Pyloric stenosis complicating duodenal ulceration

Asymptomatic free intraperitoneal gas with duodenal stenosis

A 30-year-old man was referred to our hospital in October 2006 for asymptomatic free air in the peritoneal cavity found on a plain chest X-ray on a routine health examination. Esophagogastroduodenoscopy (EGD) revealed an ulcer scar and deformity of the duodenal bulb, a healing-phase ulcer in the anterior wall of the upper gastric corpus, grade B esophagitis (Los Angeles grading system), and a sliding hiatal hernia. A test for Helicobacter pylori was negative. Upon obtaining an informed consent (asymptomatic perforation), laparoscopic selective proximal vagotomy, Toupet fundoplication, and small skin incision Finney pyloroplasty were performed. Intraoperatively, extensive adhesions of the greater omentum to the duodenal bulb were found, which were suspected to engulf the cryptic perforation. The patient's postoperative course has been uneventful and, at present, recurrence of the ulcer has not been observed. The presented case is rare considering the absence of surgical history, lack of symptoms, and incidental finding of the intraperitoneal free air during a health examination.

Proton pump inhibition is a feasible primary alternative to surgery and balloon dilatation in adult peptic pyloric stenosis (APS): report of six consecutive cases

INTRODUCTION

Surgery has been the gold standard in the treatment of adult pyloric stenosis (APS). The introduction of proton pump inhibitors (PPIs) in 1989 revolutionised the treatment of peptic ulcer disease and its complications.

PATIENTS AND METHODS

We carried out a prospective study to evaluate the effectiveness of PPIs as an alternative to surgery for treatment of APS. Six consecutive patients admitted with a diagnosis of adult peptic pyloric stenosis between November 1999 and August 2002 were studied. The diagnosis was confirmed with endoscopy. All patients were commenced on a twice-daily dose of intravenous PPI. This was changed to oral treatment after 2 days. Main outcome measures evaluated were resolution of symptoms on PPIs and failure of medical therapy.

RESULTS

There were five females and one male. Median age at diagnosis was 72 years (range, 30-90 years). Median duration of symptoms was 2 weeks (range, 1-5 weeks). Of the patients, five had a history of peptic ulcer disease. Complete resolution was achieved in 5 patients (83%). Median duration for resolution of symptoms was 9 days (range, 5-14 days). All patients were changed to oral PPIs after 2 days. One patient did not respond to oral therapy and required surgical intervention (pyloroplasty). Median follow-up was 26 months (range, 6-48 months). There was no recurrence of symptoms. All patients were discharged on low-dose PPI.

CONCLUSIONS

This study supports the view that proton pump inhibitors are a safe and feasible alternative to surgery in adult pyloric stenosis secondary to peptic ulcer disease.

Gastric outlet obstruction

Acquired gastric outlet obstruction is more commonly owing to malignancy than ulcer disease. Endoscopy is the preferred method for diagnosis. Surgical palliation for malignant disease has poor results and high rates of morbidity and mortality. Initial experiences with endoscopic palliation with expandable metallic endoprostheses appear promising. Peptic ulcer-induced gastric outlet obstruction can be treated safely with endoscopic balloon dilation. About 65% of patients have sustained symptom relief, but many require more than one dilation session. Outcomes may be improved with effective ulcer therapy with acid reduction and eradication of H. pylori. Surgery is associated with significant morbidity and mortality and should be reserved for endoscopic treatment failures.

Prospective randomized study comparing three surgical techniques for the treatment of gastric outlet obstruction secondary to duodenal ulcer

A prospective randomized clinical trial was performed in order to evaluate the results of three surgical techniques for the treatment of gastric outlet obstruction secondary to duodenal ulcer. Ninety patients with clinical and laboratory evidence of gastric retention were enrolled. After laparotomy, patients underwent either highly selective vagotomy (HSV) + gastrojejunostomy, HSV + Jaboulay gastroduodenostomy, or selective vagotomy (SV) + antrectomy. One patient died after HSV + Jaboulay gastroduodenostomy due to postoperative acute pancreatitis. There were no differences in the postoperative course of the three groups. Patients were followed for a mean of 98 months (range: 30 to 156 months). There was a significantly better result after HSV + gastrojejunostomy than after Jaboulay anastomosis (p < 0.01), but not after SV + antrectomy. Gastric acid reduction was similar in the small group of patients studied. We propose HSV + gastrojejunostomy as the treatment of choice in patients with duodenal ulcer and gastric outlet obstruction.

The successful medical management of gastric outflow obstruction associated with the use of non-steroidal anti-inflammatory drugs in the elderly

One hundred and nineteen consecutive elderly patients with endoscopically diagnosed peptic ulceration were reviewed. Associated gastric outflow obstruction was present in 10.1%. The presenting clinical features differed significantly from typical younger patients and most (11/12) were taking non-steroidal anti-inflammatory drugs, suggesting a possible role for these agents in the pathogenesis of gastric outflow obstruction. These elderly patients have been successfully managed by medical therapy alone.

Indications for parietal cell vagotomy without drainage in gastrointestinal surgery

Parietal cell vagotomy (PCV) was used for a variety of gastrointestinal conditions in 658 patients. Operative and late related deaths after PCV were 1.1% (3/273) in patients with intractable duodenal ulcers, 1.1% (1/91) in perforated ulcers, 0% (0/43) in Type I gastric ulcers, 0% (0/45) in pyloric and prepyloric ulcers, 3.2% (6/188) when combined with fundoplication, 8.7% (2/23) when combined with vascular surgery, and 4.2% (1/24) in ulcer patients with acute bleeding. The recurrent ulcer rate after PCV was 8.4% in patients operated on for duodenal ulcer, 6.4% for perforated ulcer, 5.3% for bleeding ulcers, 10% for Type I gastric ulcers, and 31% for pyloric and prepyloric ulcers. PCV was preferred to total gastrectomy in four patients in whom a gastrinoma could not be located. PCV was used in 188 patients with reflux esophagitis and in 12 patients with achalasia to facilitate fundoplication and placement of the myotomy, respectively. Based on the results of the study, PCV is contraindicated in patients with pyloric and prepyloric ulcers. PCV is not recommended when traumatic dilatation of the pylorus is required to overcome obstruction. PCV may have limited application in patients with bleeding ulcers and Type I gastric ulcers. In our experience PCV is not contraindicated in patients with ulcers resistant to H2 receptor antagonists. PCV may be contraindicated when acid hypersecretion exceeds an as-yet undetermined level. PCV is an ideal procedure for intractable duodenal ulcers and perforated ulcers.

Peptic ulcer disease in the elderly

The elderly are a growing minority; they comprise approximately 12% of the population but consume an increasing proportion of health care resources. Disease in the aged is unique in many ways, demanding special attention and study. This is particularly evident with regard to peptic ulceration, which is a more serious disorder in the elderly than in younger individuals, often presenting in an atypical manner and having a greater propensity to complications. Management traditionally tends to be conservative, enthusiasm often being tempered by the presence of frailty and associated disease. Despite technologic and pharmacologic advances, the elderly continue to account for a disproportionate number of deaths from this disorder. This paper will review the peculiarities of peptic ulcer disease of the elderly and examine currently emerging trends which may influence evolving management policies.