Special Surgery 7. Benign Diseases of the Stomach. Examination of the Stomach and the Duodenum, Surgical Aspects

I. Peptic Ulcer Disease

Definition and Epidemiology

• Peptic ulcer: Defect in gastric or duodenal mucosa reaching beyond muscularis mucosae
• Acid-pepsin injury + weakened mucosal defense → ulcer
• Incidence: Duodenal ulcer > gastric ulcer
• Classical teaching: male predominance, about 3:1
• Typical age: 20-50 years, but NSAID-related gastric ulcer is common in older patients

Etiology

1. Helicobacter pylori

• Most important cause of ordinary peptic ulcer disease
• Urease enzyme → urea converted to NH3 + CO2 → local alkalization → bacterial survival
• Colonization and epithelial attachment → cytotoxins/inflammation → mucosal barrier disruption → acid injury
• Duodenal ulcer: usually increased acid load + H. pylori-related duodenitis
• Gastric ulcer: impaired mucosal defense, chronic gastritis, atrophy

2. NSAID / Aspirin Use

• Inhibits COX-1 and COX-2 → decreased prostaglandin production
• Decreased prostaglandins → decreased mucus, bicarbonate and mucosal blood flow → mucosal erosion/ulcer
• Risk increases with previous ulcer, older age, anticoagulants, steroids and high-dose NSAID

3. Other Causes

• Smoking, alcohol irritation
• Severe physiological stress: burns, trauma, sepsis, ICU illness
• Zollinger-Ellison syndrome: gastrinoma → hypergastrinemia → marked acid hypersecretion

Clinical Features

• Dyspepsia / indigestion → epigastric burning or gnawing pain
• Gastric ulcer: pain worsens after eating/drinking → food avoidance, weight loss
• Duodenal ulcer: pain improves after eating/drinking, returns later or at night
• Nausea, bloating, belching
• Vomiting: especially if gastric outlet obstruction develops

Complications

1. Bleeding
2. Perforation
3. Penetration
4. Gastric outlet obstruction
5. Malignancy hidden as gastric ulcer

• Bleeding: anemia, melena, hematemesis, coffee-ground vomiting, shock
• Perforation: sudden severe epigastric pain → board-like abdomen/peritonitis → free air under diaphragm
• Penetration: posterior ulcer into pancreas → persistent pain radiating to back
• Gastric outlet obstruction: early satiety, vomiting of undigested food, visible peristalsis, weight loss, dehydration

Diagnosis

• Gastroscopy: gold standard

• Directly visualizes ulcer, bleeding stigmata, obstruction, polyps/tumors
• Biopsy gastric ulcers to rule out malignancy
• Biopsy suspicious duodenal lesions; ordinary duodenal ulcers are rarely malignant
• Can perform endoscopic hemostasis if bleeding

• H. pylori tests:

• Rapid urease test from biopsy
• Histology from biopsy
• Urea breath test: isotope-labelled CO2 detected
• Stool antigen test

• Labs: CBC for anemia, electrolytes/renal function if vomiting/dehydration, blood group/crossmatch in bleeding
• Serum gastrin: recurrent/multiple/refractory ulcers or Zollinger-Ellison suspicion
• X-ray: free air under diaphragm → perforation
• CT abdomen: perforation, abscess, inflammatory mass, obstruction or malignancy suspicion
• Barium meal: rarely used; can show ulcer crater, deformity, filling defect, delayed emptying, but cannot biopsy

Treatment

1. Conservative / Medical Treatment

• General: stop NSAIDs if possible; avoid smoking, alcohol excess and individual triggers
• PPI: first-line acid suppression
• H2-receptor antagonist: alternative, less potent
• Antacid: short symptomatic relief
• Sucralfate: mucosal protection
• H. pylori eradication if positive

• Classic triple therapy: PPI + clarithromycin + amoxicillin/metronidazole
• Use only if clarithromycin susceptibility is likely or local resistance is low
• Bismuth quadruple therapy: PPI + bismuth + tetracycline + metronidazole
• Confirm eradication: urea breath test or stool antigen test after treatment

