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Peptic Ulcer Disease

Gastroduodenal Peptic Ulcer Disease (PUD)

Key Points on Epidemiology and Prevalence

  1. Geographic Variation
    • Significant variation in PUD prevalence globally.
    • Lower incidence in Western countries, higher in developing countries.
    • Western Countries: Prevalence rate of 4% with 20% asymptomatic ulcers.
    • China: 17.2% prevalence with over 70% asymptomatic.
  2. Risk Factors
    • Prevalence linked to Helicobacter pylori, smoking, and use of NSAIDs.
    • Annual incidence in developed countries: 0.1% to 0.19% (physician-diagnosed), 0.01% to 0.17% (hospitalized patients).
    • Veterans Affairs study: 2% prevalence in H. pylori-positive patients.
  3. Trends in the United States
    • Decrease in prevalence and hospitalizations for PUD.
    • 1993-2006: 30% decrease in PUD-related admissions.
    • Greater decrease in duodenal ulcers compared to gastric ulcers due to H. pylori testing and effective therapies.
  4. Impact of Medical Therapies
    • H2-Receptor Antagonists (H2 blockers): 40% decrease in ulcer operations.
    • Proton Pump Inhibitors (PPIs): Further reduced acid production and increased healing rate, reduced need for emergency operations when combined with endoscopic treatments.

Complications and Risk Factors

  1. Complications
    • Bleeding: Most common in the U.S.
    • Perforation: Second most common, highest mortality rate.
    • Gastric Outlet Obstruction: Due to scarring post-healing of ulcers.
    • Complication Trends: Overall decrease in the U.S. but varies geographically (bleeding in U.S., obstruction elsewhere).
  2. Risk Factors for Complications
    • NSAID/aspirin use, H. pylori infection, ulcer size ≥ 1 cm.
    • PPIs reduce risk of hemorrhage.

Indications for Surgical Intervention

  1. Protracted Bleeding: Persistent despite endoscopic therapy.
  2. Perforation: High mortality rate, annual incidence of 11 operations per 100,000.
  3. Obstruction: Due to scarring from healed ulcers.
  4. Intractability: Unresponsive to maximum medical therapy.
  5. Cancer Suspicion: Persistent ulcer despite treatment and negative biopsies, especially in gastric ulcers.

Goals of Surgical Procedures

  1. Permit Ulcer Healing
  2. Prevent or Treat Complications
  3. Address Ulcer Etiology
  4. Minimize Postoperative Digestive Consequences

Considerations for Choosing Surgical Procedures

  • Ulcer characteristics: location, chronicity, type of complication.
  • Likely etiology: acid hypersecretion, drug-induced, H. pylori role.
  • Patient factors: age, nutrition, comorbid illnesses, presentation condition.
  • Operation factors: mortality rate, side effects.
  • Surgeon's experience and training.

Speed Notes

Key Points on Peptic Ulcer Disease (PUD)

  1. Most Common Indications for Surgery in PUD
    • Perforation: Most common indication for surgery.
    • Bleeding: Most common complication, but not the leading indication for surgery.
    • Gastric Outlet Obstruction: A significant indication but less common than perforation.
    • Refractory Disease: Uncommon indication.
  2. Complications of PUD
    • Most Common Complication: Bleeding.
    • Most Common Complication Requiring Surgery: Perforation.
    • Highest Mortality: Perforation.
  3. Recurrence Rates in Ulcer Surgery
    • Lowest Recurrence Rate: Vagotomy + Antrectomy.
    • Highest Recurrence Rate: Highly selective vagotomy (HSV).
    • Highest Complication Rate: Vagotomy + Antrectomy.
    • Lowest Morbidity: Highly selective vagotomy (HSV).
  4. Incidence of Marginal Ulcer
    • Highest Incidence: Roux-en-Y.
    • Bile Reflux: Least in Roux-en-Y, leading to higher incidence of marginal ulcers due to lack of alkaline bile.
    • Vagotomy Addition: Recommended in benign cases with Roux-en-Y to reduce marginal ulcers; not required in malignant cases.

Multiple Choice Questions (MCQs)

Answer: a. Perforation

Explanation:

  • Perforation is the most common indication for surgical intervention in patients with peptic ulcer disease due to its severity and high mortality rate.

Answer: a. Vagotomy + Antrectomy

Explanation:

  • Vagotomy combined with antrectomy has the lowest recurrence rate for ulcer surgery but also has the highest complication rate.

Answer: c. Roux-en-Y

Explanation:

  • Roux-en-Y has the highest incidence of marginal ulcers due to the least bile reflux. Bile is alkaline, and its absence leads to a higher rate of ulceration. Adding vagotomy in benign cases can help reduce this risk.

Summary Table

Aspect Details
Most Common Surgical Indication Perforation
Most Common Complication Bleeding
Complication Requiring Surgery Perforation
Highest Mortality Perforation
Lowest Recurrence Rate Vagotomy + Antrectomy
Highest Recurrence Rate Highly selective vagotomy (HSV)
Highest Complication Rate Vagotomy + Antrectomy
Lowest Morbidity Highly selective vagotomy (HSV)
Marginal Ulcer Incidence Highest in Roux-en-Y, due to least bile reflux

H Pylori

Pathogenesis of H. pylori-Induced Peptic Ulcer Disease (PUD)

Overview

Helicobacter pylori (H. pylori) is a major causative factor in the development of peptic ulcer disease (PUD). The pathogenesis involves a complex interplay between bacterial virulence factors and host responses, leading to disruption of the gastric and duodenal mucosal integrity. Here are the detailed mechanisms:

Discovery and Nobel Prize

  • Discovered by Barry Marshall and Robin Warren in 1984.
  • Marshall ingested H. pylori to prove its role in gastritis and PUD.
  • Both awarded the Nobel Prize in Medicine in 2005.

1. Bacterial Virulence Factors

  1. Urease Production:
    • H. pylori produces urease, which converts urea into ammonia and bicarbonate. This creates a local alkaline environment, allowing the bacteria to survive in the acidic stomach.
  2. Flagella and Spiral Shape:
    • The bacteria's flagella and spiral shape facilitate movement through the gastric mucus layer to the epithelial surface, evading acidic gastric juices.
  3. Adhesion to Gastric Epithelium:
    • H. pylori adheres to gastric epithelial cells via surface adhesins (e.g., BabA, SabA), enhancing colonization and persistence.
  4. Cytotoxins and Enzymes:
    • CagA (Cytotoxin-associated gene A): Strains carrying the cagA gene are more virulent. CagA is injected into host cells via a type IV secretion system, disrupting cellular functions and promoting inflammation.
    • VacA (Vacuolating cytotoxin A): Induces vacuole formation in epithelial cells, disrupting cellular processes and contributing to cell injury.
    • Mucinase, Phospholipases, and Proteases: Degrade mucus and epithelial cells, impairing the protective mucosal barrier.

2. Host Immune Response

  1. Local Inflammatory Response:
    • H. pylori infection triggers a local inflammatory response, recruiting neutrophils and monocytes to the gastric mucosa.
    • These immune cells release proinflammatory cytokines (e.g., IL-1β, IL-6, TNF-α) and reactive oxygen species (ROS), causing tissue damage.
  2. Immune Evasion:
    • H. pylori can modulate host immune responses to evade clearance. For example, it can alter dendritic cell function and skew T-cell responses towards a less effective Th1 or Th2 profile.
  3. Genetic Predisposition:
    • Host genetic factors, such as polymorphisms in genes encoding cytokines (e.g., IL-1β) and toll-like receptors (TLRs), influence the severity of the inflammatory response and susceptibility to PUD.

