Gastroenterology and Hepatology Board Review: Pearls of Wisdom, Third Edition

Section III STOMACH

CHAPTER 19. Surgical Aspects of Peptic Ulcer Disease

Joseph J. Cullen, MD and Jessica K. Smith, MD

Image What are the indications for operative treatment of peptic ulcer disease?

Perforation, obstruction, and bleeding. Traditionally, intractability was included but with the decrease in the incidence of peptic ulceration, the development of potent H2-receptor antagonists and proton pump inhibitors (PPIs), and increasing evidence regarding the role of Helicobacter pylori and nonsteroidal anti-inflammatory drug (NSAID)-induced ulceration, intractability has become rare.

Image Chest radiographs demonstrate pneumoperitoneum in what percentage of patients with perforated duodenal ulcer?

75%. In a minority of patients, omentum or liver seals the perforation and pneumoperitoneum is not seen.

Image What is the principal cause of death from peptic ulcer disease?

Hemorrhage, although the majority of patients who have acute hemorrhage from ulcers stop bleeding spontaneously.

Image Which patients with a bleeding ulcer may be appropriate for radiologic embolization as an alternative to surgery?

Poor surgical candidates or patients that have had multiple previous operations in the upper abdomen, making access to the duodenum exceedingly difficult.

Image Bleeding must be at least at what rate in order to be visualized angiographically for embolization?

1 ml/min.

Image What are the indications for emergent surgical intervention for bleeding duodenal ulcer?

Failure of initial endoscopic or radiologic therapy; bleeding refractory or inaccessibility to endoscopic control; high-risk findings for rebleeding at initial endoscopy such as large, pulsatile vessel; persistent hemodynamic instability or transfusion requirement exceeding 6 units of blood in a 24-hour period.

Image Three-point suture ligation (see Figure 19-1) of the gastroduodenal artery (GDA) complex includes the proximal and distal gastroduodenal artery and what other branch?

Image

Figure 19-1

Transverse pancreatic branch.

Image Why are fewer postgastrectomy complications seen following Billroth I reconstruction compared to other types of reconstruction?

Preservation of the duodenal passage eliminates early dumping and malabsorption seen with the other types.

Image What surgical treatment of dumping or enterogastric reflux after Billroth II reconstruction should be considered after failure of conservative (dietary and medical) management?

Conversion to Roux-en-Y gastrojejunostomy.

Image What is the mortality rate of partial gastrectomy for uncomplicated gastric ulcer?

1%–2%.

Image True/False: The risk of gastric cancer following partial gastric resection is greater than the general population.

True. The overall magnitude of the relative risk has been estimated to be about 1.5 to 3.0 but depends on the type of surgery, duration of follow-up, and general location. The risk appears to be greatest after about 15 to 20 years postoperatively.

Image What are the four major factors suggested to be involved in the pathogenesis of gastric stump cancer after partial gastrectomy for peptic ulcer disease?

Enterogastric reflux, achlorhydria, bacterial overgrowth, and H. pylori.

Image A patient, who is postoperative day 5 after antrectomy, vagotomy, and Billroth II gastrojejunostomy for an obstructing duodenal ulcer, develops an acute exacerbation of abdominal pain and fever. What is the most likely diagnosis?

Patients who have leakage from a duodenal stump have an acute exacerbation of abdominal pain, typically on the fifth to seventh postoperative day. When the leak is sizeable, symptoms of an acute abdomen result.

Image What is the mortality rate for duodenal stump blowout after an antrectomy and gastrojejunostomy for peptic ulcer disease?

About 50%.

Image True/False: Recurrent ulcers are more common after an operation for “intractable” duodenal ulcer than after an operation for gastric ulcer.

True.

Image What is the overall mortality rate for patients who undergo operation for perforated duodenal ulcer?

3%–6%.

Image What factors increase morbidity and mortality risk in patients with perforated duodenal ulcer?

Serious comorbid illness, hemodynamic instability, perforations over 48 hours in duration at time of presentation, and age over 70.

Image Figure 19-2 demonstrates a 46-year-old patient who presented with abdominal pain and pneumoperitoneum on upright chest x-ray. Rapid H. pylori testing was positive. The intraoperative findings are shown in the photograph. What operative intervention should be performed?

Image

Figure 19-2 See also color plate.

Omental (Graham) patch closure of the perforated duodenal ulcer and treatment of H. pylori postoperatively.

Image What is most commonly the first symptom of postoperative recurrent ulcer?

Upper gastrointestinal bleeding is frequently the first symptom of postoperative recurrent ulcer, occurring in 40%–60% of patients.

Image True/False: Perforation is a common presentation for recurrent ulcer in a postgastrectomy patient.

False.

Image Where are postoperative recurrent ulcers typically located?

Recurrent ulcers nearly always occur within l–2 cm of the gastrointestinal anastomosis.

Image A postgastrectomy patient presents with recurrent ulceration. Serum gastrin levels are elevated. What are some of the possible causes?

Gastrinoma, retained antrum, G-cell hyperplasia, or administration of PPIs.

Image What are the characteristic endoscopic findings of stress ulceration?

The lesions of stress ulceration are superficial, rather than deep, multiple rather than single, gastric rather than duodenal, fundic rather than antral, and usually bleed rather than perforate.

Image A patient who underwent an antrectomy, vagotomy, and gastrojejunostomy for peptic ulcer disease complains of crampy abdominal pain, diaphoresis, dizziness, and palpitations 25 minutes after a meal. What is the diagnosis?

The patient has dumping syndrome, which occurs in response to the ingestion of a hyperosmolar carbohydrate-rich meal.

