Peptic ulcer

Peptic ulceration occurs in the stomach and duodenum and leads to intestinal bleeding, perforation into the abdominal cavity and pyloric obstruction. Initial management of a bleeding ulcer is medical with surgery considered only if medical management fails.

Perforating duodenal ulcers are most often located anteriorly, while stomach ulcers may be at the front or back. Perforation causes a chemical peritonitis followed in about 12 hours by secondary bacterial contamination and sepsis. Treat with surgical closure of the perforation.

Medical management of bleeding ulcers

To manage a bleeding ulcer medically:

Most bleeding stops without surgical intervention. Refer the patient for surgery if the bleeding persists or recurs after it has stopped.

Surgery for bleeding ulcers requires a specialist surgeon.

Perforated peptic ulcer

Diagnosis

The typical history includes:

The major physical findings are:

Treatment

A perforated peptic ulcer is an indication for emergency surgery. Delay in operation will adversely affect the prognosis. The delay becomes critical 6 hours after perforation.

The aim of treatment is to close the perforation and to remove the irritant fluid by abdominal lavage and suction.

Technique

1	Preoperatively administer analgesia, pass a nasogastric tube with suction to remove the stomach contents and place an intravenous line. Give broad-spectrum antibiotics if the history of perforation is longer than 6 hours.
2	In the operating room, have suction available and prepare 5 litres or more of warm saline for peritoneal lavage.
3	Open the abdomen with an upper midline incision (Figure 7.1). Remove all fluid and food debris from the peritoneal cavity using suction and warm, moist abdominal packs. Gently retract the liver up, draw the stomach to the left by gentle traction over a warm pack and identify the perforation. Aspirate fluid, as necessary. Note the appearance of the gut wall adjacent to the perforation; scarring suggests a chronic ulcer. If a perforation is not obvious, check the posterior wall of the stomach by opening the lesser sac of the peritoneum (Figures 7.2 and 7.3).
Figure 7.1
Figure 7.2
Figure 7.3
4	Insert three 2/0 polyglycolic acid or silk sutures at right angles to the long axis of the duodenum or stomach so that the middle stitch passes across the perforation itself, taking the full thickness of the gut wall about 5 mm from the edge of the perforation. The upper and lower stitches should take a generous seromuscular “bite” of the gut. Tie off the sutures loosely, leaving the ends long (Figures 7.4, 7.5). Draw a piece of adjacent omentum across the perforation and tie the three stitches over it (Figure 7.6). Alternatively, the three sutures can be left untied and tied only after the piece of omentum has been placed across the perforation.
Figure 7.4
Figure 7.5
Figure 7.6
5	Repair the greater omentum if you have divided it to locate a posterior perforation (Figure 7.7).
Figure 7.7
6	Thoroughly cleanse the peritoneal cavity with warm saline irrigation. In particular, pay attention to the subphrenic and pelvic spaces. Repeat saline irrigation and aspiration until the returned aspirate is clear on two consecutive occasions. Close the abdominal wound in layers, except in cases of gross contamination when the skin and subcutaneous tissues are packed open with damp saline gauze in preparation for delayed primary closure two days later.
7	Continue nasogastric aspiration and the intravenous administration of fluids and record fluid balance and vital signs. Give narcotic analgesia. Give antibiotics if laparotomy was performed more than 6 hours after duodenal perforation. Recovery is indicated by: • Return of bowel sounds • Passage of flatus • Reduction in the volume of gastric aspirate • Adequate urinary output • Normal pulse, blood pressure and temperature. After recovery, treat the peptic ulcer and follow the patient to be certain they do not have further symptoms. In most patients, peptic ulceration is secondary to helicobacter infection and medical treatment to eradicate this will prevent recurrence of the ulcer and preclude the need for further surgery.