PUD

H. pylori

Characteristics

Type: Gram-negative bacilli
Flagella: Lophotrichous (multiple flagella at one end)
Environment: Microaerophilic, survives only in the gastric epithelium
Common Locations:
- Antrum of the stomach
- Gastric metaplasia in the duodenum
- Heterotopic gastric epithelium of the esophagus and rectum
- Meckel's diverticulum

H. pylori Testing

IOC (Investigation of Choice) for Diagnosing H. pylori Non-Invasively: Serology
IOC for Diagnosing Eradication: C13/C14 urea breath test
Stool Antigen Test: Cost-effective for diagnosing eradication
Timing for Eradication Testing: Tests should be done 4 weeks after completing therapy

Test	Sensitivity %	Specificity %	Invasive	Purpose	Comment
Rapid Urease	90	90-100	OGD	Rapid result	IOC if OGD done
Histology	95	99	OGD	Minimally affected in PPI setting	Gold standard
Culture	80	100	OGD	Antibiotic sensitivity	3-5 days
Serology	90	76-96	No	Best tool for screening	Antibodies present up to 1 year
C14 Breath Test	95	95	No	Test for eradication	Costly
Stool Antigen	90	88-92	No	Cost-effective	Cheap

Associations with H. pylori

Peptic Ulcer: Both gastric and duodenal
Carcinoma Stomach: Intestinal variant
MALToma and DLBCL: (Diffuse Large B-cell Lymphoma)
Non-Ulcer Dyspepsia
Type 'B' Gastritis

Demographic Variations of H. pylori Infection

Western Countries: Predominantly antrum infection leading to peptic ulceration (previously classified as Type B)
Eastern Countries: Predominantly body infection leading to achlorhydria and cancer

MCQ 1

Answer: 3. Giemsa stain is used in histology

Explanation:

Giemsa stain is commonly used in histological examination to identify H. pylori. The other statements are incorrect based on the current testing guidelines.

MCQ 2

Answer: 1, 4, 3, 2, 5

Explanation:

The list is arranged in descending order based on the percentage of association with H. pylori. Duodenal ulcer has the highest association, followed by perforated duodenal ulcer, gastric ulcer, bleeding duodenal ulcer, and cicatrised duodenal ulcer.

Duodenal ulcer (95%)
Perforated duodenal ulcer (81%)
Gastric ulcer (70%)
Bleeding duodenal ulcer (40-70%)
Cicatrised duodenal ulcer (33-57%)

MCQ 3

Answer: 4. Reinfection rate equals to recurrence of gastric ulcer

Explanation:

Reinfection rates and recurrence rates are not the same. Reinfection is less common after successful treatment, whereas recurrence can occur due to various factors.

MCQ

Answer: 2. Lymphocytic gastritis - infiltration of gastric mucosa by B cells

Explanation:

Lymphocytic gastritis typically involves the infiltration of T cells, not B cells, into the gastric mucosa. The other options are true for the respective types of gastritis.

Autoimmune Gastritis

Key Points

Antibodies: Directed against parietal cells.
Consequences:
- Achlorhydria: Lack of hydrochloric acid in gastric secretions.
- Pernicious Anemia: Due to lack of intrinsic factor leading to vitamin B12 deficiency.
- Hypergastrinemia: Due to G cell stimulation in response to achlorhydria.
Associated Conditions:
- ECL (Enterochromaffin-like) Microadenomas: Reported in cases of autoimmune gastritis. These microadenomas rarely become malignant.
- Adenocarcinoma: The most common malignancy associated with autoimmune gastritis.

Treatment of Peptic Ulcer Disease (PUD)

Principles of Treatment

Medical Treatment: Focuses on antimicrobial therapy to eradicate H. pylori.
Surgical Treatment: Aims at acid reduction through procedures like:
- Vagotomy: Targets acetylcholine (Ach) pathways to reduce acid secretion.
- Antrectomy: Reduces gastrin production.

