Quick Review: The Benign Gastric Ulcer
Abstract
Peptic ulcer disease historically presented as a surgical disease; however, with the advent of medical regimens targeted at acid production (e.g. H2-blockers, proton-pump inhibitors, etc), it has become a relatively infrequent surgical problem. When it does present, GU is most common in males & the elderly (peak age: 55 - 65). 90,000 new gastric ulcers are diagnosed annually and 3,000 patients die/yr. as a direct result or complication of gastric ulcer disease. 10% of all gastric ulcers - occur over an underlying Malignancy.
In General
Peptic ulcer disease historically presented as a surgical disease; however, with the advent of medical regimens targeted at acid production (e.g. H2-blockers, proton-pump inhibitors, etc), it has become a relatively infrequent surgical problem.
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Most Common in Males & the Elderly
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Peak Age: 55 – 65
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90,000 new gastric ulcers are diagnosed annually
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3,000 patients die/yr. as a direct result or complication of gastric ulcer disease
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10% of all gastric ulcers - occur over an underlying malignancy
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Type I: Ulcer along the lesser curve
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Type II: 2 ulcers present - one gastric, one duodenal
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Type III: Prepyloric ulcer
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Type IV: Proximal gastroesophageal ulcer
Etiology
High-Acid Production, Types II & III
Defect in the Mucosal Defense, Types I & IV
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epithelial turnover
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hydrophobic surface
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mucus & HCO3- production
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endogenous prostanoids
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trophic peptides
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gastric motility
Concomitant hemorrhage & perforation is usually due to 2 Ulcers:
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An anterior perforated ulcer (stomach or duodenum)
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A posterior, bleeding one (duodenum)
Both should be identified at the time of the original operation, and will be best treated by a definitive procedure
5 % of patients who undergo operation for perforation bleed post-operatively due to a synchronous, posterior lesion
Non-operative Treatment of the perforated ulcer:
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Continuous NG Suction
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High-dose Antibiotics
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H2-Antagonists
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May be effective in poor-surgical candidates
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High incidence of Renal Failure & Abscess Formation
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85 - 90% of patients are colonized with H. pylori!
Treatment
Antibiotics, Anti-secretory Agents, +/- Mucosal Defense Agent
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e.g. 3 weeks, Bismuth Compound, Tetracyclin, Flagyl
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12 weeks, H2 Antagonist
Indications for Elective Surgery
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Failure of Medical Tx (12 weeks x 2)
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Recurrence after initial success
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Inability to exclude malignancy
Indications for Emergent Surgery
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Hemorrhage
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Perforation
Goals of Surgery
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Correct the emergent problem
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Prevent recurrence, if possible
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Exclude malignancy
Surgical Options
1.Vagotomy -
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Truncal
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Selective
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Parietal-Cell (highly-selective)
2. Pyloroplasty -
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Heineke-Mikulicz
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Finney
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Jaboulay
3. Antrectomy -
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Billroth I (gastroduodenostomy)
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Billroth II (gastrojejunostomy)
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Roux-en-Y Gastrojejunostomy
Cameron's Text: the definitive ulcer operation should include a distal gastrectomy (with excision of the ulcer, if possible) and a Billroth I reconstruction
However
1. Pt's - requiring Blood Transfusions (“Stable”): V & A
2. Pt's with life-threatening Sepsis/Hemorrhage: Biopsy (6) Excision or Oversew
3. Pt's with an Unstable-Type IV: Ligation of the Left Gastric Artery High Anterior Gastrotomy Biopsy/Excision & Oversew
Complications of Ulcer Surgery
Early: Duodenal Stump Leak
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Gastric Retention
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Anastamotic Breakdown
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Hemorrhage
Late: Recurrent Ulcer [10% following V & P] [2 - 3% following V & A]
Gastrocolic/Gastrojejunal Fistula
Dumping Syndrome - [1 - 2% of patients]
Alkaline Gastritis
Anemia [30% of patients, five years post-op]
Postvagotomy Diarrhea [5 - 10% of patients]
Chronic Gastroparesis
* may require a Roux-en-Y Esophagojejunostomy