Chapter 3. PEPTIC ULCERS OF THE STOMACH AND DUODENUM

Definition and statistical data

Peptic ulcer is a chronic recurring disease characterized by stomach or duodenum mucous membrane steady defect formation and certain clinical manifestations.

5-10% of the adult population of the planet suffers from peptic ulcers of the stomach and duodenum. The disease more commonly affects urban population than rural population. Men suffer from peptic ulcers 4 times more often than women. Mortality rate in gastric ulcers is 7 people per 100000 of the population. Mortality rate in duodenal ulcers is 10 people per 100000 of the population.

Differential diagnostic criteria of peptic ulcer and symptomatic gastroduodenal ulcers

Basic diagnostic criteria

Peptic ulcer

Symptomatic ulcers

Age

Predominantly young and middle age

More often elderly and senile

Sex

More often in men

Both in men and women with about equal frequency

Hereditary predisposition

Frequently detected

Absent

Clinical picture

Typical with pronounced symptoma-tics in the majority of cases

Quite often poorly symptomatic, frequently camouflaged by symptoms of another (basic) disease

Duration of the ulcerous history

Usually for several years

Prolonged ulcerous history is lacking, quite often an acute onset

Presence of previous diseases

Is not typical; only accidental combinations of peptic ulcer with other diseases may occur

Ulcerous process quite often develops on the background of another (basic) disease (vast burns, myocardial infarction, pulmonary-cardiac insufficiency, cirrhosis of the liver, hyperparathyreosis, atherosclerosis) or diseases which have been treated with the help of prolonged therapy with anti-inflammatory, including steroid preparations (rheumatoid arthritis) and a number of other ulcerogenic drugs (for example, Reserpinum)

Seasonality of attacks

Typical

Not typical

Localization of the ulcer

More often in the duodenal bulb, more rarely in the stomach

Predominantly in the stomach, more rarely - in the duodenal bulb

The number of ulcers

Single ulcerous defect in the majority of cases

Frequently 2-3 and more ulcers, which quite often are combined with the mucous membrane erosions

Frequency of complications

Up to 15-20%

Frequent, may reach 40-70%

Average time of ulcers' scarring in conservative treatment

20-30 days if the ulcer is localized in the duodenal bulb, more than 30 days if the ulcer is localized in the stomach

Time of ulcers' scarring is longer and depends to a great extent on the effectiveness of therapy of the basic disease

In 2% of cases the reason of a persistent course of peptic ulcer is a gastrinoma, which causes Zollinger-Ellisson's syndrome (a hyperproduction of gastrin by the tumor). It is characterized by the high basal production of HCl and by absence of acid's debit increase after injection of histamine. A half of patients have a tumor in pancreas, in other cases - out-pancreatic localization (more often in wall of duodenum). Plural ulcers are typical in most cases. More than a half of patients have recurrent bleedings, perforations after operations. Sizes of gastrinoma are 0.1-1 cm. By this reason it is found during CT-research only in 50-60% cases. Intraoperative research has a great importance. Treatment - ablation of tumor. In cases of undetected tumors - gastrectomy is performed to eliminate the target organ for gastrinoma.

In the choice of the operation method the character of the patient's secretion plays

the determinant role

Phases of gastric secretion

Characteristics

Method of investigation

phase I

Regulated by neuron-reflex component. Vagus nerves are responsible for it.

Phase I investigation is carried out with stimulation of vagus nerves' nuclei by hypoglycemia. For this purpose insuline is injected to the patient intravenously in the dose of 0.1 U/kg. The stomach contents are collected during an hour with the help of the probe. After that hypoglycemia is neutralized by means of glucose solution injection.

phase II

Regulated by humoral mechanisms (mainly by the influence of gastrin). It is started with mechanical irritation of the antral portion by food and depends on time of food presence in the stomach.

For phase II investigation 1 ml of 1% histamine solution (analog of gastrin) is injected to the patient, and the stomach contents are collected during an hour.

