#1014 Ulcer Disease Update

January 25 to 28

Hagop S. Mekhjian, MDProfessor of Internal MedicineDivision of Digestive DiseasesMedical Director, OSU Hospitals

E. Christopher Ellison, MDZollinger Professor of Surgery and Interim Chair, Department of SurgeryThe Ohio State University Medical Center

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Hagop S. Mekhjian, MDProfessor of Internal MedicineDivision of Digestive Diseases

Medical Director, OSU Hospitals

Profile Profile 55 year old Physician• 2 melanic stools

• Fine otherwise

History• Mild coronary artery disease

• Using beta blocker

• Takes 1 aspirin / day

55 year old Physician• 2 melanic stools

• Fine otherwise

History• Mild coronary artery disease

• Using beta blocker

• Takes 1 aspirin / day

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Profile Profile

Examination• Vital signs stable• Hemoglobin 10.5g

Symptoms• No pain or indigestion

Evaluation• Performed fiber optic endoscopy• Showed active duodenal ulcer• Biopsy positive for H. pylori

Examination• Vital signs stable• Hemoglobin 10.5g

Symptoms• No pain or indigestion

Evaluation• Performed fiber optic endoscopy• Showed active duodenal ulcer• Biopsy positive for H. pylori

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Profile Profile

Treatment• Immediately started on omeprazole• Placed on amoxicillin and clarithromycin for 14 days

Follow up• Follow up 6 weeks later• Duodenal ulcer completely healed• Asymptomatic• Normal hemoglobin

Treatment• Immediately started on omeprazole• Placed on amoxicillin and clarithromycin for 14 days

Follow up• Follow up 6 weeks later• Duodenal ulcer completely healed• Asymptomatic• Normal hemoglobin

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Peptic Ulcer Disease Peptic Ulcer Disease

• 500,000 new cases per year• 4 million recurrences• 4 million physician visits• $5 - 10 billion annual cost• Decreased mortality• Increasing costs• 9,000 deaths• >130,000 operations

• 500,000 new cases per year• 4 million recurrences• 4 million physician visits• $5 - 10 billion annual cost• Decreased mortality• Increasing costs• 9,000 deaths• >130,000 operations

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Hospitalization andMortality Trends

Hospitalization andMortality Trends

• Decreased for uncomplicated duodenal ulcer• Bleeding or perforation hospitalization unchanged• Increase in elderly (NSAIDS)• Mortality 1 per 100,000 population - 3-4 fold decrease

• Decreased for uncomplicated duodenal ulcer• Bleeding or perforation hospitalization unchanged• Increase in elderly (NSAIDS)• Mortality 1 per 100,000 population - 3-4 fold decrease

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Epidemiology Epidemiology

• H. pylori• Nonsteroidals• Genetics - familial - Incidence (20-50% vs controls 10%)• All genetic markers likely relate to susceptibility of infection with H. pylori

• H. pylori• Nonsteroidals• Genetics - familial - Incidence (20-50% vs controls 10%)• All genetic markers likely relate to susceptibility of infection with H. pylori

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Peptic UlcerOther Associations

Peptic UlcerOther Associations

• Zollinger Ellison Syndrome• Systemic mastocytosis• MEN I• COPD• CRF• Cirrhosis• Kidney stones• Alpha-antitrypsin deficiency

• Zollinger Ellison Syndrome• Systemic mastocytosis• MEN I• COPD• CRF• Cirrhosis• Kidney stones• Alpha-antitrypsin deficiency

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Pathophysiology ofGastric Ulcers

Pathophysiology ofGastric Ulcers

• NSAIDS• H. pylori• Bile reflux• Gastric motility

• NSAIDS• H. pylori• Bile reflux• Gastric motility

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Smoking andPeptic Ulcer

Smoking andPeptic Ulcer

• Increased incidence• Co-factor with H. pylori• Increased complication

• COPD increased risk

• Increased incidence• Co-factor with H. pylori• Increased complication

• COPD increased risk

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Etiologic Role ofH. Pylori Peptic Ulcer

