1

Peptic Ulcer Surgery: “A shift in the Paradigm”

Indications, Operations of Choice and Operative Technique

Dr. Hardeep Gill, FCS(ECSA) Trainee, FCS(SA) Trainee,

Groote Schuur Hospital, University of Cape Town, South Africa.

1. Introduction

2. Bleeding Peptic Ulcer

3. Perforated Peptic Ulcer 3.1. Epidemiology

3.2. Surgical management

3.2.1 Perforated Duodenal Ulcer

3.2.1.1. Simple patch closure

3.2.1.2. Laparoscopic repair of perforated peptic ulcer: first choice?

3.2.1.3. Conservative approach to duodenal ulcer perforations

3.2.1.4. Management of large perforated peptic ulcers

3.2.1.5. Failure of primary omental patching

3.2.1.6. Duodenal perforations associated with a bleeding (“kissing”) ulcer

3.2.1.7. Perforations associated with Gastric Outlet Obstruction (GOO)

3.2.1.8. Perforations with duodenal destruction and local organ penetration

3.2.1.9. Tube duodenostomy

3.2.2. Perforated Gastric Ulcer

4. Gastric Outlet Obstruction

5. non healing or recurrent ulcers

6. Conclusions

7. recommendations

8. References

1. Introduction With the success of medical therapy, surgery has a very limited role in the management of peptic

ulcer disease (PUD). Helicobacter Pylori eradication has become the medical equivalent of

vagotomy, relegating definitive operations to the history chapters of surgical textbooks. (1)

Combinations of multiple antibiotics and acid reducing agents, usually PPIs, have been the

mainstay of these regimes. Cure rates of greater than 80% (intent to treat) are possible. (2)

Eradication of H.pylori infection can give long-term remission of ulcer disease; reduce

recurrence; prevent recurrent ulcer bleeding and resolve pyloro-duodenal stenosis in some cases.

(3) In light of this evidence general surgeons need to revise their indications for peptic ulcer

surgery and critically re-appraise the procedures performed for peptic ulcer disease. Elective

peptic ulcer surgery has been virtually abandoned. In the 1980s, the number of elective

operations for peptic ulcer disease dropped more than 70%, and emergent operations accounted

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for more than 80% of these. (4) Currently, surgery for peptic ulcer disease is largely restricted to

the treatment of complications, particularly bleeding, perforation, and obstruction, while relying

on H.pylori eradication to prevent ulcer recurrence, and these will be the focus of this review.

The focus of surgical therapy is to manage the complication effectively and not necessarily to

cure the ulcer.

2. Bleeding Peptic Ulcer

Bleeding is the commonest complication of peptic ulceration. Endoscopic hemostasis is now

accepted as the first-line treatment in patients with non-variceal upper gastro-intestinal bleeding.

Endoscopy is an effective tool in the diagnosis, prognostication, and therapy of bleeding PUD

and has been shown in randomized studies to lead to a reduction in blood transfusion

requirements, to shortened intensive care unit and hospital stays, to a decreased need for surgery,

and a lower mortality rate.(5,6) Early endoscopy (within 24 hours of admission) has been shown

to reduce blood transfusion requirements and length of hospital stay. (7) Patients who are

hemodynamically stable with endoscopy revealing ulcers without high-risk stigmata may be

safely discharged home after endoscopy. (8) Patients with endoscopic stigmata indicating a high

risk of rebleeding, including adherent clots, visible vessels, and active arterial bleeding should all

undergo endoscopic therapy to achieve hemostasis and reduce the risk of rebleeding.(5,9,10)

Recurrent bleeding may occur in as many as 10% of patients despite endotherapy and the use of

high-dose proton pump inhibitors. (11, 12) In patients who rebleed after initial endoscopic

therapy, repeat endoscopic therapy is suggested before considering surgical or radiologic

intervention.

Several controlled trials have shown that endoscopic therapy using a variety of combined

techniques significantly reduces the need for blood transfusion and emergency surgical

intervention.(13) Similar results are reported with acid suppression, especially when gastric pH is

kept above 6 by using high dose proton pump inhibitor (PPI) therapy.