Current Indications for Surgery

Bleeding (10-15%): The most common complication of PUD.
Perforation: Associated with the highest rate of mortality (15%).
Obstruction: Due to chronic ulceration.
Failed Medical Therapy: Although this is an uncommon indication.
Risk of Malignancy: Considered when malignancy is a concern.

Types of Vagotomy

Truncal Vagotomy (TV)
- Commonly performed as part of the treatment for bleeding duodenal ulcers.
Selective Vagotomy (SV)
- Considered obsolete in modern practice.
Highly Selective Vagotomy (HSV)
- The most common form of vagotomy performed today.
Pyloroplasty (PV)
- Pyloroplasty combined with Vagotomy (PCV).
Supradiaphragmatic Vagotomy
- Used in cases of recurrent ulcers or a hostile abdomen.

Effects of Vagotomy

Gastric Emptying:
- Rapid emptying of liquids.
- Delayed emptying of solids.
Gastric Atony: Occurs in 20-30% of cases post-vagotomy.
Reduction in Acid Output:
- Basal Acid Output (BAO): Reduced by 75%.
- Maximum Acid Output (MAO): Reduced by 50%.
Cephalic Phase: Complete loss of this phase of acid secretion.

Selective Vagotomy

Drainage Required: Due to the alteration in gastric emptying.
Diarrhea and Gallstones: No significant reduction in incidence.
Antrectomy: Not necessary when performing selective vagotomy.

Highly Selective Vagotomy (HSV)

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Key Features

Distal Stomach Innervation:
- Preserved up to 7 cm from the pylorus.
Gastric Stasis and Atony:
- Not present, hence no drainage procedure is typically needed unless there is duodenal scarring.
Emptying of Solids:
- Normal, unlike other forms of vagotomy.
Liquid Emptying:
- Rapid due to division of nerves affecting receptive relaxation.
Morbidity Rate:
- Lowest among all vagotomy procedures.
Limitations:
- Ineffective for prepyloric ulcers.

Variations of HSV

Hill-Baker Procedure:
- Combines Posterior Truncal Vagotomy (TV) with Anterior Highly Selective Vagotomy (HSV).
Taylor Procedure:
- Combines Posterior TV with Anterior Seromyotomy:
  - Anterior wall incised 1.5 cm from the lesser curvature.
  - Incision starts 6 cm from the pylorus and ends at the OG junction.
  - Circular muscles are incised, while deep oblique fibers are preserved.

Drainage Procedures

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Pyloroplasty vs Gastrojejunostomy (GJ)

Pyloroplasty

Bile Reflux: Less incidence compared to GJ.
Diarrhea: Higher incidence of diarrhea.
Dumping Syndrome: Incidence is similar to that of GJ.
Procedure: Easier to perform.

Heinecke-Mickulicz Pyloroplasty

Indications:
- When the pylorus is mobile.
- Anterior wall of pylorus is free of ulcers.
- Non-edematous pylorus.
- Suitable for small perforations.

Finney Gastroduodenostomy

Usage: Uncommonly used.
Indications:
- J-shaped stomach or extensive scarring.
- Significant narrowing of the duodenal bulb.
Features:
- Creates a larger lumen.
- Requires a long incision and has more complications.

Jaboulay Gastroduodenostomy

Characteristics:
- Does not transect the pyloric muscle.
- Anastomosis between the distal stomach and the first and second portions of the duodenum.
Usage:
- Rarely used.
- Indicated for severely scarred or deformed pylorus or duodenal bulb.
- Increased bile reflux due to the anastomosis being close to the ampulla of Vater.

MCQ

Answer: 3. Pylorus is transected.

Explanation:

The Jaboulay procedure does not involve transecting the pyloric muscle. Instead, it involves an anastomosis of the distal stomach to the duodenum, making option 3 incorrect.

Gastrojejunostomy (GJ)

Indications

Complete Duodenal Obstruction: When the duodenum is completely obstructed.
Severe Scarring/Inflammation: When the duodenal bulb is significantly scarred, inflamed, or edematous.

