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

I. Peptic Ulcer Disease

Definition

• Peptic ulcer = defect in gastric or duodenal mucosa extending beyond muscularis mucosae
• Caused by acid-pepsin injury overwhelming mucosal defense
• Duodenal ulcer is more common than gastric ulcer
• Male predominance in classical teaching
• Typical age: young/middle-aged adults for duodenal ulcer; gastric ulcer often older

Etiology and Risk Factors

1. Helicobacter pylori

• Most important infectious cause of peptic ulcer disease
• Mechanism:

• Urease enzyme → urea converted to NH3 + CO2
• NH3 alkalinizes local acidic environment → bacterial survival
• Colonization and epithelial attachment → inflammation and cytotoxin release
• Mucosal barrier disruption → acid-pepsin injury → ulcer

• Duodenal ulcer: often increased acid load + duodenal gastric metaplasia colonized by H. pylori
• Gastric ulcer: impaired mucosal defense, chronic gastritis, atrophy

2. NSAID / Aspirin Use

• Inhibits COX-1 and COX-2
• Decreased prostaglandin production → decreased mucus, bicarbonate and mucosal blood flow
• Direct topical epithelial injury also contributes
• Risk increases with older age, previous ulcer, anticoagulants, steroids and high-dose NSAID

3. Other Causes

• Smoking
• Alcohol irritation
• Severe physiological stress: burns, trauma, ICU illness, sepsis
• Zollinger-Ellison syndrome: gastrinoma → hypergastrinemia → marked acid hypersecretion
• Crohn disease, viral ulcers or medication injury in selected patients

Clinical Features

• Dyspepsia / indigestion
• Epigastric burning or gnawing pain
• Gastric ulcer: pain often worsens after eating → fear of food, weight loss
• Duodenal ulcer: pain often improves after meals and returns 2-3 h later / at night
• Nausea, bloating, belching
• Vomiting can occur, especially with gastric outlet obstruction
• Alarm symptoms:

• Weight loss
• Anemia or GI bleeding
• Progressive vomiting
• Dysphagia
• Palpable mass or lymph node
• New symptoms in older patient

Complications

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

1. Bleeding

• Most common complication
• Melena, hematemesis, coffee-ground vomiting
• Anemia, weakness, syncope
• Shock in massive bleeding
• Posterior duodenal ulcer can erode gastroduodenal artery

2. Perforation

• Sudden severe epigastric pain
• Board-like abdomen, peritonitis
• Free air under diaphragm on erect chest/abdominal X-ray
• CT with oral/water-soluble contrast can show pneumoperitoneum and leak

3. Penetration

• Ulcer penetrates into adjacent organ without free intraperitoneal perforation
• Posterior gastric/duodenal ulcer → pancreas → persistent back pain
• May cause pancreatitis-like symptoms

4. Gastric Outlet Obstruction

• Due to edema, spasm or chronic scarring around pylorus/duodenal bulb
• Early satiety, postprandial fullness
• Large-volume vomiting of undigested food
• Weight loss, dehydration
• Visible gastric peristalsis / succussion splash
• Hypochloremic, hypokalemic metabolic alkalosis from vomiting

Diagnosis of Peptic Ulcer

• Upper GI endoscopy / gastroscopy:

• Gold standard
• Shows ulcer location, size, bleeding stigmata, obstruction
• Biopsy gastric ulcers to rule out malignancy
• Duodenal ulcers are rarely malignant, but biopsy suspicious lesions

• H. pylori tests:

• Rapid urease test from biopsy
• Histology from biopsy
• Urea breath test: isotope-labeled CO2 detected
• Stool antigen test
• Serology is less useful for active infection because it can remain positive after eradication

• Laboratory tests:

• CBC: anemia, leukocytosis
• Urea/creatinine and electrolytes: dehydration, vomiting, renal risk
• Liver tests, amylase/lipase if differential diagnosis requires
• Blood group/crossmatch in bleeding ulcer
• Serum gastrin if Zollinger-Ellison syndrome suspected

• Barium meal / upper GI contrast study:

