MSC - F. Surgery Answers 2025

oDifferentiates benign from malignant ulcer based on crater shape and wall involvement.

Duodenal ulcer findings:

oUlcer crater in duodenal bulb (seen “en face”).

o Difficult filling of duodenal bulb due to edema/spasm.

oSecondary signs: mucosal edema, spasm.

5.Endoscopy (Fibroesophagogastroduodenoscopy - FGS)

Most accurate diagnostic method with about 95% diagnostic accuracy.

Flexible fiber-optic instrument allows direct visualization of:

oEsophagus.

o Stomach.

oDuodenum.

Advantages:

oVisual confirmation of ulcer.

o Ability to take biopsies for histological examination.

o Therapeutic interventions possible (e.g., cauterization). o Detection of complications or malignancy.

o Allows photographic documentation.

oReduced working ability (especially with dual localization)

2.Preoperative Preparation

Thorough examination

Anti-ulcer therapy

Correction of water-electrolyte and protein metabolism disorders

Treatment of comorbidities

3.Surgical Methods

A.Gastric Resection

Operation of choice for gastric ulcer

Typically resection of 2/3 of the stomach to remove the ulcer and acidproducing areas

Anastomosis options:

o Bilroth I: Gastroduodenal end-to-end anastomosis (preferred)

oBilroth II: Gastric stump anastomosed to jejunum if gastroduodenal anastomosis is impossible (e.g., scar tissue, periduodenitis)

oTechniques to prevent duodenal reflux (e.g., Balfour, Rhu techniques)

B. Vagotomy (aimed at reducing gastric acid secretion)

Reduces acid secretion by cutting vagus nerve branches that stimulate acid production

Allows spontaneous healing of duodenal ulcers due to decreased acidity

Three types of vagotomy:

1.Truncal Vagotomy:

Transects vagal trunks in thoracic and upper abdominal regions

Denervates stomach and other abdominal organs → may cause complications (e.g., cholecystitis, pancreatitis, diarrhea)

Gastric motor activity impaired → requires a draining operation

(e.g., pyloroplasty or gastrojejunostomy)

Draining operations after truncal vagotomy:

Pyloroplasty:

Heineke–Mikulicz

Finney

Gastrointestinal anastomosis:

Gastrojejunostomy

Jaboulay’s gastroduodenostomy

Transverse gastroduodenal anastomosis

Partial gastric resection may also be done

2.Selective Vagotomy:

Cuts only vagus branches to the stomach; spares branches to liver and celiac plexus

Denervates whole stomach → motor function impaired, so draining operation needed

3.Selective Proximal Vagotomy (SPV):

Cuts vagal branches to acid-producing regions (lesser curvature and fundus)

Preserves antral innervation → maintains gastric motility

Can be done without draining procedure

Less functional disturbance, fewer complications

Relapse rate after vagotomy: ~16%, depending on completeness

C.Antrectomy

Excision of the antrum (gastrin-producing part)

Anastomosis of stomach remnant to jejunum (usually)

A perforated ulcer is a serious complication where an untreated peptic ulcer erodes through the wall of the stomach or duodenum, leading to the leakage of gastric or duodenal contents into the peritoneal cavity and causing peritonitis.

Incidence

Occurs in approximately 7% of ulcer patients.

Around 20% of cases occur in patients with silent ulcers (no previous symptoms).

Types of Perforation

1.Open (free) perforation – Contents escape freely into the abdominal cavity.

2.Concealed (sealed) perforation – The perforation is covered by fibrin, omentum, or adjacent organs.

Clinical Stages of Open Perforation

Stage I: Primary Shock (First 3–6 hours)

Sudden, severe epigastric pain ("knife-like").

Pain spreads to the whole abdomen, especially the right side.

Radiates to shoulder or scapular region (phrenic nerve irritation).

Rigid abdomen ("wooden belly"), positive peritoneal signs.

Vitals: Bradycardia (50–60 bpm) or mild tachycardia (80–90 bpm), low BP.

Signs: Pale face, cold sweat, hypopnea, tachypnea.

Percussion: Absence of liver dullness (free gas in peritoneum).

X-ray: Free gas under the diaphragm in 75–80% of cases.

Stage II: “Sham Well-being” (6–12 hours)

Dilution of acidic content by exudate reduces pain temporarily.

Misleading clinical improvement: patient feels better.

However, peritonitis and toxic symptoms increase (tachycardia, leukocytosis).

Careful monitoring, lab, imaging, or laparoscopy is essential to avoid misdiagnosis.

Stage III: Diffuse Peritonitis (>12 hours)

Generalized peritonitis: high fever, tachycardia, vomiting, oliguria.

Enteroparesis, abdominal distension, hypotension, collapse.

Requires urgent surgical intervention.

Concealed (Sealed) Perforation

The ulcer is covered by omentum, liver, or fibrin.

Symptoms less severe than open perforation.

Pain becomes localized, often in epigastrium or right hypochondrium.

Perforation into omental bursa: causes pain radiating to the right iliac region.

No free gas, liver dullness is preserved.

Diagnosis depends on:

o FGS (Fibrogastroscopy)

oLaparoscopy

6.Diagnosis and treatment tactics in perforated gastric ulcer and duodenal ulcer.

Diagnosis

Clinical signs: Sudden epigastric pain, rigid abdomen, peritoneal signs.

X-ray abdomen (upright): Free gas under diaphragm.

Percussion: Disappearance of liver dullness.

Laparoscopy: Especially useful in concealed or posterior wall perforations.

Laboratory tests: May be normal initially; leukocytosis develops later.

Treatment

Preoperative Preparation

Depends on the duration and severity of peritonitis.

Includes intensive IV fluids, antibiotics, gastric decompression, and electrolyte correction.

Surgical Options

1.Simple Closure (Suture or Omental Patch)

Indicated in early stage (within 6 hours), when perforation is small and patient is unstable or unsuitable for radical surgery.

Graham patch (omentopexy): when ulcer edges are edematous or inflamed.

2.Radical Surgery

Indicated if:

o Ulcer is chronic or large.

o Patient is stable and within early time window.

oPerforation is part of active ulcer disease requiring definitive treatment.

Procedures include:

oGastric resection

o Vagotomy + ulcer excision + drainage procedure

Postoperative Care

Focuses on:

o Detoxification

o Treatment of peritonitis