Management of pud

MANAGEMENT OF PUD
By Biruk Ertiban(GSR III)
Moderator Dr Samuel Tesfaye(GS)

outline
• Introduction
• PUD and types
• Complications of PUD
• Managemant of PUD
Management of PUD
complications(bleeding(UGIB),perforation,obstruction,inter
actablity)
• Summary
• References

Introduction
• the stomach is asymmetrical, pearshaped, most proximal
abdo GI organ then duodenum
• parietal (oxyntic) cells(body,cardia)

Arterial and Venous Blood Supply
of stomach

Surgical importance of rich gastric blood
supply
• At least two of the four can be ligated or occluded
• rich venous interconnections in the stomach,
distal splenorenal shunt(splenic vein and lt renal
vein)
effectively decompress esophagogastric varices in portal
hypertension

Innervation
• vagus nerves provide the extrinsic parasympathetic
innervation to the stomach
• Ach

…cont
Function in stomach
• In the stomach the vagus nerves
• affect secretion (including acid),
• motor function
• mucosal bloodflow
• cytoprotection.

extrinsic sympathetic nerve supply
• originates at spinal levels T5 through T10
• There may be more intrinsic gastric neurons(myenteric
and submucosal plexuses) than extrinsic neurons, but
their function is poorly understood

…cont
• epinephrine is important in the sympathetic nerves,
• Others..
• cholinergic,
• Adrenergic
• peptidergic (e.g., substance P
and somatostatin).

…cont
• Proximal gastric distension stimulates the acid secretion
by vagovagal reflex(which is abolished by truncal or HSV)
• Antral distention also stimulates antral gastrin secretion.
• Acetylcholine stimulates gastrin release
and gastrin stimulates histamine release from ECL cells.

Basal acid secretion
• Interprandial basal acid secretion is 2 to 5 mEq
hydrochloric acid per hour
• 10% of maximal acid output (MAO),
and it is greater at night
• contributes to the relatively low bacterial counts found in
the stomach.
• Basal acid secretion is reduced 75% to 90% by vagotomy
or H2 receptor blockade.

…cont
• H2 receptor knockout mice do not secrete acid in
response to gastrin implies the pivotal role of ECL cells in
acid production
• Somatostatin inhibits histamine release from ECL cells
and gastrin release from antral G cells.
• Helicobacter pylori infection, inhibits D cells and this leads
to an exaggerated acid secretory response (see section
Helicobacter pylori Infection).

…cont
• TV and HSV significantly affects receptive relaxation and
gastric accomodiation phases
• result in decreased gastric compliance, shifting the
volume/pressure curve to the left
• Increases liquid emptying rate,
• But increases dumping symptoms after vagotomy

…cont
• Proximal gastric tone also is decreased by duodenal
distention, colonic distention, and ileal perfusion with
glucose (ileal brake)
• vagotomy abolishes phase II of the
gastric MMC but has little influence on phase III(present in
autotransplanted stomach)

MMC(fasting)
• Phase I(about half the length of the entire cycle) is a
period of relative motor inactivity. High-amplitude
muscular contractions do not occur
• Phase II (about 25% of the entireMMC cycle) consists of
some irregular, high-amplitude, generally nonpropulsive
contractions.
• Phase III, a period of intense,regular, (about three per
minute) propulsive contractions, only lasts about 5 to 10
minutes begin in the stomach, and the frequency
approximates that of the myoelectric gastric slow wave.
• Phase IV is a transition period.

PUD
• focal defects in the gastric or duodenal mucosa
that extend into the submucosa or deeper.
• They may be acute or chronic
• imbalance between mucosal defenses and acid/peptic
injury

Pathophysiology and Etiology
• H. pylori infection and/or NSAID use
• final common pathway to ulcer (“no acid, no ulcer”
remains true).
• The previous thought of all duodenal ucer dueto
hyperacidity and all gastric ulcer dueto loss of mucosal
protection is not true today

…cont
• (beneficially)
 decreased H. pylori infection prevalence ,
better medical therapy
increased outpatient management;
• (detrimentally)
NSAIDs and
aspirin use in aging population
.

