The Management of Gastric Ulcers

Rb, Adkins; rd, DeLozier Jb; Hw, Scott; Jl, Sawyers

doi:10.1097/00000658-198506000-00011

Cited by 23 publications

(10 citation statements)

References 21 publications

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“…According to the literature, the post-operative mortality of patients with perforated gastric ulcers [ 16 , 19 , 24 , 25 , 26 ] and perforated peptic ulcers [ 12 , 27 ] to be between ~10–20%, compared to <6% in the present study. A separate study found a 2.9% mortality in surgically treated patients with gastric ulcers, which was more in line with the findings of our study [ 28 ]. Interestingly, one randomized trial looking at perforated peptic ulcers found no differences in mortality between surgical and nonsurgical groups [ 7 ].…”

Section: Discussionsupporting

confidence: 93%

Risk Factors for Mortality in Emergently Admitted Patients with Acute Gastric Ulcer: An Analysis of 15,538 Patients in National Inpatient Sample, 2005–2014

Idris

Smiley

Patel

et al. 2022

IJERPH

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Background: Patients admitted emergently with a primary diagnosis of acute gastric ulcer have significant complications including morbidity and mortality. The objective of this study was to assess the risk factors of mortality including the role of surgery in gastric ulcers. Methods: Adult (18–64-year-old) and elderly (≥65-year-old) patients admitted emergently with hemorrhagic and/or perforated gastric ulcers, were analyzed using the National Inpatient Sample database, 2005–2014. Demographics, various clinical data, and associated comorbidities were collected. A stratified analysis was combined with a multivariable logistic regression model to assess predictors of mortality. Results: Our study analyzed a total of 15,538 patients, split independently into two age groups: 6338 adult patients and 9200 elderly patients. The mean age (SD) was 50.42 (10.65) in adult males vs. 51.10 (10.35) in adult females (p < 0.05). The mean age (SD) was 76.72 (7.50) in elderly males vs. 79.03 (7.80) in elderly females (p < 0.001). The percentage of total deceased adults was 1.9% and the percentage of total deceased elderly was 3.7%, a difference by a factor of 1.94. Out of 3283 adult patients who underwent surgery, 32.1% had perforated non-hemorrhagic ulcers vs. 1.8% in the non-surgical counterparts (p < 0.001). In the 4181 elderly surgical patients, 18.1% had perforated non-hemorrhagic ulcers vs. 1.2% in the non-surgical counterparts (p < 0.001). In adult patients managed surgically, 2.6% were deceased, while in elderly patients managed surgically, 5.5% were deceased. The mortality of non-surgical counterparts in both age groups were lower (p < 0.001). The multivariable logistic regression model for adult patients electing surgery found delayed surgery, frailty, and the presence of perforations to be the main risk factors for mortality. In the regression model for elderly surgical patients, delayed surgery, frailty, presence of perforations, the male sex, and age were the main risk factors for mortality. In contrast, the regression model for adult patients with no surgery found hospital length of stay to be the main risk factor for mortality, whereas invasive diagnostic procedures were protective. In elderly non-surgical patients, hospital length of stay, presence of perforations, age, and frailty were the main risk factors for mortality, while invasive diagnostic procedures were protective. The following comorbidities were associated with gastric ulcers: alcohol abuse, deficiency anemias, chronic blood loss, chronic heart failure, chronic pulmonary disease, hypertension, fluid/electrolyte disorders, uncomplicated diabetes, and renal failure. Conclusions: The odds of mortality in emergently admitted geriatric patients with acute gastric ulcer was two times that in adult patients. Surgery was a protective factor for patients admitted emergently with gastric perforated non-hemorrhagic ulcers.

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Section: Discussionsupporting

confidence: 93%

Risk Factors for Mortality in Emergently Admitted Patients with Acute Gastric Ulcer: An Analysis of 15,538 Patients in National Inpatient Sample, 2005–2014

Idris

Smiley

Patel

et al. 2022

IJERPH

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“…We cannot give an accurate figure for the overall incidence of HGU because we did not study the patients treated conservatively for this type of ulcer; however, HGU constituted approximately 4% of the total number of patients operated on for gastric ulceration. This corresponds with the figure of 4-5% quoted by others [1,2].…”

Section: Discussionsupporting

confidence: 91%

“…Thus, the ulcer is likely to recur after a local procedure to the ulcer, as occurred in one of our patients and in 40% of patients with more distal ulcers treated in this manner before the era of Hz-receptor blockers [29]. When used for bleeding ulcers, rebleeding is likely [1,2,29] as occurred with fatal outcome in one of our patients. A cancer may be overlooked, as discussed above.…”

Section: Oversewing Closure or Transfixion Onlymentioning

confidence: 85%

“…The incidence of cases that can be interpreted as missed carcinomas appears to be higher after vagotomy than after gastrectomy [28,30,34,43]. If vagotomy is to be practiced for gastric ulcer, it seems to be wise to excise the ulcer in order to decrease recurrence rates and the incidence of missed cancer [2,17,26,28,32,34,43]. As stated above, ulcer excision in patients with HGU is often difficult, hazardous, and sometimes impossible.…”

