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Benign Gastric Ulcers

E.R.. 89F w/dementia, Parkinson's disease, hypertension, and history of recent NSAID use for arthritisPresented to ER with melena, dropping Hgb to 6.6 from baseline 10Put on PPI's, stabilized, and transfused Underwent elective EGD revealing multiple ulcers. E.R.. 5 UlcersBody: 3 total, ~1cm with adherent clot (deep), and second ~3cm, third not described in sizeAntrum/Angularis: ~4cm, not bleeding, borders biopsiedAnother deep ulcer injected with epinephrine,

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Benign Gastric Ulcers

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    1. Benign Gastric Ulcers

    2. E.R. 89F w/dementia, Parkinson’s disease, hypertension, and history of recent NSAID use for arthritis Presented to ER with melena, dropping Hgb to 6.6 from baseline 10 Put on PPI’s, stabilized, and transfused Underwent elective EGD revealing multiple ulcers

    3. E.R. 5 Ulcers Body: 3 total, ~1cm with adherent clot (deep), and second ~3cm, third not described in size Antrum/Angularis: ~4cm, not bleeding, borders biopsied Another deep ulcer injected with epinephrine, “concerning for penetrating ulcer” along greater curvature Gastritis CXR/ABD film done because of distention and deep ulcer

    5. OR NGT/IVF/Antibiotics Exploratory laparotomy Oversewn gastric perforation with omental patch Transferred stable to SICU Unremarkable recovery on PPI’s

    7. Benign Gastric Ulcers Until late 1970’s treatment was primarily surgical Mortality for emergency surgery high (16% at Ohio State University) Medical therapy has reduced number of elective operations Despite this 3000 U.S. deaths/year due to gastric ulcers 10% of all gastric ulcers harbor malignancy

    8. Surgical Indication and Associated Mortality (Ohio State University 1968-1972)

    9. Ulcer Pathogenesis Decreased mucosal protection NSAID’s Steroids Hypersecretion of acid H.pylori (75% of gastric ulcers caused by this) Smoking and EtOH correlation Gastrin (Zollinger-Ellison)

    10. Treatment Primarily medical PPI or H2 blocker Triple combination (double antibiotic and PPI=amoxicillin, clarithromycin, pantoprazole for 7-14 days) Surgical indications Intractibility (after medical therapy) Hemorrhage Obstruction Perforation Relative: continuous requirement of steroid therapy/NSAIDs H pylori therapy fails in as many as 20% of patientsH pylori therapy fails in as many as 20% of patients

    11. Elective Surgical Therapy Rare; most uncomplicated ulcers heal within 12 weeks If don’t, change medication, observe addition 12 weeks Check serum gastrin (antral G-cell hyperplasia or gastrinoma) EGD: biopsy all 4 quadrants of ulcer (rule out malignant ulcer) if refractory

    12. Modified Johnson Classification

    13. Elective Surgical Therapy

    14. Type I Lesser curvature; incisura MOST COMMON Decreased mucosal protection (no vagotomy) Distal gastrectomy (INCLUDING UCLER) with BI

    16. Billroth I

    17. Elective Surgical Therapy

    18. Type 2/3 Ulcers Acid hypersecretion Antrectomy with ulcer and bilateral truncal vagotomy Billroth II or Billroth I depending on technical difficulty Parietal cell vagotomy option but higher recurrence

    19. Billroth II Note: this is subtotal gastrectomyNote: this is subtotal gastrectomy

    20. R-Y limb (subtotal gastrectomy) Note: this is subtotal gastrectomyNote: this is subtotal gastrectomy

    21. Elective Surgical Therapy

    22. Type 4 Ulcers Least common (5% of all gastric ulcers) Ulcers 2-5cm from cardia can be treated with distal gastrectomy, extending resection along the lesser curvature and BI (Pauchet/Shoemaker procedure) Ulcers closer to GEJ, tongue-shaped resection high onto lesser curve (Csendes’ procedure with Roux-en-Y reconstruction)

