Stomach: Peptic Ulcer Disease (PUD)

Peptic Ulcer Disease (PUD)

Basics

  • Definition: Macroscopic Mucosal Wounds Extending into the Submucosa or Muscularis Propria
  • Sx: Dyspepsia (Epigastric Pain) that Improves with Eating

Risk Factors

  • H. pylori (#1 Risk Factor)
    • Helical GNR
    • Resides in Mucous
    • Pathophysiology:
      • Starts in Antrum
      • Induces Increased Gastrin (G Cells) & Acid (Parietal Cells) Secretion
        • Causes Duodenal Ulcers
      • With Continued Inflammation G Cells & Parietal Cells are Lost Causing Atrophy & Decreased Acid Secretion
        • Causes Gastric Ulcers
      • Bacteria Then Migrate Proximally with Corpus (Body) Gastritis
    • Makes Urease: Splits Urea into Ammonia/Bicarbonate
      • Alkaline Environment Promotes Survival
  • Male
  • Tobacco or Alcohol
  • NSAIDs or Steroids
  • Stress

Most Common Locations

  • Within Stomach – Type I Along Lesser Curvature
  • Within Duodenum – Anterior Aspect of First Portion
    • Duodenum is the Most Common Site Overall
    • 90% of Duodenal Ulcers are in the First Portion
    • Distal Ulcers Raise Concern for Gastrinoma

Modified Johnson Classification for Gastric Ulcers

  • Type I: Lesser Curvature, Low Along Body Mn
    • Cause: Loss of Protection Mn
  • Type II: Lesser Curvature & Duodenum
    • Cause: Increased Acid
  • Type III: Pre-Pyloric
    • Cause: Increased Acid
  • Type IV: Lesser Curvature, High Along Cardia Near GE Junction
    • Cause: Loss of Protection
  • Type V: Associated with NSAID’s

Special Ulcers

  • Cushing Ulcer
    • Ulcer from Head Trauma
    • High ICP Causes Over-Stimulation of Vagus Nerve Which Causes Over-Secretion of Acid
  • Curling Ulcer
    • Ulcer from Burns
    • Reduced Plasma Volume Causes Ischemia/Sloughing of Gastric Mucosa
  • Cameron’s Ulcer
    • Ulcer Within Hiatal Hernia
  • Dieulafoy Ulcer (Dieulafoy’s Lesion/Calibre Persistent Artery)
  • “Kissing” Duodenal Ulcer
    • Ulcers of Both the Anterior & Posterior Duodenal Wall
  • “Giant” Duodenal Ulcer (GDU)
    • Ulcer ≥ 2 cm
    • Usually Involves > 50% Circumference of the Duodenal Bulb
    • NSAID Use More Common, H. pylori Less Common
    • High Risk of Leak, Nonhealing & Stricture

Complications

  • Bleeding
    • Most Common Complication Overall
    • Most Common Complication of Posterior Duodenal Ulcers (Affect GDA)
  • Obstruction (Duodenum or Gastric Outlet)
  • Perforation
    • Most Common Complication in Stomach Ulcers
    • Most Common Complication of Anterior Duodenal Ulcers
  • Fistula

Testing

  • Diagnosis:
    • Stomach: EGD & Bx (Test for H. pylori & Rule Out Malignancy)
      • Repeat After 2-3 Months
    • Duodenum: EGD & Test for H. pylori
      • Bx Not Routine Due to Higher Risk of Complications
      • Bx Only if High Malignancy Risk, Obstructing or Giant (> 2 cm)
      • Other Tests for H. pylori: Serology, Stool Antigen Test or Urea Breath Test
  • Detect H. pylori Eradication: Urea Breath Test

Bleeding Gastric Ulcer 1

“Kissing” Duodenal Ulcer; (a) Anterior, (b) Posterior 2

Peptic Ulcer Disease (PUD) – Treatment

Primary Treatment

Refractory/Intractable (> 3 mo)

  • Distal Stomach (Type I-III): Antrectomy
    • If Type II/III: Add Truncal Vagotomy
      • Caused by Increased Acid Production
    • Reconstruction:
      • Preferred: Billroth I
        • Less Complications Than Billroth II
      • If Inadequate Reach/Mobility of Duodenum: Billroth II or Roux-en-Y
  • Proximal Stomach (Type IV):
    • ≤ 2 cm From Cardia: Csendes Procedure
      • Distal Gastrectomy with In-Continuity Excision of Ulcer
      • Reconstruction: Roux-en-Y
      • May Consider Kelling-Madlener Procedure (Gastrectomy without Ulcer Excision)
    • ≥ 5 cm Below Cardia: Pauchet Procedure
      • More Limited Distal Gastrectomy
      • Reconstruction: Billroth II or Roux-en-Y
  • Type V Stomach: Wedge Resection
  • Duodenum: Truncal Vagotomy & Pyloroplasty
    • Selective Has Too High Recurrence

