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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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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