Further benefits have been shown when endoscopic therapy is combined with intravenous PPI

therapy. The combined therapy has now been endorsed by the British Society of

Gastroenterology, who have recommended intravenous PPI therapy with an initial dose of 80mg,

followed by a maintenance dose of 8mg per hour over 72 hour period. (14)The blanket use of

expensive PPI therapy has been challenged by a recent randomized study (15) showing that

smaller intravenous doses (20mg) of omeprazole administered after endoscopic therapy gave

results comparable to the recommended high dose PPI regimen when rebleeding, surgery and

mortality were analyzed. However the cost and availability of intravenous PPI therapy remain a

major consideration and should be restricted to high risk patients.

The independent pre-endoscopic predictors of rebleeding that are significant in at least two

separate studies are hemodynamic instability and comorbid illness. The independent endoscopic

predictors of rebleeding that are significant in at least two separate studies are active bleeding at

endoscopy, large ulcer size, posterior duodenal location, and lesser gastric curve location. (16 )

3

The benefit of early “second look” endoscopy and further injection if required has been debated

for some time. There is now an increasing body of evidence that this approach does not confer

benefit by further reducing the incidence of re-bleeding. (17,18 ) However the benefit of early

“second look” endoscopy is still valuable in selected cases where the initial endoscopy was

inadequate or demonstrated a Forrest I or IIA ulcer. Rebleeding can be handled effectively by

repeat endoscopic therapy or surgery: which to use should be based on the pre-existing

comorbidities of the patient. Pre-operative on table endoscopy is first done for an acute upper GI

bleed to exclude varices.

The role of surgery during acute bleeding is now restricted to patients with an exsanguinating

bleed or those in whom endoscopic therapy fails for technical reasons, or in patients who rebleed

after a second endoscopic attempt to control the bleeding.(14,19,20)

The preferred operation today for a bleeding duodenal ulcer is to under-run the bleeder with or

without a pyloroplasty.

For bleeding gastric ulcers, a gastrotomy with under-running of the bleeder with biopsy , or

depending on the site, local excision is recommended. If the source of bleeding cannot be

identified on gastroscopy, a gastrotomy commencing from the pre-pyloric region through the

pylorus to the first part of the duodenum should be done, and the incision extended in the

direction where the bleeding seems to be coming from. Gastrectomy is reserved for large

penetrating ulcers or when there is suspicion of a malignant ulcer. The move away from

definitive surgery has been vindicated by ulcer cure rates in excess of 90% in patients who have

had successful H.Pylori eradication therapy. (21-23) Patients who require long-term non-

steroidal anti-inflammatory drug (NSAIDS) therapy are advised to take PPI medication, or

alternatively use the safest NSAID available.

3. Perforated Peptic Ulcer Perforation occurs in approximately 7% of patients hospitalized for peptic ulcer disease. (24)

Duodenal perforation tends to occur in the anterior wall while gastric ulcers may perforate

anteriorly or posteriorly. Concomitant haemorrhage should suggest the presence of a „kissing‟

ulcer (ulcers involving anterior and posterior duodenal walls simultaneously).

3.1. Epidemiology

Risk factors

NSAIDs, immunosuppression (esp. transplant patients on steroids), increasing patient age,

chronic obstructive lung disease, major burns, multi-organ failure and smoking

Gender and age of patients with perforated PUD

The percentage of women with duodenal ulcer perforations has increased almost threefold over

the last 45 years. The male to female ratio is now 2:1 (initially was 7:1). The mean age of women

with perforated duodenal ulcers is 10 years higher than for their male counterparts (25).

Localization

Perforations of duodenal ulcers are 7 times more common than perforated gastric ulcers in both

sexes in Western literature. However, in developing countries 74% of the perforations may be in

the pre-pyloric area.

Predicting morbidity and mortality

It is important to stratify patients into different categories based on the likelihood of morbidity

and mortality, so that high-risk patients can receive more appropriate treatment and greater

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intensive care. Several risk scores exist for the prediction of outcomes in PUD example, Boey,

ASA, APACHE II and the Mannheim Peritonitis index ( 24-25).

The Boey scoring system (26) is among the common risk stratifications used because of its

simplicity and high predictive value for mortality in perforated peptic ulcers. Boey risk factors

include: pre-op shock (<100mmHg), perforation present for >24hours, associated medical co-

morbidities.

Each of these risk factors score 1 point to a maximum of 3 points with corresponding mortality

rates.

Boey scoring system

Risk factors Mortality rates

0 0%

1 10%

2 45.5%

3 100%

The incidence of mortality of perforated PU is 5-10%. Mortality increases up to 50% if the

perforation has been present > 24 hours.

