Complete response of severe , refractory , gastric , stomal and sclerotherapy-induced esophageal ulcer disease to omeprazole therapy

This report presents three unusual forms of resistant peptic ulcer disease, all healed completely with the use of a new class of anti-ulcer drug, a proton pump blocker, omeprazole . Each of these patients represents an unusual facet of acid-pepsin disease, namely, resistance to healing with current standard therapy, recurrence and rehealing with a second course of omcprazole, and a subsequent need for maintenance omeprazole to remain ulcer-free. The first patient had an unusual complication of a stomal ulcer after gastric bypass surgery for morbid obesity. This ulcer proved to be intractable, not healing with standard therapy, but healing with omeprazole, and subsequently recurring. A second course of the rapy resulted in complete rchealing, but maintenance therapy with omeprazole was necessary to prevent ulcer recurrence. The second patient had rheumatoid arthri tis and an NSAID associated chronic gastric ulcer which did not heal with standard therapy. A course of omeprazole resulted in complete healing; however, the ulcer recurred. A second course of omeprazole was necessary which led to complete healing, and subsequent maintenance therapy has kept this patient ulcer-free for the past 18 months. The third patient had recurrent circumferential esophageal ulcers following esophageal variceal sclerotherapy along with primary biliary cirrhosis. These ulcers took five months to heal on conventional therapy, but treatment with omeprazole resulted in healing within a three month time frame, and maintenance omeprazole has since kept this patient free from esophageal ulcers. Can J Gastroenterol t 989;3(5): 179-181 Kev Words: Omeprazole, Refractory ulcer disease D1\,r5ron of Gastroent<.'Tology, Departmem of Med,cme, Dalhousie Umt'ersity, Halrfax , Not•a Scotra Corre.spondenceand repnnu Dr C.N Williams , Room CD 1, Clrnrcal Research Centre, 5849 Un111ers1ty Avenrie, Halrfax, Nova Scotra B3H 4H7 Telephone (902) 424-2333 Presented at the syrnposrum Focu.1 on gm1ric proton pump rnhibiton An update on the treatment deci.1ions rn peprrc ulcer di1ease', May 1989, Toronto, Onrano Received for puhlicatron lune 29. 1989 Accepted October 1, /QRQ C~N J GA~TR()fNTER()I vc,t ~ N() 'i Nmr MIii RIDH' I MR~R 1989 REFRACTORY l 11 Cl-R DJS!-ASE, BY nEAN ition, implies the continuance of significant morbidity and the risk of signific.int complicatio ns despite aggressive medical m.inagement The medical .irmamentarium continues to expand ; different classes of drugs are heing introduced at regular in tervals, whi le a small proportion of patients with refractory dise.ise continue to experience symptoms and have endoscopically demonstrable ulcers. Omeprazole, ;i substi tured benzimidazole, specifically inhibits the H 1 ,KL ATPase enzy me in the pariernl cell, effectively b locking the final step tn the production of gastric acid ( I). This decrease in gastric acid occurs in hoth the fed and fasting sta tes (2-4). The rationale for the use of this class of drugs in the treatment of ulcer disease has thus been established ( 5). Omeprazole is much more potent th.in the H, b lockers in suppressing acid secretion, and should be of major benefit to patients with refractory ulcers. Herein a re presented three unusual patients, each with symptoms over at le;ist two yc::ir~. v.·ho. after

R EFRACTORY l 11 Cl-R DJS!-ASE, BY nEAN ition, implies the continuance of significant morbidity and the risk of signific.intcomplicatio ns despite aggressive medical m.inagementThe medical .irmamentariumcontinues to expand ; different classes of drugs are heing introduced at reg ular in tervals, whi le a small proportion of patients with refractory dise.isecontinue to experience symptoms and have endoscopically demonstrable ulcers.
Omeprazole, ;i substitured benzimidazole, specifically inhibits the H 1 ,KL ATPase enzy me in th e pariernl cell, effectively b locki ng the final step tn the production of gastric acid ( I).This decrease in gastric acid occu rs in hoth the fed a nd fasting states (2-4).The rationale fo r th e use of this class of drugs in the treatment of ulcer disease has thus been established ( 5).Omeprazole is much more potent th.in the H, b lockers in suppressing acid secretion, and should be of major be nefit to patients with refracto ry ulcers.He rein a re presented three unusual patients, each with symptoms over at le;ist two yc::ir~.v. aggressive medical management, demonstrated early recu rrence or refractoriness of their ulcer disease such that they requ ired tr<"atment with omeprazole to heal their ulcers completely as well as omeprazole maintenance therapy to remain ulcer-free.Gastric mucosa!biopsies on gastroscopy every three months have shown no enterochromaffin-like cell proliferation.

