260 Section II / General Surgery
What is a “kissing” ulcer?
Why may a duodenal rupture be initially painless?
Why may a perforated duodenal ulcer present as lower quadrant abdominal pain?
GASTRIC ULCERS
Two ulcers, each on opposite sides of the lumen so that they can “kiss”
Fluid can be sterile, with a nonirritating pH of 7.0 initially
Fluid from stomach/bile drains down paracolic gutters to lower quadrants and causes localized irritation
In which age group are these |
40–70 years old (older than the duodenal |
ulcers most common? |
ulcer population) |
|
Rare in patients younger than 40 years |
How does the incidence in |
Men women |
men compare with that of |
|
women? |
|
Which is more common overall: gastric or duodenal ulcers?
What is the classic pain response to food?
What is the cause?
Duodenal ulcers are more than twice as common as gastric ulcers (Think: Duodenal Double rate)
Food classically increases gastric ulcer pain
Decreased cytoprotection or gastric protection (i.e., decreased bicarbonate/ mucous production)
Is gastric acid production |
Gastric acid production is normal or low! |
high or low? |
|
Which gastric ulcers are |
Prepyloric |
associated with increased |
Pyloric |
gastric acid? |
Coexist with duodenal ulcers |
What are the associated risk |
Smoking, alcohol, burns, trauma, CNS |
factors? |
tumor/trauma, NSAIDs, steroids, shock, |
|
severe illness, male gender, advanced age |
What are the symptoms? |
Epigastric pain |
|
/ Vomiting, anorexia, and nausea |
How is the diagnosis made?
What is the most common location?
When and why should biopsy be performed?
Chapter 40 / Upper GI Bleeding 261
History, PE, EGD with multiple biopsy (looking for gastric cancer)
70% are on the lesser curvature; 5% are on the greater curvature
With all gastric ulcers, to rule out gastric cancer
If the ulcer does not heal in 6 weeks after medical treatment, rebiopsy (always biopsy in O.R. also) must be performed
What is the medical treatment?
When do patients with gastric ulcers need to have an EGD?
What are the indications for surgery?
What is the common operation for hemorrhage, obstruction, and perforation?
What are the options for concomitant duodenal and gastric ulcers?
Similar to that of duodenal ulcer—PPIs or H2 blockers, Helicobacter pylori treatment
1.For diagnosis with biopsies
2.6 weeks postdiagnosis to confirm healing and rule out gastric cancer!
The acronym “I CHOP”:
Intractability
Cancer (rule out)
Hemorrhage (massive or relentless) Obstruction (gastric outlet obstruction) Perforation
(Note: Surgery is indicated if gastric cancer cannot be ruled out)
Distal gastrectomy with excision of the ulcer without vagotomy unless there is duodenal disease (i.e., BI or BII)
Resect (BI, BII) and truncal vagotomy
What is a common option |
Truncal vagotomy and antrectomy |
for surgical treatment of a |
(i.e., BI or BII) |
pyloric gastric ulcer? |
|
What is a common option for |
Graham patch |
a poor operative candidate |
|
with a perforated gastric |
|
ulcer? |
|
262 Section II / General Surgery
What must be performed in every operation for gastric ulcers?
Define the following terms: Cushing’s ulcer
Curling’s ulcer
Marginal ulcer
Dieulafoy’s ulcer
Biopsy looking for gastric cancer
PUD/gastritis associated with neurologic trauma or tumor (Think: Dr. Cushing NeuroSurgeon CNS)
PUD/gastritis associated with major burn injury (Think: curling iron burn)
Ulcer at the margin of a GI anastomosis
Pinpoint gastric mucosal defect bleeding from an underlying vascular malformation
PERFORATED PEPTIC ULCER
What are the symptoms? |
Acute onset of upper abdominal pain |
What causes pain in the |
Passage of perforated fluid along colic |
lower quadrants? |
gutters |
What are the signs? |
Decreased bowel sounds, tympanic |
|
sound over the liver (air), peritoneal |
|
signs, tender abdomen |
What are the signs of |
Bleeding from gastroduodenal artery |
posterior duodenal erosion/ |
(and possibly acute pancreatitis) |
perforation? |
|
What sign indicates anterior |
Free air (anterior perforation is more |
duodenal perforation? |
common than posterior) |
What is the differential |
Acute pancreatitis, acute cholecystitis, |
diagnosis? |
perforated acute appendicitis, colonic |
|
diverticulitis, MI, any perforated viscus |
Which diagnostic tests are |
X-ray: free air under diaphragm or in |
indicated? |
lesser sac in an upright CXR (if upright |
|
CXR is not possible, then left lateral |
|
decubitus can be performed because air |
|
can be seen over the liver and not |
|
confused with the gastric bubble) |
|
Chapter 40 / Upper GI Bleeding 263 |
What are the associated lab |
Leukocytosis, high amylase serum |
findings? |
(secondary to absorption into the blood |
|
stream from the peritoneum) |
What is the initial treatment? |
NPO: NGT (↓ contamination of the |
|
peritoneal cavity) |
|
IVF/Foley catheter |
|
Antibiotics/PPIs |
|
Surgery |
What is a Graham patch?
What are the surgical options for treatment of a duodenal perforation?
Piece of omentum incorporated into the suture closure of perforation
Graham patch (open or laparoscopic) Truncal vagotomy and pyloroplasty
incorporating ulcer
Graham patch and highly selective vagotomy
What are the surgical options for perforated gastric ulcer?
What is the significance of hemorrhage and perforation with duodenal ulcer?
What type of perforated ulcer may present just like acute pancreatitis?
What is the classic difference between duodenal and gastric ulcer symptoms as related to food ingestion?
Antrectomy incorporating perforated ulcer, Graham patch or wedge resection in unstable/poor operative candidates
May indicate two ulcers (kissing); posterior is bleeding and anterior is perforated with free air
Posterior perforated duodenal ulcer into the pancreas (i.e., epigastric pain radiating to the back; high serum amylase)
Duodenal decreased pain
Gastric increased pain
(Think: Duodenal Decreased pain)