3. INTRODUCTION
• PEPTIC ULCER DISEASE
• Erosions in the gastric or duodenal mucosa that extend through the
muscularis mucosae.
• Epidemiology
• Prevalence of about 2%,
• Lifetime cumulative prevalence of about 10%
• Peak incidence > 70yrs
• Elective operations for PUD has decreased steadily and dramatically over the
past three decades.
• Incidence of emergency surgery and the death rate not decreased nearly so
dramatically.
3
5. • Helicobacter pylori
• Most common cause (90%DU & 70% of GU)
• 10 -15% develop peptic ulceration
• 1% develop gastric adenocarcinoma.
• Features
• Entry into the surface mucus layer,
• attachment to gastric epithelial cells
• Evasion of immune responses
• persistent colonization despite luminal acidity
5
6. • NSAIDs (including aspirin)
• Risk of peptic ulcer disease 5-fold
• upper GI bleeding about 4-fold
• Many of these patients (30% – 50 %)
remain asymptomatic
• Until they develop these life-threatening
complications.
• 50% to 75% of bleeding peptic ulcers.
• One third of deaths due to hemorrhage.
• Systemic suppression of prostaglandin
production.
• Heal rapidly when the drug is withdrawn.
6
7. 7
• Diagnosis
• History
• Abdominal pain(90%).
• 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.
• GU: pain of gastric ulcer more commonly occurs with eating
• less likely to awaken the patient at night.
• Nausea, bloating, weight loss
• A history of PUD, use of NSAIDs.
• Heartburn
• Chest discomfort
• Hematemesis or melena
• Alarm features
• Bleeding or anemia
• Early satiety
• Unexplained weight loss
• Progressive dysphagia or
odynophagia
• Recurrent vomiting
• Family history of GIT
cancer
8. • Physical Examination
• Uncomplicated peptic ulcer disease (PUD)
• Few and nonspecific:
• Epigastric tenderness (usually mild)
• Right upper quadrant tenderness
• 20% of patients
• Signs of complications
8
9. • Investigations
• Endoscopy is the most accurate &
"gold" standard.
• Detect about 90 percent of
gastroduodenal ulcer.
• Multiple biopsies of gastric ulcers
(GUs) are necessary
• The chance of malignancy is
greater in large Gus
• The optimal number of biopsies
has been debated and probably
depends upon the technique
9
10. • Contrast imaging
• Barium meal X-ray features of
benign gastric ulcer
• Niche on the lesser curve with notch
on the greater curvature
• Ulcer crater projects beyond the
lumen of the ulcer
• Regular/round margin of the ulcer
crater—stomach spoke wheel pattern
• Converging mucosal folds towards the
base of the ulcer
• Symmetrical normal gastric mucosal
folds
10
11. • Deformed or absence of duodenal
cap (because of spasm).
• ‘Trifoliate’ duodenum
11
13. 13
• Classifications – modified Johnson classification
Modified Johnson classification for
gastric ulcer.
I. Lesser curve, incisura. (60% of
gastric ulcer)
II. Body of stomach, incisura +
duodenal ulcer (active or
healed).
III. Prepyloric.
IV. High on lesser curve, near
gastroesophageal junction.
V. Medication-induced (NSAID/
acetylsalicylic acid), anywhere in
stomach.
15. • Medical management
• Mainstay of modern treatment
• Goals of treatment
• Permit ulcer healing
• Prevent ulcer complications
• Address the underlying ulcer etiology
- H.pylori ( heals > 85% of duodenal ulcers
• NSAIDS
15
16. • Treating H. pylori
Triple therapy
• Failure of monotherapy and dual therapy
• triple therapy & multidrug regimens.
• Classically a 7 day regimen with twice daily
PPI and two antibiotics
• 10 to 14 day course (particularly in
North America)
• Acid suppression with PPI
• synergistic bactericidal effects and
• stabilizes antibiotics so increasing
their half-life.
• Clarithromycin resistance is a major
determinant of the success of triple therapy
Quadruple therapy
16
17. • Surgical management
• Current indications for surgical intervention are:
• Emergency surgery for complicated peptic ulcer disease
• Bleeding
• Perforation
• Obstruction
• Elective surgery for intractable ulcer disease
• Failed medical therapy(intractability)
• Risk of malignancy(gastric ulcer)
17
18. • Emergency surgery for complicated peptic ulcer disease
• Objectives of surgery in emergency cases:
• Deal with the complication
• Reduce the risk of ulcer recurrence
• Perform a safe, quick, and effective operation
• Minimize long-term effects on the gastrointestinal tract
• Establish the H. pylori status of the patient
18
19. • Biggest intraoperative dilemma.