3. Disruption of Gastric Physiology

  1. Increased Gastrin Levels:
    • H. pylori infection, particularly in the antrum, inhibits somatostatin release from D cells. This leads to increased gastrin production from G cells, promoting acid hypersecretion.
  2. Altered Acid Secretion:
    • In the acute phase of infection, acid secretion may be decreased. Chronic infection, however, can lead to trophic effects on enterochromaffin-like (ECL) cells and G cells, resulting in acid hypersecretion.
    • If the infection leads to atrophic gastritis, particularly in the body of the stomach, acid secretion may eventually decrease due to loss of parietal cells.
  3. Gastric Metaplasia in the Duodenum:
    • Chronic acid hypersecretion can cause gastric metaplasia in the duodenum. H. pylori can colonize these areas of metaplasia, leading to inflammation (duodenitis) and increased risk of duodenal ulcers.

4. Complications

  1. Gastric and Duodenal Ulcers:
    • The combined effects of direct mucosal damage by bacterial products, the local inflammatory response, and acid hypersecretion contribute to the formation of gastric and duodenal ulcers.
  2. Gastric Cancer and MALT Lymphoma:
    • Chronic H. pylori infection is associated with an increased risk of gastric adenocarcinoma and mucosa-associated lymphoid tissue (MALT) lymphoma. The chronic inflammatory state and genetic alterations in the gastric mucosa play a critical role in carcinogenesis.

Summary Table

Pathogenic Mechanism Description
Urease Production Creates an alkaline microenvironment for bacterial survival.
Flagella and Spiral Shape Facilitates movement through mucus to epithelial surface.
Adhesion to Epithelium Surface adhesins (BabA, SabA) enhance colonization.
Cytotoxins (CagA, VacA) Disrupt cellular functions and promote inflammation.
Mucinase, Phospholipases, Proteases Degrade mucus and epithelial cells.
Local Inflammatory Response Recruitment of neutrophils, monocytes, and release of cytokines.
Immune Evasion Modulation of immune responses to avoid clearance.
Increased Gastrin Levels Inhibition of somatostatin, leading to acid hypersecretion.
Altered Acid Secretion Acute phase: decreased; Chronic phase: increased or decreased.
Gastric Metaplasia in Duodenum Promotes colonization and inflammation, increasing ulcer risk.
Complications Ulcers, gastric cancer, and MALT lymphoma.

Multiple Choice Questions (MCQs)

Answer: b. Incidence is 100% in duodenal ulcer and it colonizes acid-secreting body of the stomach.

Explanation:

  • Gram negative organism
  • Exclusive - gastric mucosa
  • 100% incidence in duodenal ulcer-colonises antrum—hyperacidity--gastric metaplasia in duodenum ; Sparing of body
  • 80-90% incidence in gastric ulcer- both body and antrum is equally affected - decreased acid production
  • Gastric Ulcer due- to decrease in defense against acid production

Diagnosis of Helicobacter pylori Infection

The diagnosis of H. pylori infection can be performed using various methods, both invasive and noninvasive. Here is a detailed explanation of each method and its use:

Invasive Tests

  1. Urease Assay
    • Procedure: Endoscopic biopsy specimens from the gastric body and antrum are tested for urease.
    • Sensitivity & Specificity: Greater than 90% sensitivity and 95%-100% specificity.
    • Usage: Rapid urease test kits can detect urease within 1 hour with similar diagnostic accuracy.
    • Note: Sensitivity is reduced in patients on PPIs, H2-receptor antagonists, or antibiotics.
  2. Histology
    • Procedure: Biopsy samples of gastric mucosa are visualized using stains such as hematoxylin-eosin, silver, Giemsa, or Genta.
    • Sensitivity & Specificity: Approximately 95% sensitivity and 99% specificity.
    • Usage: Most accurate test available, especially useful to assess the severity of gastritis and confirm H. pylori presence.
    • Note: Sensitivity is lowered in patients on PPIs or H2-receptor antagonists, but it remains the most accurate test available.
  3. Culture
    • Procedure: Culturing of gastric mucosa obtained at endoscopy.
    • Sensitivity & Specificity: Sensitivity approximately 80%, specificity 100%.
    • Usage: Provides the opportunity for antibiotic sensitivity testing.
    • Note: Requires laboratory expertise, is expensive, and diagnosis takes 3-5 days.

Noninvasive Tests

  1. Urea Breath Test
    • Procedure: Based on the ability of H. pylori to hydrolyze urea, producing labeled carbon dioxide that is measured in the breath.
    • Sensitivity & Specificity: Greater than 95%.
    • Usage: Recommended for monitoring treatment efficacy.
    • Note: Sensitivity reduced in patients on antisecretory medications and antibiotics. Patients should discontinue antibiotics for 4 weeks and PPIs for 2 weeks before testing.
  2. Stool Antigen Test
    • Procedure: Uses monoclonal antibodies to detect H. pylori antigens in fecal specimens.
    • Sensitivity & Specificity: Sensitivity greater than 90%, specificity 86%-92%.
    • Usage: Effective for detecting eradication after treatment and is cost-effective.
    • Note: Preferred for diagnosis and evaluation of treatment efficacy in PUD patients.
  3. Serology
    • Procedure: Tests for the presence of IgG antibodies to H. pylori.
    • Sensitivity & Specificity: 90% sensitivity, specificity varies between 76% and 96%.
    • Usage: Useful for initial diagnosis when endoscopy is not required.
    • Note: Cannot be used to assess response to therapy due to persistence of antibodies long after eradication.

MCQ and Explanation

Answer: B. Serology

Explanation

Serology is not used for the eradication of H. pylori infection. It is used primarily for the initial diagnosis but cannot confirm eradication after treatment because antibodies may remain elevated for a long time post-eradication.

Summary

Serology (Option B) is not used for the eradication of H. pylori infection. It is used for initial diagnosis but cannot confirm eradication after treatment. The other methods—Stool Antigen Test, Rapid Urease Test, and Urea Breath Test—are all used for diagnosis and confirmation of eradication of H. pylori infection.

