GASTRIC ULCER DISEASE

41. What is the most important factor in managing gastric ulcers?

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All gastric ulcers must be evaluated for malignancy. The incidence of malignancy is about 10%.

42. How is gastric ulcer evaluated?

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Biopsy is mandatory. Esophagogastroduodenoscopy (EGD) with multiple biopsies (typically, six) of the ulcer crater is the best method. Upper GI series may be helpful, but biopsy is not possible. The CLO test can be performed at the time of the EGD to detect H. pylori. Benign ulcers usually heal by 12 weeks. Intractability should arouse suspicion for malignancy.

43. How are gastric ulcers classified?

Type I At the incisura or most inferior portion of the lesser curvature
Type II Gastric ulcer + duodenal ulcer
Type III Prepylorus
Type IV Gastroesophageal junction or proximal cardia
Type V Any ulcer from NSAID or aspirin use

44. Which is the most common type of gastric ulcer?

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Type I.

45. How do benign gastric ulcers differ from duodenal ulcers?

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Benign gastric ulcers are difficult to treat and have a higher rate of recurrence and complications. Gastric ulcer disease and gastric carcinoma have a probable common etiologic factor, which is atrophic gastritis induced by H. pylori. By contrast, factors associated with duodenal ulcer may protect against gastric cancer.

46. How is H. pylori related to gastric ulcer disease?

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H. pylori colonization induces chronic active gastritis, which is associated with ulcer formation, although a direct cause-and-effect link has not been clearly established. Other factors such as focal defect in acid neutralization that allows acid diffusion into the stomach mucosa or hypersecretion of acid (in cases of type II and III ulcers) may play important roles.

47. What is a “trial of healing”?

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A combination of H2 receptor antagonists or hydrogen pump inhibitors with anti-H. pylori medications, if indicated, may be tried for 6-12 weeks. A second EGD should be performed to evaluate the ulcer. An additional trial of 12 weeks is acceptable provided that the biopsy results for malignancy are negative.

48. What is the aim of H. pylori eradication in the setting of gastric ulcer?

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Therapy aimed at H. pylori eradication is associated with increased ulcer healing and decreased ulcer relapse. Several series have shown decreases in recurrences from 50% to < 10% with H. pylori eradication. H. pylori is strongly linked to gastric cancer and is now classified as a group I carcinogen. It also may cause mucosa-associated lymphoid tissue lymphoma.

49. How are patients with H. pylori infection treated?

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They should be given a triple therapy of bismuth, metronidazole, and tetracycline, usually supplemented with acid-reducing medications.

50. Does gastric ulcer healing guarantee a benign ulcer?

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No. Gastric ulcers with foci of malignancy may heal completely on medical therapy.

51. What are the indications for operative therapy of benign gastric ulcers?

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Hemorrhage, perforation, obstruction, and intractability (the same as duodenal ulcers).

52. What is the definitive procedure used for benign gastric ulcers?

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Hemigastrectomy or antrectomy (including the ulcer) without vagotomy for types I and IV ulcers is the standard procedure. Type I and IV ulcers have low or normal acid levels. For types II and III, vagotomy should be added.

53. What are the options under emergent (i.e., hemorrhage or perforation) conditions?

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Hemodynamically stable: truncal vagotomy and distal gastrectomy
Unstable: truncal vagotomy and drainage procedure with biopsy followed by excision and oversewing of ulcer

54. What is the rebleeding rate if the ulcer is left in situ?

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33%.

55. What is giant gastric ulcer?

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An ulcer > 3 cm in diameter, usually located along the lesser curvature. The malignancy risk is about 30% and increases with the diameter. Early surgical resection is indicated because of the risk of malignancy. Vagotomy may be added.

56. What is Cushing’s ulcer?

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A stress ulcer found in critically ill patients with central nervous system injury. Typically, single, deep, and with tendency to perforate.

57. What is Curling’s ulcer?

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A stress ulcer found in critically ill patients with burn injuries.

58. What is Dieulafoy ulcer?

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Erosion of the gastric mucosa overlying a vascular malformation, which often leads to hemorrhage. Chronic inflammation is not associated with this lesion.

59. What is a marginal ulcer?

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An ulcer found near the margin of the gastroenteric anastomosis, usually on the small bowel side.

60. When does stress gastritis occur? Why?

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Sixty percent of them occur within 24-48 hours after trauma, shock, or sepsis. Usually, mucosal erosions begin proximally in the stomach and travel distally. These are eventually seen in nearly all critically ill patients. The integrity of cellular barrier in the lamina propria is compromised, probably from decreased blood supply, leading to back diffusion of acid; erosion of submucosa; and, finally, bleeding.

61. How are patients with bleeding stress gastritis treated?

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Blood clots should be removed from the stomach lumen by nasogastric tube suction and lavage. Fibrinolysins from clots increase bleeding. Stomach pH should be kept above 4.0 with acid-reducing medications.

References
WEB SITE
http://www.emedicine.com/med/topic1776.htm
BIBLIOGRAPHY
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