• Rarely first-line today
• Can show ulcer crater, deformity, obstruction
• Cannot biopsy, so malignancy exclusion still needs endoscopy

Medical Treatment

General Measures

• Stop NSAIDs if possible
• Stop smoking
• Avoid alcohol excess
• Avoid individual food/drink triggers; strict bland diet is not necessary
• Treat shock, anemia, dehydration or electrolyte disorder if complicated

Acid Suppression and Mucosal Protection

• Proton pump inhibitor (PPI): first-line acid suppression
• H2-receptor antagonist: alternative, less potent
• Antacids: short symptomatic relief
• Sucralfate: mucosal protective agent
• Misoprostol can prevent NSAID ulcers but limited by side effects and contraindication in pregnancy

H. pylori Eradication

• Eradicate H. pylori in all positive peptic ulcer patients
• Use local resistance pattern / susceptibility when available
• Bismuth quadruple therapy is commonly preferred when clarithromycin resistance is possible:

• PPI + bismuth + tetracycline + metronidazole, usually 14 days

• Clarithromycin triple therapy:

• PPI + clarithromycin + amoxicillin or metronidazole
• Use only if clarithromycin susceptibility is likely/confirmed or local resistance is low

• Confirm eradication after treatment:

• Urea breath test or stool antigen test
• Test at least 4 weeks after antibiotics and after stopping PPI long enough to avoid false negative result

II. Other Benign Gastric and Duodenal Diseases

Gastritis

Definition and Types

• Inflammation/injury of gastric mucosa
• Acute gastritis:

• NSAID/aspirin
• Alcohol
• Severe stress, burns, trauma, sepsis
• Bile reflux

• Chronic gastritis:

• H. pylori-associated
• Autoimmune atrophic gastritis: corpus/fundus, parietal cell loss, pernicious anemia risk
• Chemical/reactive gastropathy

Clinical Features

• Epigastric discomfort
• Nausea, fullness, bloating
• Usually no specific physical signs
• Erosive gastritis can cause hematemesis or melena

Diagnosis and Treatment

• Gastroscopy with biopsy if alarm signs, bleeding, anemia, persistent symptoms or malignancy risk
• H. pylori testing
• Remove offending agent: NSAID, alcohol, bile reflux cause if possible
• PPI therapy for erosive/acid-related symptoms
• Eradicate H. pylori if positive
• Autoimmune gastritis: monitor/treat vitamin B12 and iron deficiency; surveillance may be needed depending on atrophy/metaplasia risk

Gastric Polyps

Types

• Fundic gland polyps:

• Often small, multiple, associated with PPI use
• Usually low malignant risk unless familial adenomatous polyposis context

• Hyperplastic polyps:

• Associated with chronic gastritis and H. pylori
• Low but present dysplasia/malignancy risk, especially if large

• Adenomatous polyps:

• True neoplastic lesion
• Premalignant potential
• Often associated with atrophic gastritis / intestinal metaplasia

Diagnosis and Treatment

• Usually incidental at gastroscopy
• Biopsy or remove depending on size, number and appearance
• Endoscopic polypectomy for adenomas, large polyps, dysplastic or suspicious lesions
• Sample surrounding mucosa for gastritis, atrophy, intestinal metaplasia and H. pylori when relevant
• Eradicate H. pylori in hyperplastic polyps if positive; some regress
• Surgery is rare, reserved for lesions not safely removable endoscopically or suspicious invasive cancer

Benign Gastric Tumors and Subepithelial Lesions

• Leiomyoma, lipoma, ectopic pancreas, schwannoma, benign neuroendocrine lesions
• GIST is potentially malignant, so it is not treated as a simple benign polyp
• Diagnosis:

• Gastroscopy: mucosal/submucosal lesion
• EUS: layer of origin and size
• Biopsy/FNA or resection depending on suspicion

• Treatment: endoscopic or surgical local resection if symptomatic, growing, bleeding or suspicious