Tests for Eradication are done 4 weeks after completion of H pylori therapy and patient should be Off PPI for 2 weeks and Antibiotics for 4 weeks

Summary Table of H. pylori Diagnostic Tests:

Test Type Test Name Sensitivity Usage
Invasive Tests Rapid Urease Assay >90% Detect urease in gastric biopsy specimens
Histology ~95% Visualize H. pylori in biopsy samples
Culture ~80% Diagnose and perform antibiotic sensitivity
Noninvasive Tests Urea Breath Test >95% Monitor treatment efficacy
Stool Antigen Test >90% Detect eradication after treatment
Serology 90% Initial diagnosis, not for eradication

Treatment Regimen for Helicobacter pylori Infection

First-Line Treatment Regimen

The first-line treatment regimen for H. pylori infection varies based on the patient's antibiotic resistance profile and any allergies. Here are the key regimens:

  1. Triple Therapy (10-14 days)
    • Components:
      • PPI BID
      • Amoxicillin 1 gm BID or Metronidazole 500 mg BID
      • Clarithromycin 500 mg BID
  2. Quadruple Therapy Option 1 (14 days)
    • Components:
      • PPI BID
      • Bismuth subsalicylate 524 mg QID
      • Metronidazole 250 mg QID
      • Tetracycline 500 mg QID or Doxycycline 100 mg BID
  3. Quadruple Therapy Option 2 (14 days)
    • Components:
      • PPI BID
      • Amoxicillin 1 gm BID
      • Metronidazole 500 mg BID
      • Clarithromycin 500 mg BID

Recommendations Based on Resistance Profiles

  1. High (>15%) Clarithromycin Resistance
    • Low Metronidazole Resistance:
      • PPI-Amoxicillin-Metronidazole triple therapy
    • Low Dual Clarithromycin and Metronidazole Resistance (<15%):
      • Bismuth quadruple or concomitant non-bismuth containing quadruple therapy
    • High Dual Clarithromycin and Metronidazole Resistance (>15%):
      • Bismuth-containing quadruple therapies
  2. Patients Without Penicillin Allergy, Prior Macrolide Exposure, or in Regions With >15% Clarithromycin Resistance
    • Options:
      • Bismuth quadruple therapy
      • Clarithromycin triple therapy
      • Concomitant regimen (PPI, Clarithromycin, Amoxicillin, Nitroimidazole)
  3. Patients Without Penicillin Allergy With Either Prior Macrolide Exposure or in Regions With >15% Clarithromycin Resistance
    • Option:
      • Bismuth quadruple therapy
      • Levofloxacin triple therapy (PPI, Levofloxacin, Amoxicillin)
  4. Patients With a Penicillin Allergy But Without Prior Macrolide Exposure
    • Options:
      • Bismuth quadruple therapy
      • Clarithromycin triple therapy with Metronidazole
  5. Patients With Both a Penicillin Allergy and Either Prior Macrolide Exposure or in Regions With >15% Clarithromycin Resistance
    • Option:
      • Bismuth quadruple therapy

Summary of Treatment Regimen

  • Triple Therapy includes PPI, Amoxicillin or Metronidazole, and Clarithromycin.
  • Quadruple Therapy options include a combination of PPI, Bismuth subsalicylate, Metronidazole, and either Tetracycline or Doxycycline.
  • Treatment choice depends on antibiotic resistance profiles and patient allergies.
  • For regions with high clarithromycin resistance, bismuth-based therapies are recommended.
  • Levofloxacin-based regimens are alternatives for certain resistance profiles.

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Key Points on Stress Ulcers

  1. Pathophysiology
    • Stress ulcers develop due to severe physiological stress and splanchnic hypoperfusion combined with gastric acid.
    • Reperfusion injury after restoration of splanchnic perfusion exacerbates the condition.
    • Typically starts in the fundus and spreads distally.
  2. Prophylactic Measures
    • Prophylactic proton pump inhibitors (PPIs) and histamine H2-receptor antagonists are effective in preventing significant bleeding in patients at risk.
    • The primary goal is to prevent clinically important bleeding by identifying at-risk patients and administering appropriate prophylactic measures.
  3. Risk Factors for Stress Ulcer-Related Bleeding (Box 59.2) = Use Prophylactic PPI’s
    • Respiratory failure requiring mechanical ventilation >48 hours.
    • Coagulopathy or anticoagulation.
    • Acute renal insufficiency.
    • Acute hepatic failure.
    • Sepsis.
    • Hypotension.
    • Brain or spinal cord injury.
    • History of gastrointestinal bleeding.
    • Low intragastric pH.
    • Burn involving >35% of body surface area.
    • Major operation (>4 hours).
    • High-dose corticosteroids (>250 mg/day hydrocortisone or equivalent).

Multiple Choice Question (MCQ)

Answer: c. All patients on mechanical ventilation

Explanation:

  • Prophylactic PPI is not universally indicated for all patients on mechanical ventilation unless they have additional risk factors.

Management of Stress Ulcers

  1. First Line of Intervention: Esophagogastroduodenoscopy (EGD)
    • Helps with diagnosis but may be unsuccessful due to diffuse nature of bleeding.
  2. Angiography:
    • Considered in patients who fail endoscopic intervention.
    • Facilitates embolization of the bleeding vessel(s) or selective vasopressin infusion to reduce bleeding.
  3. Operative Intervention:
    • Last resort in patients who fail both endoscopic and angiographic interventions.

Refractory vs Recurrent Ulcer

Definition:

  • Refractory : 5 mm,not healing after 12 weeks of PPI
  • Recurrent: 5 mm, reappearing within 12 months of eradication

Acid Reducing Procedures

Truncal Vagotomy (TV)

Truncal vagotomy (TV) is a surgical procedure that involves the division of the main trunks of the vagus nerve to decrease gastric acid secretion, primarily used in the treatment of peptic ulcer disease (PUD).

Procedure

  • Division of Vagus Nerves: TV involves the division of the anterior and posterior vagal trunks below the diaphragm. The vagus nerves are identified and isolated, typically at the gastroesophageal junction, and segments of the nerves are resected to ensure complete vagotomy.
  • Drainage Procedure: Because TV disrupts pyloric relaxation, a drainage procedure, such as pyloroplasty or gastrojejunostomy, is often performed concurrently to prevent gastric stasis and promote gastric emptying.

Physiologic Changes Post-TV

  • Decreased Acid Secretion:
    • Basal Acid Output: Decreases by approximately 75%.
    • Maximal Acid Secretion: Decreases by approximately 50%.
  • Loss of Receptive Relaxation: The stomach loses its ability to relax in response to swallowing, leading to altered gastric motility.
  • Gastric Emptying:
    • Liquids: Emptying is accelerated due to loss of reflex relaxation of the gastric fundus.
    • Solids: Emptying is delayed, resulting in potential gastric stasis.
  • Increased Serum Gastrin Levels: Due to the loss of negative feedback mechanisms, serum gastrin levels increase, which can lead to gastrin cell hyperplasia.

Clinical Implications

  • Complications: Patients may experience complications such as gastric atony, chronic abdominal pain, and distention due to impaired gastric motility.
  • Ulcer Recurrence: The recurrence rate of ulcers after TV combined with a drainage procedure is generally lower compared to other surgical treatments, but postoperative complications such as dumping syndrome and diarrhea can occur.

Comparison with Other Vagotomies

  • Selective Vagotomy (SV): Divides the vagus nerves just distal to the celiac and hepatic branches but has higher ulcer recurrence rates and does not offer significant advantages in reducing post-gastrectomy symptoms compared to TV.
  • Highly Selective Vagotomy (HSV): Also known as parietal cell vagotomy or proximal gastric vagotomy, it preserves vagal innervation to the antrum and pylorus, eliminating the need for drainage procedures and resulting in fewer postoperative complications but higher ulcer recurrence rates.

Historical Context

  • TV has been largely supplanted by less invasive medical treatments for PUD, particularly with the advent of effective H. pylori eradication therapies and proton pump inhibitors (PPIs). However, it remains a viable option for patients with intractable ulcer disease or those who cannot tolerate medical therapy.

Multiple Choice Question Analysis

Answer: B. Decreased serum gastrin levels

  • This is the correct answer because after a truncal vagotomy, serum gastrin levels typically increase rather than decrease. The other options accurately describe the physiological changes that occur after the procedure.