Bleeding

  • Initial: EGD
    • Increased Risk of Rebleeding After EGD:
      • Active Pulsatile Bleeding (Highest Risk – 80%)
      • Visible Vessel (50%)
      • Adherent Clot (15-25%)
      • Clean Ulcer Base (< 5%)
  • If Fails & Stable: Second EGD
  • If Second Fails or Unstable: Surgery or Angioembolization
    • Stomach – Gastrotomy & Oversew Vessel
      • May Consider Wedge Resection if Along Greater Curvature
    • Duodenum – Duodenotomy & Oversew Vessel
      • Consider GDA Suture Ligation – Decreases Rate of Rebleeding
      • Classic Technique: Triple Ligation
        • One Above, One Below & One U-Stitch at the Left Aspect to Control Small Transverse Pancreatic Branches
      • If Stable with Known Ulcer Diathesis: Add Truncal Vagotomy & Pyloroplasty

Gastric Outlet Obstruction

  • Initial Tx: Conservative Management (Bowel Rest, PPI & H. pylori Treatment)
  • If Fails: Endoscopic Serial Dilations
  • If Endoscopy Fails: Antrectomy & Vagotomy
    • May Consider Vagotomy & Gastrojejunostomy Diversion Instead

Perforation

  • May Consider Conservative Management (NGT, ABX & PPI) if Presentation Delayed (> 24 Hours), Contained & No Peritonitis
  • Stomach:
    • Stable: Same as Refractory Tx
    • Unstable: Biopsy & Graham Patch or Wedge Resection
  • Duodenum:
    • Small (Most < 1 cm): Graham Patch
      • Pyloric Exclusion with Gastrojejunostomy Indications:
        • High Risk for Leak
        • Too Large
        • Poorly Controlled DM
      • If Known Ulcer Diathesis: Add Highly Selective Vagotomy
        • Contraindicated if > 24 Hours, Unstable or Extensive Peritonitis
    • “Giant” (≥ 2 cm):
      • No Consensus on Specific Repair
      • Options:
        • Roux-en-Y with Roux Limb to Ulcer Edge
          • Requires Kocher Maneuver & Debridement of Ulcer Edge
        • Serosal Patch with Jejunal Loop
        • Antrectomy & Billroth II Reconstruction
        • Primary Repair & Triple-Tube-Ostomy
          • Gastrostomy, Retrograde Duodenostomy & Feeding Jejunostomy
          • Requires Kocher Maneuver to Minimize Tension & Debridement of Ulcer Edge
        • Tube Duodenostomy
          • Preferred Procedure if Unstable
          • Procedure:
            • Debride Ulcer Edges
            • Place Malecot Catheter Through Defect
            • Purse-String Suture Around Catheter
            • Mobilize an Omental Pedicle
            • Wrap Omental Pedicle Around the Tube & Secure at the Base
            • Bring Malecot Externally to Drain

Antrectomy with Billroth I 3

Truncal Vagotomy 4

Graham Patch 5

Mnemonics

Gastric Ulcer Sites

  • 1 is Less/Low
  • 2 Has Two
  • 3 is Pre
  • 4 at the Front Door

Gastric Ulcer Causes

  • I/IV: Lesser Curvature, Loss of Protection
  • II/III: Lower, Where Acid Lies
  • V: Anywhere, NSAIDs

References

  1. Kim JS, Park SM, Kim BW. Endoscopic management of peptic ulcer bleeding. Clin Endosc. 2015 Mar;48(2):106-11. (License: CC BY-NC-3.0)
  2. Oluyemi A, Amole A. Portal hypertensive duodenopathy manifesting as “kissing” duodenal ulcers in a nigerian with alcoholic cirrhosis: a case report and brief review of the literature. Case Rep Med. 2012;2012:618729. (License: CC BY-3.0)
  3. Terrone DG, Lepanto L, Billiard JS, Olivié D, Murphy-Lavallée J, Vandenbroucke F, Tang A. A primer to common major gastrointestinal post-surgical anatomy on CT-a pictorial review. Insights Imaging. 2011 Dec;2(6):631-638. (License: CC BY-2.0)
  4. Rabben HL, Zhao CM, Hayakawa Y, Wang TC, Chen D. Vagotomy and Gastric Tumorigenesis. Curr Neuropharmacol. 2016;14(8):967-972.(License: CC BY-NC-4.0)
  5. Maghsoudi H, Ghaffari A. Generalized peritonitis requiring re-operation after leakage of omental patch repair of perforated peptic ulcer. Saudi J Gastroenterol. 2011 Mar-Apr;17(2):124-8. (License: CC BY-2.0)