Features

Vomiting: Decreased by a short afferent limb.
Retrocolic GJ:
- Less tension on the anastomosis.
- Less interference with gastric emptying when the colon becomes distended.
Technique: Vertical, posterior wall, isoperistaltic anastomosis.

Gastric Resection for Peptic Ulcer Disease

Key Surgical Procedure

Intractable Duodenal Ulcer:
- Antrectomy: Involves 40% distal gastrectomy combined with truncal vagotomy (TV).
- Vagotomy and Antrectomy: Removes both the cholinergic (acetylcholine) and gastrin stimulus to acid secretion.
- Effect on Acid Secretion:
  - Basal Acid Output (BAO): Reduced by 100%.
  - Maximum Acid Output (MAO): Diminished by 80%.

Advantages of Billroth I Procedure

Restoration of Normal Gastrointestinal Continuity.
Specialized Duodenal Mucosa: Remains next to the gastric mucosa.
Avoids Complications: Related to afferent and efferent limbs.
Ease of ERCP: Facilitates easier performance of endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic examination of the bowel.
Reduced Incidence of Gastric Cancer: In the remnant stomach.

Variations of Billroth Procedures

Braun Variation of Billroth II:
- Lower incidence of bile reflux compared to standard Billroth II.
Roux-en-Y:
- No bile reflux, but may cause Roux stasis syndrome.
Uncut Roux-en-Y:
- Least bile reflux, but severe bile reflux can occur if the staple line fails.

Uncut Roux-en-Y Procedure

Duodenojejunostomy: Performed with a stapled afferent limb.
Efferent Limb: Typically 60 cm in length.

MCQ

Answer: 3. HSV does not affect emptying of solids and liquid

Explanation:

Highly Selective Vagotomy (HSV) preserves the innervation to the distal stomach, which typically maintains normal emptying of solids but may cause rapid emptying of liquids. Therefore, option 3 is incorrect. Billroth I does not have the highest incidence of stump carcinoma; in fact, it reduces the incidence of gastric cancer in the remnant stomach compared to other procedures.

Ulcer Recurrence Rates for the Three Common Acid-Reducing Procedures

Surgical Procedure	Ulcer Recurrence Rate	Risk of Side Effects
Truncal vagotomy with drainage	10%	Highest
Truncal vagotomy with antrectomy	2%	High
Highly selective vagotomy	15%	Low

Surgical Management for Intractable Duodenal Ulcer

Preferred Procedure: Highly Selective Vagotomy (HSV) ???
Alternative: If there is limited experience with HSV, consider Truncal Vagotomy and Antrectomy.

Classification of Gastric ulcer - Modified Johnson

Type	Location	Acid Secretion State	Percentage
I	Lesser curvature	Low	60%
II	Antrum and duodenum	High	25%
III	Pre-pyloric (< 2-3 cm from pylorus)	High	20%
IV	Lesser curvature near OGJ	Low	-
V	NSAID-related, anywhere	Low	-

MCQ 1

Answer: B) II

Explanation:

Type II gastric ulcers, located in the antrum and duodenum, are associated with increased acid secretion.

MCQ 2

Answer: b) Pre-pylorus

Explanation:

Type III gastric ulcers are located in the pre-pyloric region, less than 2-3 cm from the pylorus.

Surgical Management for Intractable Gastric Ulcers

Type I
- Surgical Options:
  - Partial gastrectomy and Billroth I
  - Ulcer excision and Highly Selective Vagotomy (HSV)
Type II
- Surgical Approach:
  - Similar to the approach for duodenal ulcers:
    - Truncal vagotomy and antrectomy
    - Alternatively, HSV
Type III
- Surgical Approach:
  - Truncal vagotomy and antrectomy
Type IV
- Surgical Considerations:
  - If the ulcer is within 2 cm of the Gastroesophageal (GE) junction:
    - Kelly-Madiener or Csendes procedure
  - For more distal lesions, Pauchet’s procedure is recommended.
Type V
- Surgical Management:
  - If medication cannot be stopped, proceed with ulcer excision and truncal vagotomy.

