Duodenal Ulcers Flashcards
1
Q
What structures do superficial and deeper duodenal ulcers involve?
A
Superficial ulcers involve the submucosa
deeper ulcers involve the muscularis propria or the serosa
2
Q
What are common predisposing factors for duodenal ulcers
A
Helicobacter pylori infection
NSAID or aspirin use
smoking
stress.
3
Q
Name less common causes of duodenal ulcers
A
Gastrinoma (Zollinger-Ellison syndrome)
radiation
Crohn’s disease
cocaine
gastroduodenal dysmotility.
4
Q
What is the operative mortality rate for emergency peptic ulcer surgery?
A
About 30%.
5
Q
How can recurrent ulcers after surgery be minimized?
A
By eradicating H. pylori infection
avoiding NSAIDs and aspirin
and abstaining from smoking
6
Q
When should testing for H. pylori infection be performed?
A
active or a history of peptic ulcer disease
MALT
early gastric cancer
or those requiring long-term aspirin or NSAIDs
7
Q
What tests can confirm H. pylori eradication?
A
Urea breath test
fecal antigen test
endoscopic biopsy
(H. pylori serology should not be used to confirm cure).
8
Q
Some Common Helicobacter Treatment Regimens (10– 14 Days)
A
-Clarithromycin triple therapy (PPI, clarithromycin, amoxicillin, or metronidazole)
-Bismuth quadruple therapy (PPI, bismuth, tetracycline, nitroimidazole)
-Sequential therapy (PPI and amoxicillin for 5– 7 days, and then a PPI, clarithromycin, and nitroimidazole for 5– 7 days)
-Hybrid therapy (a PPI and amoxicillin for 7 days, and then a PPI, amoxicillin, clarithromycin, and nitroimidazole for 7 days)
9
Q
Patients Without Penicillin Allergy With Either Prior Macrolide Exposure or in a Region With >15% Clarithromycin Resistance
A
-Bismuth quadruple therapy
OR
-Levofloxacin triple therapy (PPI, levofloxacin, amoxicillin)
10
Q
Can daily aspirin for cardiovascular prophylaxis be safely taken in patients with a history of duodenal ulcers?
A
Yes, with daily (PPI)
11
Q
When is long-term PPI treatment recommended in patients with duodenal ulcers?
A
all patients who have been hospitalized for duodenal ulcers, unless they have undergone a vagotomy.
12
Q
In which patients should gastrectomy for duodenal ulcers be avoided?
A
avoided in thin or chronically malnourished patients.
13
Q
What are some early and late findings in a patient with a perforated duodenal ulcer?
A
Early findings include tachycardia
Late Findings: fever, tachypnea, and hypotension
14
Q
What is the mortality risk for a perforated duodenal ulcer?
A
It is high, up to 30% in some series, especially with delayed treatment.
15
Q
What is the treatment of choice for most patients with a perforated duodenal ulcer?
A
Laparotomy or laparoscopy with peritoneal washout and omental patch closure of the perforation.
16
Q
When should a biopsy of a duodenal ulcer be performed during surgery?
A
performed if there is any suspicion of malignancy.
17
Q
Is antifungal treatment routinely recommended in cases of duodenal ulcer perforation?
A
No
reserved for frail, immunosuppressed, or hospitalized patients, but not routinely used.
18
Q
What postoperative measures are typically taken after surgery for a perforated duodenal ulcer
A
Placement of at least one closed-suction peritoneal drain and sending peritoneal fluid for culture and sensitivity, including fungal studies
19
Q
What is the most common method for repairing a perforated duodenal ulcer?
A
Omental patching, also known as Graham patching
20
Q
How large is the typical perforation in the duodenum when using the omental patch technique?
A
Less than 1 cm.
21
Q
Why is primary closure of the perforation often avoided in omental patching?
A
The friable duodenal tissue adjacent to the perforation may cause sutures to pull through, enlarging the hole or narrowing a scarred gastric outlet
22
Q
How is the omental patch held in place?