    24. Elective Surgical Therapy

    25. Giant Gastric Ulcer Giant gastric ulcer: >3cm; 30% malignancy risk Subtotal gastrectomy with Roux-en-Y (high morbidity and mortality) Kelling-Madlener procedure: less aggressive, antrectomy, BI reconstruction, bilateral truncal vagotomy, leave ulcer, multiple biopsies, cautery of ulcer

    26. Emergency Surgery Hemorrhage Obstruction Perforation

    27. Hemorrhage Risk in H.pylori patients 1%/year Bleeding gastric ulcer mortality ~10% EGD with heater probe coagulation or injection therapy is first-line therapy

    28. Forrest Classification

    29. EGD vs. Operation Imhof et al, N=55, prospective, randomized, all high-risk for rebleed EGD with fibrin versus operation (usually BI) Risk of recurrence was 50% in EGD group vs. 11% in operative group 7% of EGD group ended up receiving surgery anyway No difference in mortality (7% vs. 6% in EGD) Conclusions: early elective surgery effective at preventing rebleeds, but most can be controlled by EGD only

    30. Rebleeding Risk Low risk on Forrest classification ~1%/month Penetrating ulcer posterior wall in prepyloric area with visible vessel high risk for massive rebleed However, visible vessel after EGD with injection of epinephrine or fibrin/coagulation risk goes down to ~10-30% Rebleeds usually occur before hospital day #4 Angiography not useful because of extensive collateralization of stomach

    31. Early Surgical Intervention Historically, outcome may be better if surgery performed before major transfusion (4 units) May be better if within 48 hours of initial bleed in patient at high risk for rebleed Can opt to do further endoscopy over surgery

    32. Surgical Options for Hemorrhage Excision or oversewing ulcer in unstable patient through anterior gastrotomy, avoiding nerves of Latarjet If unknown, test H.pylori antral mucosa biopsy and rapid urease test HD stable patients, distal gastrectomy and BI

    33. Surgical Options for Hemorrhage Type 1: BI w/distal gastrectomy Type 2/3: BI w/distal gastrectomy, bilateral truncal vagotomy Type 4: divide left gastric artery, biopsy ulcer, and oversew through high anterior gastrotomy Dieulafoy ulceration/anomalous artery: suture ligature

    34. Perforation Nonoperative management reserved for contained leaks in high risk stable patients with nasogastric suction Most require operation: resection not required for patients with perforation as first sign of PUD, or have untreated H.pylori, or do not require long-term ulcerogenic medications

    35. Perforation Ulcers should be biopsied or excised, omentoplasty performed, copious irrigation Laparoscopy is option If no biopsy, EGD should be done after 3 weeks In high risk patients can do truncal vagotomy and pyloroplasty

    37. Obstruction Emergency surgery for this is rare now Billroth I if possible or Billroth II if severe scarring

    38. Surgical Complications Vagotomy: Postvagotomy diarrhea in 30-50% Dumping syndrome: diarrhea with dizziness and hypotension, rapid entry of carbohydrates into small bowel (90% resolve with medical therapy: small, low fat, low carb diets, +/- octreotide), can treat with BI or BII to Roux-en-Y Alkaline reflux gastritis: postprandial epigastric pain, tx with PPI’s, H2blockers, cholestyramine or convert to Roux-en-Y Gastric remnant cancer Marginal ulcer

    39. References Imhof et al. Endoscopic versus operative treatment in high-risk ulcer bleeding patients-results of a randomised study. Langenbeck’s Arch Surg. 2003. KIM, UNSUP Sirinek et al. Benign Gastric Ulcer and Stress Gastritis in Current Surgical Therapy. 8th Ed, edited by Cameron. Elsevier Mosby. 2004. Schwesinger et al. Operations for Peptic Ulcer Disease: Paradigm Lost. J Gastrointest Surg 2001.

    40. THANK YOU

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