Depending on the ratio of discharged hydrochloric acid during phases I and II following basic types of gastric secretion are found:

Type of secretion

Debit/hour HCl (mmol)

Phase I

Phase II

Normal

1.1-4.1

1.1-5.9

Asthenic

>4.1

<5.9

Stimulated

>4.1

>5.9

Inert

<4.1

>5.9

Inhibited

<1.1

<1.1

Choice of operation method in non-complicated ulcers of duodenum and pyloric portion of the stomach

A good result of treatment is determined not by the mode of operative intervention, but by the correct choice of the treatment method in each particular case.

Type of secretion

Mode of operation

Mechanism of action

Notes

Stimulated

Selective vagotomy (SV) with drainage operation

Gastric secretion decrease in both phases

In anterior wall ulcers the preferable choice of drainage intervention is Judd's operation (the ulcer's removal)

Asthenic

Selective proximal vagotomy (SPV)

Gastric secretion decrease in phase I

Its application in isolated mode without drainage operations is recommended

Inert

Drainage operations including an-tral resection of the stomach

Gastric secretion decrease in phase II

Antral resection is performed if it is necessary to carry away the posterior wall ulcer and the area with impaired trophicity (bleeding in the case history)

At the duodenal ulcer the inhibitory type of secretion practically does not occur, so the method of choice is the SPV. At the impared evacuation and possibility of cicatrical stenosis while ulcer healing there is should be SV with drainage operation.

At localization of ulcer in the body of stomach due to the absence of an acid-peptic factor the resection of stomach is performed to remove an ulcer and a zone with a diminished trophism for the prevention of malignization and other complications. The preferable methods are Bilrot-I resection, preserving natural food passage, and resection with Roux anastomosis, excluding intestinal contents' reflux into the stump of the stomach. Roux resection is also pathogenetically argumented in accompanying duodenostasis.

Clinical picture in the typical course of the disease (perforation of the organ's anterior wall in the period «of surgical abdomen» at high acidity level of the stomach contents)

Main symptoms and signs

Subsidiary symptoms and signs

- "stabbing" pain (90%), accompanied by arterial blood pressure downfall, cold perspiration, accelerated weak pulse rate

- plaque-like tension of the abdominal wall muscles (90%) due to which Schetkin's symptom cannot be forced

- pneumoperitoneum: it is detected by percussion - Gobert's symptom (disappearance of the dullness of the liver) and by survey roentgenoscopy (in pneumogastrography it elevevates from 80% up to 95%)

- ulcerous history (80%)

- pre-perforation condition (appearance or intensification of pain in the epigastrium several days before the perforation - up to 25%)

- laboured accelerated respiration

- forced position (squat position or reclining position with the legs adducted to the abdomen)

- vomiting (more frequently unitary)

- hyperleucocytosis (12-25000)

- liquid in the abdominal cavity - it is detected by percussion (De Quervain's sign) or with the help of ultrasonic investigation

- positive phrenicus-sign

The period of "surgical abdomen" or shock is most easily diagnosed and most favorable for recovery.

Factors influencing the peculiarities of the clinical picture

Period of the disease

Clinical picture

Period of false well-being

- pain intensity decreases, signs of shock disappear

- the abdomen becomes softer (though tension in the epigastrium almost always remains)

Period of spread peritonitis

- enteroparesis

- abdominal distention

- positive Blumberg's sign

- pulse rate acceleration

- body temperature elevation

Localization of perforation

Posterior stomach wall (into the omentum bursa)

- lack of "stabbing" pain, shock

- lack of plaque-like tension of the abdominal wall

- possible lack of pneumoperitoneum and large amounts of liquid in the free abdominal cavity

- lack of phrenicus-sign

Camouflaged perforation

Obstruction of the opening with a piece of food, fibrin or adjacent organ - liver, omentum

- quick disappearance of the "surgical abdomen" signs after discontinuation of the stomach contents' passage into the abdominal cavity

- muscular tension in the epigastrium remains for a long time

- possible lack of pneumoperitoneum and large amount of liquid in the free abdominal cavity

- negative phrenicus-sign

Acidity of the stomach contents

Low

- lack of "stabbing" pain, shock

- lack of plaque-like tension of the abdominal wall

Diagnostic difficulties are most probable in the second and third periods, as well as in camouflaged perforations and low acidity of the stomach contents.

