enteric bacterial flora and bacterial overgrowth syndrome.in: Sleisenger MH Fordtran JS 5th ed. Gastrointestinal Disease: Pathophysiology, Diagnosis, Management. Vol 2. Saunders, Philadelphia1993: 1106-1118Google Scholar Deconjugation of bile acids by the increased enteric flora reduces the level of conjugated bile acids below the critical micellar concentration and causes steatorrhea. In addition, other factors, such as the release of bacterial metabolites, enhance stool osmolarity and cause direct damage to the intestinal mucosa, which also contributes to the pathogenesis of diarrhea. Because of our patient's history of recurrent peptic ulcer disease, Zollinger-Ellison syndrome should be included in the differential diagnosis. Zollinger Ellison syndrome is characterized by the triad of recurrent peptic ulcer disease, non-β islet cell tumor of the pancreas, and gastric acid hypersecretion. Although ulcers may develop in unusual sites such as the distal duodenum or upper jejunum, most ulcers occur in the first portion of the duodenum. Almost 10% of patients with gastrinomas have diarrhea as an initial manifestation. Several mechanisms are postulated to cause the diarrhea: increased production of gastric acid that inactivates pancreatic enzymes and leads to poor digestion of fat and protein, direct mucosal damage by the acidic environment, increased volume of acid secretion (several liters a day), and, finally, an increased gastrin level, which promotes decreased absorption of sodium and water and increased secretion of potassium by the small intestine.5DelValle J Yamada T Zollinger-Ellison syndrome.in: Yamada T 2nd ed. Textbook of Gastroenterology. Vol l. Lippincott, Philadelphia1995: 1430-1445Google Scholar Chronic pancreatitis should also be part of the differential diagnosis in our patient because of the history of alcohol use. The absence of either diabetes mellitus or a heavily calcified pancreas on abdominal roentgenograms or computed tomographic scans should not lead one to disregard this diagnosis. Efferent loop syndrome and dumping are classic complications of a Billroth II procedure. The efferent loop syndrome usually manifests with diffuse abdominal pain, nausea, and bilious vomiting; the onset may occur months to years after the operation. It is related to partial or complete mechanical obstruction of the intestine near the gastrojejunostomy site, and the diagnosis is made by an upper gastrointestinal series, which will reveal poor or absent emptying of the stomach. Because our patient did not have any of these symptoms, this diagnosis is unlikely. The dumping syndrome is associated with explosive diarrhea due to early emptying of hyperosmolar content into the small bowel as well as cramping, nausea, and vomiting.20 The long interval (more than 20 years) between the Billroth II operation and the onset of diarrhea makes this diagnosis unlikely in our patient. Moreover, the dumping syndrome does not cause nocturnal diarrhea, as experienced by our patient, but only postprandial diarrhea. In summary, Zollinger-Ellison syndrome and bacterial overgrowth are potential causes for our patient's diarrhea. The latter, however, does not lead to recurrent peptic ulcer disease. Therefore, Zollinger-Ellison syndrome was a strong diagnostic consideration. In our patient, a small bowel biopsy specimen obtained at the time of EGO showed normal histologic findings. The small bowel aspirates, however, grew Escherichia coli (more than 105DelValle J Yamada T Zollinger-Ellison syndrome.in: Yamada T 2nd ed. Textbook of Gastroenterology. Vol l. Lippincott, Philadelphia1995: 1430-1445Google Scholar colonies/mL), Aeromonas hydrophila, and viridans streptococci. The finding of bacterial overgrowth (more than 105 colonies/mL) in our patient with an anastomotic ulcer raises the possibility of a rare complication in a patient with a postoperative ulcer. 3.Which one of the following tests is most appropriate for assessment of our patient's diarrhea? a.Quantitative fecal fat assessmentb.Computed tomography of the abdomenc.Serum gastrin leveld.Secretin teste.Small bowel roentgenograms A quantitative fecal fat assessment from a 72-hour stool collection after a strict high-fat diet (100 g/24 h) is an important test in the investigation of chronic diarrhea. If it is properly performed, a normal result (less than 6 g/24 h) rules out appreciable malabsorption. An abnormal test result in our patient, however, would not accurately distinguish chronic pancreatitis, bacterial overgrowth, and gastrinoma. Furthermore, the presence of fecal incontinence in our patient makes this study impractical. The history of recurrent peptic ulcer disease should raise the possibility of a gastrinoma. Computed tomography of the abdomen alone is only 30 to 40% sensitive in demonstrating a primary gastrinoma and 30 to 50% sensitive for metastatic gastrinoma; therefore, it is unlikely to be helpful. A serum gastrin level should always be determined in patients with recurrent peptic ulcer disease, and a result that exceeds 1,000 pg/mL is virtually diagnostic of Zollinger-Ellison syndrome. The differential diagnosis in a patient with a modest increase in the serum gastrin level and postoperative ulcer recurrence includes the following: history of vagotomy, Zollinger-Ellison syndrome, antral G-cell hyperfunction, retained annum, gastric outlet obstruction and