A
By using interrupted seromuscular Lembert sutures placed into healthy duodenum on either side of the perforation.
23
Q
How is the adequacy of the seal tested after omental patch placement?
A
By submerging the site under irrigation fluid and injecting air or methylene blue into a nasogastric tube, which remains in place postoperatively
24
Q
What is a key challenge in repairing large duodenal ulcer perforations (> 2 cm)?
A
They are difficult to securely close using the standard Graham patch technique, and primary repair is prone to breakdown, especially in chronic ulcers.
25
What is a potential buttress material used to support the closure of a large ulcer perforation?
Omentum or falciform ligament can be used to buttress the closure.
26
How can a Kocher maneuver help in repairing large duodenal ulcer perforations?
It facilitates primary closure if it can be done safely
27
What surgical technique can be used if a large perforation cannot be closed primarily?
The perforation can be plugged with omentum or falciform ligament
or a loop of jejunum can be used as a serosal patch.
28
What is the risk of using direct intubation with or without an omental buttress in treating large perforations?
It is prone to ongoing leakage but may be used as a last resort or bailout procedure.
29
What is the triple-tube technique, and when is it used?
It involves placing a gastrostomy, antegrade feeding jejunostomy, and a retrograde jejunostomy tube (in duodenum) for decompression.
It is used in high-risk perforations
30
What is pyloric exclusion, and when might it be considered?
It involves closing the pylorus with heavy absorbable suture and creating a dependent loop gastrojejunostomy, used for tenuous duodenal closures.
31
What is a surgical option for repairing a large chronic duodenal perforation in a stable low-risk patient?
Roux-en-Y duodenojejunostomy, creating a tension-free two-layer anastomosis between the debrided duodenal opening and a Roux limb.
32
In which patients can definitive ulcer surgery be considered for perforated duodenal ulcers?
In stable
low to medium-risk patients (ASA 1 or 2) requiring emergency surgery
with a history of duodenal ulcer
or a large perforation (> 2 cm)
33
When should definitive ulcer surgery be avoided?
It should be avoided
if peritonitis is severe or well-established (exudative).
34
What are the two current options for definitive ulcer surgery?
1) Truncal vagotomy and gastrojejunostomy (V/GJ) with or without temporary pyloric closure
(2) truncal vagotomy and antrectomy (V/A) if the perforated duodenum can be safely resected with the antrum
35
When should resection be avoided in definitive ulcer surgery?
If there is a risk of a tenuous duodenal stump or possible injury to the ampulla or bile duct.
36
How can the ampulla be protected during definitive ulcer surgery?
A biliary Fogarty catheter can be advanced from above via the cystic duct or common bile duct if the ampulla is at risk.
37
What are the two types of vagotomy that may be considered during laparoscopic surgery for a perforated duodenal ulcer?
(1) Bilateral truncal vagotomy
(2) the modified Taylor procedure.
38
What is the modified Taylor procedure in vagotomy?
posterior truncal vagotomy with division of the segmental vagal branches to the anterior stomach, while preserving the anterior innervation to the antropyloric region to facilitate gastric emptying.
39
Where does postoperative management typically begin for perforated ulcer patients?
In the ICU
with continued optimization of critical organ function, fluid management, and treatment of sepsis.
40
What imaging studies are performed postoperatively to rule out ongoing leaks and demonstrate gastric emptying?
Postoperative contrast study, either fluoroscopy or CT.
41
When are antibiotics typically discontinued after surgery for a perforated duodenal ulcer?
On postoperative day 5, unless there is evidence of ongoing infection
42
When can peritoneal drains be removed postoperatively?
Drains can be removed 24 hours after the initiation of oral liquids if drainage is benign and the patient is stable
43
What may necessitate reoperation in a postoperative perforated duodenal ulcer patient?
Persistent leakage from the perforation site
or abdominal wound dehiscence.
44
What is the treatment for localized infected fluid collections postoperatively?