• whether to proceed with a definitive antiulcer operation
• Recognition of the role of H. pylori, and improvements in medical therapy have
confused
• trend toward favoring of less complex procedures in the setting of emergencies
• modern trend in peptic ulcer operation could be described as “less is more
• Avoiding vagotomy or gastric resections
• A defnitive procedure is always more appropriate in the setting of NSAIDs
• especially if the patient is unlikely to be able to stop the treatment
• Defnitive operation is generally avoided during emergency procedures
• Major underlying medical illness or
• intraoperative hemodynamic instability.
19
20. • Bleeding Peptic Ulcer
• Most common cause of ulcer-related
death
• Annual Incidence :19 to 57 cases per
100,000 population
• Mortality : 5% to 10%
• All patients admitted to hospital
• adequately resuscitated and
• started on continuous IV PPI
• 75% will stop bleeding
• 25% will continue to bleed or will
rebleed.
• all the deaths occur in this
group.
• Early identification important
• Clinical/endoscopic
• Clinical
• >60 years of age,
• Presenting in shock
• requiring more than 4 units of blood
in 24 hrs or 8 units in 48 hrs
• Those with rebleeding.
20
21. • Endoscopic features
• Active bleeding (grade I)
• Non bleeding visible vessel (IIa)
• large ulcers > 2 cm
• especially when localized at the
posterior wall of the duodenal bulb
or lessor curvature
21
22. 22
Risk-stratification tools for upper gastrointestinal hemorrhage
For Blacthford :- Scores of 6 or more
were associated with a greater than 50%
risk of needing an intervention.
For Rockall :- clinical Rockall score of 0
& complete Rockall score of <2
• considered to be at low risk of
rebleeding or death
• Good prognosis
• Most widely known risk-
stratification tool
• Total score more than 8 carries
high(>50%) risk of mortality
23. • Management
• All patients admitted to hospital
• Adequately resuscitated
• started on continuous IV PPI
• Endoscopic examination of the stomach and the first and second part of
duodenum
• Endoscopic hemostatic therapy (cautery, epinephrine injection, clipping)
• 10 - 20% fail medical therapy (25% in 2nd endoscopic attempt)
23
24. • Current indications for surgery for
bleeding PUD:
• Hemodynamic instability despite
vigorous resuscitation (>4-units or >6-
units)
• Failure of endoscopic techniques
• Recurrent hemorrhage after initial
stabilization
• Shock associated with recurrent
hemorrhage
• Continued slow bleeding with a
transfusion requirement exceeding 3
units per day
• Secondary or relative indications
• rare blood type or difficult
crossmatch, refusal of transfusion,
• Shock on presentation,
• advanced age,
• severe comorbid disease
• bleeding chronic gastric ulcer.
• Lower threshold in elderly patients
• Mortality rate 5-10%
• most patients dying of non–bleeding-
related causes such as MOF
24
25. 25
• Surgery for Bleeding Duodenal Ulcer
• Esophagogastroduodenoscopy- locate
source
• most likely to be bleeding is the
gastroduodenal artery
• Upper midline laparotomy/laparoscopy
• A Kocher maneuver
• Anterior wall of the duodenal bulb is
opened longitudinally
• Manual finger pressure
• Gastroduodenal artery is oversewn
• three-point U stitch
• Heavy suture material on a stout needle
• Not to take excessively deep bites
• Hainake-Mikulicz pyloroplasty.
26. • Definitive acid-reducing operation TV.
• Even in the era of H. pylori and our ability to eradicate it
• Only 40% to 70% of pts with a bleeding duodenal ulcer are positive for H. pylori.
• H. pylori testing in the setting of an acute hemorrhage is less reliable(18% versus 1%)
• Up to 50% of patients are at risk of recurrent bleeding.
• Conflicting evidence that H. pylori treatment changes the risk of recurrent bleeding.
• less aggressive operation exposes the patient to a high rebleeding risk
postsurgery- ‘less is not more’.
26
27. • If no bleeding is encountered
• Carefully inspect mucosa for an ulcer to identify a visible vessel
• should be ligated.
• If no active bleeding is seen
• carry out a careful inspection for other potential bleeding ulcers
• can be done by manual palpation of the lumen using a finger.
• On occasion, a second gastrostomy near the esophageal junction
• To inspect the proximal stomach.
27
28. • Bleeding Gastric Ulcer.
• Distal gastrectomy With
Billroth I or II reconstruction is
preferred.
• Permits excision and histologic
evaluation
• Add TV (2,3)
• Second best is V + D
• with oversewing and biopsy of
the ulcer.
• Oversewing of the bleeder,
biopsy followed by long-term
acid suppression
• Reasonable alternative in high-
risk or unstable patients.
28
29. • Perforated Peptic Ulcer
• Second most common complication
• More common indication for operation than bleeding.
• NSAID and/or aspirin.
