PEPTIC ULCER DISEASE

BERNARD M. Jaffe, MDProfessor of Surgery

Emeritus

PEPTIC ULCER DISEASE• 8% Annual Incidence in the

Population• 500,000 New Cases/Year• 4,000,000 Recurrences/Year• 130,000 Operations/Year• 9,000 Deaths/Year

PEPTIC ULCER DISEASE• Elective Admissions Declining, for

Complications Unchanging• Gastric Ulcer More Common in Elderly• Admissions for Bleeding GU Increasing• Decreasing Incidence in Males,

Increasing in Females• ? Due to Changes in Smoking

Patterns

CAUSES OF PUD• H. Pylori Infection• NSAID’s • Acid Hypersecretion• Zollinger- Ellison Syndrome• Acid Plays a Role in All Four

GASTRIC CELLS• Acid- Fundus Parietal Cells• Gastrin- Antrum G Cells• Pepsinogen- Diffuse Chief Cells• Histamine- Diffuse

Enterochromaffin-Like Cells

• Somatostatin- Diffuse D Cells

H. Pylori INFECTION• 90% Duodenal, 75% Gastric Ulcers• Nearly 100% Have Antral Gastritis• Eradication Prevents Recurrence• Strong Association with MALT

Lymphoma• Microaerophilic, Urease Producing• Can Live in Gastric Epithelium

GASTROINTESTINAL INJURY• Production of Toxic Products• Ammonia, Cytokines, Mucinases,

Phospholipases, Platelet Activating Factor

• Induction in Local Mucosal Immune Responses• Increases Gastrin → Increasing Acid

Secretion

H. Pylori INFECTION• World-Wide Pandemic• Usually Acquired in Childhood• Inverse Relationship Between Infection

Rates and Socio Economic Status• Transmission Mouth-to-Mouth• Higher Rate in Developing Countries-

Sanitation is a Real Issue

NSAID’S• Second Most Common Cause of PUD• Increased Use in Women >50 Years Old• Risk of Ulcers/Bleeding Parallels Drug

Use• 10% of Patients Taking NSAID’s

Develop Acute Ulcer• 2-4% Develop GI Complications/Year

ACID- INCREASED• Nocturnal Acid 70%Daytime Acid

50%• Duodenal Acid Load Maximal Acid

65% 40%• Gastrin Sensitivity Basal Gastrin• 35% 35%• Gastric Emptying 30% Parietal Cells 30%

GASTRIC ULCERS• Type I- Lesser Curvature Near Incisura• 60%• Low Levels of Acid• Type II- Combination Type I Plus DU• 15%• Excess Acid Secretion

GASTRIC ULCERS (2)• Type III- Pre-Pyloric• 20%• Behave Like DU’s • Excess Acid Secretion• Type IV- High on Lesser Curvature• <10%• Low Acid Secretion• <5% Greater Curvature

GASTRIC ULCER• Rare Before Age 40, Common 55-65

Years• Caused By NSAID’s• Acid, Pepsin Abnormalities• Co-Existing DU• Delayed Gastric Emptying• Duodenal-Gastric Reflux• Gastritis• H. Pylori Infection

DU PREDISPOSITION• Chronic Alcohol Intake• Smoking• Long-Term Steroid Use• Infection

SYMPTOMS• Mid-Epigastric Pain• Relieved By Pain• Spring > Fall• Relapses with Stress• Constant Pain- Deeper Penetration• Back Pain- Penetration Into Pancreas

COMPLICATIONS• Perforation• Bleeding• Obstruction• Chronicity

PERFORATION• Sudden Abdominal Pain, Fever• Tachycardia, Ileus, Dehydration• Exquisite Abdominal Tenderness,

Rebound, Rigidity• Free Air Under the Diaphragm, Can

Verify by Gastrograffin Swallow• Surgical Emergency

PERFORATION• Treat with Gramm Patch Omental Closure• Simultaneous Definitive Procedure IF• PUD with NO Symptoms • Failure to Respond to Medical Therapy• Best Definitive Procedure for Perforation-

Parietal Cell Vagotomy• Non-Operative Therapy Reserved for Late

Presentation with No Acute Abdomen

BLEEDING• Most Common Cause of PUD Death• Bleeding Accounts for 25% of All Upper

GI Bleeds• Can Present with Melena,

Hematemesis, or Bright Red Rectal Bleeding• Gastroduodenal Artery Lies Posterior

to Duodenal Bulb- “Visible Vessel”

OBSTRUCTION• Chronic Scarring Can Occlude Pylorus• Acute Inflammation Also Causes

Obstruction• Anorexia, Nausea, Vomiting• Hypochloremic, Hypokalemic Metabolic

Alkalosis, Dehydration, Malnutrition• Stomach Becomes Massivel Dilated and

Loses Muscular Tone

GASTRIC ULCER• Must Distinguish Benign From Malignant• Causes Same Complications as DU• 8-20% Need Operation for Complications• Bleeding Occurs in 35-40%• Perforation is Most Life-Threatening• Obstruction Occurs in Types I and II

ZOLLINGER-ELLISON SYNDROME• Triad- Gastric Acid Hypersecretion, Severe

PUD, Non-β Islet Cell Tumors• Gastrinomas in Head of Pancreas,

Duodenum • 50% Multiple, 65% Malignant, 25%

Associated with MEN Syndrome• Abdominal Pain, Diarrhea, Steatorrhea• Elevated Basal, Stimulated Gastrin Levels• Treatment Focuses on Tumor Resection

ELEVATED GASTRIN LEVELS• Z-E Syndrome• Antral G Cell Hyperplasia• Retained Gastric Antrum• Hypercalcemia• Gastric Outlet Obstruction• Anti-Secretory Drugs

ELEVATED GASTRIN LEVELS• Previous Ulcer Operation• Atrophic Gastritis• Pernicious Anemia• Chronic Renal Failure• H. Pylori Infection

PEPTIC ULCER DIAGNOSIS• EGD, Barium Swallow• H. Pylori Testing• Serology- ELISA 90% Sensitive• Urea Breath Test- Uses 14C

Specificity, Sensitivity >95%• Rapid Urease- Endoscopic Biopsy, Tissue

Placed in Urea, >90% Sensitive• Histology, Biopsy of Antrum- Best Test• Culture is Slow, Expensive

MEDICAL MANAGEMENT• Avoid Smoking, Caffeine, Alcohol, NSAID’s• Antacids- Large Frequent Doses Needed• H2 Receptor Antagonists- 70-80% Healing in

4 Weeks, 80-90% in 8 Weeks• Proton Pump Inhibitors- Most Complete

Acid Inhibition- Healing 85% in 4 Weeks, 90% in 8 Weeks

• Sucralfate- Aluminum Salt of Sulfated Sucrose- Protective Coating

OPERATIVE MANAGEMENT• Subtotal Gastrectomy- Highest

Complication Rate• Vagotomy and Antrectomy- Most

Efficacious• Vagotomy and Pyloroplasty- Major

Indication is Bleeding Gastritis• Parietal Cell Vagotomy- Most

Physiologic