Summary of Changes Post-Truncal Vagotomy

  • Basal Acid Secretion: 75% decrease
  • Maximal Acid Secretion: 50% decrease
  • Receptive Relaxation: Lost
  • Liquid Emptying: Increased
  • Solid Emptying: Decreased
  • Serum Gastrin: Increased

Highly Selective Vagotomy (HSV)

Highly Selective Vagotomy (HSV), also known as parietal cell vagotomy or proximal gastric vagotomy, is a surgical procedure aimed at reducing acid secretion in the stomach while preserving the motor function of the stomach and pylorus. This operation targets only the vagus nerve branches that innervate the acid-producing part of the stomach, sparing the nerves that affect gastric motility.

Procedure Details

  • Nerve Division: The procedure involves severing the branches of the vagus nerve that innervate the corpus and fundus of the stomach. These branches are located along the lesser curvature of the stomach.
  • Preservation of Motor Function: The hepatic and celiac branches, as well as the distal vagal branches extending to the antrum and pylorus, are preserved to maintain normal gastric emptying and motility.
  • Crow's Feet Nerves: The nerves of Latarjet are identified and the crow's feet nerves innervating the fundus and body are divided. This division is carried up to about 7 cm proximal to the pylorus.

Physiologic Changes Post-HSV

  • Acid Secretion:
    • Basal Acid Output: Reduced by more than 75%.
    • Maximal Acid Output: Reduced by about 50%.
  • Gastric Emptying:
    • Liquids: Slightly increased emptying due to division of nerves affecting receptive relaxation.
    • Solids: Normal emptying as the motor innervation is preserved.
  • Serum Gastrin Levels: Typically increased due to loss of negative feedback mechanisms on gastrin secretion.

Clinical Implications

  • Ulcer Recurrence: Recurrence rates vary and depend on the surgeon's skill and the length of follow-up. Rates are reported between 5% and 20%.
  • Postoperative Complications: Lower incidence of complications such as dumping syndrome and diarrhea compared to truncal vagotomy with drainage procedures.
  • Not Suitable for Prepyloric Ulcers: HSV is not the operation of choice for prepyloric ulcers because it may not adequately reduce acid secretion in these cases.

Special Procedures

  • Hill-Baker Procedure: Combines posterior truncal vagotomy with anterior highly selective vagotomy.
  • Taylor Procedure: Combines posterior truncal vagotomy with anterior lesser curve seromyotomy.

Multiple Choice Question Analysis

Answer: A and B

  • Option A: Incorrect. Crow foot nerves of the antrum are not divided in HSV; only the nerves innervating the corpus and fundus are targeted.
  • Option B: Incorrect. HSV is not the operation of choice for prepyloric ulcers But TV + antrectomy is.
  • Option C: Correct. Recurrence rate is indeed 5-20%.
  • Option D: Correct. The Taylor procedure involves posterior vagotomy and anterior HSV.

Summary of HSV

  • Basal Acid Output: Reduced by 75%
  • Maximal Acid Output: Reduced by 50%
  • Recurrence Rate: Highest among vagotomy procedures (5-20%)
  • Suitability: Not suitable for prepyloric ulcers
  • Hill-Baker Procedure: Posterior TV + Anterior HSV
  • Taylor Procedure: Posterior TV + Anterior lesser curve seromyotomy
  • Morbidity: Least among vagotomy procedures due to preservation of motor function

Giant Duodenal Ulcer (GDU)

Giant duodenal ulcer (GDU) is defined as a benign duodenal ulcer that measures at least 2 cm in diameter. Here are the detailed characteristics and considerations for GDU:

Characteristics

  • Size: GDUs are defined by their size, being more than 2 cm in diameter.
  • Etiology:
    • GDUs are less often associated with H. pylori infection compared to standard-size duodenal ulcers.
    • NSAID use plays a more prominent role in their development.
  • Malignancy Risk: There is an approximate 19% risk of malignancy associated with GDUs, necessitating careful biopsy and evaluation to rule out cancer.
  • Clinical Presentation: Patients often present with epigastric pain that may radiate to the back, particularly when the ulcer penetrates into the pancreas. Complications may include bleeding, perforation, and obstruction.

Diagnosis

  • Upper Endoscopy: This is essential for diagnosing GDU and distinguishing it from other types of ulcers or malignancies. The ulcer typically involves more than 50% of the duodenal bulb circumference.
  • Biopsy: It is critical to perform a biopsy to rule out cancer, given the risk of malignancy in GDUs.

Treatment

  • First-Line Treatment:
    • Use of proton pump inhibitors (PPIs).
    • Eradication of H. pylori if present.
    • Discontinuation of NSAIDs.
  • Confirmation of Healing: This includes noninvasive tests such as the urea breath test and repeat endoscopy to confirm healing within 8 to 12 weeks.

Surgical Intervention

  • Indications for Surgery:
    • Hemorrhage that persists despite maximum endoscopic intervention.
    • Perforation.
    • Gastric outlet obstruction.
    • Intractability or recurrent disease despite maximum medical therapy.
  • Surgical Options:
    • Antrectomy and Vagotomy: Recommended for refractory ulcers. [ Antrectomy is added in cases of GDU when compared to small sized DU]
    • Billroth II Reconstruction: Often performed when there is significant inflammation and scarring.
    • Duodenostomy Tube: Can be used in cases of difficult duodenal stump, providing a safe and effective means of dealing with postoperative complications.

Multiple Choice Question Analysis

Answer: B. Usually associated with H. pylori

  • Option A: Correct. GDUs are defined as ulcers larger than 2 cm.
  • Option B: Incorrect. GDUs are less often associated with H. pylori infection, and more with NSAID’s.
  • Option C: Correct. GDUs have a malignancy risk of approximately 19%.
  • Option D: Correct. Antrectomy combined with vagotomy is often recommended for refractory GDUs.

MCQ

Answer: C. Pyloromyotomy + Hemostasis + Antrectomy + Vagotomy

Explanation: Given the patient's continued bleeding despite endoscopic intervention and the presence of a large 3 cm duodenal ulcer, a more aggressive surgical approach is warranted:

  • Antrectomy removes the gastrin-producing part of the stomach, which significantly reduces acid production and decreases the likelihood of recurrent ulcers.
  • Vagotomy further reduces acid secretion by severing the vagus nerve fibers that stimulate acid production.
  • Pyloromyotomy and hemostasis are necessary to control the immediate bleeding.

Methods for Managing a Difficult Duodenal Stump

Difficult duodenal stump management is a critical consideration in gastrointestinal surgery, particularly following gastrectomy or when dealing with complex ulcer cases. Here are the standard methods used to manage a difficult duodenal stump:

  1. Nissen's Closure:

    • This technique involves anastomosing the duodenal stump to the pancreatic capsule or to the duodenal wall left in place on the pancreatic capsule. It is used when the duodenum is heavily scarred to the pancreatic capsule.

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  2. Bancroft Closure:

    • Bancroft closure involves transecting the stomach proximal to the pylorus where the tissue is less fibrotic. The duodenal stump is managed by securing the gastric mucosa with a purse-string suture, and the healthy seromuscular layer is closed over the stump, which is away from scarred duodenum proximally.

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  3. Tube Duodenostomy:

    • This method involves the insertion of a tube through the second portion of the duodenum to create a controlled fistula. It helps by taking pressure off the stump and allowing for healing.

