Peptic Ulcer Disease


Peptic Ulcer Disease

  1. Pathogenesis
    • results from an imbalance between acid-pepsin secretion and mucosal defense mechanisms
    • ‘no acid, no ulcer’
    • degree of acid secretion may range from massive hypersecretion, as in Zollinger-Ellison syndrome, to hyposecretion, as in type I and IV gastric ulcers

    1. Helicobacter pylori
      • isolated in > 90% of duodenal ulcer patients and 75% of gastric ulcer patients
      • eradication of H. pylori infection is associated with an almost complete elimination of recurrence following treatment
      • only 10% of patients with H. pylori develop ulcers

      1. Mechanisms of Injury
        • secretes toxic factors that produce local tissue injury
        • causes a local inflammatory reaction that produces proinflammatory cytokines and reactive oxygen metabolites
        • causes increased gastrin levels, and increased acid secretion, secondary to reduced antral D cells

    2. NSAIDS
      • play an important role in the pathogenesis of both gastric and duodenal ulcers
      • suppress prostaglandin synthesis
      • prostaglandins inhibit acid secretion and stimulate mucus and bicarbonate secretion and mucosal blood flow
      • 10% to 30% of chronic NSAID users develop peptic ulcers

    3. Acid Hypersecretion
      • most obvious example is gastrinoma, in which massive hypersecretion of acid leads to ulceration, often in atypical locations
      • in general, patients with duodenal ulcers secrete more acid, both at rest and in response to stimulation, and have more parietal cells than do normal control subjects
      • however, there is considerable overlap in the amount of acid secretion between duodenal ulcer patients and normal control subjects
      • also, there appears to be no direct relationship between the degree of acid hypersecretion and the severity of the ulcer disease
      • in contrast, acid secretion is normal to very low in patients with gastric ulcers

    4. Impaired Mucosal Defense Mechanisms
      • duodenal ulcer patients have a reduction in basal and peak duodenal bicarbonate secretion, with a resulting loss of mucosal buffering capacity
      • in gastric ulcer patients, there is evolving evidence that pyloric dysfunction, which allows reflux of bile and pancreatic secretions, results in gastritis and ulceration

    5. Gastric Motility Disorders
      • some duodenal ulcer patients have rapid gastric emptying of meals, which results in the duodenum being exposed to more acid
      • contrarily, gastric ulcers may develop in patients with stasis and delayed gastric emptying, as a result of inadequate clearance of normal amounts of acid

  2. Clinical Manifestations
    1. Duodenal Ulcer
      • epigastric pain relieved by food or antacids
      • usually develops several hours after a meal
      • develops typically in the fourth decade of life
      • back pain suggests penetration into the pancreas

    2. Gastric Ulcer
      • gnawing or burning epigastric pain brought on by eating
      • peak incidence is from 50 to 65 years

  3. Diagnosis
    • the two main diagnostic studies are an UGI and an EGD
    • H. pylori testing should be done in all patients
    • the decision on when to study a patient is based on the character, severity, and duration of symptoms, as well as the age of the patient

    1. H. pylori Testing
      • mucosal biopsy during EGD can identify H. pylori with 95% sensitivity and 99% specificity
      • serology has 90% sensitivity and specificity, but since antibody titers remain elevated for at least one year, serology cannot be used to assess eradication after treatment
      • urea breath test is the method of choice to document eradication (must wait for 4 weeks after treatment)

    2. Endoscopy
      • most reliable method of diagnosing a peptic ulcer
      • has a therapeutic role in bleeding and obstruction

  4. Medical Management
    1. Duodenal Ulcers
      • treatment is based on the eradication of H. pylori
      • active infection should be confirmed by serology, antral biopsy, or breath test
      • standard treatment regimen includes 14 days of antibiotics (amoxicillin + clarithromycin) and a PPI
      • NSAIDs and ASA should be avoided
      • patients must stop smoking
      • if the ulcer does not heal, then it is necessary to confirm that H. pylori has been eradicated