CASE STUDIES
Case A: Patient A is a 27-year-old female who underwent gastric bypass surgery for morbid obesity.She subsequently developed symptoms suggestive of peptic ulcer disease and had an endoscopically proven ( I cm) stomal ulcer in December 1986.The patient was treated with sucralfate l g qid and ranitidine 150 mg bid with no improvement of symptoms.Indeed, a repeat gastroscopy after eight weeks of treatment revealed that the initial ulcer was partially healed, but that three new superficial ulcers were present.Serum gastrin was no rmal at 40 ng/mL.Misoprostol 200 µg qid was added; however, two months later a re-peat gastroscopy revealed active ulceration, corresponding to a worsening of the patient's symptoms.
Treatment of this patient's chronic, resistant ulcer in May 1987 with omeprazole 20 mg daily for fou r weeks resulted in ulcer healing and the complete loss of symptoms; treatment was then stopped.In January 1988 the ulcer symptoms recurred, and a large 3 cm anastomotic ulcer was seen on endoscopy.Omeprazole therapy was restarted and 12 weeks later the ulcer was 99% healed.The patient was then maintained on omeprazole 20 mg every second day and remained asymptomatic.In July 1988, a gastroscopy revealed no evidence of stomal ulceration.In January 1989, a small stomal ulcer had recurred.The omeprazole dose was increased to 20 mg daily, leading to complete healing.Continued therapy at this dose has resulted in no endoscopically demonstrable ulcer recurrence.Case B: A SO-year-old female presented with a histologically proven, benign, chronic (2 cm), gastric ulcer in May 1986.This patient was anemic with active rheumatoid arthritis requiring continued NSAID therapy (piroxicam); she also had active extensive psoriasis, which required continuous weekly methotrexate therapy.She had had abdominal symptoms of ulcer d isease for more than two years and required antacids, sucralfate 1 g qid and ranitidine 150 mg bid, all without sustained benefit.Omeprazole 20 mg daily was the n given, resulting in shrinkage of the ulcer to 4 mm after four weeks and total healing at eight weeks.Ulcer symptoms disappeared after eight days.Omeprazole was then discontinued and ranitidinc 150 mg bid was restarted.Endoscopy in October 1986 showed a few scattered e rosions, and in January 1987 two gastric ulcers were seen .Sucralfate I g qid was started and ran itidine discontinued.In March 1987, no change in ulcer healing had occurred and misoprostol 200 µg qid was added.In late April, repeat endoscopy confirmed a chronic deep gastric ulcer with multiple erosions.Ranitid ine had been restarted as the only medication, as misoprostol had provoked intolerable diarrhea.A second course of omeprazole 40 mg daily was started and at eight weeks gastroscopy revealed complete healing.In March 1988, the omeprazole dose was reduced to 20 mg daily, a nd the patient has remained symptom-free with maintained healing to this day.Case C: A 65-year-old female patient with primary b iliary ci rrhosis and esophageal and fundal varices developed recurrent circumferen tial esophageal ulcers after successful sclerotherapy for life threatening bleeding (six injections of 5% ethanolamine given over three months).Sequential treatment with ranitidine 150 mg bid, famotidine 40 mg daily and sucralfate I g qid, prescribed by d ifferent physicians, fai led to heal these ulcers.A combination of famotidine and sucralfate eventually healed the ulcers after five months; however, they recurred with severe heartburn and dysphagia in October 1988.Endoscopy showed circumferential esophageal ulcers with gastric erosions.Omeprazole 20 mg daily was started , and within three months all ulceration was healed with a complete loss of symptoms.Omeprazole was continued at the same dose and has kept the patient free from esophageal ulcers to date.

DISCUSSION
These cases represent th ree scenarios in which standard medica l treatment failed to alleviate symptoms.and ulcers did not heal o r recurred while on treatment.Patient A had a deep, anasromotic ulcer occu rring after bariatric surgery for morbid obesity.Stomal ulcers fo llowing this operation arc rare.In a review of the authors' first 100 patients undergoing chis procedure, this complication did not occur (6).When the ulcer d id not h eal with appropriate ranitidine therapy, consideration was given for su rgical therapy.However, tech n ical considerations and increased operative risk swayed the judgement in favour of o meprazole therapy.When the ulcer recurred, hyperacidic conditions were considerations; however, scrum gastnn was within normal limits.
Pauent B had recurrent gastric ulcers complicated by recurrent bleeding, compromising a poor genera l medical condition from progressive rheumatoid arthritis requiring con tmuo u s NSAID use, and severe widespread psoriasis requiring methotrexate therapy.we re intractable to co nventi onal H 1 blocker therapy and recu rred after omeprazole was discontinued and on low dose omeprazole therapy (20 mg daily).
Com plete h ealing and no recu rrences have been achieved with omeprazolc 40 mg daily.
Severe ulce rated esophagitis is difficult to heal with conventional or high dose H 1 blocker therapy (7).Consequently, when patient C did not improve, there were few alternatives.Fortunately, omcprazole the rapy, found co be successful in ocher patients with resistant peptic ulcer problems, also proved successful here in completely eradicating che sclerotherapy induced, intractable, circumferentia l ulcers.In nonsclerotherapy-induced, resistant esophageal ulceration, omeprazole therapy is also reported to be effective (8,9) and has been reviewed (10) The long term use of omcprazole in a ll three patients has resulted in no apparent clmical.hematologic, hiochemicn l o r h istological abnormalities attributable to omcprazole Patients with duodenal ulcers treated with omeprazolc ini- T h is study of omeprazole therapy in refractory gastric, esophageal and stomal ulcers has demonstrated its effectiveness with regard to the amelioration of symptoms and healing.Each patien t requires dose monito ring for recu rrence, and individual doses for an ulcer-free life.The n um ber o f patients in this study is admittedly small, but in view of the response to omcprazolc, it is suggested that this drug be considered for the treatment and prophylaxis of unusual variants of refractory ulcer disease.Submit your manuscripts at http://www.hindawi.com in patients with peptic ulcerations resistant to extended high dose ranitidine treatment.D1gest1on I 988;39:80-90.10 HowardJM.O mcprazole 111 the treatment of reflux disea,e Can J Gastrocnterol 1989,3(Suppl A):62A-6A J L Solvell L. C linical safety of omeprazole.Can J Gastoenterol 1989, 3(Suppl A):91A-7A.12. Sharma BK , Sa ntana IA , Watt RP, ct al. Omeprazole and liver funct ion tests Lancet J 983;ii: 346 13.Hakanson R, Sandler F. Carlsson E, Mattson H, Larsson H . Proliferation of enrerochromaffin-like (ECL) cells in the rat stomach following omeprazolc treatment.He pa cogastroenrerology 1985.32:48-9