Classification of gastroduodenal ulcer perforation :

Type A: solitary prepyloric ulcer located anteriorly. Treatment of choice should be an open/

laparoscopic closure by suture with omentopexy and post-op endoscopic biopsy to identify

H.Pylori and to exclude malignancy.

Type B: perforated ulcer with a large defect. Excision and suture is necessary by open surgery.

Type C: complicated perforated ulcer with proximal duodenal destruction and penetration into

adjacent organs, often pancreas, for which resectional surgery may be indicated like Billroth I, II,

with Roux-en-Y or an atypical resection.

Regardless of the ulcer types, those patients that are critically ill and high risk can be offered

minimal surgical intervention by percutaneous peritoneal drainage which may significantly lower

the mortality in this selected patient group.(27)

Presentation

Classically: acute onset of severe epigastric pain with / without radiation to the shoulders.

Anxiety, fever, tachypnoea and tachycardia, generalized peritonitis, loss of liver dullness are also

present. These classic features may be absent in the very young/old, immunosuppressed,

quadriplegic and comatose patient.

Radiology: Free air on erect chest or left decubitus x-ray. This may not be visible in 30% cases

and a water-soluble contrast may facilitate the diagnosis.

Management

Resuscitation – with view to stabilization for anaesthesia and surgery:

Nasogastric tube, intravenous fluids, catheterize and monitor urine output

Analgesia, intravenous antibiotics, acid suppression, eradication therapy.

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3.2. Surgical management

3.2.1 Perforated Duodenal Ulcer The primary aim is to close the perforation, and decontaminate the peritoneal cavity.

3.2.1.1. Simple patch closure

The long debate, about the choice between simple patch closure and definitive surgery, has now

been settled in favour of patch closure combined with H.Pylori eradication. (27, 28) There is

conclusive evidence that the risk of recurrent ulceration is below 10% with this combination

therapy. Simple patch closure is also the treatment of choice for NSAID induced perforations

since PPI therapy provides effective ulcer protection in these patients.

3.2.1.2. Laparoscopic repair of perforated peptic ulcer: first choice?

The controversy about the surgical management of perforated peptic ulcers has now shifted to

the choice between open or laparoscopic closure. Several laparoscopic techniques have been

described, ranging from a simple stitch to the use of fibrin glue. Controlled studies have shown

that laparoscopic closure is associated with less postoperative analgesic requirements, a lower

incidence of respiratory infection, a lower median hospital stay and earlier return to normal

activity. (27-30)

A recent literature review has concluded that laparoscopic ulcer repair is safe even in patients

with prolonged peritonitis. (29) It is however technically demanding and requires a surgeon

experienced in laparoscopy. A remarkable difference in morbidity (14.35 in laparoscopic group

vs. 26.9% in open group) and mortality (3.6% vs 6.4%) should advocate laparoscopy as a

diagnostic and therapeutic tool. The overall conversion rate is around 12.4% (range 0-28.5%).

The most common reason for conversion was the size of the perforation, but by using a pedicled

omentoplasty, size might not necessarily be a reason to convert anymore. Other common reasons

for conversion include failure to locate the perforation, shock on admission (conversion rate 50%

vs. 8%) and time elapsed since perforation and presentation (33% vs. 0%). The reported series on

laparoscopic repair of perforated peptic ulcers comes from specialized centres and cannot be

recommended for general community practice where most of these patients are treated.

The new “stamp” method which consists of closure of the perforation by gluing a biodegradable

patch onto the outside of the stomach could, in the future, further improve the ease of

laparoscopic management.

Open simple patch closure remains the gold standard in the management of perforated peptic

ulcers and, when performed through a small midline incision, the outcome should be similar to

the laparoscopic approach.

3.2.1.3. Conservative approach to duodenal ulcer perforations

The feasibility of non-operative management for perforated peptic ulcers was first reported by

Taylor in 1951. Croft from Hong Kong in 1989 reported the first prospective randomized trial

comparing the outcome of non-operative treatment with that of emergency surgery in patients

with a clinical diagnosis of perforated peptic ulcer. (31)

Approximately half of the duodenal ulcers will have self-sealed by the time of admission. The

presence of self-sealing can be reliably established by a water-soluble contrast meal and follow-

through. The spontaneous seal for a perforated duodenal ulcer is remarkably secure (only 2 out

of 152 re-leaked) and non surgical treatment should include nasogastric drainage, antibiotics, IV

PPIs and serial abdominal examinations.