• The outcome depends on:
• Time delay to presentation and treatment
• Site of perforation-gastric perforation poorer prognosis.
• Patient’s age- elderly
• Presence of hypotension at presentation (systolic blood pressure <100)
29
30. • Stages of Perforation
• Stage of chemical peritonitis
• acid causes chemical peritonitis
• Pain started "as if someone flipped a
switch."
• Stage of reaction (Stage of illusion)
• Peritoneum secretes lot of fluid to
neutralise the escaped content
• temporarily the pain reduces.
• Lasts for about 6 hours
• Stage of diffuse bacterial
peritonitis:
• After about six hours
• Clinical Features
• Presents with severe persistent
pain
• in the epi gastrium initially,
• later in the right side abdomen
• Finally becomes generalised.
• Pain is of sudden in onset
• contact of expelled gastric contents
with the parietal peritoneum.
• Tenderness and rebound
tenderness all over the abdomen
(Blumberg sign)
30
31. • Plain X-ray abdomen
• gas under diaphragm in 80% of
cases.
• 20% of cases, there is no gas
under diaphragm.
• the gas leak is less than 1 ml
• previous surgery causing adhesions
between liver and diaphragm,
• sealed peptic ulcer.
31
32. • Perforated Duodenal Ulcer.
• 2% to 10% of DU
• Traditionally performed
• simple patch closure
• TV with pyloroplasty (incorporating the
perforation).
• With the identification of H. pylori
• Ideal surgery again questioned.
• 5% recurrence H. pylori-eradicated
• equivalent to definitive antiulcer procedure.
• Simple patch closure appropriate
for
• Acute NSAID-related perforation
(discontinued postoperatively)
• Who have never been treated for
PUD but who can be treated with PPIs
and H. pylori eradication.
• Perforation in the setting of
• ongoing shock,
• Delayed presentation,
• considerable comorbid disease,
• marked peritoneal contamination
32
34. • Nonoperative management of perforated ulcers
• water-soluble contrast gastroduodenogram showing no
extravasation,
• no signs of septic shock, and
• abdominal examination findings confined to the upper
abdomen
• Perforation > 24 hrs
• Elderly with comorbidities
• Not recommended for gastric perforation
• nasogastric decompression,
• antibiotics to cover enteric pathogens,
• antibiotics to cover Helicobacter pylori if present, and
• proton pump inhibitors
• 30% of patients do not improve and require surgical
intervention.
• extremely high failure rate (70%) in the elderly(>70
34
35. 35
• Perforated Gastric Ulcer.
• overall mortality :10% to 40%,
• Debate in types I and IV gastric
ulcers
• Perform a partial gastrectomy or
• Proceed with a simple patching of the
perforation
• Perforated type I gastric ulcer
• Partial gastrectomy unless the patient is
unstable with significant comorbidities.
• Perforated high type IV ulcer
• Biopsy and patch closure may be an
appropriate
• Antacid procedure is not required
• Adequate four-quadrant biopsy
36. • Perforated type II ulcers
• Similar to that for perforated duodenal ulcers
• Intraoperative biopsy
• Definitive surgery is not required, unless
• history of recurrent ulcer disease
• previously treated for H. pylori.
• HSV or a TV with drainage
• Perforated type III ulcers
• similar pathogenesis to duodenal ulcers, but d/f Rx
• Patch repair of prepyloric ulcers = high incidence of GOO
• HSV = high recurrence rate for these ulcers.
• Antrectomy with vagotomy may be the best surgical approach.
36
37. Management of omental pacth leak
March 20, 1999 and March 20,2006 in
Iran
of 422(375, 88.9% duodenal and
prepyloric [gastric], 47, 11.1%)
perforated
17(4%) leak
Age was 60.6 years (range 39 to 80),
Previous history of PUD, 6 (35.3%)
patients and 2 (11.8%) hypotensive on
admission. All reoperated, 5 (patch
gangre), 12 ( unkown cause). Of the 17
patients, 5 died
Study done from January 2019 to
July 2020, in Egypt
20 patients reperforation after
initial omental patch
Triple-tube drainage versus jejunal
serosal patch
Mortality 1 vs 2, overall (3)
leak dx (36 hrs – 96hrs)
37
38. • Obstructing Peptic Ulcer
• 5-8% of ulcer related complications
• Malnourished, dehydrated, and have
a metabolic alkalosis
• Increase the operative risk.
• Operation is generally indicated if
obstruction fails to resolve despite 48
to 72 hours
• Adequate intravenous fluid
replenishment,
• Antisecretory therapy, and
• Nasogastric tube decompression.
• Balloon dilation of the scarred
pylorus
• Acute Incomplete obstruction
• unacceptably high recurrence rate
over the short term
• complication – perforation
• rule out an underlying malignancy
• Era PPI, malignancy in greater than
50% of GOO
• H. pylori’s role in the pathogenesis
of GOO
• Low incidence of H. pylori infection
(33% to 57%).
