Bleedingpeptic ulcer

Surgical treatment
If 2 attempts at endoscopic control of the bleeding vessel are unsuccessful, avoid
further attempts (ie, because of increased rebleeding and mortality rates) and pursue
surgical intervention. The indications for surgery in patients with bleeding peptic
ulcers are as follows:
Severe, life-threatening hemorrhage not responsive to resuscitative efforts
Failure of medical therapy and endoscopic hemostasis with persistent
recurrent bleeding
A coexisting reason for surgery, such as perforation, obstruction, or
malignancy
Prolonged bleeding, with loss of 50% or more of the patient's blood volume
A second hospitalization for peptic ulcer hemorrhage
The operative treatment options for a bleeding duodenal ulcer historically include
vagotomy, gastric resection, and drainage procedures. Each specific operative
option is associated with its own incidence of ulcer recurrence, postgastrectomy
syndrome, and mortality (as seen in the table below). When making an intraoperative
judgment on how to best manage the bleeding ulcer, it is extremely important for the
surgeon to be aware of these differences. [16]
Table 6. Recurrent Ulcer and Postgastrectomy Syndromes After Operations for
Duodenal Ulcer (Open Table in a new window)
Original Operation Recurrence Rate, % Postgastrectomy Syndrome Rate, % Mortality Rate, %

Proximal gastric vagotomy 10 5 0.1

Truncal vagotomy and drainage 7 20-30 <1

Truncal vagotomy and antrectomy

Billroth I or Billroth II 1 30-50 0-5

Truncal vagotomy and antrectomy

Roux-en-Y 5-10 50-60 0-5

The 3 most common operations performed for a bleeding duodenal ulcer are as
follows [10] :
Truncal vagotomy and pyloroplasty with suture ligation of the bleeding ulcer
Truncal vagotomy and antrectomy with resection or suture ligation of the
bleeding ulcer
Proximal (highly selective) gastric vagotomy with duodenostomy and suture
ligation of the bleeding ulcer
The purpose of the vagotomy is to divide the nerves to the acid-producing body and
fundus of the stomach. This inhibits acid production that occurs during the cephalic
phase of gastric secretion. Although acid secretion is controlled, gastric motility and
gastric emptying is affected, as indicated in the following table. [16]
Table 7. Effects of Operations for PUD on Gastric Emptying and Motility (Open Table
in a new window)
Operation Antral Innervation Liquid Emptying Solid Emptying

Proximal gastric vagotomy Preserved Fast Normal

Truncal vagotomy Divided Fast Slow

Truncal vagotomy and drainage Divided Fast Fast

Truncal vagotomy and antrectomy Divided Fast Fast

Proximal vagotomy abolishes gastric receptive relaxation and impairs storage in the
proximal stomach. As a result, a more rapid gastric emptying of liquids occurs. A
drainage procedure is not required, because the innervation of the antrum and
pylorus is still intact. Because of this, the gastric emptying of solid food is not altered.
The antropyloric mechanism still functions normally and continues to prevent
duodenogastric reflux.
In addition to having the same effects as a highly selective vagotomy in the proximal
stomach, a truncal vagotomy also has marked effects on distal gastric motor
function. It weakens distal gastric peristalsis, thus requiring the creation of a
pyloroplasty to decrease the resistance to outflow from the stomach.
Truncal vagotomy and suture ligation of a bleeding ulcer is a frequently used
operation for treating upper gastrointestinal bleeding (UGIB) in elderly patients with
life-threatening hemorrhage and shock. The procedure can be performed rapidly,
minimizing the time spent in the operating room under general anesthesia.
The principles of suture ligation of a duodenal bleeding ulcer that involves the
gastroduodenal artery require the use of the 3-point ligation technique.
The gastroduodenal artery is ligated proximally and distally to the arterial bleeding
site. The third suture is a horizontal mattress placed to control hemorrhage from the
transverse pancreatic branch of the gastroduodenal artery. Failure to place this third
stitch may result in recurrent bleeding that requires another emergent laparotomy of
the abdomen. Vagotomy with antrectomy is reserved for patients whose conditions
have failed to respond to more conservative attempts at surgical intervention and for
those with aggressive and recurrent duodenal ulcer diathesis, such as gastric outlet
obstruction.
When performing a highly selective vagotomy, the duodenostomy or the
pyloroduodenostomy is closed anatomically, preserving the normal pyloric sphincter
muscle. Most commonly, this operation is reserved for young, stable, low-risk
patients. Although long-term follow-up care is still necessary, the recurrent ulcer rate
is less than 10% at a mean follow-up of 3.5 years. [10]
Much of what is now known about the operations performed for bleeding duodenal
ulcers came from the era before the etiologic role for H pylori and NSAIDs in the
development of peptic ulcers was understood. Reducing gastric acidity has been
proven to be beneficial, with lower rebleeding rates when using high-dose
omeprazole. [6] Although PPIs seem to have an advantage, they have no affect on
mortality.
The diagnosis of H pylori infection is important in the management of patients with a
complicated bleeding peptic ulcer. If a patient with a bleeding ulcer requires surgery,
then knowledge of the patient's H pylori status becomes pertinent, because it may
help guide the decision to choose a particular surgical procedure (eg, simply
oversewing the ulcer as opposed to performing an antiulcer operation). Many studies
support the decision to manage the bleeding ulcer in conjunction with eradication
of H pylori.
The 2008 SIGN guideline recommends testing for H pylori in patients with peptic
ulcer bleeding and a 1-week course of therapy prescribed for those who test positive.
Three weeks of continuous treatment should be given. In those who use NSAIDs,
maintenance antisecretory therapy should not persist after successful healing of the
ulcer and H pylori eradication. [35]
Bleedin gastric ulcer

