Professional Reference articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use, so you may find the language more technical than the condition leaflets.
Surgery for peptic ulcers is now performed less often, partly but not only as a result of improved medical treatment with H2-receptor antagonists.Proton pump inhibitors (PPIs) and the treatments to eradicate Helicobacter pylori have further reduced the requirement for surgery.
Nevertheless, there are still some complications that require surgical interventions, and many patients still alive who have had surgery for peptic ulcers. The complications of peptic ulceration include chronicity, perforation, stenosis, haemorrhage and malignant change.
It should be remembered that although the frequency of peptic ulcer disease is decreasing in the developed world, it is increasing in developing countries.
Indications for surgery
There are still indications for surgical interventions, including intractable ulcers, haemorrhage, perforation and obstruction (usually pyloric stenosis). Otherwise, the only remaining indication for remedial gastric surgery for peptic ulcer disease is when there is a defined risk for gastric cancer in an unhealed gastric ulcer and very rarely for recurrent or therapy-resistant peripyloric ulcer.
The options for malignant ulcers are discussed in the separate article on Gastric Cancer. The mortality associated with haemorrhage and perforation is still in excess of 10%. There are a variety of procedures that have been assessed.
The operations that have been used traditionally are:
- Billroth I gastrectomy
- Billroth II or Pólya gastrectomy
- Truncal vagotomy and pyloroplasty
- Highly selective vagotomy
Gastric ulcers were in the past best removed together with the gastrin-secreting zone of the antrum (achieved by the Billroth I gastrectomy).
Duodenal ulcers were treated either by removing the body and lesser curve of the stomach (where acid secretion mainly occurs) or by dividing the vagi. As this could interfere with gastric emptying, it was performed with either gastrojejunostomy or pyloroplasty. Gastrojejunostomy alone was used occasionally in elderly patients but this was often complicated by stomal ulcers. In theory this achieved ulcer healing by introducing alkali secretions from the jejunum. Partial gastrectomy with a gastrojejunal anastamosis is called a Pólya gastrectomy.
The partial gastrectomies are largely superseded by the vagotomy operations but many patients may be found who had such operations many years ago. Nowadays even operations to repair perforated ulcers are often performed via the laparoscope and there may be a lower risk of immediate complications in low-risk patients.[4, 5] Gastric resection can also be achieved via the laparoscope.
Complications after surgery
Complications can occur soon after surgery. Early complications usually occur whilst the patient is still in hospital and include wound infections, anastomotic leaks, or recurrence of bleeding.
Late complications vary according to the surgical procedure but they are generally more marked after partial gastrectomy than after vagotomy. Simple truncal vagotomy would lead to failure of gastric emptying and so a drainage procedure such as pyloroplasty is performed but this leads to poor control of gastric outflow. Highly selective vagotomy is supposed to overcome the problem in that it does not require a drainage procedure. It requires great skill to get enough denervation to heal the ulcer but not too much to cause delayed gastric emptying. Highly selective vagotomy has a much lower incidence of complications but a significantly higher incidence of recurrence.
Late complications after peptic ulcer surgery include:
- Recurrent ulceration
- Dumping syndrome
- Iron deficiency, vitamin B12 deficiency, folate deficiency
The stomach transforms the intermittent intake of food into a more gradual release into the duodenum and small intestine as well as initiating the process of digestion. The control of gastric emptying is both neural and hormonal. The post-gastrectomy syndromes include:
- Small capacity or 'small stomach' syndrome - this is associated with fullness after only moderate-sized meals and may be associated with weight loss and reduced appetite.
- Dumping syndrome - can be early or late, as set out in more detail under the heading 'Dumping syndrome', below.
- Bile gastritis and bilious vomiting - can occur particularly after emptying of the afferent loop of a Pólya gastrectomy into the stomach remnant.
- Blind loop syndrome (sometimes called stasis syndrome or stagnant loop syndrome) - this affects digestion and absorption, causing:
- Bloating, loss of appetite, abdominal pain and nausea.
- Fatty stools (steatorrhoea).
- Diarrhoea with weight loss.
- Food unable to move through the bypassed section of bowel, producing a bacterial overgrowth syndrome. The bacteria may produce toxins as well as interfere with the absorption of nutrients.
- Anaemia usually results from iron deficiency from failure of iron absorption. It can also occur with loss of intrinsic factor and less B12 absorption (typically about two years after total gastrectomy).
- Steatorrhoea occurs particularly with a long afferent loop when fatty food is less well absorbed.
- Stomal ulceration may occur following gastrectomy for duodenal ulcer.
- Metabolic bone disease.
Highly selective vagotomy aims to maintain the nerves of Latarjet (branches of the vagus nerve which supply the pyloric sphincter) and obviate the need for an accompanying drainage procedure (usually pyloroplasty). Complications afterwards include:
- Steatorrhoea and diarrhoea, which are common after vagotomy (although this is less of a problem after highly selective vagotomy). Often such symptoms are transient or episodic. However, in about 2% of cases symptoms are severe or persistent.