Percutaneous drainage can be performed
45
What is the best treatment for multiple fluid collections or extensive peritoneal fluid in the setting of sepsis postoperatively
Reoperation and washout.
46
What is recommended for patients after emergency surgery for a perforated duodenal ulcer regarding medication and lifestyle?
Chronic PPI therapy
empiric treatment of H. pylori infection
and avoidance of NSAIDs, aspirin (except low-dose with PPI), and smoking
47
What endoscopic hemostatic therapies have decreased the need for surgery in bleeding duodenal ulcers?
Cautery, topical agents, epinephrine injection, and clips
48
What percentage of patients with bleeding duodenal ulcers will stop bleeding with only IV fluid and IV PPIs?
Three-fourths (75%) of patients.
49
What characteristics are more common in patients with ongoing or recurrent bleeding duodenal ulcers?
Hematemesis
hypotension
multiunit transfusion requirement
and endoscopic stigmata such as visible vessels or active bleeding
50
What is the primary purpose of the Rockall score?
To predict mortality risk in patients with upper GI bleeding.
51
The Glasgow-Blatchford score (GBS)
designed to identify low-risk patients who do not require hospitalization
52
Why are deep posterior bleeding ulcers in the proximal duodenum particularly concerning?
may involve the gastroduodenal artery, leading to exsanguinating hemorrhage.
53
What is the usual treatment for high-risk bleeding duodenal ulcer patients?
PPI infusion and endoscopic hemostasis.
54
What should be done if a patient rebleeds after initial treatment for a bleeding duodenal ulcer?
Repeat endoscopic treatment
and consider arteriography with possible angioembolization
55
When should surgery be considered for patients with bleeding duodenal ulcers?
-For persistent or recurrent bleeding in patients with hemodynamic instability
-or requiring more than 6 units of red blood cells.
56
What is the predicted postoperative mortality rate for an older patient with a bleeding duodenal ulcer, hypotension, COPD, and a visible vessel on EGD according to the Rockall score?
40%
57
Glasgow-Blatchford Score
Elevated BUN 2– 6 points
Low Hgb 1– 6 points
Low BP 1– 3 points
Elevated HR 1 point
Melena 1 point
Syncope 2 points
Liver disease 2 points
Heart failure 2 points
58
What are the three surgical options for treating a bleeding duodenal ulcer?
(1) Oversewing alone
(2) oversewing with vagotomy and drainage
(3) vagotomy and antrectomy (V/A).
59
According to clinical trials, how do survival outcomes compare between oversewing with vagotomy and drainage versus vagotomy and antrectomy (V/A)?
Survival outcomes are similar, but reoperation for rebleeding is less common after V/A
60
Why is resection for bleeding duodenal ulcer rarely performed nowadays?
Most surgical patients are high-risk, and fashioning a secure duodenal stump can be difficult
61
What does the National Surgical Quality Improvement Program data suggest about vagotomy and drainage for bleeding peptic ulcers?
Vagotomy and drainage may result in a significantly lower 30-day postoperative mortality rate (12%) compared to vagotomy with resection (23%) or oversewing alone (27%).
62
What is the first step in oversewing a bleeding duodenal ulcer?
Exposure of the lesion, usually through a longitudinal duodenotomy or pyloroduodenotomy
63
Why is a Kocher maneuver performed during oversewing of a bleeding duodenal ulcer?
It decreases tension on the closure and facilitates manual control of the bleeding gastroduodenal artery
64
How is the gastroduodenal artery manually controlled during oversewing?
The surgeon standing on the patient's left side uses their left hand, with fingers behind the pancreas and thumb in front, to control the artery
65
How are deep posterior ulcers typically managed during oversewing?
By placing two or three heavy suture ligatures in a figure-of-8 or over-and-over fashion in the ulcer bed.
66
What is the U-stitch, and when is it used?
The U-stitch is a technique well described for securing hemostasis in the ulcer bed
67
Why is extraluminal ligation of the gastroduodenal artery above and below the duodenum typically inadvisable?