…cont
• H.pylori,NSAIDs,cigarette(90% of serious peptic ulcer
complications )
• ZES (gastrinoma),
• antral G-cell hyperfunction and/ or hyperplasia, systemic
mastocytosis,
• trauma,
• Burns
• major physiologic stress
• drugs (all NSAIDs, aspirin, and cocaine),
• Smoking
• psychologic stress

Southern Ethiopia
• Peptic ulcer disease in south Ethiopia is strongly
associated with Hebcobacter pylori
• Helicobacterpylori infection was detected in 93% of 174
patients with a peptic ulcer compared with 63% of 116
patients with normal findings

H.Pylori eradication vs ucer recurrrence

Acid Secretion and Peptic Ulcer
• duodenal ulcer more than gastric ulcer
• There is no correlation between acid
secretion and the severity of the ulcer
disease
• 70% of patients with duodenal ulcers have
an acid output within
the normal range

…cont
• Duodenogastric reflux may play a role weakening the
gastric mucosal defenses(bile, lysolecithin, and
pancreatic juice)
• NSAIDs and aspirin
• Impaired feedback mechanism of gastrin level
• associated with H. pylori infection
• increased rates of gastric emptying
• decreased duodenal bicarbonate secretion(decreases the
buffering capacity

NSAIDS
• Inc. risk of peptic ulcer disease about 5-fold
• Inc. upper GI bleeding about 4-fold
• risk for bleeding and ulceration is proportional to the daily
dosage of NSAIDs
• Complications of PUD (hemorrhage and perforation) are
much more common

…cont
• overall risk of significant serious adverse GI events in
patients taking NSAIDs is more than three times that of
controls
• NSAIDs Vs cyclooxygenase enzymes Vs PGs(rate
limiting)
• NSAID-induced ulcers are more often found in the
stomach

Age more 60 years old(on NSAID)
• risk of complication increases to five times in patients In
elderly patients taking NSAIDs,
• require an operation related to a GI complication is 10
times that of the control group
• will die from a GI cause is about four and half times higher

Smoking
• smokers are twice as likely to develop PUD as
nonsmokers
• increases gastric acid secretion and
duodenogastric reflux
• decreases gastroduodenal prostaglandin production and
pancreaticoduodenal bicarbonate production

Stress
• Both physilogic and psychologic
• Curling ulcer(burn)
• Cushing ‘s ulcer(head trauma)
• Stressful life events increase the occurrence of PUD
comlications
• NB…. Alcohol is commonly mentioned as a risk factor for
PUD, but confirmatory data are lacking

Modified Johnson classification for gastric
ulcer

mortality
• duodenal ulcer was 3.7%
• 2.1% for gastric ulcer of the admitted
• High rates of hospitalization and mortality in elderly
patients for the peptic ulcer complications of bleeding
and perforation.
• use of NSAIDs and aspirin in this elderly cohor
• H. pylori infection.

Clinical Manifestations
• 90% of patients with PUD complain of abdominal pain
• Reffered pain signifies penetration into the pancrease
• nonradiating, burning in quality, and located in the epigastrium
• DU pain >>2 to 3 hours after a meal and at night
• pain that awakens them from sleep(2/3rd )
• nausea,
• bloating,
• weight loss,
• stool positive for occult blood,and anemia

…cont
• Duodenal ulcer is about twice as common in men
• incidence of gastric ulcer is similar in men and women
• gastric ulcer patients are older than duodenal ulcer
patients
• GU incidence is increasing in the elderly(NSAID and
aspirin)

Diagnosis of PUD
• In the young patient(clinical Dx)
• empirical PPI therapy for PUD without confirmatory
testing after pt counseling of small possibility of an
alternative diagnosis
.

