58. Peptic ulcer: modern surgical treatment

1. Definition

• Peptic ulcer → defect of the gastric or duodenal mucosa extending through the muscularis mucosae
• Erosion → defect confined to the mucosa
• Duodenal ulcer (DU) → 90% in the first part of the duodenum
• Gastric ulcer (GU) → most on the lesser curvature, at the incisura

2. Epidemiology

• DU → more common than GU, younger patients
• GU → older patients, more often linked to NSAIDs

3. Aetiology and risk factors

• Helicobacter pylori infection → 70–80% of DU
• Non-steroidal anti-inflammatory drugs (NSAIDs) and aspirin
• Smoking
• Zollinger–Ellison syndrome → gastrinoma, multiple or atypical ulcers
• Stress ulcers:
  • Curling's ulcer → after major burns
  • Cushing's ulcer → after head injury
• Hyperparathyroidism → hypercalcaemia, raised gastrin

4. Pathogenesis

• Imbalance → aggressive factors exceed mucosal defence
• Aggressive factors:
  • Acid and pepsin
  • H. pylori → antral gastritis → raised gastrin → raised acid (DU)
  • NSAIDs → loss of prostaglandins → reduced mucus and bicarbonate
• Defensive factors:
  • Mucus-bicarbonate layer
  • Mucosal blood flow
  • Epithelial renewal
• DU → high acid output
• GU types I and IV → normal or low acid; mucosal defence fails

5. Classification

Modified Johnson classification of gastric ulcer

1. Type I → lesser curvature at the incisura; normal or low acid
2. Type II → gastric body ulcer with a DU; high acid
3. Type III → prepyloric; high acid
4. Type IV → high lesser curvature near the gastro-oesophageal junction; low acid
5. Type V → anywhere in the stomach; NSAID-induced

By course

• Acute → stress, NSAIDs, burns, head injury
• Chronic → fibrotic base, may penetrate neighbouring organs

6. Clinical picture

Symptoms

• Epigastric pain, burning or gnawing
• DU:
  • Pain 2–3 h after meals and at night
  • Relieved by food or antacids
• GU:
  • Pain soon after meals
  • Food fear, weight loss
• Periodicity → episodes over weeks with pain-free months
• Nausea, vomiting, bloating
• Back pain → posterior ulcer penetrating the pancreas
• Complications as first presentation → bleeding, perforation, obstruction

Signs

• Epigastric tenderness
• Pallor → chronic blood loss
• Succussion splash → gastric outlet obstruction

7. Diagnosis

Laboratory

• Full blood count → iron-deficiency anaemia
• H. pylori tests:
  • Urea breath test
  • Stool antigen test
  • Rapid urease test (CLO test) on antral biopsy
  • Histology
• Fasting serum gastrin → suspected Zollinger–Ellison syndrome; stop proton pump inhibitor (PPI) first

Imaging

• Oesophagogastroduodenoscopy (OGD) → investigation of choice
  • Every GU → multiple biopsies from the edge and base
  • Repeat OGD after 8–12 weeks → confirm healing of GU
• Barium meal → only if OGD not possible
• Computed tomography (CT) → complications, penetration

8. Differential diagnosis

• Gastro-oesophageal reflux disease
• Functional dyspepsia
• Gastric carcinoma
• Biliary colic, cholecystitis
• Pancreatitis
• Myocardial infarction

9. Treatment

Conservative

• H. pylori eradication → triple therapy (PPI + 2 antibiotics) for 14 days
• PPI for 4–8 weeks (DU) and 8–12 weeks (GU)
• Stop NSAIDs; if essential → PPI cover or a cyclo-oxygenase-2 (COX-2) inhibitor with PPI
• Stop smoking
• Confirm eradication after treatment
• Medical treatment heals most ulcers → elective ulcer surgery now rare

Surgical

• Indications:
  1. Perforation
  2. Bleeding not controlled by endoscopy
  3. Gastric outlet obstruction
  4. Intractable ulcer despite full medical therapy
  5. Suspected malignancy, GU that does not heal
  6. Zollinger–Ellison syndrome not controlled medically
• Operations for DU:
  • Highly selective vagotomy (HSV) → nerves of Latarjet preserved, no drainage, fewest side effects, highest recurrence
  • Truncal vagotomy + drainage (pyloroplasty or gastrojejunostomy)
  • Truncal vagotomy + antrectomy → lowest recurrence, most side effects
• Operations for GU:
  • Type I → distal gastrectomy with Billroth I gastroduodenostomy
  • Types II and III → antrectomy + truncal vagotomy
  • Type IV → resection including the ulcer (Pauchet or Csendes) with Roux-en-Y
  • Any GU → resection or excision must include the ulcer for histology
• Reconstruction after distal gastrectomy:
  1. Billroth I → gastroduodenostomy
  2. Billroth II (Polya) → gastrojejunostomy, duodenal stump closed
  3. Roux-en-Y → less bile reflux and dumping

10. Complications

Of the ulcer

• Bleeding
• Perforation
• Penetration → pancreas, liver, colon
• Gastric outlet obstruction
• Malignant change → GU only

Of ulcer surgery

• Early:
  • Duodenal stump blow-out (Billroth II)
  • Anastomotic leak
  • Stomal obstruction
  • Gastric remnant necrosis → left gastric artery ligated at origin with splenectomy
• Late:
  • Alkaline reflux gastritis → commonest late problem; treated by Roux-en-Y conversion
  • Early dumping → 30–60 min after meals; osmotic fluid shift; 10%
  • Late dumping → 2–3 h after meals; reactive hypoglycaemia; 5%
  • Post-vagotomy diarrhoea
  • Afferent loop syndrome → long afferent loop after Billroth II
  • Recurrent ulcer → exclude Zollinger–Ellison syndrome
  • Small stomach syndrome
  • Iron and vitamin B12 deficiency, bone disease
  • Gastric stump carcinoma