Image What percentage of chronic duodenal ulcers heal after highly selective vagotomy? What is the ulcer recurrence rate following this elective procedure?

About 90% heal; 10%–20% recur.

Image What common side effects of truncal vagotomy with antrectomy or pyloroplasty are rarely seen after highly selective vagotomy?

Diarrhea, delayed gastric emptying, dumping syndrome, and bile reflux.

Image What are the mechanisms that lead to the dumping syndrome?

Loss of gastric reservoir function and rapid emptying of hyperosmolar carbohydrates into the small intestine.

Image Which enteric hormones contribute to the vasomotor symptoms of early dumping?

Serotonin, gastric inhibitory peptide, vasoactive intestinal peptide, and neurotensin.

Image What is the incidence of the dumping syndrome after Billroth II gastrectomy?

The incidence of the dumping syndrome may exceed 50% because the operation bypasses both pyloric control and duodenal inhibiting mechanisms.

Image True/False: Long-acting somatostatin analogues are effective in improving the symptoms of dumping in patients unresponsive to other medical therapy.

True. These agents improve the symptoms in 90% of patients with early dumping.

Image Which type of vagotomy is responsible for the highest incidence of postvagotomy diarrhea—truncal, selective, or proximal?

Truncal vagotomy has the highest incidence (20%), followed by selective vagotomy (5%) and proximal gastric vagotomy (4%).

Image What percentage of postgastrectomy patient exhibit histologic gastritis?

Over 60% exhibit histologic gastritis; however, the vast majority remain asymptomatic.

Image The highest incidence of alkaline gastritis occurs after which operation for peptic ulcer disease?

Billroth II gastrojejunostomy has the highest incidence, followed by loop gastrojejunostomy, Billroth I gastroduodenostomy, and then pyloroplasty.

Image What is the surgical treatment in refractory cases of alkaline reflux gastritis?

Although rarely necessary, conversion to Roux-en-Y gastrojejunal anastomosis.

Image What medical disorders increase the risk of gastric atony?

Preoperative gastric outlet obstruction, diabetes mellitus, hypothyroidism, and autonomic neurologic disorders.

Image What percentage of patients who have the combination of vagotomy, antrectomy, and Roux-en-Y gastrojejunostomy develop epigastric fullness, abdominal pain, nausea, and vomiting—the so-called Roux stasis syndrome?

Up to 50%.

Image A patient who had an unknown gastric operation for peptic ulcer disease presents with epigastric fullness, nausea, and vomiting. Upper gastrointestinal barium radiographs demonstrate a mass in the gastric remnant. What is the most likely diagnosis?

A bezoar is the most likely diagnosis; however, endoscopy is needed to distinguish the bezoar from a neoplasm.

Image What percentage of patients have abnormal bone loss following gastric resection?

About 25%.

Image True/False: The large majority of patients who require treatment for perforation or bleeding due to duodenal ulcer do not have an antecedent history of ulcer pain.

False. Only about 20% of patients who require treatment for bleeding or perforation do not have a history of ulcer pain.

Image Which factor does NOT predict death in perforated duodenal ulcer: preoperative shock, perforation for longer than 24 hours, concomitant medical illness, or age?

Age is not an independent predictor of death in perforated duodenal ulcer.

Image True/False: A second hospitalization for ulcer hemorrhage is an indication for operation in the treatment of bleeding from duodenal ulcer.

True, depending on the treatment and prevention recommendations performed previously.

Image Which artery is primarily responsible for bleeding duodenal ulcers?

Gastroduodenal artery. Operative management for bleeding from duodenal ulcer includes proximal and distal ligation of the gastroduodenal artery and ligation of the transverse pancreatic branch. (see Figure 19-1).

Image True/False: Operative treatment of a gastric polyp is indicated for a sessile lesion of 3 cm in diameter.
True. Operative treatment is indicated for sessile lesions over 2 cm in diameter, when tissue removed endoscopically arouses a question of malignancy, or when definitive treatment cannot be completed endoscopically.

Image What are the two most common side effects after vagotomy for treatment of peptic ulcer disease?

Diarrhea and delayed gastric emptying.

Image What percentage of patients with early dumping do not respond to nonoperative measures and what treatment options exist for these patients?

About 1%. Jejunal interposition or conversion to Roux-en-Y gastrojejunostomy.

Image What is the typical presentation of the afferent loop syndrome? What is the treatment?

Epigastric pain after eating relieved by bilious vomiting. Surgical correction is the only treatment.

Image What is the recurrence rate of peptic ulcers in patients with retained antrum syndrome? How can this be diagnosed?

Up to 80%; technetium scan.

Image True/False: Most marginal ulcers after laparoscopic Roux-en-Y gastric bypass are associated with previously undiagnosed H. pylori infection.

False.

Image In Figure 19-3, the patient has undergone laparoscopic Roux-en-Y gastric bypass and has developed a marginal ulcer. What commonly associated finding is being demonstrated in Figure 19-4?

Gastro-gastric fistula.

Image

Figure 19-3 See also color plate.

Image

Figure 19-4

• • • SUGGESTED READINGS • • •

Yeo CJ. Shackelford’s Surgery of the Alimentary Tract. 6th ed. Philadelphia, PA: Saunders Elsevier, 2007; 791-939.

Gumbs AA, Duffy AJ, Bell RL. Incidence and management of marginal ulceration after laparoscopic Roux-Y gastric bypass. Surg Obes Relat Dis. 2006 Jul-Aug;2(4):460-463.

Gralnek IM, Barkun AN, Bardou M. Management of acute bleeding from a peptic ulcer. N Engl J Med. 2008 Aug 28;359(9): 928-937.