Routine laboratory studies include
• complete blood count;
• liver chemistries;
• serum creatinine,
• serum amylase
• calcium levels.
• A serum gastrin level(ulcers that
are refractory to medical therapy or require surgery)
• H.pylori(urea breath test, serum,stool Ag).

…cont
• The two principal means of diagnosing duodenal ulcers
flexible upper endoscopy(need to perform a biopsy to R/o
malignancy, upper endoscopy has replaced upper GI
radiography all with
Age > 45 years old, all patients, regardless of age, should
have this study if any alarm symptoms

Biopsy(gastric ulcer)
• >>>H.pylori(urease assay,culture)
• >>> histologic evaluation
• first biopsy >>only a 70% sensitivity
in detecting gastric cancer
• four biopsy specimens increased this yield to 95%
• taking seven specimens increased it to 98%

Medical Treatment of Peptic Ulcer
Disease
• Acid supressants>>>PPIs, high doseH2RAs
• Protective>>>sucralfate
• H.pylori>>> ABCs
• Iv PPIs for admitted patients+ lifelong PPI on discharge
• acid supressive therapy for 3 months(if underlying cause
resolved)
• Avoid alcohol,smoking NSAIDs
• Pt on NSAIDs is a must, always take concomitant PPIs or
high dose H2 receptor blockers

…cont
• Treat documented H. pylori infection
• give eradication Tx if H. pylori testing is negative and
ulcer symptoms persist
• H. pylori eradication will decrease of elective surgical
procedures and decline complications and mortality from
emergent complications

long-term maintenance
PPI
• all patients admitted to hospital with ulcer complications,
• all high-risk patients on NSAIDs
or aspirin (the elderly or debilitated),
• all patients with a history of recurrent ulcer or bleeding

Complications of PUD
• bleeding,
• Perforation
• Obstruction
• Interactablity
• >>>>>>>7% of hospitalized patients need surgery

Bleeding peptic ulcer
• present with melena and/or hematemesis
• NG tube aspirate Is diagnostic
• Abdominal pain is quite uncommon
• Shock could be the presentation
• Early endoscopy is important to diagnose the cause and
manage

…cont
• Three-fourths of the patients who come to the hospital
with bleeding peptic ulcer will stop bleeding with acid
supression ,resuscitation and NPO
• one fourth will continue to bleed or will rebleed after an
initial quiescent period(all mortalities of UGIB)

high-risk group
• Shock,
• hematemesis,
• transfusion requirement exceeding four units in 24 hours
• endoscopic stigmata (active bleeding or visible vessel)
• these patients benefit from
endoscopic therapy to stop the bleeding

…cont
• most common endoscopic hemostatic modalities used
• injection with epinephrine
• Electrocautery
• Clipping
• Persistent bleeding or rebleeding afterendoscopic therapy
is an indication for operation(vs repeat endoscopic
treatment)

…cont
• elective operation even after initially successful
endoscopic treatment in elderly patient, especially if they
have a high-risk ulcer.

high-risk lesions
• Deep bleeding ulcers on the posterior duodenal bulb ()
gastroduodenal vessel erosion
• Bleeding at lesser gastric curvature(left gastric vessels
erosion)
• early operation should be considere since not
amenable for conservative control

classifying the endoscopic
appearance of bleeding ulcers

Causes of upper GI bleeding(up to 70% of
non variceal bleeding(PUD))

…cont
• operation for ulcer perforation is much more common than
operation for bleeding ulcer
• suture ligation of the bleeder;
• Suture ligation and definitive nonresective ulcer operation
(HSV or V +D)
• gastric resection (usually, including vagotomy and ulcer
excision).
• Take biopst of gastric ulcer if not resected.