38
39. 39
• Surgery
• TV with antrectomy is the ideal procedure
• Feeding jejunostomy tube is usually
recommended
• preoperative malnutrition
• GOO predisposes to delayed postoperative
gastric emptying.
• Inflammation and scarring at the
duodenal bulb
• TV and drainage is the preferred approach
• biopsy of the lesion
• Debate persists as to the optimal drainage
procedure.
• Jaboulay side-to side duodenoplasty has
gained popularity
• technical simplicity
• anastomosis is performed in healthy tissue,
distinct from the ulcer bed
40. 40
• Non healing ulcer (Intractability)
• Ulcer fails to heal after 8-12wks of optimal
Rx
• Endoscopy→ diminished ulcer size →2nd
course Rx
• A rare indication for surgery today
• PPIs + H.pylori-eradication…..”why
intractable?”
• Cancer
• Persistent H.pylori infection
• Re-infection
• False –ve tests
• Non-compliant pts.
• Chronic NSAIDs use
• ZES
41. • Zollinger-Ellison syndrome (ZES).
• Uncontrolled secretion of abnormal amounts of gastrin by gastrinoma.
• 80%) are sporadic, but 20% are inherited(MENI)
• 0.1% of all peptic ulcer disease and in 2%ofpatientswith recurrent ulcer
• 50% to 60% of gastrinomas are malignant
• Five-year survival in metastatic disease is approximately 40%.
• More than 90% of patients with sporadically, completely resected gastrinoma
will be cured.
41
42. • Epigastric pain, GERD, and diarrhea.
• More than 90% have PUD.
• Most ulcers are in the typical location
(proximal duodenum),
• Atypical ulcer location (distal duodenum,
jejunum, or multiple ulcers) should
prompt an evaluation for gastrinoma.
• Recurrent or refractory peptic ulcer
• symptomatic for several years(6-7yrs
delay)
• diagnosed familial (20s and 30s) while
sporadic ZES (40s and 50s).
•
• Diagnosis
• Fasting serum gastrin concentration (>1000
pg/mL) and an abnormally elevated BAO (>15
mEq/L)
• secretin stimulation test
• 200 pg/mL increase of gastrin concentration
above baseline
• Localization
• preoperative localization difficult
• CT,U/S,EUS,MRI
• somatostatin receptor scintigraphy(SRS) (the
octreotide scan)
• sensitivity and specificity approach 100%.
• Angiographic localization
42
44. • Treatment
• High-dose PPIs
• Two to five limes the usual dose of PPIs to
bep the BAO <10 mEq/h
• PPIs should be continued after surgery
• Titrated 3 to 4months postoperatively
• Surgery For Gastrinoma
• All patients with sporadic gastrinoma
should be considered
• Open rather than Laparoscopic exploration
• Extended Kocher maneuver
• Extensive lymphadenectomy
• No tumor=Generous longitudinal
duodenotomy
• ZES/MEN-1
• Multiple gastrinomas & cure rate is
low
• Surgical resection is controversial.
• Imageable tumor >2 cm
• To prevent metastatic spread
• Prognosis
• postoperative cure rate
• 40% at 5 years.
• 34%at 10years.
44
45. • Giant duodenal ulcers(GDUs)
• Full-thickness peptic ulcer that is >2 in
diameter and usually involving a large
portion of the duodenal bulb.
• 1 to 2% of all duodenal ulcers
• 5% of peptic ulcers requiring surgery.
• Male to female ratio = 3:1.
• Greater morbidity than usual duodenal
ulcers
• Massive hemorrhage and perforation.
• GDUs associated with H.pylori is less
• when compared to standardized ulcers
• NSAIDS use may play a more prominent role.
45
46. • Management of GDUs
• H.pyelori eradiation + PPIs and stop NSAID
• Emergent indications for surgery
• Uncontrolled hemorrhage
• Perforation
• obstruction.
• Perforation
• Hazardous because of the extensive duodenal tissue loss and surrounding tissue
inflammation
• Preclude simple closure with omental patch
46
47. Surgical options for Perforation of GDUs
• Partial gastrectomy with Billroth I
or II reconstructions.
• Gastric disconnection
• vagotomy, antrectomy , gastrostomy
• lateral duodenostomy.
• Feeding jejunostomy
• Conversion of the perforation into
pyloroplasty
• Closure of the perforation using a
serosa patch
47
48. 48
References
Schwartz, 11th ed.
MasterTechniques in Surgery/Gastric Surgery
Sabiston, 21th ed.
Shackfold, 8th ed.
Maingot’s abdominal operation 13th ed.
Journal
Internet