    2. Gastric Ulcers
      • endoscopy and biopsy are necessary to rule out malignancy
      • NSAIDS must be stopped
      • screening for H. pylori should be done, and an appropriate antibiotic regimen started
      • patients should have a 12-week course of acid suppression with a PPI, and then undergo repeat endoscopy and biopsy
      • if the ulcer is still not healed, and H. pylori has been eradicated, then surgery should be strongly considered because of the risk of underlying malignancy

  5. Surgical Management of Duodenal Ulcers
    1. Indications
      • intractability (rare), perforation, bleeding, and obstruction

    2. Surgical Approach
      • goal is to reduce acid secretion either by (1) dividing the vagus nerves, (2) eliminating the hormonal stimulation (gastrin) from the antrum, and (3) decreasing the number of parietal cells

      1. Vagotomy
        1. Truncal Vagotomy
          • involves division of the main trunks of the left anterior and right posterior vagi
          • results in a 60% to 70% reduction in acid secretion
          • a complete vagotomy requires circumferentially stripping the esophagus bare of areolar tissue overlying its longitudinal muscle for 5 to 7 cm
          • this is to ensure that any small nerve trunks that come off in the mediastinum are divided (‘criminal’ nerve of Grassi)
          • has a relatively high recurrence rate (10%)
          • high incidence of postoperative dumping syndrome, gastroparesis, and postvagotomy diarrhea
          • truncal vagotomy markedly alters gastric motility
          • receptive relaxation and trituration are impaired
          • emptying of liquids is speeded up
          • emptying of solids is significantly slowed
          • a drainage procedure is also required

          Truncal Vagotomy
        2. Highly Selective Vagotomy
          • no drainage procedure is required
          • involves dividing all the branches of the nerves of Latarjet along the lesser curvature that innervate the fundus and body
          • goal is to eliminate vagal stimulation to the acid-secreting part of the stomach while preserving motor innervation to the antrum and pylorus
          • receptive relaxation is impaired and the emptying of liquids is faster, even though the pylorus is intact
          • incidence of dumping is much lower, but not completely eliminated
          • has the highest recurrence rate (5% to 30%), but most recurrences can be managed with PPIs
          • contraindications include prepyloric ulcers, gastric ulcers, gastric outlet obstruction, and patients with a high risk of recurrence (cigarette smokers)

          Highly Selective Vagotomy
        3. Drainage Procedures
          1. Heineke-Mikulicz Pyloroplasty
            • simplest to perform
            • requires a pliable duodenum

            Heineke-Mikulicz Pyloroplasty
          2. Finney Pyloroplasty
            • used if the duodenum is scarred
            • involves lengthening the pyloroplasty incision past the scar

            Finney Pyloroplasty
          3. Jaboulay Pyloroplasty
            • 2 incisions are required: one in the duodenum, and one in the distal antrum
            • essentially a gastroduodenostomy
            • used if the duodenum is extensively scarred

            Jaboulay Pyloroplasty
          4. Gastrojejunostomy
            • used if the duodenum is extensively scarred

            Gastrojejunostomy
      2. Vagotomy and Antrectomy
        • produces the maximal reduction in acid secretion by removing the cholinergic and gastrin stimulus to acid secretion
        • basal acid secretion is nearly eliminated and stimulated acid secretion is reduced by 85%
        • ulcer recurrence rate is < 2%
        • the incidence of dumping (25%) and diarrhea (25%) is high and may be difficult to manage
        • gastrointestinal continuity may be restored with either a Billroth I or Billroth II reconstruction

        1. Billroth I
          • gastric remnant is anastomosed to the duodenum
          • considered to be more physiologic
          • avoids problems with afferent and efferent limb obstruction, duodenal stump blowout
          • tension and duodenal scarring are contraindications

        2. Billroth II
          • involves duodenal closure and a loop gastrojejunostomy
          • usually placed in the retrocolic position to facilitate gastric emptying
          • complications include afferent and efferent limb obstruction, and duodenal stump blowout