MCQ

Answer: A) Kelling Madlener

Explanation:

The Kelling Madlener procedure is a non-resective surgical option, meaning it does not involve the removal of any part of the stomach. It is primarily used for managing type IV gastric ulcers that are located close to the gastroesophageal junction. The other options listed, such as Pauchet and Csendes, involve resective techniques.

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Maruyama index

MCQ

Answer: A) Gastric cancer

Explanation:

The Maruyama index (MI) is used to predict the likelihood of disease in undissected lymph node stations during gastric cancer surgery. It is a prognostic tool that helps estimate the percentage likelihood of disease based on various factors, including the tumor's characteristics and patient demographics. An MI of less than 5 is associated with a better prognosis and is considered a strong predictor of survival.

MCQs on Gastric Ulcers

MCQ 1: Giant Gastric Ulcer

Answer: 3. Medical therapy cures 98%

Explanation:

Medical therapy typically heals about 80% of giant gastric ulcers, not 98%, making option 3 incorrect.

MCQ 2: Refractory Peptic Ulcer

Answer: B) Ulcer more than 5 mm diameter which does not heal after 12 weeks of PPI

Explanation:

A refractory peptic ulcer is defined as an endoscopically proven ulcer greater than 5 mm in diameter that does not heal after 12 weeks of proton pump inhibitor (PPI) therapy.
A recurrent peptic ulcer is defined as an endoscopically proven ulcer greater than 5 mm in diameter that develops within 12 months following complete ulcer healing, which is documented by repeat endoscopy.

MCQ 3: Giant Gastric Ulcer Characteristics

Answer: d. Incidence of malignancy is less than 3%

Explanation:

The incidence of malignancy in giant gastric ulcers is typically around 10%, not less than 3%, making option d incorrect.

Bleeding in Gastrointestinal (GI) Tract

Key Points on Bleeding

Mortality Rate: 5-10%
Common Cause of Mortality: Multiorgan failure
Surgical Intervention: 10-20% of cases require operation

Common Causes of GI Bleeding

Upper GI Bleeding:
- Most common cause: Peptic ulcer
Lower GI Bleeding:
- Most common causes: Diverticulosis and angiodysplasia

GI Bleed Terminology

Obscure Hemorrhage:
- Bleeding not detected after upper GI endoscopy (UGI) and colonoscopy (usually from the small bowel).
Occult Hemorrhage:
- Manifested only by anemia, not visible bleeding.
Acute Upper GI Bleeding:
- Most cases stop spontaneously; however, 15% require intervention.

MCQ 1: Resuscitation for Upper GI Bleeding

Answer: 2. Hematocrit is the guide for blood transfusion

Explanation:

Hematocrit is unreliable in the acute setting as it does not immediately reflect blood loss. Management should be guided by the response to crystalloids and the patient’s hemodynamic stability.

MCQ 2: Stratifying Upper GI Bleeding at Admission

Answer: 3. APACHE II

Explanation:

The Rockall and Blatchford scores are specifically designed for stratifying risk in upper GI bleeding. The APACHE II score is used more broadly in critical care settings and is not specific for GI bleeding.

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Important Points in Gastrointestinal Bleeding and Ulcers

Key Points

Duodenal Ulcer: Involves the Gastroduodenal Artery (GDA).
Gastric Ulcer: Involves the Left Gastric Artery.
Endotherapy Success Rates:
- First endotherapy: 90% successful.
- Second endotherapy: 75% successful.

MCQ 1: High Risk of Rebleeding

Answer: 3. Gastric ulcer > duodenal ulcer

Answer: 4. Visible non-bleeding vessel > clot

Explanation:

Gastric ulcers have a higher risk of rebleeding compared to duodenal ulcers, and the presence of a visible non-bleeding vessel poses a higher risk of rebleeding than a clot.