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If the signs of peritonitis are not beginning to resolve within 12 hours, the diagnosis of a self-

sealed ulcer should be questioned. In patients with severe co-morbid disease preventing surgical

intervention, sump suction drains can be placed under local anaesthesia to the site of perforation

with an aim of creating an external fistula.

3.2.1.4. Management of large perforated peptic ulcers

Large perforations are between 1 and 3 cm in size; with giant perforations exceeding 3cm in size

occurring in only 2.5% of peptic ulcers. It should be stressed that large perforations may not be

suitable for simple patch closure. The leak rates with its attendant morbidity and mortality is high

in these patients. Different authors have recommended various surgical options as these large

perforations are particularly hazardous because of the extensive duodenal tissue loss and

surrounding tissue inflammation. (32)

These options include resection of the perforation bearing duodenum and the antrum in the form

of a partial gastrectomy with either a BI or BII anastomosis, or the more morbid procedure of

gastric disconnection in which an antrectomy, gastrostomy, lateral duodenostomy and feeding

jejunostomy are performed, with restoration of gastrointestinal continuity electively at 4 weeks.

Others have recommended conversion of the perforation into a pyloroplasty, or closure of the

perforation using a serosal jejunal patch or a pedicled jejunal graft. It is probably advisable

where possible to attempt the simplest closure technique. Omentopexy is still safe to perform in

perforations of up to 3cm. it is simple and avoids a major resection in an already compromised

patient. (33,34)

Omental plugging can be safely performed with giant perforated duodenal ulcers with indurated,

fibrotic, friable margins and seems to have a better long term outcome with regards to gastric

outlet obstruction when compared to omentopexy.

The technique of omental plugging is as follows:

The tip of the NG tube is guided through the perforation. The free edge of the omentum is then

sutured to the tip of the tube, which is then carefully withdrawn, pulling the plug of omentum

into the stomach. 5-6cm of omental plug is usually enough to occlude the perforation. The

omentum is then fixed with interrupted sutures taken between the omentum and the healthy

duodenum, approximately 3-4mm from the margins of the perforation.

An alternative approach described in critically ill patients with giant perforations, where a

resection would increase the patients‟ morbidity, is to perform a gastric partition,

gastrojejunostomy and simple closure of the perforated peptic ulcer. The gastric body partition

above the angular incisura is expected to avoid or minimize hypergastrinemia, as well as avoid

uncontrollable leakage from the site of ulcer repair. A tube duodenostomy is added for bile

drainage.

3.2.1.5. Failure of primary omental patching

Failure is defined as an early post-operative re-perforation, obstruction and or hemorrhage. A

more aggressive surgical procedure is then recommended, such as pyloroplasty or an antral

resection.

3.2.1.6. Duodenal perforations associated with a bleeding (“kissing”) ulcer

In this situation a pyloroplasty should be performed to allow undersewing of the posterior

bleeder. The pyloroplasty will then include closure of the perforation. Pyloroplasty options

7

include Jabulay, Finney or Heinecke-Mikulicz techniques. Alternatively, partial gastrectomy

may be considered as a definitive procedure.

pyloroplasties

3.2.1.7. Perforations associated with Gastric Outlet Obstruction (GOO)

If an element of GOO is suspected in a duodenal perforation it is safest to perform a

pyloroplasty, or consider simple omentopexy with a diverting gastrojejunostomy, before a partial

gastrectomy is considered. If post-operatively the patient develops GOO treatment options

include: pyloroplasty or antral resection; balloon dilatation; removable stent.

3.2.1.8. Perforations with duodenal destruction and local organ penetration

In situations with significant duodenal obstruction and local organ penetration any repair will be

difficult due to much inflammation and friable, fibrotic tissue edges. A higher than normal

duodenal leak rate must be anticipated. Various authors will advocate different techniques of

management from partial gastrectomy to gastric disconnection. Again, the simplest technique

possible should be advised: pyloroplasty or omentopexy or plugging with diverting

gastrojejunostomy. A Billroth I may provide a safe option than a Billroth II using a Horsley slit

technique. If a formal resection is unavoidable, be aware of the high risk of duodenal stump

blow-out and always leave a drain. In this situation some recommend a tube duodenostomy.

3.2.1.9. Tube duodenostomy

Duodenal stump leakage remains one of the most feared complications of gastric resection.

Despite good results reported with this technique it has not gained wide acceptance and is rarely

used. (35) It may be considered when surgical closure of the inflamed or scarred duodenum is

not safe after resection for chronic peptic ulcer disease, or when a duodenal stump leakage has

occurred following previous duodenal stump closure.