          Billroth 1 and Billroth 2 Reconstructions
      3. Subtotal Gastrectomy
        • involves resection of 75% of the distal stomach
        • a vagotomy is not necessary since a large part of the parietal cell mass is removed, as well as the antrum
        • a Billroth II or Roux-en-Y reconstruction must be done because the duodenum will not reach the stomach without tension
        • one advantage of a Roux limb is that it diverts biliary and pancreatic secretions away from the stomach; one major disadvantage is that it is associated with motility problems

        Subtotal Gastrectomy with Roux-en-Y Reconstruction
        Roux-en-Y Reconstruction

    3. Management of Specific Problems
      1. Intractability
        • a rare indication because of the efficacy of modern antisecretory medicines
        • need to rule out a gastrinoma
        • if done open, a highly selective vagotomy is the procedure of choice
        • laparoscopically, a posterior truncal vagotomy and anterior seromyotomy is usually performed

      2. Perforation
        1. Patch Closure
          • closure of an anterior perforated ulcer can be done with a simple omental patch (Graham patch)
          • procedure of choice if the patient has significant medical comorbidities, shock, or duration of perforation > 24 hours
          • historically has been associated with a high rate of ulcer recurrence and the need for an additional operation
          • however, with effective treatment for H. pylori virtually eliminating ulcer recurrence, omental patch closure is now the operation of choice
          • may be done laparoscopically
          • large perforations may require an onlay serosal patch of jejunum

          Graham Patch closure
        2. Definitive Ulcer Procedures
          • should be considered for chronic NSAID users, patients known to be H. pylori negative, or patients who cannot comply with the medical treatment for H. pylori
          • candidates should be healthy, hemodynamically stable, and have perforations less than 24 hours old
          • truncal vagotomy and pyloroplasty is the usual procedure performed because it is quick and easy
          • the pyloroplasty usually incorporates the perforation into the pyloroplasty closure
          • highly selective vagotomy can be chosen but it takes longer to perform
          • vagotomy and antrectomy is usually not indicated in the emergent or urgent setting

        3. Nonoperative Management
          • safe and beneficial in the occasional patient
          • consists of nasogastric suction, antibiotics, and H2-blockers
          • best candidate for this approach is a patient with a perforation < 24 hours old that has been shown on a Gastrografin study to have sealed
          • close observation is necessary in case the patient deteriorates

      3. Bleeding
        1. Indications for Surgery
          • hemorrhage is the principle cause of death from a duodenal ulcer
          • endoscopy should be performed early to establish the diagnosis and to initiate therapy (heater probe, clips, and epinephrine injection)
          • uncontrolled bleeding, transfusion of > 6 units of blood, rebleeding after endoscopic control are indications for surgery

        2. Surgical Procedures
          • the patient should be approached through a pyloroplasty incision and the ulcer bed oversewn
          • three-point U stitch ligation is recommended for ulcers that have penetrated the gastroduodenal artery
          • it can be difficult to place sutures securely in a scarred ulcer bed
          • finger pressure over the ulcer base allows volume resuscitation in an unstable patient
          • given the very low recurrence rates after treatment for H. pylori, suture ligation of the bleeding vessel only is the standard treatment
          • acid-reducing operations should be reserved for chronic NSAID users, patients known to be H. pylori negative, or patients who cannot comply with the medical treatment for H. pylori

          3 Point Ligation of a bleeding Duodenal Ulcer
      4. Obstruction
        1. Evaluation and Initial Management
          • barium swallow and endoscopy are necessary studies
          • the purpose of endoscopy is to rule out a malignant etiology
          • initial management includes nasogastric suction and fluid and electrolyte replacement
          • endoscopic dilatation of the strictured pylorus and H. pylori therapy is usually the first treatment once malignancy has been ruled out
          • if endoscopic dilatation is not successful or available, then surgery will be necessary