Etiologic Role ofH. Pylori Peptic Ulcer

• Natural history of H. pylori gastritis - 11% peptic ulcer in 10 years - 1% controls

• Association - age independent - 90% duodenal ulcer; H. pylori positive - 70-90% gastric ulcer; H. pylori positive

• Treatment outcome of H. pylori - Eradicates recurrent duodenal ulcer and gastric ulcer - Reduction in re-bleeding

• Natural history of H. pylori gastritis - 11% peptic ulcer in 10 years - 1% controls

• Association - age independent - 90% duodenal ulcer; H. pylori positive - 70-90% gastric ulcer; H. pylori positive

• Treatment outcome of H. pylori - Eradicates recurrent duodenal ulcer and gastric ulcer - Reduction in re-bleeding 9

Peptic UlcerClinical Presentation

Peptic UlcerClinical Presentation

• Abdominal discomfort - Epigastric - Nocturnal - Relief by food or antacids

• Bleeding or perforation initial presentation - 10%

• Abdominal discomfort - Epigastric - Nocturnal - Relief by food or antacids

• Bleeding or perforation initial presentation - 10%

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Peptic Ulcer DiagnosisPeptic Ulcer Diagnosis

• Endoscopy gold standard

• Single contrast x-rays worthless

• Double contrast x-rays valuable

• Endoscopy gold standard

• Single contrast x-rays worthless

• Double contrast x-rays valuable

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Diagnosis ofHelicobacter Pylori

Diagnosis ofHelicobacter Pylori

Endoscopy• Duodenal ulcer highly predictive• Antral nodularity specific (96%), but insensitive (32%), “plucked chicken”• Biopsy - two antral, antral and angle ~ 100% sensitivity

• Prior therapy important

Endoscopy• Duodenal ulcer highly predictive• Antral nodularity specific (96%), but insensitive (32%), “plucked chicken”• Biopsy - two antral, antral and angle ~ 100% sensitivity

• Prior therapy important12

Diagnosis ofHelicobacter Pylori

Diagnosis ofHelicobacter Pylori

• Histology is Gold Standard• Highly reproducible readings• Giemsa stain 96% specific• Acute or chronic inflammation always presents

• Immunohistochemical stains highly reliable

• Histology is Gold Standard• Highly reproducible readings• Giemsa stain 96% specific• Acute or chronic inflammation always presents

• Immunohistochemical stains highly reliable

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Treatment ofHelicobacter Pylori

Treatment ofHelicobacter Pylori

• Resistance to metronidazole high - South Korea 95%

• Resistance to clarithromycin ~ 10%

• Resistance to tetracycline rare

• Resistance to metronidazole high - South Korea 95%

• Resistance to clarithromycin ~ 10%

• Resistance to tetracycline rare

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Cure for H. PyloriBMT for 14 Days

Cure for H. PyloriBMT for 14 Days

• Pepto-Bismol 2 tabs 4 x day

• Metronidazole 250 mg 4 x day

• Tetracycline 500 mg 4 x day

plus

• H2RA for 4 weeks

• Pepto-Bismol 2 tabs 4 x day

• Metronidazole 250 mg 4 x day

• Tetracycline 500 mg 4 x day

plus

• H2RA for 4 weeks

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Cure for H. PyloriOAC for 14 DaysCure for H. PyloriOAC for 14 Days

• Omeprazole 20 mg 2 x day

• Amoxicillin 1 gram 2 x day

• Clarithromycin 500 mg 2 x day

• Omeprazole 20 mg 2 x day

• Amoxicillin 1 gram 2 x day

• Clarithromycin 500 mg 2 x day

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Cure for H. PyloriLAC for 14 Days

Cure for H. PyloriLAC for 14 Days

• Lansoprazole 30 mg 2 x day

• Amoxicillin 1 gram 2 x day

• Clarithromycin 500 mg 2 x day

• Lansoprazole 30 mg 2 x day

• Amoxicillin 1 gram 2 x day

• Clarithromycin 500 mg 2 x day

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Peptic UlcerComplicationsPeptic Ulcer

Complications

• Hemorrhage 15%

• Perforation 7%

• Penetration ?

