Peptic ulcer disease

  • Number of admissions for uncomplicated disease is falling
  • Incidence of complications rated to NSAID use is increasing

Gastric ulcer

Helicobacter pylori

  • H. pylori is gram-negative spiral flagellated bacterium
  • Produces urease
  • Important in the aetiology of peptic ulcers and gastric cancer
  • Found in:
    • 90% patients with duodenal ulceration
    • 70% patients with gastric ulceration
    • 60% patients with gastric cancer

Investigation

  • The organism can be detected by
  • Microscopy silver or Giemsa staining of antral biopsies
  • Culture difficult and requires special culture techniques
  • Rapid urease test colour changes due to change in pH
  • 13C or 14C breath test Ingested radioactive urea is broken down to carbon dioxide
  • Serology detected immunologically using an ELISA

Sensitivity and specificity of H. pylori diagnostic tests

Test Sensitivity (%) Specificity (%)
Rapid urease 90 90-95
Culture 80 100
Microscopy 90 90
Carbon breath test 95 95
Serology 98 100

Medical management of peptic ulcer disease

H2 Antagonists

  • 65% healing at one month
  • 85% healing at two months
  • If stop treatment - 90% recurrence at 2 years
  • If maintenance therapy - 20% recurrence at 5 years

Proton Pump inhibitors

  • 90 - 100% healing at 2 months
  • Low recurrence on long term maintenance

H. Pylori eradication

  • 80% cured with dual or triple therapy
  • Two weeks amoxycillin, metronidazole and omeprazole
  • Short term recurrence rates low
  • Long term recurrence rates are at present unknown
  • Drugs have changed the need for ulcer surgery over last 20 years
  • Admissions for elective surgery have significantly reduced
  • The number of complications however remain unchanged
  • May be increasing due to increased NSAID use in elderly
  • Bleeding and perforation still have mortality of >10%

History of peptic ulcer surgery

  • Harberer (1882) - First gastric resection for benign ulcer
  • Billroth (1885) - Billroth II Gastrectomy
  • Von Fiselberg (1889) - 'Valve' to prevent bile reflux through gastroenterostomy
  • Hofmeister (1896) & Polya (1911) - Retrocolic anastomosis
  • Dragstedt (1943) - Truncal vagotomy
  • Visick (1948) - Truncal vagotomy and drainage
  • Johnson & Wilkinson (1970) - Highly selective vagotomy

Billroth I gastrectomy

  • Originally described for the resection of distal gastric cancers
  • Still used in gastric cancers if radical gastrectomy is inappropriate
  • Later applied in the treatment of benign gastric ulcers
  • Useful if ulcer situated high on the lesser curve or bleeding ulcer that requires resection
  • Less effective than Polya Gastrectomy for duodenal ulcers

Billroth II / Polya gastrectomy

  • Initially described for duodenal ulceration but rarely performed today
  • Some form of vagotomy is the surgical treatment of choice for uncomplicated DU
  • Occasionally used below a high gastric ulcer
  • Ulcer invariably heals after surgery
  • Useful in recurrent ulceration following previous vagotomy
  • When constructing the anastomosis need to consider:
  • Antecolic vs. retrocolic anastomosis
  • Hofmeister valve so as direct bile in to the efferent loop
  • Isoperistaltic vs. anteperistalitic anastomosis

Current surgical options

Indications for surgical treatment of duodenal ulceration are:

  • Intractability
  • Haemorrhage
  • Perforation
  • Obstruction

Gastric outflow obstruction due to pyloric stenosis

Aims of surgery are: 

  • To cure the ulcer diathesis with
  • The lowest risk of recurrence and complications

Surgical options for duodenal ulceration

  • Operations for duodenal ulceration reduce acid production by the stomach
  • Cephalic phase reduced by vagotomy
  • Antral phase reduced by antrectomy
  • May require gastric drainage procedure to overcome effects of vagotomy on gastric drainage

Open surgical procedures

  • Truncal vagotomy and pyloroplasty
  • Truncal vagotomy and gastrojejunostomy
  • Truncal vagotomy and antrectomy
  • Highly selective vagotomy
  • Anterior seromyotomy and posterior truncal vagotomy

Laparoscopic peptic ulcer operations

  • Thoracoscopic truncal vagotomy and pyloric stretch
  • Truncal vagotomy and pyloric stretch
  • Highly selective vagotomy
  • Posterior truncal vagotomy and selective anterior vagotomy
  • Posterior truncal vagotomy and anterior seromyotomy

Post gastrectomy complications

Percentage
Recurrent ulceration 2
Diarrhoea 16
Dumping 14
Bilious vomiting 10
Iron deficiency anaemia 12
B12 deficiency 14
Folate deficiency 32

Post vagotomy complications

Percentage
Diarrhoea 2
Dumping 2
Bilious vomiting <2

Bibliography

Chan F K L, Leung W K.  Peptic-ulcer disease. Lancet 2002;  360:  933-641

Ching C K  Lam S K.  Drug therapy of peptic ulcer disease.  Br J Hosp Med 1995: 54; 101 -106.

Singh P  Colin-Jones D G.  Modern management of peptic ulceration.  Br J Hosp Med 1992: 47;  44 -50.

Taylor T V et al.  Current indications for peptic ulcer surgery.  Curr Pract Surg 1995: 7;  131 -134.

Williams J G  Fielding J W.  Duodenal Ulcer.  Surgery 1993: 11 ;  558 - 562.

 

 
 

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