Instrumental diagnostics of perforating ulcers

Methods of investigation

Advantages of the method

Survey roentgenoscopy of the abdominal cavity

Reliable detection of pneumoperitoneum

Inflation of the stomach with air through the probe followed by X-ray investigation (pneumogastrography)

Reliable detection of pneumoperitoneum in camouflaged perforations

Fibrogastroduodenoscopy (FGD)

Visualization of the ulcer, biopsy

Ultrasonic investigation (US)

Reliable detection of free liquid in the abdominal cavity

Laparoscopy

Visualization of the origin and signs of peritonitis

Differential diagnostics. It is carried out with other acute diseases of the abdominal cavity organs. The clinical picture of acute pancreatitis and pancreonecrosis is most similar to that of perforating gastroduodenal ulcer.

Table of differential diagnostics of perforating ulcer and acute pancreatitis

Signs

Scale values

Female sex

3

Age: 40 years and older

1

Irradiation of the pain into the lumbar region

4

Dietary errors

1

Lack of gastritic history

2

Recurrent attack

3

Supernutrition

2

No forced position

3

No motor anxiety

1

The abdomen participates in respiration

4

Peristalsis is heard

3

No dullness in the stepless parts of the abdomen

2

No anterior abdominal wall muscles' tension

4

Dullness of the liver is preserved

3

Negative Blumberg's sign

3

The data in this table have been obtained by means of mathematical processing of a great number of clinical materials. The table is applied in case of difficulties in differential diagnostics between perforating ulcer and acute pancreatitis.

Algebraic sum of all signs' scale values is calculated at the patient's side.

If the sum is less than 19 the diagnosis of perforating ulcer is made.

The table is applied as a screening-test, its effectiveness accounting for 80-90%.

Methods of treatment of perforating gastroduodenal ulcers

Operative methods

Conservative

methods

Palliative

Radical

Suturing of perforation.

Perforation closing by omentum strand.

Judd's operation.

Truncal or selective vagotomy in combination with Judd's operation.

Antral resection of the stomach in combination with selective vagotomy.

Taylor's method: continuous aspiration of the stomach contents through the probe in combination with antibacterial therapy.

Palliative interventions are aimed to liquidate the origin of peritonitis. Radical interventions combine two tasks: liquidation of the origin of peritonitis and treatment of peptic ulcer. In a number of cases palliative operations are the final interventions. Taylor's method is applied only to the patients in extremely severe condition.

Choice of the surgical method of treatment in perforating ulcer

Indications to radical operations

The character of ulcer

Mode of the operation

Conditions

Chronic ulcer (ulcerous history, dense ulcerous infiltrate) of the duodenum and pylorus

Vagotomy + Judd's operation

Prior to the purulent peritonitis development

"Kissing" duodenal ulcers Combined complications (perforation + penetration + stenosis; perforation + bleeding) occur more frequently in the duodenal ulcer

Chronic ulcer of the antral portion and body of the stomach

Antrumectomy + selective vagotomy (SV)

The lack of severe accompanying diseases

Chronic ulcer of the body of the stomach

Resection of the stomach + selective vagotomy (SV)

Radical operations are carried out when there are indications and conditions for their performance.

Methods of bloodloss volume detection

According to the Allgower-Burri shock index

It is determined by division of the pulse rate into the value of the systolic blood pressure

Allgower-Burri index

Deficiency of circulating blood (DCB)

0.8 and less

up to 10% (up to 500 ml)

0.9-1.2

up to 20% (500-1000 ml)

1.3-1.4

up to 30% (1000-1500 ml)

more than 1.4

more than 30% (more than 1500 ml)

It has an approximate value. It can be used on pre-hospital stage.