        2. Surgical Management
          • must decide whether the duodenal stump can be safely closed
          • vagotomy and antrectomy with a Billroth II reconstruction is the procedure of choice if the duodenum can be safely closed
          • if the duodenum is very scarred, then vagotomy with gastrojejunostomy is a safe choice

      5. Management of the Difficult Duodenum
        • if a resection has been carried out and the duodenum cannot be safely closed, then a tube duodenostomy must be placed to control secretions
        • after 3 to 4 weeks the duodenostomy tube can be removed, allowing the stump to close by secondary intention

      6. Posterior Penetrating Ulcers
        • usually erode into the pancreas
        • the pancreatic duct may lie in the ulcer base
        • it is unnecessary, and dangerous, to excise these ulcers
        • anterior wall of the duodenum should be sutured to the pancreas just proximal to the ulcer, thereby incorporating the pancreatic duct into the closure

        Closure of a Posterior Penetrating Ulcer
  6. Surgical Management of Gastric Ulcers
    1. Location and Classification
      • most are found within 2 cm of the junction between the antral and fundic mucosa on the lesser curve
      • greater curvature ulcers are uncommon (5%) and often associated with malignancy
      • classified into 5 types based on their location and acid secretory status:
        • Type I: adjacent to the incisura; low acid output
        • Type II: gastric body ulcer associated with a duodenal ulcer; high acid output
        • Type III: prepyloric; high acid output
        • Type IV high lesser curve, low acid output
        • Type V: occur anywhere in the stomach; associated with chronic NSAID or aspirin use

      Classification of Gastric Ulcers
    2. Elective Surgical Therapy
      • malignancy must be considered if the ulcer has not healed completely after an adequate trial of medical therapy (12 weeks)
      • resection is indicated for nonhealing gastric ulcers, even if the pretreatment biopsies were benign

      1. Type I Ulcer
        • primary operation is a distal gastrectomy with the ulcer in the resected specimen
        • another option is ulcer excision
        • vagotomy is not usually performed

      2. Type II and III Ulcer
        • associated with acid hypersecretion
        • vagotomy and distal gastrectomy to include the ulcer

      3. Type IV Ulcer
        • located near the gastroesophageal junction
        • Csendes procedure: distal gastrectomy along the lesser curve incorporating the ulcer and a small portion of the esophageal wall, with Roux-en-Y esophagogastrojejunostomy
        • if the ulcer is large, then a near-total or total gastrectomy with Roux-en-Y jejunal anastomosis must be considered
        • if the patient cannot tolerate these extensive procedures, then a truncal vagotomy and antrectomy with the ulcer left in situ may be performed (Kelling-Madlener procedure)
        • must do extensive biopsies of any ulcer left in situ

        Procedures for Type 4 Gastric Ulcers
    3. Emergent Surgical Therapy
      1. Perforation
        • exclusion of gastric carcinoma must be part of the treatment plan
        • all gastric perforations must be biopsied or resected
        • distal gastrectomy to include the ulcer is commonly done for type I ulcers (vagotomy is not necessary)
        • since Type II and III ulcers act like duodenal ulcers, patch closure and H. pylori treatment may be sufficient
        • wedge excision may be adequate for perforated Type I and IV ulcers
        • biopsy and closure for Type V ulcers may be sufficient if the predisposing factor (NSAIDs) can be eliminated

      2. Hemorrhage
        • operative strategy is similar to that described for perforations
        • in unstable patients bleeding from a Type IV ulcer, ligation of the left gastric artery, biopsy and oversewing of the ulcer through a high anterior gastrotomy can be done







References

  1. Schwartz, 10th ed., pgs 1050 - 1074
  2. Sabiston, 20th ed., pgs 1197 - 1211
  3. Cameron, 11th ed., pgs 69 - 84
  4. UpToDate. Surgical Management of Peptic Ulcer Disease. Vernon MD, Ashley. Oct 07, 2019. Pgs 1 - 31