MCQ 2: Role in Torrential Upper GI Bleeding

Answer: 4. Tagged RBC scan

Explanation:

While surgery, angiography, and endoscopy are critical interventions in managing torrential upper GI bleeding, a tagged RBC scan is typically used to locate the source of bleeding in cases of slower or intermittent bleeds, not in torrential bleeding scenarios.

MCQ 3: Forrest Classification of Type IIB Peptic Ulcer

Answer: c. Adherent clot

Explanation:

Forrest classification type IIB refers to a peptic ulcer with an adherent clot, indicating a recent bleed that carries a moderate risk of rebleeding.

MCQ 4: Acute Gastrointestinal Bleeding

Answer: B. Black spot intermediate risk

Explanation:

A black spot on an ulcer typically indicates a low risk of rebleeding, not an intermediate risk, making option B false.

Key Points on Management of GI Bleeding and Peptic Ulcers

Endotherapy

Monotherapy Options:
- Clip: Mechanical hemostasis.
- Thermotherapy: Includes techniques like heater probes or argon plasma coagulation.
Epinephrine Injection:
- Not recommended as a monotherapy.
- Should always be combined with another endoscopic technique for effective hemostasis.

Success of Endotherapy

First Attempt: 90% success rate.
Second Attempt: 75% success rate.

Proton Pump Inhibitors (PPI) in Bleeding

Administration:
- Start with a bolus loading dose.
- Followed by continuous infusion for 72 hours.
Indication:
- Recommended for all high-risk cases of GI bleeding.

Anti-H. pylori Treatment in Bleeding Peptic Ulcer Disease (PUD)

Association: 60-70% of bleeding PUD cases are associated with H. pylori.
Testing:
- H. pylori testing should be done at the time of endotherapy.
- If positive, eradication therapy should be initiated and confirmed.
- If negative, the patient should be retested to confirm the absence of H. pylori.

Emergency Surgery: Absolute Indications

Hemodynamic Instability:
- Despite vigorous resuscitation (e.g., >4 units or >6 units transfusion, taking into account the patient's age).
Failure of Endoscopic Techniques:
- When endoscopy fails to arrest hemorrhage.
Recurrent Hemorrhage:
- After initial stabilization, with up to two attempts at endoscopic hemostasis.
Shock Associated with Recurrent Hemorrhage:
- Persistent or recurrent shock requiring urgent intervention.
Continued Slow Bleeding:
- With a transfusion requirement exceeding 3 units per day.

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Surgical Management for Bleeding Duodenal Ulcer (DU)

Techniques

Gastroduodenal Artery (GDA) Bleeding:
- Use two figure-of-8 stitches to control bleeding from the GDA.
Transverse Pancreatic Branch:
- Apply a U stitch to secure the transverse pancreatic branch.
Pyloroplasty and Truncal Vagotomy (TV):
- Typically performed in conjunction with the above procedures to reduce acid secretion and improve gastric emptying.

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Surgical Management for Bleeding Gastric Ulcer

Stable Patient

Distal Gastrectomy:
- Perform with Billroth I or Billroth II reconstruction.
- Add Vagotomy: Particularly for type II and type III ulcers to reduce acid production and prevent recurrence.

Unstable Patient with High Ulcers

Ulcer Excision:
- Excision of the ulcer may be performed.
- +/− Truncal Vagotomy: To decrease acid secretion and reduce recurrence risk.
- Pyloroplasty:
  - Considered particularly for type II and type III ulcers to ensure adequate gastric emptying and prevent obstruction.

MCQs on Gastrointestinal Bleeding and Ulcer Management

MCQ 1: Correctness of Statements

Answer: 3. Forrest IB is an example of stigmata of recent hemorrhage

Explanation:

Forrest IB (oozing bleeding) is indeed an example of stigmata of recent hemorrhage, making this statement correct. However, the question asks for the "wrong" statement. Given the options, statement 3 is correct but possibly misleading in the context of the question's intent.

