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Prepyloric and duodenal ulcers are typically related to acid
hypersecretion, whereas NSAID-induced ulcers may be
located anywhere in the stomach (Table 3).
TABLE 2. Etiology of Gastric Ulcer
TABLE 3. Modified Johnson Classification of Gastric Ulcers
Medical therapy directed at ulcer etiology is an
important adjunct to endoscopic and surgical interventions.
Acid suppression with a proton pump inhibitor (PPI)
decreases the risk of rebleeding after endoscopic
hemostasis, ai ds in ulcer healing and prevents ulcer
recurrence. NSAIDs should be withheld if medically
possible. If NSAIDs are to be continued, concurrent acid
suppression or use of misoprostol is imperative. Smoking
cessation is strongly encouraged. For patients with
H.
pylori
, eradication of the bacteria results in lower ulcer
recurrence rates than acid suppression therapy alone. In
over 90% of colonized patients, this can be accomplished
with a single course of “triple therapy”—two antibiotics
active against
H. pylori
and a PPI. Confirmed clearance of
H. pylori,
in combination with a maintenance PPI, is
associated with <2% risk of recurrent bleeding in the first
year. Endoscopy should be performed after 6 weeks to
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document ulcer healing. Almost uniformly, recurrence is
related to
H. pylori
reinfection or NSAID use.
Surgical Approach
While surgery remains the primary means of managing
anatomic complications of ulcer disease, the development
of effective pharmacotherapy for acid suppression and
H.
pylori
clearance has reduced the role of surgery in
addressing the underlying etiology. When treating anatomic
complications, the operation should be carefully tailored to
the patient’s clinical scenario. The appropriate surgical
procedure for a bleeding gastric ulcer is also dependent
upon the patient’s condition (Fig ure 2). For unstable
patients, midline laparotomy is followed by anterior
gastrotomy. Once the lesion is identified, the ulcer is
oversewn, biopsied (if possible) and the gastrotomy
repaired. For stable patients with a history of refractory
ulcer disease, an antisecretory procedure such as truncal
vagotomy or distal gastrectomy should be considered.
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FIGURE 2 • Algorithm for management of bleeding gastric ulcer.
Truncal Vagotomy
In patients with bleeding gastric ulcers, truncal vagotomy is
indicated for those who have failed previous medical
therapy. These patients usually have a long-standing history
of ulcer disease and have proven refractory to (or serially
noncompliant with) PPIs and
H. pylori
eradication.
Vagotomy markedly reduces cholinergic stimulation of
gastric acid secretion. Because vagotomy also results in
pyloric denervation, a concurrent procedure such as
pyloroplasty or antrectomy is thus necessary to ensure
gastric drainage.
To perform a truncal vagotomy, the left hepatic lobe is
retracted cephalad and laterally with division of the
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triangular ligament as needed to expose the hiatus. The
overlying peritoneum is incised and the esophagus
dissected circumferentially for several centimeters about
the gastroesophageal (GE) junction. Anteriorly, the vagal
trunk is found closely applied to the esophageal wall. In
contrast, the posterior vagus may reside 1 cm or more
posterolateral to the esophagus. Palpation may aid in initial
identification of the nerves. Once both trunks are located,
proximal and distal clips are placed to allow for resection of
a 2-cm intervening segment of nerve. These specimens are
sent to pathology for histologic confirmation. There may be
several divisions of each vagal trunk, so the area of the GE
junction is carefully inspected to determine that all vagal
fibers have been divided. Prior to closure, cruroplasty may
be required to prevent development of a hiatal hernia.
Distal Gastrectomy
If a patient with bleeding gastric ulcer is stable, there are a
few scenarios in which a distal gastrectomy can be
considered. As with truncal vagotomy, patients are usually
only considered candidates for distal gastrectomy i f they
have a history of failed medical management, especially
patients with large antral ulcers that cannot be easily
oversewn or patients with ulcers suspicious for cancer.
Risks of operative death and complications are much
higher for distal gastrectomy than simple oversewing or
vagotomy, so this procedure should only be undertaken
when clear indications exist.
To perform distal gastrectomy, a vertical incision in the
supraumbilical midline affords adequate exposure in most
cases. Following exploration of the abdomen, a Kocher
maneuver is performed to mobilize the duodenum.
Mobilization of the distal stomach begins with division of
the gastrocolic ligament. Entry into the lesser sac permits
examination of the posterior gastric wall. The omentum is
then divided along the greater curvature, from the
duodenum halfway to the GE junction. The right
gastroepiploic vessels are ligated and divided near the
gastroduodenal artery (GDA). The gastrohepatic ligament
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is then incised. The right gastric artery is identified, ligated,
and divided near the superior border of the duodenum.
Branches of the left gastric artery are divided along the
lesser curve in preparation for resection and anastomosis.
An area of healthy proximal duodenum is chosen and
transected with a stapling device. The proximal extent of
the resection is determined by the location of the ulcer and
the condition of the gastric wall. The stomach is also
divided with a stapling device and all staple lines are
oversewn. Continuity of the GI tract can be reestablished
via either Billroth I or II reconstruction, depending upon the
length and health of the duodenal stump.
Special Intraoperative Considerations
Type IV gastric ulcers can be particularly challenging to
manage due to their proximity to the GE junction. In most
cases, the ulcer can be resected as part of the distal
gastrectomy with an extension along the lesser curve.