• Gastric outlet obstruction 2%

• Hemorrhage 15%

• Perforation 7%

• Penetration ?

• Gastric outlet obstruction 2%

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NSAIDS andBleeding Ulcers

NSAIDS andBleeding Ulcers

• Gastric ulcers 10 - 20 x increase

• Duodenal ulcers 5 - 15 x increase

* Increase risk proportional to daily dose of NSAID

• Gastric ulcers 10 - 20 x increase

• Duodenal ulcers 5 - 15 x increase

* Increase risk proportional to daily dose of NSAID

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Risk Factors forGI Bleeding

Risk Factors forGI Bleeding

• Age > 60 years

• Co-morbid medical illness

• Hematochezia or red blood aspirate

• Hypotension or shock

• Transfusion > 6 units of blood

• Rebleeding in hospitals

• Age > 60 years

• Co-morbid medical illness

• Hematochezia or red blood aspirate

• Hypotension or shock

• Transfusion > 6 units of blood

• Rebleeding in hospitals27

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E. Christopher Ellison, MDZollinger Professor of Surgery and

Interim Chair, Department of SurgeryThe Ohio State University Medical Center

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Profile Profile

Mr. Tidball

• Presented 18 years ago with ulcer

• Partial removal of stomach

Condition• Did well initially• Then developed disphagia• Early satiety caused vomiting

Mr. Tidball

• Presented 18 years ago with ulcer

• Partial removal of stomach

Condition• Did well initially• Then developed disphagia• Early satiety caused vomiting

Profile Profile

Mr. Tidball

Diagnostic tests• UGI series• Endoscopy• Fasting serum gastrin level

Diagnosis• Gastric stasis with a marginal ulcer

Mr. Tidball

Diagnostic tests• UGI series• Endoscopy• Fasting serum gastrin level

Diagnosis• Gastric stasis with a marginal ulcer

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Ulcer DiseaseUlcer Disease

Indications for Surgery• Bleeding• Perforation

• Obstruction

• Intractability

Indications for Surgery• Bleeding• Perforation

• Obstruction

• Intractability

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Ulcer DiseaseUlcer Disease

Operations• Truncal vagotomy and pyloroplasty• Truncal vagotomy and antrectomy - Billroth I - Billroth II• Subtotal gastrectomy

• Highly selective vagotomy

Operations• Truncal vagotomy and pyloroplasty• Truncal vagotomy and antrectomy - Billroth I - Billroth II• Subtotal gastrectomy

• Highly selective vagotomy

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Truncal VagotomyTruncal Vagotomy

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AntrectomyAntrectomy

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ReconstructionAfter AntrectomyReconstruction

After Antrectomy

Billroth I Billroth II Billroth I Billroth II

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Highly SelectiveVagotomy

Highly SelectiveVagotomy

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Duodenal Ulcer DiseaseBleeding

Duodenal Ulcer DiseaseBleeding

• Endoscopic therapy - Injection - Heater probe - Clips

• Operation if - UNSTABLE - Rebleeding - > 6 units PRBC

• A major indication for surgery

• Endoscopic therapy - Injection - Heater probe - Clips

• Operation if - UNSTABLE - Rebleeding - > 6 units PRBC

• A major indication for surgery

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Bleeding Duodenal UlcerBleeding Duodenal Ulcer

Method of LigationMethod of Ligation

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Perforated UlcerPerforated Ulcer

• Clinical presentation• Free air on AAS (absent in 25%)

• Operative vs. non-operative treatment - Operation in most cases - NG decompression, antibiotics if “sealed”• Mortality rate high if >24 hours between onset of symptoms and surgery

• Clinical presentation• Free air on AAS (absent in 25%)

• Operative vs. non-operative treatment - Operation in most cases - NG decompression, antibiotics if “sealed”• Mortality rate high if >24 hours between onset of symptoms and surgery