retention of food, and use of acid-lowering medications-proton pump inhibitors (PPIs) and H2-blockers.2Thirlby RC Postoperative recurrent ulcer.Gastroenterol Clin North Am. 1994 Jun; 23: 295-311PubMed Google Scholar Serum gastrin levels of less than 1,000 pg/mL necessitate stimulatory tests (secretin test, calcium, or standard meal test) for confirmation. Small bowel roentgenograms can be helpful in delineating such conditions as mucosal lesions (lymphoma, Crohn's disease, tuberculosis), small bowel diverticulosis, fistulas, and segmentation of barium within the lumen, but subtle mucosal lesions can be missed. As an initial screening test in patients with diarrhea, small bowel roentgenograms may not be helpful. In our patient, the serum gastrin level was normal. Therefore, Zollinger-Ellison syndrome was excluded. Furthermore, a normal gastrin level suggests an incomplete vagotomy, as one would anticipate a slight increase in gastrin postoperatively. 4.With the information obtained thus far, which one of the following is the most likely cause of our patient's diarrhea? a.Phlegmonous gastritisb.Afferent loop syndromec.Crohn's disease of the stomachd.Gastroparesise.Gastrocolic fistula Phlegmonous gastritis is a rare type of bacterial infection of the stomach; all layers of the stomach can be involved, and perforation and sepsis can occur. Underlying debilitating illnesses such as acquired immunodeficiency syndrome (AIDS) or alcoholism are common. The most frequent causative agent is a-hemolytic streptococci, but other types of bacteria have been reported, including E. coli, staphylo-cocci, Haemophilus, and gas-forming organisms (Clostridium perfringens). Death is uniform if early intravenous administration of antibiotics and gastric resection are not implemented. Therefore, this condition is unlikely in our patient. Afferent loop syndrome is the result of intestinal obstruction attributable to a kink, anastomotic stricture, carcinoma, adhesions, herniation, or volvulus at the anastomotic site. In the acute variant (1 to 2 weeks after operation), abdominal pain, nausea, and vomiting without bile are frequent signs of afferent loop obstruction. In the chronic variant, partial obstruction of the loop of bowel allows passage of bile into the stomach. Symptoms (nausea, bilious vomiting, and pain in the right upper abdominal quadrant) are usually precipitated by ingestion of food and relieved by emesis. Surgical revision of the anastomosis is imperative in both types of the syndrome.6Carvajal SH Mulvihill SJ Postgastrectomy syndromes: dumping and diarrhea.Gastroenterol Clin North Am. 1994 Jun; 23: 261-279PubMed Google Scholar Our patient did not have the clinical features of afferent loop syndrome. Crohn's disease rarely involves the stomach and duodenum as an isolated finding, and such manifestations commonly are indicative of ileal or colonie disease. EGD often discloses linear and aphthous ulcers in the antrum rather than large gastric ulcers. Gastroparesis is not associated with diarrhea and wasting, unless the presence of small bowel dysmotility promotes bacterial overgrowth. Therefore, by exclusion, a gastrocolic fistula attributable to benign peptic ulcer disease is the most likely cause of this patient's diarrhea. A barium enema examination was performed, which confirmed the presence of a large fistulous tract between the transverse colon and the stomach. Poor filling of the ascending colon was also noted. 5.Which one of the following therapeutic measures is initially inappropriate in our patient? a.Total parenteral nutritionb.Medical therapy for peptic ulcer diseasec.Enterai dietd.No oral feedinge.Surgical repair Preoperative nutritional support is imperative in this patient. Because of his hypoalbuminemia, postoperative complications (such as infection and dehiscence) are likely to develop. Total bowel rest, total parenteral nutrition, and medical therapy for his peptic ulcer disease are the most sensible measures before definitive surgical repair is undertaken. Administration of enterai nutrition, delivered distal to the site of the fistula, is also reasonable nutritional therapy in our patient.7Voitk AJ Eschave V Brown RA McArdle AH Gurd FN Elemental diet in the treatment of fistulas of the alimentary tract.Surg Gynecol Obstet. 1973; 137: 68-72PubMed Google Scholar Until surgical treatment is performed, oral intake should be prohibited. When the patient's nutritional status has adequately improved, operative intervention becomes the definitive therapy. Our patient underwent surgical repair after 9 weeks of medical therapy; in addition to the gastrocolic fistula, an intact posterior vagus nerve was detected and excised. Therefore, incomplete vagotomy was the underlying cause of the recurrent peptic ulcer disease, which resulted in a gastrocolic fistula and diarrhea. Incomplete vagotomy and poor antral drainage after pyloroplasty (gastric retention stimulates secretion of gastric acid) are among the most common causes of postoperative recurrence of ulcer due to an inadequate procedure. Currently, however, surgical treatment is rarely necessary for peptic ulcer disease, except in patients who have complications (for example, bleeding, perforation, or refractory disease). The patient was dismissed and has had no further diarrhea or recurrence of ulcer. The role of H. pylori in the pathogenesis of ulcer disease and