Peptic Ulcer (Gastric And Duodenal Ulcer)

PEPTIC ULCER (GASTRIC AND DUODENAL ULCER)

•  Peptic ulcers never occur in association with pernicious anaemia (no acid and pepsin-secreting parietal and chief cells respectively) 

Types of gastric ulcer

• I – near the incisura on lesser curvature
• II – associated with active or quiescent duodenal ulcer
• III – Prepyloric region
• IV – Near gastro-esophageal junction 

Most important factors causing peptic ulcer

• H pylori infection
• NSAID use 

• Cushing ulcer – due to intracranial injury/increased ICP/after neurosurgical operations
• Curling ulcer – after burn injury (>35%); in the body and fundus; not in antrum and duodenum
• Cameron ulcers – linear gastric erosions in hiatal hernias
• Kissing ulcers – both anterior and posterior duodenal ulcers are present 

Medical treatment: Proton pump inhibitors or H2 blockers; H.pylori eradication 

Surgeries for Duodenal ulcer

• Highly Selective Vagotomy or Parietal cell Vagotomy or Proximal gastric Vagotomy
• Procedure of choice
• Nerves of Latarjet are preserved (and hence gastric motility)
• Lowest mortality rate and side effects
• Minimal chances of dumping syndrome
• Gastrectomy – highest mortality
• Vagotomy and Antrectomy – lowest recurrence & highest morbidity
• Gastroenterostomy alone – highest recurrence
• Billroth II gastrectomy 
• Duodenal blow out following Billroth II gastrectomy occurs on 4th day (2-7days) 

Surgery for gastric ulcer

• Partial gastrectomy with Billroth I gastroduodenal anastomosis
• Type IV ulcer – subtotal gastrectomy 

Sequelae of peptic ulcer surgery

• Recurrent ulceration
• Small stomach syndrome
• Follows most ulcer operations, does not occur following Highly selective vagotomy
• Due to loss of receptive relaxation
• Gets better with time
• Revisional surgery is not necessary

Bile vomiting (Afferent loop syndrome)

• Following gastrectomy, best treatment is Roux-en-Y diversion
• In patients with gastroenterostomy, small Pyloroplasty may be performed

Dumping syndrome (Post cibal syndrome)

• More common after partial gastrectomy with the Billroth II reconstruction.
• Much less common following the Billroth I gastrectomy or after vagotomy and drainage procedures

Efferent loop obstruction

• More than 50% of cases occur within the first postoperative month

Alkaline reflux gastritis

• Although the diagnosis can be made by taking a careful history HIDA scans usually demonstrate biliary secretion into the stomach and even into the esophagus.
• Most patients had gastric resection and Billroth II anastomosis

Post vagotomy diarrhea

• Patient managed as for early dumping
• Octreotide not effective