- Stomal ulceration, which can occur particularly if the vagotomy is incomplete.
This is the most troublesome of the syndromes after surgery to eradicate peptic ulcer. Dumping syndrome is a frequent complication of oesophageal, gastric or bariatric surgery.
There is rapid gastric emptying, with the delivery to the small intestine of a significant proportion of solid food as large particles that are difficult to digest. This causes excessive intravascular fluid to move to the intestinal lumen, which results in cardiovascular symptoms, release of several gastrointestinal and pancreatic hormones and late postprandial hypoglycemia.
Early dumping causes symptoms 30 to 60 minutes after a meal. Early dumping symptoms include both gastrointestinal and vasomotor symptoms. Symptoms include:
- Desire to lie down (with fatigue, faintness and possibly syncope).
- Epigastric fullness.
- Nausea, vomiting and diarrhoea.
- Abdominal cramps and borborygmi (abdominal gurgling or rumbling sounds).
Late dumping occurs between one and three hours after a meal. Late dumping symptoms are the result of reactive hypoglycaemia. Symptoms include:
- Sweating and tremor.
- Difficulty concentrating and even reduced level of consciousness.
Failure to absorb essential nutrients may be caused by a combination of factors:
- Poor dietary intake (as a result, for example, of bloating and decreased appetite).
- Intestinal hurry (with, for example, changes in the gut flora in blind loop syndromes).
- Reduced intrinsic factor (for example. after gastrectomy).
- Reduced acid secretion (after gastrectomy).
These may be vague and the onset is usually slow:
- Iron-deficiency anaemia may be accompanied by fatigue. FBC will show a microcytic, hypochromic anaemia and ferritin will be low.
- Folate deficiency will cause macrocytosis and macrocytic anaemia. Poor intake and blind loop syndromes are probably to blame for this common problem.
- Pernicious anaemia occurs after partial gastrectomy. Production of intrinsic factor is reduced (and hence absorption of B12). This produces a macrocytic anaemia.
- A mixed picture results from a combination of iron, B12 and folate deficiency.
- Chronic intake of an inadequate number of calories will cause weight loss and even muscle wasting.
Patients who have had such surgery need long-term follow-up with periodic weighing, FBC, ferritin, folate and B12 levels.
- Small, frequent meals may enable an adequate intake of nutrients and reduce dumping syndrome. Avoid simple sugars and reduce fluid intake with meals.
- Iron and folic acid supplements may be required.
- Hydroxocobalamin injections to prevent vitamin B12 deficiency.
- Acarabose can reduce the absorption of glucose and help prevent late dumping but it may also aggravate bloating and diarrhoea
- Octreotide is a somatostatin antagonist that can inhibit the release of insulin and various gut peptide hormones. Trials have shown benefit in severe dumping syndrome but it is not licensed for this purpose.
- A number of surgical reconstructions are possible of which the best known is the Roux-en-Y gastrojejunostomy. Symptoms may improve with time and so remedial surgery should not be undertaken without giving time.
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Further reading & references
- Peptic ulcer disease; Surgical-tutor.org.uk
- Peptic ulcer is rare without H pylori or NSAID; Bandolier
- Dyspepsia - proven peptic ulcer; NICE CKS, December 2012 (UK access only)
- Bardhan KD, Royston C; Time, change and peptic ulcer disease in Rotherham, UK. Dig Liver Dis. 2008 Jul 40(7):540-6. doi: 10.1016/j.dld.2008.02.024. Epub 2008 Apr 14.
- Lundell L; Acid secretion and gastric surgery. Dig Dis. 2011 29(5):487-90. doi: 10.1159/000331516. Epub 2011 Nov 16.
- Millat B, Fingerhut A, Borie F; Surgical treatment of complicated duodenal ulcers: controlled trials. World J Surg. 2000 Mar 24(3):299-306.
- Sanabria A, Villegas MI, Morales Uribe CH; Laparoscopic repair for perforated peptic ulcer disease. Cochrane Database Syst Rev. 2013 Feb 28 2:CD004778. doi: 10.1002/14651858.CD004778.pub3.
- Lunevicius R, Morkevicius M; Systematic review comparing laparoscopic and open repair for perforated peptic ulcer. Br J Surg. 2005 Oct 92(10):1195-207.
- Rivera RE, Eagon JC, Soper NJ, et al; Experience with laparoscopic gastric resection: results and outcomes for 37 cases. Surg Endosc. 2005 Dec 19(12):1622-6. Epub 2005 Oct 12.
- Tack J, Arts J, Caenepeel P, et al; Pathophysiology, diagnosis and management of postoperative dumping syndrome. Nat Rev Gastroenterol Hepatol. 2009 Oct 6(10):583-90. doi: 10.1038/nrgastro.2009.148. Epub 2009 Sep 1.
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