Stomach and Duodenum—Gastric Ulcer

Stomach and Duodenum—Gastric Ulcer

Concept

Four basic types of gastric ulcers categorized by location and etiology. Always, ALWAYS, have a high index of sus- picion for malignancy and do everything possible to rule it out. Four types of gastric ulcers:

I Lesser curve, unrelated to acid

II Gastric ulcer with associate duodenal ulcer, related to acid exposure

III Prepyloric ulcer (within 3 cm of pylorus), related to acid exposure

IV Adjacent to gastroesophageal junction (juxtac- ardial), unrelated to acid

Way Question May be Asked?

“45 y/o male with history of UGIB who has a gastric ulcer identified on EGD. He has been on omeprazole for 8 weeks and repeat EGD shows ulcer still present. What do you want to do?” Question may go in the direction of how to initially treat this patient, how long to trial acid sup- pressive therapy, and when to operate, or it may jump right into a discussion of how to manage a bleeding or perfo- rated gastric ulcer. Size and pH are particularly important as most ulcers > 3 cm and most ulcers in the achlorhydric patient will eventually need surgery.

How to Answer?

History

Risk factors for PUD

Steroid/NSAID use History of epigastric pain Iron deficiency anemia

Vomiting/bloating (from gastric outlet obstruction)

FHx ZE syndrome

Use of anti-ulcer medications

Relevant medical history (heart disease)

Prior surgeries (especially prior surgery for PUD)

Physical Exam

Vital signs (tachycardia/hypotension to suspect shock) Abdominal exam (rigidity/peritoneal signs to suggest

perforation)

Rectal exam (heme +, Blummer’s shelf)

Diagnostic Studies

Routine labs including T +C and coags especially if bleeding

Do lytes show evidence of gastric outlet obstruction (low K, low Cl, high bicarb)?

Abdominal x-rays (r/o free air)

+/− Barium UGI (no Barium if suspect perforation) Gastric acid analysis (achlorhydria suggestive of Ca) EGD + bx! (at least 10 biopsies)

Any attempt at biopsy should include four quadrant margins, central biopsy, and brushings!

Surgical Treatment

(1) Resuscitate the unstable pt

(2) Repeat EGD/biopsy at 6–8 weeks for the chronic ulcer, treat medically, and repeat EGD at 6–8 weeks, if improving, repeat EGD at 6–8 weeks:

no improvement at 1st 6–8 week follow-up → OR failure to disappear at 2nd 6–8 week EGD → OR (3) Indications for surgery: Intractability

Bleeding Perforation Obstruction

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(4) For Type I (lesser curve) ulcer (most common):

antrectomy to include ulcer (goblet cells on duodenal side indicate adequate resection)

reconstruction with BI (make sure frozen section is negative for malignancy before reconstruct with BI)

recurrence rate 2%

(5) For Type II and III ulcers:

antrectomy and truncal vagotomy (6) For Type IV ulcers:

resection with Roux-en-Y esophagogastrojejunos- tomy

(Csendes’ procedure) (7) For bleeding ulcer:

EGD + biopsy

+/− Angiogram with vasopressin/embolization Have threshold in your mind of when to operate on

pt (more than 6U pRBC in 48 h—remember baseline comorbidities in your limit)

In OR:

(a) pt stable → antrectomy to include ulcer when possible suture ligate ulcer/biopsy + antrec- tomy vagotomy for Type II,III ulcer

(b) unstable pt → wedge resection or suture/biopsy to ulcer + vagotomy/pyloroplasty

(8) For perforated ulcer:

(a) stable pt → antrectomy to include ulcer or antrectomy + omental patch and biopsy ulcer

(b) unstable pt → biopsy and omental patch (wedge resection of ulcer always an option if easy to do)

Common Curveballs

Biopsies will come back malignant, indeterminant, benign

Type of ulcer (I-IV) will change during scenario

Asked your method to test for H. pylori Pt will fail medical management

Will turn out to be gastric cancer (check frozen section before reconstruct)

Asked your treatment algorithm for H. pylori Will be asked how to manage type IV ulcer intra-op Won’t be able to encompass ulcer in antrectomy Ulcer will perforate

Pt will bleed post-op

Gastric acid measurements will show achlorhydria Discussion of postgastrectomy complications:

Bleeding Dumping

Afferent/efferent obstruction Postvagotomy diarrhea Carcinoma

Strikeouts

Describing any laparoscopic approach

Not knowing how to treat postgastrectomy syndromes Not knowing how to describe your chosen operation Misdiagnosing a gastric cancer as a benign ulcer Not testing for or treating H. pylori

Not knowing importance of achlorhydria and its link to malignancy

Not rescoping/re-biopsying pt with chronic non-healing ulcer

Not knowing indications for surgery

Spending too long with angiographic or nonoperative methods to control bleeding

Not checking for malignancy before performing recon- struction (BII is preferred for malignant gastric ulcer)

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