Multiple Choice Question Analysis

Answer: D. Sump closure

  • Option A: Correct. Nissen's closure is a valid method.
  • Option B: Correct. Bancroft closure is a valid method.
  • Option C: Correct. Tube duodenostomy is a valid method.
  • Option D: Incorrect. Sump closure is not a recognized method for managing a difficult duodenal stump.

Refractory Duodenal Ulcer

Refractory duodenal ulcers are defined as ulcers that do not heal after 8 to 12 weeks of appropriate medical therapy, including eradication of H. pylori and the use of proton pump inhibitors (PPIs). Here is a detailed explanation based on the context provided:

Definition and Characteristics

  • Refractory Ulcer: An ulcer greater than 5 mm in diameter that does not heal after 12 weeks of PPI therapy.
  • Recurrent Ulcer: An ulcer that redevelops within 12 months after complete healing documented by endoscopy.

Initial Evaluation

  • Biopsy: Perform endoscopy with adequate biopsy of the ulcer edge and base to rule out malignancy.
  • Gastrinoma: Measure fasting serum gastrin levels to rule out gastrinoma (Zollinger-Ellison syndrome).
  • Calcium Levels: Measure total serum calcium to screen for hyperparathyroidism.
  • Medications: Review and eliminate ulcerogenic medications such as NSAIDs and aspirin.
  • H. pylori: Confirm eradication of H. pylori using tests like urea breath test or stool antigen test. Ensure the patient has been off PPIs for at least 2 weeks to avoid false-negative results.

Management of Refractory Ulcers

  • Persistent Symptoms: For patients who continue to have symptoms despite appropriate medical therapy:
    • Biopsy of Ulcer: Essential to rule out malignancy.
    • Urea Breath Test: Confirm eradication of H. pylori.
    • Smoking Cessation: Chronic smoking can contribute to ulcer persistence, and cessation should be advised.
  • Surgical Options: Considered when medical therapy fails, or complications arise:
    • Highly Selective Vagotomy (HSV): Preserves gastric motility but has higher recurrence rates.
    • Truncal Vagotomy and Antrectomy (TV + Antrectomy): Reduces acid secretion more effectively and is often used for refractory ulcers.
    • Truncal Vagotomy and Drainage (TV + Drainage): Used when antrectomy is not performed, requires an additional drainage procedure to prevent gastric stasis.

Multiple Choice Question Analysis

Answer: A. Biopsy of ulcer, urea breath test, Smoking cessation

  • Option A: Correct. The first step should be to re-evaluate the patient to rule out malignancy, confirm H. pylori eradication, and address smoking cessation.
  • Option B: Incorrect. HSV can be considered later if initial re-evaluation and medical management fail.
  • Option C: Incorrect. TV + Antrectomy is a surgical option but should follow a thorough re-evaluation.
  • Option D: Incorrect. TV + Drainage is also a surgical option but should not be the immediate next step without re-evaluation.

Summary

For a patient with a refractory duodenal ulcer who has persistent symptoms despite 12 weeks of appropriate therapy:

  1. Re-evaluate to rule out malignancy, confirm H. pylori eradication, and address any ongoing risk factors such as smoking.
  2. Consider surgical options ONLY if the ulcer persists despite thorough re-evaluation and continued medical management.

Management Algorithm for Duodenal Ulcer

Initial Management

  1. Medical Therapy:
    • PPIs and H. pylori Eradication: Standard initial treatment includes proton pump inhibitors (PPIs) and a combination of antibiotics to eradicate H. pylori. Common regimens include triple therapy (PPI + amoxicillin + clarithromycin) or quadruple therapy (PPI + bismuth + metronidazole + tetracycline).
    • Lifestyle Modifications: Discontinuation of NSAIDs, smoking cessation, and avoidance of alcohol.
  2. Follow-Up:
    • Confirmation of H. pylori Eradication: Non-invasive tests such as urea breath test or stool antigen test.
    • Repeat Endoscopy: To confirm ulcer healing and rule out malignancy.

Complicated Duodenal Ulcers

  1. Bleeding Ulcer:
    • Initial Management:
      • IV Access and Fluid Resuscitation: Establish large-bore IV access and initiate fluid resuscitation.
      • IV PPI Therapy: Administer IV PPIs to reduce gastric acidity.
      • Endoscopy: Perform upper endoscopy within 24 hours for diagnosis and therapeutic intervention (e.g., hemostasis via coagulation, clipping, or injection therapy).
    • Refractory Bleeding:
      • Surgical Intervention: Indicated if endoscopic hemostasis fails or if there is recurrent bleeding. Options include oversewing the bleeding vessel and adding a definitive acid-reducing procedure such as truncal vagotomy with pyloroplasty.
  2. Perforated Ulcer:
    • Initial Management:
      • Empiric Antibiotics: Broad-spectrum antibiotics covering gram-negative rods, anaerobes, and oral flora.
      • Surgical Consultation: Immediate surgical consultation for emergent management.
      • Imaging: Chest X-ray or CT scan to confirm perforation (free air in the abdomen).
    • Surgical Repair:
      • Simple Patch Closure: Primary closure with an omental patch (Graham patch).
      • Acid-Reducing Surgery: Consider adding a definitive acid-reducing procedure (e.g., vagotomy) during the repair to prevent recurrence.
  3. Gastric Outlet Obstruction:
    • Initial Management:
      • Nasogastric Decompression: Placement of an NG tube for gastric decompression.
      • IV Fluids and Electrolyte Correction: Correct fluid and electrolyte imbalances.
      • Endoscopic Evaluation: Perform upper endoscopy to evaluate and dilate the obstruction if feasible.
    • Refractory Obstruction:
      • Surgical Intervention: Primary antrectomy and reconstruction with vagotomy. Alternative options include vagotomy with gastrojejunostomy or Jaboulay gastroduodenostomy.

Surgical Management for Refractory Ulcers

  • Indications for Surgery:
    • Failure of medical therapy after 8-12 weeks.
    • Recurrent ulceration despite medical management.
    • Complications such as bleeding, perforation, or obstruction that cannot be managed endoscopically.
    • Inability to rule out malignancy despite negative biopsies.
  • Surgical Options:
    • Truncal Vagotomy and Antrectomy: Effective for reducing acid secretion and treating refractory ulcers.
    • Highly Selective Vagotomy (HSV): Preserves gastric motility but has higher recurrence rates.
    • Truncal Vagotomy and Drainage Procedures: Used when antrectomy is not performed, often combined with a pyloroplasty.

Drainage Procedures for Duodenal Ulcer Management

Drainage procedures are critical surgical techniques used to manage complications of duodenal ulcers, particularly in cases where vagotomy is performed to prevent gastric stasis. Here are the details from the background context:

Types of Drainage Procedures

  1. Heineke-Mikulicz Pyloroplasty:
    • Procedure: A longitudinal incision is made on the pylorus, which is then closed transversely to widen the pyloric canal.
    • Indication: Commonly performed when the pylorus is scarred but still relatively pliable.
    • Advantages: Simple to perform and effective in preventing gastric stasis.
  2. Finney Pyloroplasty:
    • Procedure: A larger incision than the Heineke-Mikulicz, creating a new, larger pyloric channel.
    • Indication: Used when there is significant scarring or deformity that needs more extensive widening.
    • Advantages: Provides a larger lumen but is more technically demanding and has a higher complication potential.