The surgical management of bleeding gastric ulcers is slightly different from that of
duodenal ulcers, but the concepts are identical. The 3 most common complications
of a gastric ulcer that mandate emergent surgical intervention are hemorrhage,
perforation, and obstruction. The goals of surgery are to correct the underlying
emergent problem, prevent recurrent bleeding or ulceration, and exclude
malignancy.

A bleeding gastric ulcer is most commonly managed by a distal gastrectomy that

includes the ulcer, with a gastroduodenostomy or a gastrojejunostomy
reconstruction.

The common operations for the management of a bleeding gastric ulcer include (1)
truncal vagotomy and pyloroplasty with a wedge resection of the ulcer, (2)
antrectomy with wedge excision of the proximal ulcer, (3) distal gastrectomy to
include the ulcer, with or without truncal vagotomy, and (4) wedge resection of the
ulcer only.

Types of gastric ulcers

The choice of operation for a bleeding gastric ulcer depends on the location of the
ulcer and the hemodynamic stability of the patient to withstand an operation. Five
types of gastric ulcers occur, based on their location and acid-secretory status.

Type 1 gastric ulcers are located on the lesser curvature of the stomach, at or near
the incisura angularis. These ulcers are not associated with a hypersecretory acid
state.

Type 2 ulcers represent a combination of 2 ulcers that are associated with a

hypersecretory acid state. The ulcer locations occur in the body of the stomach in the
region of the incisura. The second ulcer occurs in the duodenum.

Type 3 ulcers are prepyloric ulcers. They are associated with high acid output and
are usually within 3 cm of the pylorus.

Type 4 ulcers are located high on the lesser curvature of the stomach and (as with
type 1 ulcers) are not associated with high acid output.
Type 5 ulcers are related to the ingestion of NSAIDs or aspirin. These ulcers can
occur anywhere in the stomach.

Surgical management according to ulcer type

A vagotomy is added to manage type 2 or type 3 gastric ulcers.

Patients who are hemodynamically stable but have intermittent bleeding requiring
blood transfusions should undergo a truncal vagotomy and distal gastric resection to
include the ulcer for type 1, 2, and 3 ulcers.

In patients who present with life-threatening hemorrhage and a type 1, 2, or 3 ulcer,

biopsy and oversew or excision of the ulcer in combination with a truncal vagotomy
and a drainage procedure should be considered.

Patients with type 4 ulcers usually present with hemorrhage. The left gastric artery
should be ligated, and a biopsy should be performed on the ulcer. Then, the ulcer
should be oversewn through a high gastrotomy.

Rebleeding rates for the procedures that keep the ulcer in situ range from 20-40%. [16]

Gastric bleeding in the immediate postoperative period from recurrent PUD is initially
best managed by endoscopic or angiographic means. If reoperation is required,
gastric resection is usually indicated, because a repeat vagotomy is not reliable. A
more definitive solution is warranted.

According to the 2008 SIGN guidelines, patients with confirmed gastric variceal
hemorrhage require endoscopic therapy, preferably with cyanoacrylate injection. [35]
Mallory-Weiss Syndrome Treatment

Distinguishing Mallory-Weiss syndrome from Boerhaave syndrome is

critical. Although both entities share a common pathogenesis, their
management is completely different.

Boerhaave syndrome represents a full-thickness transmural laceration with

perforation of the esophagus. A Gastrografin swallow helps to confirm the
presence of the perforation in most cases, and prompt surgical intervention
is necessary to prevent mediastinitis and sepsis.

On the other hand, surgical intervention in Mallory-Weiss syndrome is

required to achieve hemostasis in only 10% of cases. [18] The bleeding from
a Mallory-Weiss tear spontaneously ceases in 50-80% of patients by the
time endoscopy is performed.[18]
For patients in whom bleeding is visualized at endoscopy, the endoscopic
treatment options are electrocoagulation, heater-probe application,
hemoclips, epinephrine injection, or sclerotherapy.

In a series published by Bataller et al, hemostasis was achieved in 100% of

patients with Mallory-Weiss tears by using endoscopic sclerotherapy with
epinephrine (1:10,000) and 1% polidocanol. Other nonoperative therapies
are reserved for cases in which endoscopic attempts at creating
hemostasis have failed.

Other available options are angiographic intra-arterial infusion of

vasopressin and transcatheter embolization of branches of the left gastric
artery using Gelfoam. Avoid the balloon tamponade technique using the
Sengstaken-Blakemore tube in this particular circumstance, because this
apparatus may extend the mucosal laceration into a transmural laceration
with perforation. [18]

Surgical intervention is indicated in patients with continued bleeding after

failed attempts at nonoperative therapies.

Bleeding from the gastroesophageal junction is visualized through an

anterior gastrotomy. Once the tear is localized, the bleeding is controlled by
oversewing the lesion.