MCQ 2: Scoring Systems for Upper GI Bleeding

Answer: d. Hinchey

Explanation:

The Hinchey classification is used for diverticulitis, not for upper GI bleeding. The other options are valid scoring systems used in the context of upper GI bleeding.

MCQ 3: Absolute Indication for Surgery in Bleeding Peptic Ulcer

Answer: 5. Daily requirement > 3 units

Explanation:

A transfusion requirement exceeding 3 units per day is an absolute indication for surgery in the management of a bleeding peptic ulcer.

MCQ 4: Gastric Ulcer Management Pairs

Answer: b. Type 1 - Bleeding - Distal gastrectomy + vagotomy

Explanation:

Type 1 gastric ulcers typically involve the lesser curvature and are often managed with distal gastrectomy without the need for vagotomy, especially in bleeding cases. The incorrect pairing here is the combination of distal gastrectomy and vagotomy for a Type 1 bleeding ulcer.

Key Points on Perforated Peptic Ulcer

Risk Factors for Perforation

Smoking
NSAIDs Usage
Elderly Women

Prognostic Factors

Delay in Surgical Treatment: Longer delays worsen prognosis.
Site of Perforation: Gastric perforations are associated with poorer prognosis compared to duodenal perforations.
Patient's Age: Elderly patients have a worse prognosis.
Presence of Hypotension: Systolic blood pressure < 100 mmHg at presentation indicates a poorer prognosis.

Conservative Management Criteria

Perforation Duration: More than 24 hours.
Patient Stability: Hemodynamically stable.
Significant Comorbidities: Where surgical intervention poses high risk.
Gastrograffin Study: Mandatory to document sealed perforation (not indicated for gastric ulcers).

Definitive Operation in Emergency Situations

Not Recommended: Usually avoided in emergency settings.
Contraindications:
- If the patient is hemodynamically unstable or not fit for surgery.
- If the patient is H. pylori positive (difficult to confirm in an emergency).
Indications:
- Should be performed if NSAIDs cannot be discontinued.
- Should be considered if H. pylori is negative, although this is difficult to establish in an emergency setting.

MCQ

Answer: 1. Smoking, NSAIDs, and elderly women are common risk factors.

Explanation:

Smoking, NSAIDs, and being an elderly woman are recognized risk factors for perforated peptic ulcers. Gastric perforations generally have a poorer prognosis compared to duodenal perforations, delay in surgical treatment worsens prognosis, and hypotension at presentation is a significant concern.

Gastric Outlet Obstruction (GOO)

Key Points

Incidence: 5-8% of patients with peptic ulcer disease develop GOO.
Malignancy: More than 50% of GOO cases are due to malignant causes.
Surgical Options:
- Truncal Vagotomy (TV) and Antrectomy
- Highly Selective Vagotomy (HSV) with Drainage

MCQ 1: Metabolic Abnormality in GOO

Answer: a. Hypokalemic metabolic alkalosis

Explanation:

Gastric outlet obstruction (GOO) typically leads to hypokalemic metabolic alkalosis due to the loss of gastric acid (HCl) and subsequent electrolyte disturbances.

MCQ 2: Matching Procedures with Conditions

Answer: 4. Perforated DU <24 hours, contained in gastrograffin study - Conservative

Explanation:

Conservative management is typically considered for perforations greater than 24 hours, not less, and only when specific conditions are met.

MCQ 3: Incorrect Statement

Answer: 3. HSV is the most commonly performed procedure in intractable DU and has the least recurrence

Explanation:

Highly Selective Vagotomy (HSV) is effective but not the most commonly performed procedure for intractable duodenal ulcers, and while it reduces recurrence, it is not universally preferred over other procedures like TV and antrectomy.

MCQ 4: Treatment of Choice for Bleeding Gastric Ulcer

Answer: 1. Gastrectomy

Explanation:

Gastrectomy is often the treatment of choice for bleeding gastric ulcers, especially when the ulcer is large, recurrent, or not responding to less invasive treatments.