Surgical Treatment of Bleeding Peptic Ulcers

Introduction:

Peptic ulcers are of two types acute and chronic, based on the duration of the ulcers. Acute peptic ulcers have mainly two causes:

• Helicobacter pylori (spiral-shaped, gram-negative bacteria).

• Non-steroidal anti-inflammatory drugs, like Aspirin, inhibit prostaglandin production, which is responsible for mucosal protection of gastric mucosa.

Chronic ulcers are the advanced or progressive form of acute peptic ulcers of more than six months. Based on the location, peptic ulcers can be gastric and duodenal ulcers. The basic outline for forming a peptic ulcer is the low pH or acidic medium that triggers the formation of a peptic ulcer, which is mediated by the vagus nerve (tenth cranial nerve), as the nerve is responsible for stimulation of gastric secretion. Perforation of peptic ulcers leads to internal bleeding, which is the emergency indication for surgical intervention to prevent blood loss and iron deficiency anemia.

What Are the Indications for Surgical Intervention for Peptic Ulcers?

Indications for surgical intervention:

• Peptic ulcers fail to heal after rigid medical treatment.

• When peptic ulcer patients want rapid relief and do not want the medication burden.

• Ulceration that persists over five years.

• The patient becomes intolerant to recurrent peptic ulcers.

• Peptic ulcers obstruct in the form of an hourglass stomach or pyloric stenosis (narrowing of the stomach part).

• History of the previous perforation of peptic ulcers.

• Ulcer gives rise to hemorrhage.

• Ulcer perforation and bleeding.

What Are the Complications of Peptic Ulcers if Not Treated?

• Perforation of peptic ulcers.

• Hemorrhage is indicated by haematemesis (blood in the vomit) or melaena (dark brown tar-like stool due to blood content).

• Stenosis (narrowing or constriction) of the stomach part, mainly the pyloric segment.

• Penetration (or involving) into adjacent viscera.

• Carcinoma, mainly adenocarcinoma and B cell lymphoma.

• Residual abscess.

What Are the Surgical Procedures for Bleeding Peptic Ulcers?

Bleeding ulceration, either gastric or duodenal ulcers, can negatively affect the patient's health. Thus, surgical intervention is the only option to treat the perforation or to control the bleeding of the ulcer. Some of the procedures or approaches used to treat hemorrhagic ulceration are as follows:

Simple Suture Operation: This approach is traditional yet most effective in treating the perforation of ulcers. It is accomplished with the help of anesthesia and muscle relaxant prescribed by the experts, followed by a choice of incision between - midline or paramedian over the affected area as determined by the expertise. The simplest method of closing the perforated ulcer is to use a three-suture approach, where the first suture is at the upper part of the perforation, the second is at the lower part of the perforation, and in the middle, the third suture is placed.

Vagotomy: This is the most popular procedure for the transection of the vagus nerve, which ultimately decreases gastric muscle's acid secretion and motility, thus hampering gastric emptying. Vagotomy can be done through the thorax and abdomen. Hence transabdominal vagotomy is the preferred approach by choice. There are three basic types of vagotomy are:

1. Truncal Vagotomy: Where both trunks of vagus nerves are removed.

2. Selective Vagotomy: This is aimed at removing all gastric fibers of the vagus nerve and keeping the hepatic and coeliac branches intact.

3. Proximal Gastric or Highly Selective Vagotomy: It is designed to denervate the acid secretion part of the stomach, keeping the vagal supply to the alkali-secreting gastric antrum and other abdominal viscera.

Drainage Operation: This should always accompany vagotomy by pyloroplasty or gastro-jejunostomy.

1. Pyloroplasty: This is the surgical method of widening the pyloric canal, mainly followed after vagotomy. It has two types: Heinke-Mikulich pyloroplasty and Finney pyloroplasty.

2. Gastro-jejunostomy: A procedure that makes an anastomosis between the stomach and jejunum. It is also mostly used along the vagotomy. The anterior gastro-jejunum variation is seldom used due to the regurgitation of the vomiting.

Antrectomy: A surgical procedure of excision of the antrum and making the anastomosis between the stomach's remnant and the jejunum's first coil. As the antrum is responsible for gastric formation and thus, this procedure will considerably reduce the gastric acid level and may or may not be associated with a vagotomy.

Partial Gastrectomy: The surgical operation of choice for gastric ulcers, also known as Billroth I partial gastrectomy, involves the removal of distal two-thirds of the stomach followed by anastomosis between the remnants of the stomach and duodenum. Billroth II gastrectomy incorporates access through the right upper paramedian incision.

Based on the Pentagastrin test, which is used to assess the gastric acid status of the individual, surgical modalities options are decided.

• The maximal free acid range of 30 to 40 mol/hour indicates vagotomy and drainage operation is performed.

• 40 to 50 mol/hour indicates an antrectomy operation is performed.

• Over 50 mol/hour indicates partial gastrectomy or vagotomy, and an antrectomy operation is performed.

What Is the Complication After the Gastric Operation?

• Paralytic ileus.

• Bleeding from the suture line.

• Leakage from the duodenal stump.

• Stomal obstruction due to mucosal edema.

• Following Billroth II gastrectomy, a duodenal blowout is related to leakage from the duodenal stump.

• Dumping (Postcibal) syndromes start within half an hour after ingestion of a meal and lead to abdominal colic, nausea, vomiting, fainting, diarrhea, epigastric discomfort, sweating, pallor, and palpitation with association with increased insulin activity accompanied by a fall in blood sugar level.

• A large quantity of vomiting of bile and pancreatic juice (bilious vomiting).

• Alkaline reflux gastritis is accomplished by epigastric pain, which aggregates after the next meal.

• Infection, mainly tuberculosis.

• Gallstone cases are reported following the vagotomy.

• Carcinoma.

• Intestinal obstruction.

• Acute pancreatitis.

• Recurrent ulceration.

• Gastro-jejunal fistula.

• Nutritional deficiency related to diarrhea and steatorrhea, which cause, iron-deficiency anemia, megaloblastic anemia, calcium deficiency, vitamin B12 deficiency, and weight loss.

Conclusion:

It is always good to be vigilant regarding the various signs and symptoms indicated by the body, which are indicative of health. Thus, epigastric pain, dyspepsia, vomiting, heartburn, and hematemesis (bloody vomiting) are the symptoms related to upper gastric problems. Perforation and bleeding are emergencies that require special attention and care. Surgical intervention is the only treatment for treating such hemorrhagic conditions with better outcomes.