Gastric Outlet Obstruction

Causes

• Chronic peptic ulcer scarring / pyloroduodenal stenosis
• Edema and spasm around active ulcer
• Congenital hypertrophic pyloric stenosis in infants
• Malignancy must always be excluded in adults
• Other rare causes: Crohn disease, caustic stricture, pancreatic disease

Clinical Features

• Early satiety
• Postprandial fullness
• Large-volume non-bilious vomiting of undigested food
• Weight loss and dehydration
• Visible peristalsis, succussion splash
• Hypochloremic hypokalemic metabolic alkalosis

Treatment

• Initial:

• Nil by mouth
• Nasogastric tube decompression
• IV fluids and electrolyte correction
• PPI
• Endoscopy with biopsy to exclude malignancy

• Definitive:

• Treat H. pylori and stop NSAIDs
• Endoscopic balloon dilatation for benign pyloric/duodenal stenosis
• Surgery if recurrent, fixed fibrotic stenosis or failed dilation
• Options: antrectomy, gastrojejunostomy, pyloroplasty depending on anatomy and indication

Duodenal Surgical-Relevant Benign Disease

• Duodenal ulcer disease: bleeding, perforation, penetration and obstruction are key surgical problems
• Duodenal diverticula:

• Usually incidental
• Periampullary diverticulum can complicate ERCP or biliary drainage
• Surgery only for rare complications: perforation, bleeding, obstruction, diverticulitis

• Benign duodenal polyps/adenomas:

• Can occur sporadically or with familial adenomatous polyposis
• 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 in relation to meals
• Dyspepsia, nausea, vomiting, hematemesis, melena
• Weight loss and anorexia
• NSAID/aspirin, anticoagulants, steroids
• Smoking, alcohol
• Previous ulcer, previous abdominal surgery
• Family history and cancer alarm signs

• Physical examination:

• Epigastric tenderness
• Peritonitis / guarding → perforation
• Pallor, tachycardia, hypotension → bleeding
• Dehydration, succussion splash → gastric outlet obstruction
• Signs of chronic disease: weight loss, cachexia

Upper GI Endoscopy / Gastroscopy

• First-line and most important investigation
• Direct visualization of esophagus, stomach and duodenum
• Diagnostic uses:

• Ulcer, gastritis, duodenitis
• Bleeding source and Forrest classification
• Gastric outlet obstruction
• Polyps, tumors, subepithelial lesions
• Biopsy of gastric ulcer to rule out malignancy
• Biopsy for H. pylori / rapid urease test

• Therapeutic uses:

• Hemostasis: injection, clips, thermal therapy, hemostatic powder
• Foreign body removal
• Polypectomy / EMR / ESD
• Balloon dilation of benign stenosis
• Feeding tube placement in selected patients

Contrast Studies

• Barium meal / upper GI series:

• Outlines stomach and duodenum
• Shows ulcer crater, deformity, filling defect, delayed emptying
• Less used today because it cannot biopsy or treat

• Water-soluble contrast study:

• Preferred if perforation/leak is suspected
• Avoid barium in suspected free perforation

Imaging

• Plain erect chest/abdominal X-ray:

• Free air under diaphragm → perforation
• May show gastric dilatation in obstruction

• CT abdomen with contrast:

• Best cross-sectional test for complications
• Perforation, abscess, inflammatory mass, obstruction, malignancy suspicion
• Can detect pneumoperitoneum when X-ray is negative

• Endoscopic ultrasound (EUS):

• Subepithelial gastric lesions
• Layer of origin, cystic/solid character, relation to muscularis propria

Laboratory and Functional Tests

• CBC: anemia, infection, chronic bleeding
• CRP/leukocytes: inflammation, perforation
• Electrolytes and renal function: vomiting/dehydration, preoperative correction
• Liver tests and pancreatic enzymes for differential diagnosis
• Coagulation, blood group and crossmatch in bleeding or before surgery
• H. pylori: breath test, stool antigen, biopsy urease/histology
• Serum gastrin:

• Suspected Zollinger-Ellison syndrome
• Multiple/recurrent/refractory ulcers
• Ulcers distal to duodenal bulb
• Must interpret with gastric pH and PPI use