It is hazardous and misses the pancreatic branch for which the U-stitch is used
68
What step is taken after achieving hemostasis in the ulcer bed?
The ulcer bed should be abraded with the sucker tip to prevent rebleeding.
69
How is the anterior incision closed after oversewing a bleeding duodenal ulcer?
It can be closed either longitudinally or transversely as a pyloroplasty
70
In which patients may definitive ulcer surgery be appropriate?
In patients with a history of ulcer chronicity or those with a large (> 2 cm) deep posterior ulcer
71
In which patients is definitive ulcer surgery contraindicated?
It is contraindicated in ASA 4 and 5 patients and should be done selectively in ASA 3 patients
72
What is the preferred definitive surgery for stable patients with bleeding duodenal ulcers?
Truncal vagotomy and drainage (pyloroplasty or gastrojejunostomy).
73
How is postoperative management similar to the care following the repair of a perforated duodenal ulcer?
High-dose PPIs are used in the early postoperative period to decrease the risk of rebleeding
74
What should be done if early rebleeding occurs after surgery for a bleeding duodenal ulcer?
It should be evaluated with upper endoscopy and arteriography (either CT angiography or standard arteriography)
75
What lifestyle change is imperative for patients following surgery for duodenal ulcer complications?
Long-term smoking cessation.
76
What is recommended if NSAIDs are medically necessary for patients postoperatively?
A selective COX-2 inhibitor should be considered, along with long-term PPI therapy
77
When should long-term PPI therapy be prescribed after surgery for a bleeding duodenal ulcer?
If the patient requires chronic aspirin or anticoagulants, or in all patients admitted for duodenal ulcer complications unless definitive surgery has been performed.
78
What is now the second most common indication for duodenal ulcer surgery in some hospitals?
Chronic gastric outlet obstruction secondary to chronic inflammation and scarring
79
What physical sign may be present in patients with chronic gastric outlet obstruction?
A succussion splash on abdominal auscultation
80
What electrolyte and metabolic disturbance is common in high-grade obstruction with dehydration?
Hypokalemic hypochloremic metabolic alkalosis.
81
What major differential diagnosis should be considered in patients with gastric outlet obstruction symptoms?
Malignant gastric outlet obstruction, including pancreatic, duodenal, or gastric cancer.
82
What evaluations are typically performed for suspected gastric outlet obstruction?
EGD with biopsy, upper gastrointestinal fluoroscopy with oral barium, and CT
83
What is considered the gold standard surgery for obstructing duodenal ulcers?
Vagotomy and antrectomy (V/A)
84
What is an alternative to V/A for some patients with obstructing duodenal ulcers?
Vagotomy and gastrojejunostomy (V/GJ).
85
What are the advantages of V/A compared to V/GJ?
V/A has a lower recurrence rate and confirms that the cause of the obstruction is benign
86
What is an advantage of V/GJ over V/A?
lower operative mortality and can be reversed if dumping syndrome becomes intolerable.
87
What is a disadvantage of V/GJ compared to V/A?
There is a risk that obstructing cancer may be missed, and marginal ulcers may occur.
88
What is the recommended reconstruction after antrectomy in V/A?
Antecolic isoperistaltic Billroth II gastrojejunostomy.
89
Why is Roux-en-Y reconstruction generally avoided in V/A for large gastric remnants?
Due to the possibility of marginal ulceration and delayed gastric emptying.
90
How is the duodenal staple line managed during surgery for obstructing duodenal ulcers?
The duodenal staple line is typically irrigated and covered with well-vascularized omentum
91
How should patients treated with V/GJ for obstructing chronic duodenal ulcer disease be followed postoperatively?
They should be closely followed for 2 years to ensure that an obstructing cancer was not missed
92
What should be considered if a patient is not doing well after V/GJ?
Reevaluation and open exploration with conversion of the loop gastrojejunostomy to a distal gastrectomy, including the area of obstruction.
