#1014
Ulcer Disease Update
January 25 to 28
Hagop S. Mekhjian, MD
Professor of Internal Medicine
Division of Digestive Diseases
Medical Director, OSU Hospitals
E. Christopher Ellison, MD
Zollinger Professor of Surgery and
Interim Chair, Department of Surgery
The Ohio State University Medical Center
Hagop S. Mekhjian, MD
Professor of Internal Medicine
Division of Digestive Diseases
Medical Director, OSU Hospitals
1
Profile
55 year old Physician
• 2 melanic stools
• Fine otherwise
History
• Mild coronary artery disease
• Using beta blocker
• Takes 1 aspirin / day
2
Profile
Examination
• Vital signs stable
• Hemoglobin 10.5g
Symptoms
• No pain or indigestion
Evaluation
• Performed fiber optic endoscopy
• Showed active duodenal ulcer
• Biopsy positive for H. pylori
2A
Profile
Treatment
• Immediately started on omeprazole
• Placed on amoxicillin and
clarithromycin for 14 days
Follow up
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Follow up 6 weeks later
Duodenal ulcer completely healed
Asymptomatic
Normal hemoglobin
2B
Peptic Ulcer Disease
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500,000 new cases per year
4 million recurrences
4 million physician visits
$5 - 10 billion annual cost
Decreased mortality
Increasing costs
9,000 deaths
>130,000 operations
3
Hospitalization and
Mortality Trends
• Decreased for uncomplicated
duodenal ulcer
• Bleeding or perforation
hospitalization unchanged
• Increase in elderly (NSAIDS)
• Mortality 1 per 100,000
population
- 3-4 fold decrease
4
Epidemiology
• H. pylori
• Nonsteroidals
• Genetics - familial
- Incidence
(20-50% vs controls 10%)
• All genetic markers likely relate
to susceptibility of infection
with H. pylori
5
Peptic Ulcer
Other Associations
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Zollinger Ellison Syndrome
Systemic mastocytosis
MEN I
COPD
CRF
Cirrhosis
Kidney stones
Alpha-antitrypsin deficiency
6
Pathophysiology of
Gastric Ulcers
• NSAIDS
• H. pylori
• Bile reflux
• Gastric motility
7
Smoking and
Peptic Ulcer
• Increased incidence
• Co-factor with H. pylori
• Increased complication
• COPD increased risk
8
Etiologic Role of
H. Pylori Peptic Ulcer
• Natural history of H. pylori gastritis
- 11% peptic ulcer in 10 years
- 1% controls
• Association - age independent
- 90% duodenal ulcer; H. pylori positive
- 70-90% gastric ulcer; H. pylori positive
• Treatment outcome of H. pylori
- Eradicates recurrent duodenal ulcer and
gastric ulcer
- Reduction in re-bleeding
9
Peptic Ulcer
Clinical Presentation
• Abdominal discomfort
- Epigastric
- Nocturnal
- Relief by food or antacids
• Bleeding or perforation initial
presentation - 10%
10
Peptic Ulcer Diagnosis
• Endoscopy gold standard
• Single contrast x-rays
worthless
• Double contrast x-rays
valuable
11
Diagnosis of
Helicobacter Pylori
Endoscopy
• Duodenal ulcer highly predictive
• Antral nodularity specific (96%),
but insensitive (32%), “plucked
chicken”
• Biopsy - two antral, antral and angle
~ 100% sensitivity
• Prior therapy important
12
Diagnosis of
Helicobacter Pylori
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Histology is Gold Standard
Highly reproducible readings
Giemsa stain 96% specific
Acute or chronic inflammation
always presents
• Immunohistochemical stains
highly reliable
13
14
Treatment of
Helicobacter Pylori
• Resistance to metronidazole high
- South Korea 95%
• Resistance to clarithromycin ~ 10%
• Resistance to tetracycline rare
15
Cure for H. Pylori
BMT for 14 Days
• Pepto-Bismol 2 tabs 4 x day
• Metronidazole 250 mg 4 x day
• Tetracycline 500 mg 4 x day
plus
• H2RA for 4 weeks
16
Cure for H. Pylori
OAC for 14 Days
• Omeprazole 20 mg 2 x day
• Amoxicillin 1 gram 2 x day
• Clarithromycin 500 mg 2 x day
17
Cure for H. Pylori
LAC for 14 Days
• Lansoprazole 30 mg 2 x day
• Amoxicillin 1 gram 2 x day
• Clarithromycin 500 mg 2 x day
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Peptic Ulcer
Complications
• Hemorrhage
15%
• Perforation
7%
• Penetration
?
