Stomach and Duodenum—Duodenal Ulcer

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Stomach and Duodenum—Duodenal Ulcer

Concept

Majority of questions will be related to obstruction, bleed- ing, or perforation. Most ulcers are related to H. pylori or NSAID use. Nonoperative therapy may be appropriate for initial discovery of ulcer and for initial bleeding ulcer. Be sure to rule out ZE syndrome, ulcerogenic medications, hyperparathyroidism, and antral G cell hyperplasia when appropriate.

Way Question May be Asked?

“A 43 y/o man presents to ED with acute onset of severe epigastric pain with a rigid abdomen on physical exam.

Upright AXR reveals free air.” Unlikely to get a presenta- tion this classic. Be sure to go through your DDx for epi- gastric pain ruling out MI and pancreatitis, or your DDx for UGI bleeding if appropriate.

How to Answer?

History

NSAID, smoking, ethanol use

History of ulcer symptoms (chronic hx affects your choice of operation!)

H. pylori treatment Family history (MEN I) H

₂

blocker therapy Foreign body ingestion Diarrhea (gastrinoma)

History should also focus on symptoms being sure to r/o other possibilities:

Pancreatitis MI

Pneumonia → all less likely if see free air, make sure AXR is upright!

Esophagitis Gastritis Gallbladder dx Aortic dissection

Physical Exam

Check vital signs

Look for peritoneal signs (guarding, rebound)

Remember findings are more subtle in elderly and in pt on steroids

Labs

Full laboratory panel including amylase/lipase

Gastrin/Ca

⁺⁺

if suspicion of gastrinoma, hyperparathy- roidism or chronicity

Radiologic Studies

For perforated ulcer, need:

Upright AXR

CT scan could demonstrate free air and r/o diverticulitis

For bleeding ulcer, need EGD → will r/o other pathol- ogy, help predict course, treat bleeding, and check for H. pylori

Treatment of bleeding ulcer by EGD:

Electrocautery Heater probe Injection therapy

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Endoscopic appearance

Clean-based ulcer (rarely rebleed) Adherent clot ( likely to rebleed) Non-bleeding vessel (likely to rebleed) For obstruction, need UGI

Treatment

For Perforated Ulcer:

No role for conservative treatment!

Need to initially resuscitate pt (IVF, antibiotics, H2 blockers)

Take to OR, upper midline incision Three choices:

High risk pt (elderly, > 24 h, unstable, advanced peritonitis)

Omental patch and abdominal lavage (> 5 liters saline)

Good risk pt (young, < 24 h, stable, early peritonitis) Omental patch, parietal cell vagotomy, lavage Good risk pt with hx of PUD:

Antrectomy (will include ulcer)/vagotomy, lavage

For Bleeding Ulcer:

Treatment initially is conservative with EGD, transfu- sions, H

₂

blockers

Should have your limit of transfusions before going to OR (> 6 in 24 h or hemodynamic instability) Should know what endoscopic appearance is relative

indication for OR Three choices here too:

High risk pt:

Vagotomy/pyloroplasty/oversew of ulcer (U stitch)

Good risk pt with small ulcer

Oversew ulcer and parietal cell vagotomy Good risk pt with large ulcer (> 2 cm) or hx PUD

Antrectomy/vagotomy

For Obstruction:

Initial conservative Tx with trial of NGT decompres- sion

H

₂

blockers

Check UGI to confirm

If this fails (which it will), then proceed to OR Two choices here:

High risk pt:

Gastrojejunostomy +/− vagotomy Low risk pt:

Antrectomy and vagotomy (Bilroth I reconstruc- tion)

Notes about Surgery:

Should always try for Bilroth I (avoids afferent/efferent problems with Bilroth II and problems with second anas- tomotic line). Be sure to extend at least 0.5 cm beyond dis- tal edge of pylorus and check proximal antrectomy line with frozen section to show parietal cells.

If doing pyloroplasty, may not be able to do typical Heineke-Mikulicz pyloroplasty with a scarred duodenum, so do a Finney or a Jaboulay (anastomosis involving distal stomach to second portion of duodenum). If all three are impossible, gastrojejunostomy is effective emptying proce- dure.

Truncal vagotomy involves stripping the esophagus bare of areolar tissue in the distal 5–7 cm of esophagus.

If pt has had prior surgery, and pre-op work-up reveals no specific cause for recurrence, take next most aggressive option:

If prior vagotomy with drainage →antrectomy If prior antrectomy with vagotomy →subtotal gas- trectomy

Common Curveballs

EGD will see adherent clot or visible vessel Perforation will be over 24 h old

Perforation will be in pt with long hx refractory ulcer dx Perforation will be in elderly pt

Pt will have had prior abdominal surgery

Won’t be able to close duodenal stump after antrectomy Pt will keep requiring blood transfusions, but spread

out over several days

Nonoperative treatment will work and pt will later pres- ent with gastric outlet obstruction

Asked to describe how to perform vagotomy/pyloro- plasty/antrectomy/ and/or “U stitch” for bleeding duodenal ulcer

Gastrojejunostomy will be complicated by marginal ulcer, afferent loop syndrome, bile reflux, gastritis, dumping syndrome.

Duodenal stump will leak post-op

Pt may rebleed post-op after U stitch performed (con- sider angiographic embolization of gastroduodenal artery)

Pt will have ZE syndrome

Pt will have had prior ulcer surgery

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Strikeouts

Not ruling out other etiologies of epigastric pain Trying to treat perforated ulcer conservatively Not trying to conservatively treat a bleeding ulcer at

first presentation

Not being prepared to perform a different operation in someone with chronic sxs

Not performing EGD for bleeding ulcer

Trying to treat gastric outlet obstruction with endo- scopic balloon dilatation

Performing any operation laparoscopically

Not knowing how to manage the difficult duodenal stump

Not knowing how to manage duodenal stump leak Not oversewing bleeding site when performing vago-

tomy/pyloroplasty

Not having an idea in your head about recur- rence/mortality rates after different operations Forgetting H. pylori