93
Vagotomy and Antrectomy Steps
-upper midline or transverse incision
-Exploration of the gastroduodenal area for malignancy
-Truncal vagotomy
-The peritoneum over the abdominal esophagus is incised
-Gastrohepatic ligament is opened above the hepatic vagal branches
-Pulling down on these branches makes the anterior vagal trunk stand out, and it is clipped
-Send for Histopath
-phrenoesophageal ligament opened along the right crus
-retroesophageal space is entered
-posterior vagus is located, clipped, sent for biopsy
-Antrectomy
-The lesser curvature neurovascular bundle is divided at the angularis incisura
-Right gastroepiploic arcade is divided on the greater curvature directly opposite.
-stomach is transected with a green handheld GIA or a purple or black laparoscopic GIA
-The gastrocolic ligament attached to the antrum is taken usually outside the gastroepiploic arcade
-progressing distally to the right gastroepiploic pedicle, which is ligated and divided.
-The right gastric is also ligated and divided
-The pylorus and duodenal bulb are carefully separated from the pancreas
-then the postpyloric duodenum is transected with a GIA or TA stapler
-The outlet obstruction should be resected.
-The surgeon should try hard to rule out cancer if the site of outlet obstruction is left behind
94
Then Cont
-Antecolic isoperistaltic Billroth II gastrojejunostomy on the greater curvature side of the gastric remnant
-the afferent loop on the greater curvature side
-the efferent limb on the lesser curvature side.
avoid Roux-en Y reconstruction with a large gastric remnant because of the possibility of marginal ulceration and/ or delayed gastric emptying.
before abdominal closure irrigate the staple line and cover it with well-vascularized omentum held in place by two or three sutures.
95
V/GJ Steps
-open or minimally invasive
-evaluation of the stomach and proximal duodenum
-vagotomy is performed
-Either a bilateral truncal or posterior truncal with anterior highly selective technique
-Loop gastrojejunostomy is to the dependent greater gastric curvature
-divide the little branches from the gastroepiploic to the stomach for a length of 6 to 8 cm, creating a target for the handsewn or stapled antecolic isoperistaltic gastrojejunostomy.
96
What must be ruled out before considering surgery for a persistent duodenal ulcer?
Gastrinoma and cancer must be ruled out.
97
What conditions must be fulfilled for a duodenal ulcer to heal without surgery?
H. pylori infection must be cleared.
The patient must take PPIs as prescribed.
The patient must avoid NSAIDs and aspirin.
The patient must not smoke
98
How is routine closure of the proximal duodenum during Billroth II distal gastrectomy usually accomplished?
With a GIA- or TA-type stapler (blue cartridge) or a two-layer suture closure.
99
Why should excessive suturing and imbrication be avoided during duodenal stump closure?
It may predispose to stump leakage.
100
What should be done if secure duodenal stump closure is difficult due to ulcer size, location, or inflammation?
A distal gastrectomy should be avoided, as operative mortality increases significantly with duodenal leakage
101
How is the integrity of a duodenal closure tested intraoperatively?
By placing an NG tube at the ligament of Treitz, distending the duodenum with air, and checking for leaks.
102
What is the role of omentum in difficult duodenal stump closures?
Healthy omentum is sewn over the closure to reinforce it.
103
What options are available for duodenal decompression after duodenal stump closure?
-Retrograde tube via the proximal jejunum
-Lateral duodenostomy
-NG decompression through the gastrojejunostomy into the duodenum
104
How should postoperative duodenal stump leakage be managed if the patient does not develop diffuse peritonitis or worsening sepsis?
It is usually managed nonoperatively with wide drainage and source control.
105
What should be done if suture closure of a leaking duodenal stump fails?
A tube is placed into the leak, and the duodenum is snugged around the tube, buttressed with omentum, falciform ligament, or peritoneum/skeletal muscle
106
How is a chronic duodenal fistula treated if it persists after initial management?
A definitive repair can be attempted later with Roux-en-Y duodenojejunostomy or resection.