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Duodenal Ulcer DiseaseGastric Outlet ObstructionDuodenal Ulcer Disease

Gastric Outlet Obstruction

• NG decompression

• Correct electrolytes

• Nutrition

• H-2 antagonist

• Proton pump inhibitor

• NG decompression

• Correct electrolytes

• Nutrition

• H-2 antagonist

• Proton pump inhibitor

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Recurrent UlcerRecurrent Ulcer

Operation Incidence

• Vagotomy & Pyloroplasty 10 - 15%

• Vagotomy & Antrectomy 0 - 2%

• Subtotal Gastrectomy 2 - 5%

• Highly selective Vagotomy 10 - 20%

Operation Incidence

• Vagotomy & Pyloroplasty 10 - 15%

• Vagotomy & Antrectomy 0 - 2%

• Subtotal Gastrectomy 2 - 5%

• Highly selective Vagotomy 10 - 20%

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Recurrent UlcerEtiology and Treatment

Recurrent UlcerEtiology and Treatment

• Exclude ZES, PTH, etc

• Aggressive medical Rx

• Tailor operation - Revagotomy - Re-resection

• Exclude ZES, PTH, etc

• Aggressive medical Rx

• Tailor operation - Revagotomy - Re-resection

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PostgastrectomySyndromes

PostgastrectomySyndromes

• Dumping syndrome

• Alkaline reflux gastritis

• Gastric stasis

• Loop syndromes

• Gastric remnant carcinoma

• Dumping syndrome

• Alkaline reflux gastritis

• Gastric stasis

• Loop syndromes

• Gastric remnant carcinoma

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Dumping SyndromeEarly

Dumping SyndromeEarly

• Fluid shifts - Intravascular space - Bowel lumen

• Enteric peptides (Vasodilation) - Neurotensin - Serotonin - VIP - Motilin

• Fluid shifts - Intravascular space - Bowel lumen

• Enteric peptides (Vasodilation) - Neurotensin - Serotonin - VIP - Motilin

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Dumping SyndromeTreatment

Dumping SyndromeTreatment

• Dietary modification - Consult dietician - Reduce carbohydrates

• Somatostatin (50-100 mcg subq TID) - Reduces intestinal hypermotility - Increases fluid and electrolyte absorption - Inhibits enteric peptide secretion

• Acarbose (alpha glucosidase inhibitor 50-100 mg ac) reduces postprandial hyperglycemia

• Surgical treatment is roux-en-Y or pyloroplasty closure

• Dietary modification - Consult dietician - Reduce carbohydrates

• Somatostatin (50-100 mcg subq TID) - Reduces intestinal hypermotility - Increases fluid and electrolyte absorption - Inhibits enteric peptide secretion

• Acarbose (alpha glucosidase inhibitor 50-100 mg ac) reduces postprandial hyperglycemia

• Surgical treatment is roux-en-Y or pyloroplasty closure

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Post-Gastrectomy SyndromesAlkaline Reflux Gastritis

Post-Gastrectomy SyndromesAlkaline Reflux Gastritis

• Epigastric pain and bilious vomiting

• Incidence 15-20%

• Diagnosis - EGD & Bx

• ETIOLOGY - Decreased emptying - Poor clearance of bile - Bile irritation - Inflammatory infiltrate - Helicobacter pylori

• Epigastric pain and bilious vomiting

• Incidence 15-20%

• Diagnosis - EGD & Bx

• ETIOLOGY - Decreased emptying - Poor clearance of bile - Bile irritation - Inflammatory infiltrate - Helicobacter pylori

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Alkaline GastritisCombination Therapy

Alkaline GastritisCombination Therapy

• Protect mucosa- sulcralfate

• Improve gastric emptying - Metaclopramide or cisapride - Erythomycin

• Bile salt binding - Aluminum hydroxide antacids - Cholestyramine

• Alter bile composition - Ursodeoxycholic acid

• Surgical treatment - Roux-en-Y

• Protect mucosa- sulcralfate

• Improve gastric emptying - Metaclopramide or cisapride - Erythomycin

• Bile salt binding - Aluminum hydroxide antacids - Cholestyramine

• Alter bile composition - Ursodeoxycholic acid

• Surgical treatment - Roux-en-Y

Roux-en-Y Roux-en-Y

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Gastric StasisGastric Stasis