Surgery indication for bleeding PUD
• similar to the approach to a trauma patient(ABCs)
• massive hemorrhage unresponsive to endoscopic control,
• transfusion requirement of more than four to six units of
blood despite attempts at endoscopic control
• Lack of availability of a therapeutic endoscopist,
• recurrent hemorrhage after one or more
attempts at endoscopic control,
• lack of availability of blood for
transfusion,

…cont
• Age more than 60 years of age
• Shock at presentation,
• more than four units of blood in 24 hours or eight units of
blood in 48 hours,
• rebleeding,
• ulcers >2 cm in diameter

…cont
• repeat hospitalization for bleeding ulcer
• concurrent indications for surgery(perforation or
obstruction)
• Bleeding from posterior duodenal ulcer or lesser curvature
gastric ulcer

surgeries
• oversewing of the ulcer usually without vagotomy

…cont
• initial pyloromyotomy incision allows access to the
bleeding posterior duodenal ulcer
• expeditious Kocher maneuver allows the surgeon to
control the hemorrhage with the left hand .
• Heavy suture material
• figure-of-eight sutures or U-stitch to securethe bleeding
vessel at the base of the posterior duodenal ulcer.
• Multiple sutures are usually necessary

…cont
• Vagotomy+antrectomy

Perforated PUD
• second most common complication of peptic
ulcer
• a more common indication for operation
than bleeding
• sudden onset of the excruciating abdominal pain
• Previous Hx of PUD
• Phases of peritonitis
chemical peritonitis develops from the gastric and/or
duodenal secfretions
bacterial peritonitis supervenes within hours

Clinical examination
• marked involuntary guarding
• Rebound tenderness is evoked by a gentle examination
• Upright chest X-ray shows free air in about 80% of
patients

Management approach
• NGT insertion
• Analgesic
• Antibiotic
• Resuscitation with isotonic flids
• Take to OR

surgery
• Supraumblical incision
• 1st portion of duodenum
• Those <1 cm can generally be closed primarily
• buttressed >>>wellvascularized omentum.

…cont
• larger perforations or ulcers ,a Graham patch repair
with a tongue of healthy omentum is performed.
• stay sutures are placed that incorporate a bite of healthy
tissue on the proximal and the distal side of the ulcer.
• The omentum is placed underneath these sutures,

…cont
• very large perforations (>3 cm)
Primary closure is difficult
The defect should be closed by the application of healthy
tissue(omentum or jejunal serosa from a Rouxen-Y type
limb)
bypass the duodenum (Billroth II or
Roux-en-Y fashion)
several weeks, the pyloric exclusion stitches or staples
give way

…cont
• simple patch closure
• patch closure and HSV
• Patch closure and V + D
• biopsy
• Simple patch closure, currently the most
commonly performed
• laparoscopy appears to be the superior approach in
patients with duodenal perforations who are
hemodynamically stable

…cont
• should be done in patients with hemodynamic instability
and/ or exudative peritonitis signifying a perforation >24
hours old
• Vagotomy procedures are ommited this days even in
stable patients because of the availablity of PPIs
• Perforation has the highest mortality rate of any
complication of ulcer disease, approaching 15%

Post OP care
• stomach is decompressed until bowel activity
returns
• Drains should be kept in place until patients have eaten
without a change in drain output or quality
• A routine contrast radiograph
• H. pylori–positive patients should undergo eradication
with appropriate triple-therapy

Nonoperative management
of perforrated PUD
• Surgery is a rule
• objective evidence that
the leak has sealed (i.e., radiologic contrast study)
• The absence of clinical peritonitis

perforation in an inopportune location
• Patch closure with biopsy
• local excision and closure
• biopsy (for gastric ulcers if not resected)
• closure
• truncal vagotomy and drainag

Gastric outlet obstruction
• 5% of patients with PUD
• due to duodenal or prepyloric ulcer disease,
• may be acute (from inflammatory swelling
and peristaltic dysfunction) or chronic (from cicatrix)>>do
not need surgery
• Significant obstruction from chronic ulceration will require
some sort of more substantial intervention(baloon
dilitation,surgery)

presentation
• nonbilious vomiting
• hypokalemic hypochloremic metabolic alkalosis
• Pain
• Wt loss
• Suction splash