Traditional Billroth I or II reconstruction is avoided as it is
likely to result in narrowing of the GE junction. Instead, rouxen-Y gastrojejunostomy permits construction of a wide
anastomosis, incorporating the distal GE junction and the
entirety of the gastrotomy. In rare circumstances, the ulcer
may be oversewn and left
in situ.
A concurrent antisecretory
procedure with
H. pylori
eradication, PPI, and cessation of
NSAIDs results in satisfactory ulcer healing in most
patients.
TABLE 4. Key Technical Steps in Distal Gastrectomy and Truncal
Vagotomy
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Postoperative Management
Following surgery for a bleeding gastric ulcer, patients
remain on bowel rest with NG decompression. These
measures may be discontinued as gastric emptying
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resumes. Patients should be observed for potential
postoperative complications such as surgical site infection
(SSI), hemorrhage, or anastomotic leak. For those with a
Billroth II reconstruction, duodenal stump leak is a
particularly morbid complication.
With initiation of oral intake, patients who undergo
gastrectomy should also be monitored for postgastrectomy
dumping syndrome. This is characterized by postprandial
GI and vasomotor symptoms, such as nausea, abdominal
pain, dizziness, and even syncope. In most patients, these
symptoms are temporary, and easily managed with
frequent small meals. In a small minority of patients,
however, dumping symptoms can become debilitating.
Octreotide may be helpful in this circumstance. At
discharge, all patients are counseled to avoid tobacco and
NSAIDs as well as to continue PPI therapy. Those
colonized with
H. pylori
receive triple therapy and
eradication is confirmed at follow-up.
Case Conclusion
The patient’s immediate management included
placement of two large-bore ivs, crystalloid
resuscitation, and a pantoprazole infusion. His initial
hematocrit was 28%, with normal coagulation studies.
Endoscopy performed while the patient was still in the
emergency room revealed a 2-cm gastric ulcer in the
prepyloric region (type III) with a nonbleeding visible
vessel. Clips were applied and biopsies performed
endoscopically. He was then admitted to the hospital
for observation. The following day, he had another
episode of hematemesis. Endoscopy was again
attempted, but unsuccessful in controlling the bleeding.
He required two units of packed red blood cells but
remained hemodynamically stable. He was taken to the
operating room emergently for surgical intervention.
Given the history of recurrent type III gastric ulcer
following
H. pylori
eradication and long-term acid
suppression, an antisecretory procedure was deemed
appropriate. Truncal vagotomy was performed in
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conjunction with distal gastrectomy. The patient
tolerated the procedure well, and recovered without
recurrent bleeding or serious complication. Final
surgical pathology confirmed a benign gastric ulcer.
TAKE HOME POINTS
Although decreasing in incidence, peptic ulcer
remains the most common cause of upper GI
bleeding, with significant associated mortality.
H. pylori
infection and NSAID use are the most
frequent inciting factors in bleeding gastric ulcers.
Endoscopy is the first-line diagnostic intervention and
is therapeutically effective in a majority of patients.
Surgery is indicated in patients with massive
bleeding, failure of endoscopic therapy, recurrent
hemorrhage, or neoplasm.
Anterior gastrotomy, ulcer oversewing, and bi opsy is
the procedure of choice for patients without a history
of refractory ulcer disease.
Truncal vagotomy is indicated only for patients with
ulcers refractory to adequate PPI therapy and
H.
pylori
eradication.
Distal gastrectomy with inclusion of the ulcer in the
specimen is the procedure of choice in stable
patients with refractory ulcer disease who have large
antral ulcers.
Acid suppression and clearance of
H. pylori
decrease the risk of recurrent bleeding gastric ulcer.
SUGGESTED READINGS
Enestvedt BK, Gralnek IM, Mattek N, et al. An evaluation of endoscopic
indications and findings related to nonvariceal upper-GI hemorrhage in a
large multicenter consortium. Gastrointest Endosc. 2008;67(3):422–429.
Gisbert JP, Khorrami S, Carballo F, et al. H. pylori eradication therapy vs.
antisecretory non-eradication therapy (with or without long-term
maintenance antisecretory therapy) for the prevention of recurrent
bleeding from peptic ulcer. Cochrane Database Syst Rev.
2004(2):CD004062.
Gralnek IM, Barkun AN, Bardou M. Management of acute bleeding from a
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peptic ulcer. N Engl J Med. 2008;359(9):928–937.
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17
Bleeding Duodenal Ulcer
WENDY L. WAHL
Presentation
A 57-year-old man with multiple medical problems
presents to the emergency department feeling
lightheaded with hematemesis and melena. His
medical history includes end-stage renal disease and
bladder cancer, for which he recently underwent
cystectomy with an ileal conduit. He is hypotensive, and
placement of a nasogastric tube yielded bright red
blood clots. He is currently on hemodialysis three times
each week and has no prior history of ulcers. He does
not take nonsteroidals or aspirin on a regular basis.
Large-bore intravenous access is established and his
blood pressure improves with fluid resuscitation. His
abdomen is mildly distended but nontender on
palpation. He has a healing midline abdominal incision
with a pink ileal conduit with minimal dark-appearing
urine. Digital rectal examination reveals dark, tarry
stool, which is guaiac positive.
Differential Diagnosis
His recent major surgery, and the attendant lack of oral
intake, place him at risk for stress gastritis or peptic ulcer
disease. His history of renal failure may also make him
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