  3. Jaboulay Gastroduodenostomy:

    • Procedure: Bypasses the pylorus by creating an anastomosis between the stomach and the first part of the duodenum.
    • Indication: Used primarily when the pylorus is severely scarred or deformed, making traditional pyloroplasty unsafe.
    • Advantages: Avoids transecting the pyloric muscle but has a risk of bile reflux as the anastomosis is close to the ampulla of Vater.

  4. Gastrojejunostomy:

    • Procedure: Creates a direct connection between the stomach and the jejunum, bypassing the duodenum.
    • Indication: Used when the duodenal bulb is severely scarred or inflamed, and a pyloroplasty or gastroduodenostomy is technically demanding.
    • Advantages: Effective in relieving obstruction and preventing gastric stasis but may cause bile reflux and marginal ulcers if vagotomy is not performed.

Summary

  • Heineke-Mikulicz Pyloroplasty: Simple, effective, less technically demanding.
  • Finney Pyloroplasty: Larger lumen, more complex, higher risk of complications.
  • Jaboulay Gastroduodenostomy: Bypasses pylorus, risk of bile reflux.
  • Gastrojejunostomy: Bypasses duodenum, effective for severe cases, risk of bile reflux and marginal ulcers.

Modified Johnson Classification of Gastric Ulcers

Types of Gastric Ulcers and Treatment Options

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Type I Gastric Ulcer = Most Common

  • Location: Lesser curvature at the incisura
  • Acid Secretion: Low to normal
  • Treatment of Choice:
    • Distal Gastrectomy with Billroth I or II Reconstruction: Removes the ulcer and the diseased antrum.
    • Alternative: Distal gastrectomy with Roux-en-Y gastrojejunostomy to avoid bile reflux gastritis but may have delayed gastric emptying.

Type II Gastric Ulcer

  • Location: Gastric body with duodenal ulcer
  • Acid Secretion: Increased
  • Treatment of Choice:
    • Vagotomy and Antrectomy: Preferred approach due to increased acid secretion.
    • Biopsy: Preoperative endoscopy with biopsy to rule out malignancy.

Type III Gastric Ulcer

  • Location: Prepyloric region (within 2-3 cm of pylorus)
  • Acid Secretion: Increased
  • Treatment of Choice:
    • Vagotomy and Antrectomy: Most prudent approach due to high acid secretion and potential for malignancy.
    • HSV: Not recommended due to high recurrence rates.

Type IV Gastric Ulcer

  • Location: High on lesser curve, near gastroesophageal junction
  • Acid Secretion: Normal
  • Treatment of Choice:
    • Distal Gastrectomy: To remove the ulcer and prevent recurrence.
    • Vagotomy: Added if high acid secretion is a concern.

Type V Gastric Ulcer

  • Location: Anywhere in the stomach, typically medication-induced (NSAIDs)
  • Acid Secretion: Normal
  • Treatment of Choice:
    • Discontinuation of Offending Medications: Primary treatment.
    • PPIs: For managing symptoms and promoting healing.

Algorithm for Management of Complicated Gastric Ulcer Disease (Fig. 49.10)

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  1. Stable Patient:
    • Perforation: Antrectomy to include ulcer (+ vagotomy for Type II and III).
    • Obstruction: Surgical bypass, ulcer biopsy.
    • Bleeding: Oversew bleeding, ulcer biopsy.
  2. Patient Unstable or Medically Unfit for Resection:
    • Perforation: Graham patch closure, ulcer biopsy.
    • Obstruction: Surgical bypass, ulcer biopsy.
    • Bleeding: Oversew bleeding, ulcer biopsy.

Multiple Choice Question Analysis

Answer: A. Antrectomy + Vagotomy

  • Option A: Correct. Antrectomy combined with vagotomy is the most effective treatment for refractory type III gastric ulcers due to high acid secretion.
  • Option B: Incorrect. HSV is not suitable for ulcers with high acid secretion.
  • Option C: Incorrect. Vagotomy with biopsy and drainage is not the primary treatment choice.
  • Option D: Incorrect. Long-term PPI therapy is initially used but not for refractory cases requiring surgical intervention.

Summary of Ulcer Types and Treatments

  1. Type I: Lesser curvature ulcers - Distal gastrectomy with Billroth I or II, or Roux-en-Y reconstruction.
  2. Type II: Gastric body with duodenal ulcer - Vagotomy and Antrectomy.
  3. Type III: Prepyloric ulcers - Vagotomy and Antrectomy.
  4. Type IV: High lesser curvature ulcers - Distal gastrectomy with consideration of vagotomy.
  5. Type V: Medication-induced ulcers - Discontinuation of medications, PPI

Surgical Procedures for Type IV Gastric Ulcers

Type IV Gastric Ulcers

  • Location: High along the lesser curvature, close to the gastroesophageal junction.
  • Characteristics: Associated with gastric hyposecretion, presents early with dysphagia and reflux. Large size and surrounding inflammation make operative management challenging.

Procedures

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  1. Pauchet Procedure:
    • Description: Modification of the Schoemaker procedure involving lower gastrectomy and excision of the ulcer.
    • Indication: Recommended for ulcers 5 cm below the cardia.
    • Extent: Involves resection of the ulcer.
  2. Kelling-Madlener Procedure:
    • Description:
    • Indication: Used to manage type IV gastric ulcers without removing the ulcer itself.
    • Recurrence: High ulcer recurrence rate.
  3. Csendes Procedure:
    • Description: Near-total gastrectomy with Roux-en-Y esophagogastrojejunostomy for reconstruction. The operation removes the high gastric ulcer while preserving the esophageal mucosa.
    • Indication: Recommended for ulcers within 2 cm of the cardia.
    • Extent: Involves resection of the ulcer.
  4. Schoemaker Procedure:
    • Description: Modification of Billroth I resection with tube-shaped resection of high gastric ulcers and anastomosis of the duodenum to the greater curvature side of the stomach.
    • Indication: Used when subtotal resection is needed to avoid total gastrectomy.
    • Extent: Involves resection of the ulcer.

Multiple Choice Question Analysis

Answer: A. Kelling-Madlener

  • Option A (Kelling-Madlener): Correct. This procedure involves antrectomy without resecting the ulcer.
  • Option B (Csendes): Incorrect. This procedure involves near-total gastrectomy and resection of the ulcer.
  • Option C (Schoemaker): Incorrect. This procedure involves tube-shaped resection of the ulcer.
  • Option D (Pauchet): Incorrect. This procedure involves lower gastrectomy and resection of the ulcer.

Summary

  • Kelling-Madlener Procedure: Does not involve resection, has a high ulcer recurrence rate.
  • Csendes Procedure: Involves resection, near-total gastrectomy, and Roux-en-Y reconstruction.
  • Schoemaker Procedure: Involves resection, tube-shaped resection, and anastomosis.
  • Pauchet Procedure: Involves resection, lower gastrectomy, and excision of the ulcer.