the introduction of PPIs to treat ulcer disease have revolutionized the management of peptic ulcer disease. H. pylori infection, the use of NSAIDs, or both factors are responsible for most cases of benign peptic ulcer disease. H. pylori is present in 95% of patients with duodenal ulcer and in more than 80% of those with gastric ulcers,8Kuipers EJ Thijs JC Festen HP The prevalence of Helicobacter pylori in peptic ulcer disease.Aliment Pharmacol Ther. 1995; 9: 59-69PubMed Google Scholar Eradication of H. pylori infection notably decreases recurrence and rebleeding rates of duodenal and gastric ulcers. Therefore, the use of NSAIDs and the presence of H. pylori infection should be carefully excluded. PPIs seem to have a synergistic effect with antibiotics against H. pylori. Most regimens combining a PPI with two antimicrobial agents (triple therapy) have eradication rates that exceed 85%. Overall, patients who have undergone a gastric surgical procedure for refractory duodenal ulcers are more likely to have postoperative recurrence (10%) than those who have had surgical intervention for gastric ulcer (2%). These rates will likely decline during the next few years because of the introduction of PPls.2Thirlby RC Postoperative recurrent ulcer.Gastroenterol Clin North Am. 1994 Jun; 23: 295-311PubMed Google Scholar Currently, surreptitious use of aspirin and NSAIDs is probably the most common cause of recurrent ulcers and must be carefully excluded in all patients before extensive investigations are launched. Cigarette smoking also places the patient at a higher risk for recurrence of ulcers. Initially, three diagnostic tests should be performed if recurrent ulcers are suspected: EGD, determination of serum gastrin level, and assessment of serum calcium concentration. Hypercalcemia attributable to hyperparathyroidism is associated with an unusually high incidence of peptic ulcer disease. In patients with underlying hyperparathyroidism, multiple endocrine neoplasia type I (primary hyperparathyroidism, pituitary adenomas, and gastrinomas) should be ruled out. Our patient did have a history of a parathyroid surgical procedure; however, both the corrected serum calcium and the serum gastrin levels were normal. Gastrocolic fistulas are an uncommon complication of benign peptic ulcer disease in stomachs that have not been subjected to operation.9Frikker MJ Lucas RJ Gastrocolic fistula caused by benign gastric ulcer in the patient who has not had prior operation: case reports and review of the literature.Am Surg. 1986; 52: 446-451PubMed Google Scholar Crohn's s disease, gastric and colonic cancer, lymphoma, placement of percutaneous gastrotomies, and diverticulitis are other causes of gastrocolic fistulas.10Tavenor T Smith S Sullivan S Gastrocolic fistula: a review of 15 cases and an update of the literature.J Clin Gastroenterol. 1993; 16: 189-191Crossref PubMed Scopus (36) Google Scholar Recently, long-term use of NSAIDs also has been associated with this complication. In the past, most gastrojejunostomies were placed anterior to the transverse colon (antecolic), a technique that resulted in gastrojejunocolic fistulas in patients who had recurrent ulcers. This complication is currently uncommon because most anastomoses are created in a retrocolic site. Patients with this complication frequently complain of diarrhea, epigastric pain, or feculent vomiting. In a review of 15 cases of gastrocolic fistula reported by Tavenor and associates,10Tavenor T Smith S Sullivan S Gastrocolic fistula: a review of 15 cases and an update of the literature.J Clin Gastroenterol. 1993; 16: 189-191Crossref PubMed Scopus (36) Google Scholar two-thirds of the patients had diarrhea or epigastric pain. Only three patients (20%) had gastrointestinal bleeding, and six patients (40%) had feculent vomiting. Diarrhea is usually attributable to overgrowth of bacteria in the stomach and small bowel and perhaps due to the emptying of stomach contents into the colon, bypassing any effective absorption.10Tavenor T Smith S Sullivan S Gastrocolic fistula: a review of 15 cases and an update of the literature.J Clin Gastroenterol. 1993; 16: 189-191Crossref PubMed Scopus (36) Google Scholar, 11Russell LJ Kearl GW Gastrocolic fistula presenting as acute diarrhea.Am Fam Physician. 1989; 40: 223-225PubMed Google Scholar The diagnosis is based on barium enema examination, as in our patient, and less often on EGO, an upper gastrointestinal series, or colonoscopy because the pressure required to introduce the contrast medium into the colon facilitates flow of the contrast agent through the fistula. En bloc resection of the involved portion of stomach and colonic wall is the most common treatment. Patients with gastrocolic fistula are frequently profoundly malnourished and are poor surgical candidates. Total parenteral nutrition, bowel rest, and treatment for peptic ulcer disease can, in some patients, promote complete healing of the fistula and eliminate the need for surgical repair.12Thyssen EP Weinstock LB Balfe DM Shatz BA Medical treatment of benign gastrocolic fistula.Ann Intern Med. 1993; 118: 433-435Crossref PubMed Scopus (13) Google Scholar In summary, gastrocolic fistula is a rare complication of benign peptic ulcer disease. Because of recent developments in the treatment of peptic ulcer disease, this complication may be infrequently encountered in the future.