treatment of peptic ulcer Flashcards
How should a peptic ulcer be treated medically?
- H. pylori -ive -> H2RAs (cimitidine, ranitidine, famotidine) or PPIs (omeprazole)
- H. pylori positive -> triple or quadruple therapy
- if symptoms persist -> empiric trial of H. pylori eradication therapy
3 months are effective with endoscopic assessment every 4-6 weeks - mucosal surface protectors -> sucralfate, misoprostol
What are the treatment regiments for H. pylori infections?
BISMUTH TRIPLE THERAPY
- Bismuth -> 2 tablets 4 times a day
- Metronidazole -> 250mg 3 times a day
- Tetracycline -> 500mg 4 times a day
PPI TRIPLE THERAPY
- PPI -> twice daily
- Amoxicillin -> 1000mg 2 times a day
- Clarithromycin OR Metronidazole 500mg 2 times a day
QUADRUPLE THERAPY
- PPI -> twice a day
- Bismuth -> 2 tablets 4 times a day
- Metronidazole -> 250mg 3 times a day
- Tetracycline -> 500mg 4 times a day
When should long term maintenance be considered?
- all patients admitted with complications
- high risk patients on NSAIDs or aspirin (old or debilitated)
- all patients with history of recurrent ulcer or bleeding
- persistent smokers with history of peptic ulcer
When is surgical intervention needed in case of peptic ulcer?
- intractable non-healing ulcer
- complicated ulcer
- gastric cancer must be suspected in gastric ulcers -> BIOPSY
What are the surgical procedures used?
- highly selective vagotomy
- vagotomy & drainage (pyloroplasty or gastroenterostomy)
- vagotomy & distal gastrectomy (antrectomy)
What are the goals of operative therapy of duodenal ulcers?
- promotion of healing
- treatment of complications
- reduction of recurrence
- minimization of post-op side effects
What are the operative procedures preformed in case of a duodenal ulcer?
- truncal vagotomy & drainage
- truncal vagotomy & antrectomy -> gastrojuejunostomy
- parietal cell vagotomy
What are the gastric effects of a truncal vagotomy?
- decreased acid secretion
- accelerated liquid emptying
- altered emptying of solids
- increased serum gastrin -> reflex in younger patients -> do anterectomy with vagotomy
- gastrin cell hyperplasia -> reflex in younger patients -> do anterectomy with vagotomy
What are the non gastric effects of truncal vagotomy?
- decreased pancreatic exocrine secretion
- decreased postprandial bile flow
- increased gallbladder volume
- diminished release of vagally mediated peptide hormones
What is the difference between the Billroth I & Billroth II procedures?
- Billroth I -> Gastroduodenostomy
- Billroth II -> Gastrojejunostomy
What are the consequences of duodenal ulcer operations?
ULCER RECURRENCE RATE
- parietal-cell vagotomy -> 5-15%
- truncal vagotomy & pyloroplasty -> 5-15%
- truncal vagotomy & antrectomy -> <2%
MORTALITY
- parietal-cell vagotomy -> 0
- truncal vagotomy & pyloroplasty -> <1
- truncal vagotomy & antrectomy -> 1
DUMPING
- parietal-cell vagotomy -> <5%
- truncal vagotomy & pyloroplasty -> 10%
- truncal vagotomy & antrectomy -> 10-15%
DIARRHEA
- parietal-cell vagotomy -> <5%
- truncal vagotomy & pyloroplasty -> 25%
- truncal vagotomy & antrectomy -> 20%
What are the indications for operations in duodenal ulcers?
- intractability
- perforation
- obstruction
- hemorrhage
What are the standard operations for gastric ulcers?
- TYPE I -> distal gastrectomy + Billroths I
- TYPE II & III -> distal gastrectomy + vagotomy
- TYPE IV -> depends on the site of ulcer
- > TV + drainage + biopsy/excision of ulcer
- > distal gastrectomy with ulcer excision
- > distal gastrectomy with ulcer biopsy
- > proximal gastrectomy
What are the indications for elective surgery in a gastric ulcer?