The technique is as follows: a soft 22F Pezzer catheter is inserted through the open end of the

duodenal stump to a depth of 4-5cm. the holes on the catheter tip may be widened to improve

drainage and also to make removal as atraumatic as possible. A purse string suture is then

invaginated into the lumen to keep the catheter in place. A viable omental pedicle may be

secured around the junction of the tube end and duodenum. A closed suction drain (Jackson-

Pratt) is then left near the tube duodenostomy. Depending on the surgeon, the duodenostomy

8

tube stays in place between 10-21 days. The choice of the site of introduction of the catheter,

either through the lateral duodenal wall or the duodenal stump, is of great importance.

Conceptually these two techniques differ. Lateral duodenostomy through the 2nd

part of the

duodenum is primarily used for intra-luminal decompression, but it has been shown that this

does not lead to a significant decrease in intra-duodenal pressures. End tube duodenostomy is an

effort to create a controlled duodenal fistula, and is employed when technical factors prevent

adequate surgical closure of the duodenal stump.

3.2.2. Perforated Gastric Ulcer

Distal gastrectomy was always considered the preferred surgical management of perforated

gastric ulcers. However, gastric ulcers are now curable by medical treatment, therefore omental

patch closure and ulcer excision are being increasingly employed as alternatives to gastrectomy.

The complication rate is significantly lower in patch closure patients than in both the

gastrectomy and ulcer excision groups. The focus of surgical therapy is to manage the

complication effectively and not necessarily to cure the ulcer. This makes simple operations such

as omentopexy and ulcer excision possible primary interventions for all, not just being confined

to elderly, unfit or unstable high-risk patients. Biopsy of perforated gastric ulcers is mandatory

due to the reported incidence of malignancy being between 3-14%. (36) Candida may also be an

associated pathogen. In addition, endoscopy should be performed post operatively to re-biopsy

and follow up persistent ulcers until healed. Considering the early and late morbidity associated

with gastrectomy, this procedure should be reserved for giant, penetrating or atypically situated

perforations that preclude a patch or excision and repair for technical reasons.

4. Gastric Outlet Obstruction

Gastric outlet obstruction (GOO) occurs in 6-8% of patients with duodenal ulcer disease. Before

the H.Pylori era most patients with outlet obstruction required surgical intervention, including

those who underwent endoscopic balloon dilatation. (37-39) The prevalence of H.Pylori varies

widely (33-91%) in reported series on GOO and the association appears to be less established

when compared with the other complications. (40)

Patients with gastric outlet obstruction are frequently malnourished, hypovolemic, and have

metabolic alkalosis. Operation is usually indicated if the obstruction fails to resolve after 72

hours with correction of fluid and electrolyte abnormalities, antisecretory therapy, and

nasogastric tube decompression.

Several reports have now shown that H.Pylori eradication with or without balloon dilatation can

successfully overcome GOO in the short to midterm, including patients who have an associated

fibrotic stricture. (41) However not all reports are favourable and there is increasing evidence

that NSAID users are less likely to respond. More data is required to assess the efficacy of

combining H.pylori eradication and endoscopic balloon dilatation of stenosis but, at present, it

would seem reasonable to try balloon dilatation before considering surgery.

The conventional treatment for GOO was vagotomy and a drainage procedure or alternatively

vagotomy and antrectomy. As with bleeding and perforated ulcers, in this situation definitive

operations have also become obsolete and addressing the obstruction is all that is needed after

successful eradication of H.Pylori. For “burnt-out” ulcers with residual fibrotic strictures a

9

pyloroplasty or Jaboulay gastroduodenostomy is all that is required. A more difficult question is

what to offer patients with persistent or recalcitrant penetrating ulcers despite successful H.Pylori

eradication. The reason why these ulcers fail to heal remains uncertain, but an important local

healing process may play an important role. Nevertheless, a limited distal resection with excision

or exclusion of the ulcer should be performed in these situations.