• Uncommon condition (5 cases / year)• Symptoms - Early satiety, vomiting, recurrent bezoars

• Etiology - Obstruction (recurrent ulcer, efferent loop) - Atony - Roux syndrome

• Treatment - Prokinetic agents - Completion gastrectomy (improves 50-70%)

• Uncommon condition (5 cases / year)• Symptoms - Early satiety, vomiting, recurrent bezoars

• Etiology - Obstruction (recurrent ulcer, efferent loop) - Atony - Roux syndrome

• Treatment - Prokinetic agents - Completion gastrectomy (improves 50-70%)

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Loop SyndromesComplication of Gastrojejunostomy

Loop SyndromesComplication of Gastrojejunostomy

• Afferent loop syndrome - Nausea, non bilious vomiting, pain (episodic bilious emesis that relieves postprandial pain) - Caused by kink, herniation, volvulous - Diagnosis > US, CT, MRCP - Treatment > jejunojenostmy or BRII to BRI

• Efferent loop obstruction - Bilious vomiting, bezoars - Diagnosis > GI contrast studies, EGD - Treatment adhesiolysis, revision +/- resection

• Afferent loop syndrome - Nausea, non bilious vomiting, pain (episodic bilious emesis that relieves postprandial pain) - Caused by kink, herniation, volvulous - Diagnosis > US, CT, MRCP - Treatment > jejunojenostmy or BRII to BRI

• Efferent loop obstruction - Bilious vomiting, bezoars - Diagnosis > GI contrast studies, EGD - Treatment adhesiolysis, revision +/- resection

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Gastric Remnant CarcinomaGastric Remnant Carcinoma

• Etiology (P53, K-ras mutations)

• Enterogastric reflux

• H. pylori, EB virus

• N-nitrosocompounds

• Etiology (P53, K-ras mutations)

• Enterogastric reflux

• H. pylori, EB virus

• N-nitrosocompounds

• Incidence 0.8%• >20 years postop• Etiology• Differentiate from loop syndromes, new ulcer• EGD critical in dx.• Requires completion gastrectomy

• Incidence 0.8%• >20 years postop• Etiology• Differentiate from loop syndromes, new ulcer• EGD critical in dx.• Requires completion gastrectomy

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Summary Summary

Mr. Tidball

Surgical Procedure• Completion gastrectomy with a Roux-en-Y esophagojejunostomy• Necessary in a small number of patients who have had previous stomach surgery for ulcer disease

Indications• Gastric stasis with a marginal ulcer

Mr. Tidball

Surgical Procedure• Completion gastrectomy with a Roux-en-Y esophagojejunostomy• Necessary in a small number of patients who have had previous stomach surgery for ulcer disease

Indications• Gastric stasis with a marginal ulcer

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Summary Summary

Mr. TidballPrognosis• Excellent

Currently• 2 months post-op and has gained nearly 10 pounds• Vitamin B-12 regularly• No other medications required

Mr. TidballPrognosis• Excellent

Currently• 2 months post-op and has gained nearly 10 pounds• Vitamin B-12 regularly• No other medications required

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speak with Dr. Mekhijian, and Dr. Ellison

Visit OMEN OnLine

http://omen.med.ohio-state.eduVisit OMEN OnLine

http://omen.med.ohio-state.edu

Questions on this subject?Questions on this subject?

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#1015 Approach to Chronic Cough

February 1 to 4

Jeffrey E. Weiland, MDAssociate Professor of Clinical Internal MedicineDivision of Pulmonary and Critical Care MedicineThe Ohio State University Medical Center

Ruairi Fahy, MDClinical Instructor of Internal MedicineDivision of Pulmonary and Critical Care MedicineThe Ohio State University Medical Center

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