Current indications for operation for peptic ulcer hemorrhage include 1. Hemodynamic instability despite vigorous resuscitation

(>4 units or >6 units taking into consideration the patient’s age, with more transfusion tolerated for the younger patient)

  1. Failure of endoscopic techniques to arrest hemorrhage
  2. Recurrent hemorrhage after initial stabilization (with up to two attempts at obtaining endoscopic hemostasis)
  3. Shock associated with recurrent hemorrhage

  4. Continued slow bleeding with a transfusion requirement

    exceeding 3 units per day

  5. GDU

Complications of Peptic Ulcer disease

Bleeding

Indications for Surgical Intervention in Peptic Ulcer Hemorrhage

Surgery for peptic ulcer hemorrhage is indicated under the following circumstances:

  1. Hemodynamic instability despite vigorous resuscitation (requiring >4 units or >6 units of transfusion considering the patient’s age).
  2. Failure of endoscopic techniques to arrest hemorrhage.
  3. Recurrent hemorrhage after initial stabilization (with up to two attempts at endoscopic hemostasis).
  4. Shock associated with recurrent hemorrhage.
  5. Continued slow bleeding with a transfusion requirement exceeding 3 units per day.
  6. Gastroduodenal ulcer (GDU).

Secondary or relative indications include rare blood type or difficult crossmatch, refusal of transfusion, shock on presentation, advanced age, severe comorbid disease, and bleeding chronic gastric ulcer. Elderly patients poorly tolerate prolonged resuscitation, large-volume transfusion, and periods of hypotension, necessitating a lower surgical threshold.

The mortality rate for bleeding PUD is approximately 6%, with most deaths due to non-bleeding-related causes, such as multiple organ system failure. Thus, the focus should be on appropriate management to avoid organ failure.

Surgical Procedures

Bleeding Duodenal Ulcer (DU):

  1. Control of Bleeding Site: The primary goal is to control the bleeding. If endoscopy has failed to identify the hemorrhage source, a longitudinal pyloroduodenotomy is necessary to inspect the duodenal bulb and gastric antrum.
  2. Suture Ligature: The gastroduodenal artery, a common source of bleeding, is controlled by suture ligatures.
  3. Acid-Reducing Operation: Although the necessity of vagotomy has been questioned, it is often recommended for patients with bleeding DU because:
    • Only 40% to 70% of bleeding DU patients are H. pylori positive.
    • H. pylori testing is less reliable during acute hemorrhage.
    • Without an acid-reducing procedure, up to 50% of patients risk recurrent bleeding.
  4. Procedure: The most common operation is truncal vagotomy (TV) with pyloroplasty (usually Heineke-Mikulicz pyloroplasty). The pyloroplasty allows inspection of the duodenal mucosa for active bleeding or ulceration.

Bleeding Gastric Ulcer (GU):

  1. Distal Gastrectomy: Preferred procedure for Type I and IV, with ulcer excision and B I or II reconstruction, allowing for excision and histologic evaluation of the ulcer to rule out malignancy.
  2. Vagotomy + Antrectomy: In high-risk patients or in ulcers due to high acid secretion (types II and III), a vagotomy may be added.

MCQ and Explanation

Answer: D. Oversewing of ulcer + Anti H pylori treatment

Explanation:

  • Antrectomy + Vagotomy (A): This is an appropriate procedure for a bleeding duodenal ulcer, especially if there is high acid secretion.
  • Highly Selective Vagotomy (B): Suitable for reducing acid secretion while preserving antral and pyloric function.
  • Truncal Vagotomy + Drainage (C): A standard procedure for bleeding duodenal ulcers to reduce acid secretion.
  • Oversewing of Ulcer + Anti H pylori Treatment (D): While anti-H. pylori treatment is essential, oversewing alone without addressing acid secretion (e.g., vagotomy or other definitive acid-reducing surgery) is not sufficient for long-term management and prevention of recurrent bleeding.

Thus, the correct answer is D. Oversewing of the ulcer along with anti-H. pylori treatment alone is not sufficient and is therefore inappropriate compared to the other surgical options.

Background Knowledge on Bleeding Duodenal Ulcers

  1. H. pylori Association
    • Approximately 40% to 70% of patients with bleeding duodenal ulcers are positive for H. pylori.
    • H. pylori testing is less reliable during acute hemorrhage, with false-negative rates being higher during active bleeding.
  2. Risk of Rebleeding
    • Without an acid-reducing procedure, up to 50% of patients are at risk of recurrent bleeding.
    • Acid-reducing procedures such as vagotomy are often recommended to decrease this risk.
  3. Mortality Risk
    • The mortality risk associated with bleeding peptic ulcers (including duodenal ulcers) is approximately 5% to 10%. This risk is influenced by factors such as patient comorbidities, age, and the effectiveness of initial resuscitation and treatment.
  4. H. pylori Eradication
    • Eradicating H. pylori is crucial as it significantly reduces the rate of ulcer recurrence and subsequent rebleeding.
    • The exact percentage reduction in rebleeding rates due to H. pylori eradication can vary, but a commonly cited figure is that eradication reduces the rebleeding rate by about 50% to 70%. The figure of 80% reduction is an overestimation.

MCQ and Explanation

Answer: D. H. pylori eradication reduces the rate of rebleeding by 80%

Explanation:

  • A. 40-70% of patients are associated with H. pylori: This is true as 40% to 70% of patients with bleeding duodenal ulcers are positive for H. pylori.
  • B. 50% risk of rebleed if acid-reducing procedure is not done: This is true. Without an acid-reducing procedure, up to 50% of patients are at risk of recurrent bleeding.
  • C. Mortality risk is 5-10%: This is true. The mortality risk for bleeding peptic ulcers is approximately 5% to 10%.
  • D. H. pylori eradication reduces the rate of rebleeding by 80%: This is false. While H. pylori eradication significantly reduces the rebleeding rate, it does not reduce it by 80%. The reduction is more accurately in the range of 50% to 70%.

Thus, the statement that H. pylori eradication reduces the rate of rebleeding by 80% is an overestimation and is the correct answer for the exception in the given options.

Management of Ulcer Perforation

Key Factors Influencing Outcomes in Ulcer Perforation

  • Smoking and NSAIDs are important etiologic factors.
  • Increased rate of perforation is noted, particularly in older women.
  • Factors affecting outcomes include:
    1. Time delay to presentation and treatment.
    2. Site of perforation: Gastric perforation has a poorer prognosis.
    3. Patient’s age: Older patients with comorbidities have worse outcomes.
    4. Presence of hypotension at presentation (systolic blood pressure <100 mm Hg).

Conservative Management

  • Nonoperative management can be considered if a water-soluble contrast study confirms that the ulcer is sealed with no extravasation.
  • Indications for nonoperative management include:
    1. Stable patients with perforation >24 hours.
    2. Significant comorbidities that increase surgical risk.
    3. Close monitoring for signs of sepsis.
  • Contraindications: Perforated gastric ulcers due to higher risk of complications and re-perforation are generally managed surgically.