• Gastric outlet obstruction
2%
20
NSAIDS and
Bleeding Ulcers
• Gastric ulcers
• Duodenal ulcers
10 - 20 x increase
5 - 15 x increase
* Increase risk proportional to
daily dose of NSAID
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Risk Factors for
GI Bleeding
• Age > 60 years
• Co-morbid medical illness
• Hematochezia or red blood aspirate
• Hypotension or shock
• Transfusion > 6 units of blood
• Rebleeding in hospitals
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E. Christopher Ellison, MD
Zollinger Professor of Surgery and
Interim Chair, Department of Surgery
The Ohio State University Medical Center
30
Profile
Mr. Tidball
• Presented 18 years ago with ulcer
• Partial removal of stomach
Condition
• Did well initially
• Then developed disphagia
• Early satiety caused vomiting
Profile
Mr. Tidball
Diagnostic tests
• UGI series
• Endoscopy
• Fasting serum gastrin level
Diagnosis
• Gastric stasis with a marginal ulcer
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Ulcer Disease
Indications for Surgery
• Bleeding
• Perforation
• Obstruction
• Intractability
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Ulcer Disease
Operations
• Truncal vagotomy and pyloroplasty
• Truncal vagotomy and antrectomy
- Billroth I
- Billroth II
• Subtotal gastrectomy
• Highly selective vagotomy
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Truncal Vagotomy
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Antrectomy
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Reconstruction
After Antrectomy
Billroth I
Billroth II
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Highly Selective
Vagotomy
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Duodenal Ulcer Disease
Bleeding
• Endoscopic therapy
- Injection
- Heater probe
- Clips
• Operation if
- UNSTABLE
- Rebleeding
- > 6 units PRBC
• A major indication
for surgery
39
Bleeding Duodenal Ulcer
Method of Ligation
40
Perforated Ulcer
• Clinical presentation
• Free air on AAS (absent in 25%)
• Operative vs. non-operative treatment
- Operation in most cases
- NG decompression, antibiotics
if “sealed”
• Mortality rate high if >24 hours
between onset of symptoms and
surgery
41
Duodenal Ulcer Disease
Gastric Outlet Obstruction
• NG decompression
• Correct electrolytes
• Nutrition
• H-2 antagonist
• Proton pump
inhibitor
42
Recurrent Ulcer
Operation
Incidence
• Vagotomy & Pyloroplasty
10 - 15%
• Vagotomy & Antrectomy
0 - 2%
• Subtotal Gastrectomy
2 - 5%
• Highly selective Vagotomy
10 - 20%
43
Recurrent Ulcer
Etiology and Treatment
• Exclude ZES,
PTH, etc
• Aggressive
medical Rx
• Tailor operation
- Revagotomy
- Re-resection
44
Postgastrectomy
Syndromes
• Dumping syndrome
• Alkaline reflux gastritis
• Gastric stasis
• Loop syndromes
• Gastric remnant carcinoma
45
Dumping Syndrome
Early
• Fluid shifts
- Intravascular space
- Bowel lumen
• Enteric peptides (Vasodilation)
- Neurotensin
- Serotonin
- VIP
- Motilin
46
Dumping Syndrome
Treatment
• Dietary modification
- Consult dietician
- Reduce carbohydrates
• Somatostatin (50-100 mcg subq TID)
- Reduces intestinal hypermotility
- Increases fluid and electrolyte absorption
- Inhibits enteric peptide secretion
• Acarbose (alpha glucosidase inhibitor 50-100 mg ac)
reduces postprandial hyperglycemia
• Surgical treatment is roux-en-Y or pyloroplasty
closure
47
Post-Gastrectomy Syndromes
Alkaline Reflux Gastritis
• Epigastric pain and
bilious vomiting
• Incidence 15-20%
• Diagnosis - EGD & Bx
• ETIOLOGY
- Decreased emptying
- Poor clearance of bile
- Bile irritation
- Inflammatory infiltrate
- Helicobacter pylori
48
Alkaline Gastritis
Combination Therapy
• Protect mucosasulcralfate
• Improve gastric emptying
- Metaclopramide or cisapride
Roux-en-Y
- Erythomycin
• Bile salt binding
- Aluminum hydroxide antacids
- Cholestyramine
• Alter bile composition
- Ursodeoxycholic acid
• Surgical treatment
- Roux-en-Y
49
Gastric Stasis
• Uncommon condition (5 cases / year)
• Symptoms
- Early satiety, vomiting, recurrent bezoars
• Etiology
- Obstruction (recurrent ulcer, efferent loop)
- Atony
- Roux syndrome
• Treatment
- Prokinetic agents
- Completion gastrectomy (improves 50-70%)
50
Loop Syndromes
Complication of Gastrojejunostomy
• Afferent loop syndrome
- Nausea, non bilious vomiting, pain (episodic bilious
emesis that relieves postprandial pain)
- Caused by kink, herniation, volvulous
- Diagnosis > US, CT, MRCP
- Treatment > jejunojenostmy or BRII to BRI
• Efferent loop obstruction
- Bilious vomiting, bezoars
- Diagnosis > GI contrast studies, EGD
- Treatment adhesiolysis, revision +/- resection
51
Gastric Remnant Carcinoma
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• Etiology (P53, K-ras
mutations)
• Enterogastric reflux
• H. pylori, EB virus
Incidence 0.8%
>20 years postop
Etiology
Differentiate from
loop syndromes,
new ulcer
• EGD critical in dx.
• Requires completion
gastrectomy
• N-nitrosocompounds
52
Summary
Mr. Tidball
Surgical Procedure
• Completion gastrectomy with a
Roux-en-Y esophagojejunostomy
• Necessary in a small number of patients
who have had previous stomach
surgery for ulcer disease
Indications
• Gastric stasis with a marginal ulcer
53
Summary
Mr. Tidball
Prognosis
• Excellent
Currently
• 2 months post-op and has gained
nearly 10 pounds
• Vitamin B-12 regularly
• No other medications required
53 A
Questions on this subject?
Press: # (pound) + 71
on your phone keypad to
speak with Dr. Mekhijian, and Dr. Ellison
Visit OMEN OnLine
http://omen.med.ohio-state.edu
54
NEXT WEEK
#1015
Approach to Chronic Cough
February 1 to 4
Jeffrey E. Weiland, MD
Associate Professor of Clinical Internal Medicine
Division of Pulmonary and Critical Care Medicine
The Ohio State University Medical Center
Ruairi Fahy, MD
Clinical Instructor of Internal Medicine
Division of Pulmonary and Critical Care Medicine
The Ohio State University Medical Center