…cont
• Other causes of GOO must be ruled out(pancreatic,
gastric, or duodenal malignancy)
• ulcer disease is now less common than obstruction from
cancer

operation for obstructing PUD(GOO)
• Most managed with endoscopic dilitation
• Surgery is for refractory cases
• Vagotomy and antrectomy.
• vagotomy and gastrojejunostomy(difficult duodenal
stump)
• HSV and gastrojejunostomy (curable gastric or duodenal
cancers can be missed)

Intractable or Nonhealing Peptic Ulcer
• failure of an ulcer to heal after an initial trial of 8 to 12
weeks of therapy
• patients relapse after therapy has been discontinued
• unusual indication for peptic ulcer operation
• The surgeon should review the differential diagnosis of
nonhealing ulcer before any
consideration of surgery

Endoscopic and UGI radiography
features that suggest malignancy
• Intraluminal location
• Irregularity and nodularity
• Surrounded by asymmetric mass
• Clubbed mucosal fold
• Ulcers in the fundus(rare but malignant if they present)
• Larger ulcers
• irregular or heaped edges

…cont
• With single-contrast radiographic techniques, 50% of
duodenal ulcers missed
• double-contrast studies, 80% to 90% of ulcer craters can
be detected

Surgical Treatment of Peptic Ulcer
Disease
• The indications for surgery in PUD
bleeding,
perforation,
Obstruction
intractability or nonhealing
Non compliant to medical Tx
Refractory H.pylori inf.
thin or marginally nourished individual(relative C/I)

Goal of surgical therapy
• to reduce gastric acidsecretion
vagotomy,
gastrin-driven secretion >>antrectomy
Vagotomy decreases peak acid output by
approximately 50%
vagotomy plus antrectomy decreases>> 85%

Surgical options
• Highly selective vagotomy(HSV)
• vagotomy and drainage (V+D),
• vagotomy and distal gastrectomy
• Taylor procedure(posterior truncal vagotomy and anterior
seromyotomy)

…surgical options
Depends on
• Typeofulcer(duodenal,gastric,recurrent,marginal)
• condition of the patient,
• surgeons experience
• Superimposed lesions(duodenal scarring/inflammation,
adhesions,
or difficult exposure),

…surgical options
• the ulcer diathesis status of the patient,
• H. pylori infection
• NSAID therapy, previous treatment
• future compliance with

Indications for surgery
• nonhealing or intractable PUD
• multiple recurrences,
• large ulcers (>2 cm),
• complications
• Obstruction
• perforation,
• Hemorrhage
• suspected malignancy

Surgery types for interactable ulcers
• lesser operation
• avoid truncal vagotomy and/or distal gastrectomy
• HSV with or without gastrojejunostomy
• distal gastrectomy (to include the ulcer)
• don’t add a vagotomy in patients with type I or type IV
(juxta-esophageal) gastric ulcers

• Type IV gastric ulcers may be difficult to resect as part of
a distal gastrectomy,special procedures are used

summary
Stomach is a pear shaped,1st intra abdominal organ of
the digestive tract followed by duodenum
It has its own protective mechanism from its own acid
secretion
PUD occurs when the protective mechanism fail to control
the stress usually dueto the undelying
causes(H.pylori,NSAIDs,ASA)

…summary
• PUD can complicate if its not treated
Bleeding
Perforation
GOO
Interactablity
• The need for admission and surgery comes when it
complicates
• Surgery is the last(not the first) management for PUD

References
1. Schwartz principle of surgery,10th Ed, P1050-1090
2. Sabiston text book of surgery,20th Ed, P1200-1240
3. Harrison’s prinsiple of Internal medicine,19th edition
4. Uptodate 20.1
5. Netter Atlas Of Human anatomy,6th Edition

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