According to the blood concentration indices and hemodynamics

Bloodloss index

DCB

up to 10% (up to 500 ml)

up to 20% (500-1000 ml)

up to 30% (1000-1500 ml)

Erythrocyte count

>3.5x10¹²/l

2.5-3.5x10¹²/l

<2.5x10¹²/l

Hemoglobin level, g/l

>100

83-100

<83

Pulse rate per minute

up to 80

80-100

more than 100

Systolic arterial blood pressure AP (mm. in column of mercury)

>110

110-90

<90

Hematocrit (%)

>30

25-30

<25

According to the blood viscosity (V) and hematocrit (Ht)

For males DCB (ml) = 1000V + 60Ht - 6600

For females DCB (ml) = 1000V + 60Ht - 6060

According to the relative amounts of blood, hemoglobin content and hematocrit

Bloodloss degree

Relative amount

Hemoglobin

Hematocrit

Mild

(up to 10% of circulating blood volume - CBV - 0.5 l)

1057-1054

120-100

44-40

Average

(up to 20% of CBV - 1.0 l)

1053-1050

99-85

39-32

Severe

(up to 30% of CBV - 1.5 l)

1049-1044

84-70

31-23

Massive

(> 30% of CBV - > 1.5l)

<1044

<70

<23

Hemoglobin, hematocrit levels and erythrocyte count may not change for 2-4 hours following hemorrhage until hemodilution occurs.

To establish DCB radioisotopic, colorimetric and electrometric methods are also applied, however their application in emergency surgery conditions is not always possible because of the investigation duration.

Tactics of treatment for patients with gastroduodenal ulcer bleedings

The bleeding has stopped or has been arrested

DCB

Hemostasis

Stable

Unstable

up to 500 ml

Anti-ulcerous therapy.

Planned operation.

Hemostatic, anti-ulcerous therapy.

Delayed operation.

500-1000 ml

Bloodloss compensation.

Hemostatic and anti-ulcerous therapy.

Delayed operation (3-4 days for preparing the

patient).

Bloodloss compensation.

Hemostatic, anti-ulcerous therapy.

Emergency operation.

more than

1000 ml

Bloodloss compensation.

Hemostatic and anti-ulcerous therapy.

Emergency operation (1-2 days for preparing the patient).

Bloodloss compensation.

Hemostatic therapy.

Emergency operation (during the first 24 hours).

In patients with endoscopically-non-arrested bleedings in the operating Rouxm and with a sig-nificant AP fall, as well as in cases of recurrent bleedings, the emergency operation is per-formed with simultaneous antishock therapy.

For the patients in a grave condition (severe bloodloss, severe accompanying pathology), pal-liative interventions are preferable. If the circumstances permit it, the radical operation is performed.

Differential diagnostics

Pyloroduodenal stenoses with similar clinical pictures are also observed in other diseases (cancer of the stomach, pancreatitis, pancreatic tumor, retroperitoneal neoplasm). Differential diagnostics is based on medical history data (ulcerous history) and is either verified or rejected with the help of instrumental methods of investigation (roentgenologic, endoscopic investigation with biopsy, CT, Nuclear-Magnetic Resonance Imaging - NMRI).

Treatment of pyloroduodenal ulcerative stenosis

Treatment tactics

Compensated edematous stenosis

Antiulcerous therapy for 3 weeks, operative treatment may be possible later on.

Subcompensated edematous stenosis

Anti-ulcerous therapy, hemostasis disturbances' correction. Surgical treatment may be possible after correction.

Compensated scarry stenosis

Surgical treatment

Subcompensated scarry stenosis

Hemostasis disturbances' correction. Surgical intervention is performed after correction.

Decompensated scarry stenosis

In surgical treatment preference is given to organosparing interventions - SV (selective vagotomy) + drainage operation.

Resection of the stomach with SV is indicated in combined ulcers of the stomach and duodenum, as well as in combination of stenosis with other complications of peptic ulcer.

Preoperative measures

Anti-ulcerous treatment (it is applied in edematous stenoses)

Anti-microbial medications: clarithromycin, amoxicillin, metronidazolum; H₂-blockers: ranitidine, famotidine; proton pump inhibitors: omeprasol; cytoprotectors: Bismuthate tripotassium dicitrate, sucralfate; prokinetics: motilium.

Normalization of aqueous-electrolyte impairments

Intravenous injection of dextran, albumin, protein solutions, polyionic solutions.

Parenteral and catheterized intestinal nutrition

Officinal multicomponent balanced preparations for medical nutrition

Systematic decompression of the stomach (aspiration of the gastric contents via the probe)

In order to reduce the overdistended stomach and restore its peristalsis.

Hemostasis correction and decompression of the stomach are to be continued during the post-operative period until the normal peristalsis of the stomach is restored.