Surgical Management of Perforated Duodenal Ulcers

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  1. Initial Steps in Surgery
    • Control of Bleeding: Primary goal is to control the bleeding site.
    • Debridement and Lavage: Cleansing the abdomen of debris and contamination.
  2. Surgical Techniques
    • Simple Patch Closure:
      • Procedure: A midline laparotomy is performed, and the perforation is identified and closed with a simple omental patch.
      • Steps:
        • Silk or polydioxanone sutures are placed across the perforation, tied over an omental pedicle to secure it in place.
        • Ensures full-thickness bites to prevent suture cut-through.
        • Thorough irrigation of the peritoneal cavity with warm saline is performed.
      • Indications: Appropriate for patients with acute NSAID-related perforation, or those without prior PUD treatment.
    • Truncal Vagotomy (TV) with Pyloroplasty:
      • Procedure: Involves a vagotomy to reduce acid secretion and a pyloroplasty to facilitate gastric emptying.
      • Steps:
        • The pylorus is opened longitudinally, and the bleeding site (often the gastroduodenal artery) is controlled.
        • The vagus nerves are cut to reduce acid production.
        • The pyloroplasty incision is closed transversely.
      • Indications: Recommended for patients with a history of recurrent ulcers or those who have been treated for H. pylori.
  3. Laparoscopic Repair
    • Procedure: Minimally invasive approach similar to the open procedure.
    • Steps:
      • Diagnostic laparoscopy is performed.
      • The perforation is patched using sutures and an omental pedicle.
      • Peritoneal lavage is performed to clean the abdominal cavity.
    • Indications: Suitable for stable patients; reduces hospital stay and postoperative pain.
    • Conversion to Open Surgery: Indicated in cases of generalized peritonitis or if the perforation is located posteriorly.
  4. Postoperative Management
    • H. pylori Eradication: Patients should receive appropriate antibiotic therapy to eradicate H. pylori.
    • Proton Pump Inhibitors (PPIs): Long-term PPI therapy to reduce acid production.

Surgical Management of Perforated Gastric Ulcers

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  1. Initial Steps in Surgery
    • Control of Perforation: Immediate identification and control of the perforation site.
    • Debridement and Lavage: Cleansing the abdominal cavity of debris and contamination.
  2. Surgical Techniques
    • Partial Gastrectomy:
      • Procedure: Involves the removal of the perforated portion of the stomach.
      • Steps:
        • The stomach is resected, including the perforated ulcer.
        • Reconstruction is performed via Billroth I (gastroduodenostomy) or Billroth II (gastrojejunostomy).
      • Indications: Preferred for types I and IV gastric ulcers unless the patient is high-risk due to comorbidities.
    • Patch Closure with Biopsy:
      • Procedure: For high-risk patients, involves closing the perforation with an omental patch and taking biopsies.
      • Steps:
        • Similar to the patch closure for duodenal ulcers.
        • Biopsies are taken from the ulcer to rule out malignancy.
      • Indications: Used when a more extensive resection is contraindicated due to patient instability or severe comorbidities.
  3. Specific Management Based on Ulcer Type
    • Type I Gastric Ulcers:
      • Typically managed with partial gastrectomy unless contraindicated.
    • Type II Gastric Ulcers:
      • Managed similarly to duodenal ulcers with patch closure, biopsy, and appropriate H. pylori eradication.
    • Type III Gastric Ulcers:
      • Antrectomy with vagotomy is preferred due to high risk of gastric outlet obstruction with patch repair alone.
  4. Laparoscopic Repair
    • Procedure: Minimally invasive approach similar to the open procedure.
    • Steps:
      • Diagnostic laparoscopy is performed.
      • The perforation is patched using sutures and an omental pedicle.
      • Peritoneal lavage is performed to clean the abdominal cavity.
    • Indications: Suitable for stable patients; reduces hospital stay and postoperative pain.
    • Conversion to Open Surgery: Indicated in cases of generalized peritonitis or if the perforation is located posteriorly.
  5. Postoperative Management
    • H. pylori Eradication: Patients should receive appropriate antibiotic therapy to eradicate H. pylori.
    • Proton Pump Inhibitors (PPIs): Long-term PPI therapy to reduce acid production.
    • Follow-Up Endoscopy: To rule out malignancy in the case of gastric ulcers.

Summary

  • Duodenal Ulcer:
    • Acute perforation requires closure of the perforation and abdominal lavage.
    • Options include simple patch closure or truncal vagotomy (TV) with pyloroplasty.
    • Studies show a recurrence rate of 48% for simple repairs over 25 years, whereas vagotomy with pyloroplasty reduces recurrence rates.
    • H. pylori eradication postoperatively reduces recurrence significantly.
  • Gastric Ulcer:
    • Perforated gastric ulcers have higher mortality (10%-40%) and require more aggressive treatment.
    • Partial gastrectomy is preferred unless the patient is at high risk due to comorbidities or instability.
    • Biopsy and patch closure may be suitable for high-risk patients or certain ulcer types.
    • Type I gastric ulcers typically require partial gastrectomy.
    • Type II and III ulcers often managed similarly to duodenal ulcers, with additional biopsy to rule out malignancy.

Summary of Approach

  • Duodenal ulcers: Generally managed with patch closure and antisecretory therapy, particularly if associated with H. pylori.
  • Gastric ulcers: Typically managed with more definitive surgical procedures such as partial gastrectomy.

MCQ and Explanation

Answer: D. Gastric ulcer

Explanation:

  • A. Old patient with comorbidity: This is an indication for conservative management due to higher surgical risk.
  • B. Duodenal ulcer: Duodenal ulcer perforations can be managed conservatively if conditions are favorable.
  • C. No leak on contrast study: If a contrast study confirms no leak, conservative management is viable.
  • D. Gastric ulcer: Gastric ulcers have a higher risk of complications and re-perforation, thus generally not suitable for conservative management.

Conservative management is not typically recommended for gastric ulcers due to their higher rate of complications and the need to rule out malignancy, making D the correct answer.

Case Summary

Answer: C. Antrectomy + Vagotomy

Conclusion

Antrectomy + Vagotomy (Option C) is the most appropriate procedure of choice for a prepyloric perforation in a patient with a history of anti-H. pylori treatment and PPI use. This procedure ensures immediate control of the perforation and addresses the underlying issue of acid hypersecretion, reducing the risk of recurrence and further complications.

Case Summary

Answer: B. Patch closure + Biopsy + H. pylori treatment

Explanation

Background on Perforated Duodenal Ulcers (D1):

  • Perforated duodenal ulcers, particularly in the first part of the duodenum, require prompt surgical intervention to control the perforation and prevent further complications.
  • Management often involves addressing both the immediate perforation and underlying causes such as H. pylori infection.

Surgical Options:

  1. Patch Closure + Biopsy + Highly Selective Vagotomy (HSV) (A):
    • Consideration: Although effective, HSV is more complex and may not be necessary if the patient has no history of ulcer disease.
  2. Patch Closure + Biopsy + H. pylori Treatment (B):
    • Consideration: This approach is less invasive and directly addresses the common etiology of the ulcer, making it appropriate for a patient without a history of ulcer disease or significant comorbidities.
  3. Vagotomy + Antrectomy (C):
    • Consideration: This is a more aggressive approach, typically reserved for patients with recurrent ulcer disease or those with severe complications.
  4. Patch Closure + Truncal Vagotomy (TV) + Drainage (D):
    • Consideration: Suitable for recurrent or complicated cases but may be more than necessary for a first-time perforation without significant past medical history.

Conclusion

Patch Closure + Biopsy + H. pylori Treatment (Option B) is the most appropriate treatment of choice for a 65-year-old male with a first-time perforated duodenal ulcer (D1) and no significant past medical history. This approach effectively addresses the immediate perforation, rules out malignancy, and treats the underlying H. pylori infection, which is a common cause of duodenal ulcers. This method is less invasive and sufficient for a patient without a history of ulcer disease or comorbidities.