2. Surgical Treatment

• Indications: complication, suspected malignancy, non-healing ulcer, intractable/recurrent disease despite correct therapy
• Bleeding not controlled endoscopically → embolization or surgery depending on stability/availability
• Perforation → emergency operation, usually simple closure with omental patch
• Gastric outlet obstruction → decompression/correction first, then endoscopic dilation or surgery

II. Other Benign Gastric and Duodenal Diseases

Gastritis

• Gastritis: inflammation/injury of gastric mucosa
• Acute gastritis: NSAID/aspirin, alcohol, stress, burns, trauma, sepsis, bile reflux
• Chronic gastritis: H. pylori-associated or autoimmune atrophic gastritis
• Symptoms: epigastric discomfort, nausea, fullness, bloating
• Erosive gastritis → hematemesis or melena
• Diagnosis: gastroscopy with biopsy + H. pylori testing when indicated
• Treatment: remove offending agent, PPI, eradicate H. pylori if present
• Autoimmune gastritis: B12/iron deficiency risk; atrophy/metaplasia surveillance may be needed

Gastric Polyps

• Usually asymptomatic, incidental gastroscopy finding
• Types:

• Fundic gland polyp: often small/multiple, often PPI-associated, usually low risk
• Hyperplastic polyp: chronic gastritis/H. pylori background, low but present dysplasia risk if large
• Adenomatous polyp: neoplastic, premalignant potential

• Diagnosis/treatment: biopsy or remove depending on size, number and appearance
• Endoscopic removal: adenoma, large polyp, dysplasia or suspicious lesion
• Surgery: rare; for lesions not safely removable endoscopically or suspected invasive cancer

Gastric Outlet Obstruction

• Causes: chronic PUD scarring/edema, congenital pyloric stenosis in infants, malignancy
• Adult obstruction → malignancy must be excluded
• Symptoms: vomiting of undigested food, early satiety, postprandial fullness, weight loss, visible peristalsis
• Metabolic consequence: dehydration + hypochloremic, hypokalemic metabolic alkalosis
• Diagnosis: clinical picture + gastroscopy/biopsy; barium study or CT if needed
• Initial treatment: nil by mouth, NG tube decompression, IV fluids, electrolyte correction, PPI
• Definitive treatment: H. pylori eradication/NSAID stop, endoscopic balloon dilation, antrectomy or gastrojejunostomy

Duodenal Benign Surgical Problems

• Duodenal ulcer: bleeding, perforation, penetration and obstruction are the main surgical problems
• Duodenal diverticula: usually incidental
• Periampullary diverticulum can complicate ERCP/biliary drainage
• Surgery only for rare complications: perforation, bleeding, obstruction, diverticulitis
• Benign duodenal adenomas/polyps: endoscopic removal/surveillance if possible; surgery if large, periampullary, dysplastic or not endoscopically manageable

III. Examination of the Stomach and Duodenum

Clinical Examination

• History: pain timing with meals, dyspepsia, nausea/vomiting, hematemesis, melena, weight loss
• Risk history: NSAID/aspirin, anticoagulants, steroids, smoking, alcohol, previous ulcer, previous surgery
• Physical examination:

• Epigastric tenderness → ulcer/gastritis
• Guarding/peritonitis → perforation
• Pallor, tachycardia, hypotension → bleeding/shock
• Dehydration, visible peristalsis, succussion splash → gastric outlet obstruction

Gastroscopy / Upper GI Endoscopy

• First-line diagnostic tool for stomach and duodenum
• Direct visualization + biopsy
• Used for ulcers, bleeding, tumors, polyps, gastritis and obstruction
• Biopsy: gastric ulcer/mass/polyp and H. pylori testing
• Therapeutic uses: hemostasis, polypectomy/EMR/ESD, balloon dilation, foreign body removal, feeding tube placement