IV. Surgical Aspects

Indications for Surgery in Benign Gastric / Duodenal Disease

1. Perforated ulcer
2. Bleeding ulcer not controlled by endoscopy / interventional radiology
3. Gastric outlet obstruction from benign stenosis
4. Non-healing or suspicious gastric ulcer
5. Large/suspicious gastric polyp or benign tumor not manageable endoscopically
6. Intractable/recurrent ulcer disease despite correct medical therapy

Perforated Peptic Ulcer

Initial Management

• ABCDE resuscitation
• Nil by mouth
• Nasogastric tube decompression
• IV fluids and electrolyte correction
• Broad-spectrum antibiotics
• IV PPI
• Analgesia and urgent surgical consultation

Operation

• Generalized peritonitis, free leak or significant pneumoperitoneum → urgent operation
• Small perforated duodenal/prepyloric ulcer:

• Simple closure with or without omental patch
• Graham patch = pedicled omentum placed over closed perforation
• Laparoscopic repair possible in stable patients and experienced hands

• Large perforation, suspicious gastric ulcer, concomitant bleeding or obstruction:

• Tailored surgery
• Biopsy / wedge excision / distal gastrectomy may be needed
• Always consider malignancy in gastric ulcer perforation

Bleeding Peptic Ulcer

• First steps:

• Resuscitation, IV access, blood group/crossmatch
• Correct coagulopathy if possible
• IV PPI
• Early endoscopy after stabilization

• Endoscopic hemostasis:

• Injection therapy alone is not enough for high-risk ulcers
• Combine mechanical/thermal method with injection when needed
• Clips, coagulation, adrenaline injection, hemostatic powder depending on lesion

• Escalation:

• Rebleeding → repeat endoscopy if patient stable
• Failed endoscopy → transcatheter arterial embolization if available
• Surgery if unstable, massive bleeding, failed endoscopy/embolization or large high-risk ulcer

• Surgical options depend on location:

• Duodenal ulcer bleeding → duodenotomy + underrunning gastroduodenal artery / bleeding vessel, often with ulcer closure
• Gastric ulcer bleeding → wedge excision or partial gastrectomy if suspicious or not controllable
• Definitive acid-reducing surgery is now uncommon because PPI + H. pylori therapy changed ulcer treatment

Gastric Outlet Obstruction Surgery

• Operate only after resuscitation and correction of dehydration/electrolytes
• Exclude malignancy by endoscopy/biopsy and imaging
• Options:

• Endoscopic balloon dilation for benign short stenosis
• Antrectomy if ulcerated/scarred distal stomach or suspicion persists
• Gastrojejunostomy bypass if obstruction cannot be resected safely or patient is high-risk
• Pyloroplasty as drainage procedure, often historically combined with vagotomy

Acid-Reducing Operations: Historical but Exam-Relevant

Vagotomy

• Surgical division of vagal acid-stimulating input → decreased acid production
• Types:

• Truncal vagotomy: divides main vagal trunks; requires drainage procedure
• Selective gastric vagotomy: denervates stomach, preserves hepatic/celiac branches; usually drainage needed
• Highly selective vagotomy / parietal cell vagotomy: denervates acid-producing proximal stomach, preserves antrum/pylorus; drainage often not needed

• Complications:

• Diarrhea
• Delayed gastric emptying
• Dumping if combined with drainage/resection
• Bile reflux gastritis
• Recurrent ulcer if incomplete

Antrectomy / Distal Gastrectomy

• Removes gastrin-producing antrum and diseased distal stomach
• Can be combined with vagotomy in classical ulcer surgery
• Reconstruction:

• Billroth I: gastroduodenostomy
• Billroth II: gastrojejunostomy
• Roux-en-Y gastrojejunostomy: reduces bile reflux in selected cases

Partial Gastrectomy / Wedge Resection

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

Postoperative Complications of Gastric Surgery

• Early:

• Bleeding
• Anastomotic leak
• Intra-abdominal 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
• Weight loss and postgastrectomy syndrome