- failure to heal on optimal medical therapy
- suspicion of malignancy
- distal gastric obstruction
- giant gastric ulcer
What is the recurrence rate in elective gastric ulcer operation?
- gastrectomy -> 2.8%
- Vagotomy/drainage -> 9.1%
- highly selective vagotomy -> 8.2%
What are the indications for emergency surgery in a gastric ulcer?
- bleeding gastric ulcer
- perforated gastric ulcer
What are the treatment options for GASTRIC ulcer disease complications?
BLEEDING
- oversew & biopsy -> in shocked patient
- oversew + biopsy + vagotomy & drainage OR distal gastrectomy
PERFORATION
- biopsy & patch -> in shocked patient
- wedge excision + Vagotomy & drainage OR distal gastrectomy
OBSTRUCTION
- biopsy + HSV + gastrojejunostomy
OR
- distal gastrectomy
NONHEALING
- HSV + wedge excision
OR
- distal gastrectomy
What are the treatment options for duodenal ulcer disease complications?
BLEEDING
- oversew -> in shocked
- oversew & vagotomy + drainage -> in old
- vagotomy + antrectomy -> good general condition
PERFORATION
- patch -> shock
- patch + HSV
- patch + vagotomy & drainage
OBSTRUCTION
- HSV + gastrojejunostomy
- vagotomy + drainage
NONHEALING
- HSV
- vagotomy + drainage
- Vagotomy + antrectomy
How should a perforated peptic ulcer be diagnosed?
- X-ray in erect or left lateral decubitus position -> pneumoperitoneum
- gastrografin
How should a pyloric obstruction be diagnosed?
- picture of gastric outlet obstruction + saline load test
- hypokalemia
- increased gastric fluid levels
- hour-glass stomach
What are the complications of peptic ulcer surgery?
EARLY
- duodenal stump leakage
- gastric retention
- hemorrhage
LATE
- recurrent ulcer
- dumping syndrome
- afferent loop syndrome
- postvagotomy diarrhea
- anemia
- gastrojejuno-colic fistula
how should a recurrent ulcer be treated?
potent antisecretory agents
H2RA (cimitidine, ranitidine, famotidine)
PPI (omeprazole)
What is the clinical picture of a gastrojejuno-colic fistula?
ULCER PENETRATES TRANSVERSE COLON
- severe diarrhea following every meal
- foul breath & may vomit faeces
- severe weight loss & dehydration rapid in onset
How is a gastrojejuno-colic fistula diagnosed & treated?
- barium enema
- correct dehydration & malnutrition first then reversional surgery
When does small stomach syndrome occur?
- following most ulcer operations including HSV -> loss of receptive relaxation
EARLY SATIETY
When does bile vomiting occur & how is it treated?
- following any vagotomy with drainage or gastrectomy
- eating precipitates abdominal pain & reflux symptoms (water-brash)
- reversional therapy -> Roux-en-Y diversion
What is the cause of a hypotensive picture after gastrectomy or vagotomy with drainage?
EARLY DUMPING
- loss of receptive relaxation of stomach
- signs & symptoms occur right after eating (meals rich in sucrose & fructose)
SYMPTOMS
- bloated
- nausea
- vomiting
- abdominal cramps
- diarrhea
- flushing
- dizziness
- rapid HR
How is early dumping managed?
- small, dry meals
- avoid fluids high in carbohydrates
- if it doesnt get better over time -> octreotide before meals
- reversional surgery
What is the cause of reactive hypoglycemia?
LATE DUMPING
- carbohydrate load in small bowel -> rise in plasma glucose -> increase insulin -> secondary hypoglycemia
OCTREOTIDE effective
What is the cause of postvagotomy diarrhea?
rapid gastric emptying
- severe & explosive diarrhea
- like passing boiling water
- treat with antidiarrheal preparations
What nutritional consequences follow a gastrectomy?
- weight loss
- anemia -> iron or vit B12
- bone disease in women
What is the cause of gallstone development post op?
TRUNCAL VAGOTOMY
- stasis in biliary tree -> stone formation
- cholecystectomy