Radiology and Other Tests

• Barium meal / upper GI series: mucosal irregularity, ulcer crater, filling defect, delayed emptying; less used today
• Water-soluble contrast: use if leak/perforation is suspected
• Plain erect X-ray: free air under diaphragm in perforation
• CT abdomen: complication, mass, obstruction, abscess, malignancy suspicion
• EUS: subepithelial gastric lesions, layer of origin, local staging if tumor suspected
• Lab tests: CBC, electrolytes/renal function, CRP/leukocytes, coagulation, blood group/crossmatch in bleeding
• H. pylori tests: biopsy urease/histology, urea breath test, stool antigen
• Gastrin level: Zollinger-Ellison suspicion

IV. Surgical Aspects

Indications for Surgery

1. Perforated ulcer
2. Bleeding ulcer not controlled by endoscopy / interventional radiology
3. Gastric outlet obstruction
4. Non-healing gastric ulcer or suspected malignancy
5. Suspicious or large gastric polyp/tumor not manageable endoscopically
6. Intractable/recurrent ulcer disease despite correct medical treatment

Perforated Peptic Ulcer

• Clinical picture: sudden severe pain + peritonitis + free air
• Initial treatment: ABCDE, nil by mouth, NG tube, IV fluids, antibiotics, IV PPI, analgesia
• Operation: urgent laparoscopic/open repair in most patients
• Small duodenal/prepyloric perforation: simple closure + omental patch
• Graham patch: pedicled omentum placed over closed perforation
• Gastric ulcer perforation: biopsy or resection if suspicious → rule out cancer

Bleeding Peptic Ulcer

• Initial treatment: resuscitation, IV access, blood group/crossmatch, correct coagulopathy, IV PPI
• Early gastroscopy after stabilization
• Endoscopic hemostasis: clips, thermal coagulation, injection, hemostatic powder
• Injection alone is insufficient for high-risk ulcers
• Rebleeding: repeat endoscopy if stable
• Failed endoscopy: transcatheter arterial embolization if available
• Surgery: unstable massive bleeding, failed endoscopy/embolization or high-risk ulcer
• Duodenal ulcer bleeding: duodenotomy + underrunning bleeding vessel/gastroduodenal artery
• Gastric ulcer bleeding: wedge excision or partial gastrectomy if suspicious or not controllable

Gastric Outlet Obstruction Surgery

• Before operation: NG decompression + correction of dehydration/electrolytes
• Exclude malignancy with gastroscopy/biopsy and imaging
• Endoscopic balloon dilation: benign short stenosis
• Antrectomy/distal gastrectomy: scarred distal stomach, recurrent stenosis or suspicious ulcer
• Gastrojejunostomy: bypass obstructed pylorus when resection is unsafe/unnecessary
• Pyloroplasty: drainage procedure, classically combined with vagotomy

Classical Ulcer Operations

Vagotomy

• Division of vagus nerve acid-stimulating input → decreased acid production
• Historical but exam-relevant; now uncommon because PPI + H. pylori treatment changed ulcer surgery
• Types:

• Truncal vagotomy: divides main vagal trunks; needs drainage procedure
• Selective gastric vagotomy: denervates stomach, preserves hepatic/celiac branches
• Highly selective vagotomy: denervates acid-producing proximal stomach, preserves antrum/pylorus

• Complications: diarrhea, delayed gastric emptying, dumping, bile reflux gastritis, recurrent ulcer

Antrectomy / Distal Gastrectomy

• Removes gastrin-producing antrum and diseased distal stomach
• Can be combined with vagotomy in classical ulcer surgery
• Billroth I: gastroduodenostomy
• Billroth II: gastrojejunostomy
• Roux-en-Y gastrojejunostomy: selected cases, reduces bile reflux

Partial Gastrectomy / Wedge Resection

• For non-healing/suspicious gastric ulcer, large benign tumor or uncontrollable bleeding
• Specimen must be sent for histology
• Margin depends on malignancy suspicion

Postoperative Complications of Gastric Surgery

• Early: bleeding, anastomotic leak, abscess, delayed gastric emptying, pulmonary complications
• Late: dumping syndrome, bile reflux gastritis, afferent loop syndrome after Billroth II, marginal ulcer
• Nutritional deficiencies: iron, vitamin B12, calcium/vitamin D