5. Non healing or recurrent ulcers. The definition of a non-healing ulcer is failure to heal, after appropriate treatment, in two months

for DU or three months for GU. It must be said that these are rare, especially in the developing

world. A diagnostic dilemma in these cases has been observed. (43) H. pylori persistence or re-

infection needs to be ruled out, as does Zollinger Ellison syndrome (a gastrinoma secreting

abnormally high levels of gastrin). Other aggravating factors - NSAIDS, smoking, alcohol - need

to be eliminated if possible. If the ulcer recurs, one option is long term PPI therapy. If there is

failure to heal on these, surgery becomes indicated. In GUs, particularly Type I, the standard

procedure has been the Bilroth I gastrectomy with excision of the ulcer. (44) Pre/peri-operative

biopsies should be performed to make sure the ulcer is not malignant and a larger resection not

required. For DUs, the modern options have been some form of vagotomy, truncal vagotomy

with drainage or highly selective vagotomy (parietal cell vagotomy) versus vagotomy and

antrectomy. (45) The latter procedure has an improved cure rate with increased side effects.

Recurrence of ulcer after surgery has long been a problem, often requiring more aggressive

surgery. (46)

6. Conclusions

With the discovery of H.Pylori, and the availability of effective acid suppressing drugs and

eradication therapy, one needs to question the validity and appropriateness of vagotomy and

gastrectomy and its numerous variations to control acid secretion. The present generation

surgeon is modestly trained and not equipped with the experience of elective gastric surgery.

Surgeons should therefore only intervene when complications of peptic ulceration present and

then too, should the surgery be tailored and kept to a minimum procedure. With perforation and

bleeding, the surgeon should allow for selective conservative treatment under appropriate

conditions, simple patching which may be performed via minimal access or more conventional

open surgery and, under-run a bleeding vessel when endoscopic haemostasis has failed. Early

surgery is still recommended in the elderly in view of the associated high morbidity and

mortality. The surgeon should leave acid control and eradication of H.Pylori to drug therapy.

Occasionally when operating for a bleeding ulcer or gastric outlet obstruction, a distal

gastrectomy may be necessary for scarring. But even here the resection should be limited and

undertaken for technical reasons and not for long term control.

In an editorial in the BMJ in 1991, appropriately titled “A requiem for vagotomy, despite the last

ditch efforts of surgeons”, John Alexander-Williams predicted that “vagotomy for ulcers will

soon go the way of vagotomy for tabes, made obsolete by the conquest of spiral organisms”.

These prophetic words have now become a reality. Surgeons should graciously accept their

10

diminishing role in the management of peptic ulcer disease, a role now confined, in the main, to

conservative surgery for complications - which ultimately is to the benefit of our patients. (42)

7. Summary and Recommendations:

GENERAL:

The major complications of peptic ulcer disease (PUD) include bleeding, perforation, and

gastric outlet obstruction.

The overall incidence of PUD has declined significantly, due to better medical therapy,

including proton pump inhibitors (PPI), regimens for eradication of Helicobacter

pylori, and improvements in endoscopic methods for control of hemorrhage. Surgery

for peptic ulcer disease is now typically confined to high risk patients.

Early surgical consultation for patients with complications of PUD is required to assure

stabilization of the patient, collaboration among services, and agreement on initial

nonoperative therapy.

BLEEDING:

Most patients with bleeding ulcers are treated with fluid resuscitation to correct

hypovolemia, blood transfusions as necessary, medical therapies, and endoscopic

intervention. Surgery is required when endoscopic techniques are unsuccessful or if the

patient is hemodynamically unstable or has continued bleeding.

The major endoscopic predictors of persistent or recurrent bleeding include

o Active bleeding during endoscopy - 90 percent recurrence

o Visible vessel - 50 percent recurrence

o Adherent clot (in elderly patients particularly with large ulcers) - 25 to 30 percent

recurrence

Patients with actively bleeding peptic ulcers or ulcers with high-risk stigmata (such as a

visible vessel or adherent clot) should receive an intravenous proton pump inhibitor

(PPI) .

11

PERFORATION:

For patients with a perforated ulcer, initial management includes insertion of a

nasogastric tube, intravenous hydration, and broad spectrum antibiotics. Operation is

almost always indicated and the surgical approach will depend upon whether the ulcer

is duodenal or gastric.

GASTRIC OUTLET OBSTRUCTION:

For patients with gastric outlet obstruction, a simple drainage procedure is indicated if the

obstruction fails to resolve after 72 hours of nasogastric suction and intravenous PPI.

The indications for a definitive ulcer operation, which generally involves an acid-

reducing procedure (such as a truncal, selective, highly-selective, or parietal-cell

vagotomy), are now very limited.

Dr. Hardeep Gill, FCS(ECSA) Trainee, FCS(SA) Trainee,

Groote Schuur Hospital, University of Cape Town, South Africa.

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