Section: Total Gastrectomymentioning

confidence: 99%

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High gastric ulcer

1987

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Fifty-six patients with high gastric ulcers were studied retrospectively. There were 38 women and 18 men. The mean age was 66 years. Findings were: 25% had ulcer histories of more than 5 years; 45% had illnesses in other systems making them poor operative risks; 34% were taking ulcerogenic drugs, and 36 % were on antiulcer treatment prior to surgery; 43% presented with severe bleeding, 16% with perforation, and 2 patients had simultaneous bleeding and perforation; 38% had deeply penetrating ulcers and many ulcers were very large; 7 patients had ulcers in hiatus hernias. Sixty-three percent of the procedures were emergencies. Half of the operations were nonresective, with or without vagotomy. The other half were gastric resections of various types. The overall mortality rate was 18%, but the mortality rate was 24% for emergency procedures and 9% for elective ones. The highest mortality rate, 45%, occurred after emergency resective procedures. Vagotomy did not increase postoperative mortality when added to a nonresective procedure. Beside the 10 patients who died, 6 others developed severe postoperative complications, usually respiratory failure or suture line leakage. Follow-up of between 6 months and 12 years (average 3 years) was possible in 55% of the patients. Two developed recurrent ulcers and 2 had overlooked gastric carcinomas. An approach of management for high gastric ulcer is outlined recommending a Pauchet operation for good-risk patients, and vagotomy and drainage for old and frail patients. Medical treatment should be pursued as long as possible to avoid an often hazardous operation.

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“…This philosophy is also shared by others [25,26] who have had a wide experience in ulcer surgery. The recent report by Adkins [27] in a review of the Vanderbilt series states the same opinion. For the type I Johnson ulcer, which is located along the incisura angularis delineating the parietal-antral junction, vagotomy is not necessarily included as a component of the resection unless the patient is an alcoholic or drug abuser.…”

Section: Choice Of Operation: Massively Bleeding Gumentioning

confidence: 80%

Bleeding gastroduodenal ulcers: Choice of operations

Herrington

Davidson

1987

World j. surg.

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Management of upper gastrointestinal tract hemorrhage continues to present a challenge in surgical judgment. Endoscopy is the mainstay to precise diagnosis and, although some authorities feel that this modality has not reduced overall mortality, it has, however, played an important role in overall patient management. A bleeding patient may be classified into 1 of 3 separate categories and the algorithms outlined in this article are useful in selecting patients for nonoperative and operative treatment. For the good-risk patient with a massively bleeding duodenal ulcer (DU) who is hemodynamically stable, truncal vagotomy-antrectomy, Billroth I reconstruction is our procedure of choice if the inflammatory process in the duodenum is conducive to a safe resection. Our operative method is described along with variations in technique which are used when conventional end-to-end gastroduodenostomy is not feasible. Closure of the duodenal stump and Roux-en-Y reconstruction or placement of a Roux limb on a severely diseased duodenum following resection is employed in highly selected cases. The Biilroth I1 type of reconstruction is rarely used today in our experience. Truncal vagotomy and pyloroplasty (TV-P) is reserved for the high-risk patient who is bleeding massively. An increasing number of these patients are currently encountered as transfers from our intensive care units with associated multiple organ disease and organ failures. Proximal gastric vagotomy with ulcer undersewing has limited application, in our judgment, when faced with the massively bleeding patient. Gastric resection with or without vagotomy along with ulcer excision is our choice for the massively bleeding gastric ulcer (GU) located in the distal 50-60 % area of the stomach. For the high-risk patient with GU, ulcer excision followed by TV-P is indicated. For the rarely encountered giant GU, gastric resection may be the only option even though the patient is high risk.The choice of the proper operative procedure for the individual patient with massive gastric or duodenal hemorrhage should rest on the experience and the judgment of the surgeon.Upper gastrointestinal tract hemorrhage continues to present a challenging problem in patient management. During the past 2 decades, with the widespread use of fiberoptic endoscopy, the diagnostic accuracy in defining the exact site of bleeding from the gastric and duodenal mucosa is currently in excess of 95%. This modality has virtually rendered radiographic examination in this clinical setting all but obsolete. Although angiography and isotope labeling have been of immense value in the diagnosis of small intestinal and colonic hemorrhage, these studies are infrequently used for the patient suspected of bleeding from the stomach or duodenum.

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The Management of Gastric Ulcers

Cited by 23 publications

References 21 publications

Risk Factors for Mortality in Emergently Admitted Patients with Acute Gastric Ulcer: An Analysis of 15,538 Patients in National Inpatient Sample, 2005–2014

Risk Factors for Mortality in Emergently Admitted Patients with Acute Gastric Ulcer: An Analysis of 15,538 Patients in National Inpatient Sample, 2005–2014

High gastric ulcer

Bleeding gastroduodenal ulcers: Choice of operations

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