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Surgery 1: Ulcers - Comprehensive Exam-Oriented Notes

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QUICK ORIENTATION MNEMONIC

"PEPTIC ACE" - covers the whole topic

• Pathogenesis (H. pylori + NSAIDs)
• Epidemiology (DU > GU)
• Presentation (epigastric pain)
• Types (Johnson I-V)
• Investigation (endoscopy + CLO test)
• Complications (Bleed, Perforate, Obstruct)
• Acid suppression (PPIs + H. pylori eradication)
• Cuts (Surgery - rare now)
• Emergencies (perforation management)

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1. DEFINITION

Key axiom: "No acid, no ulcer." In the absence of acid, peptic ulcers do not occur. Nearly all heal with PPIs. - Bailey & Love, p.1181

1. First part of duodenum (D1) - most common
2. Lesser curve of stomach (body, near angularis incisura)
3. Pre-pyloric/pyloric channel
4. Stomal ulcer (post-gastric surgery)
5. Oesophagus (in GERD)
6. Meckel's diverticulum (ectopic gastric epithelium)

Mnemonic for sites: "D1 LeSs Pre-Sto-ME" D1 duodenum, Lesser curve, Prepyloric, Stomal, Meckel's

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2. PATHOGENESIS - THE BALANCE MODEL

PROTECTIVE FACTORS          DAMAGING FACTORS
(Mucosal Defense)           (Aggressive Factors)
─────────────────           ────────────────────
• Bicarbonate secretion  vs • HCl + pepsin
• Mucus production       vs • H. pylori infection
• Mucosal blood flow     vs • NSAIDs / Aspirin
• Prostaglandins         vs • Bile reflux
• Cell renewal           vs • Smoking
• Growth factors         vs • Alcohol, ischemia

Sabiston, p.1778

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3. ETIOLOGY - THE BIG TWO

H. pylori ("The Bug")

• Global prevalence ~43% (down from 58% in 1980s)
• ~80% of infected people are asymptomatic
• Causes 90% of duodenal ulcers and 70-90% of gastric ulcers

• Flagellate (spiral-shaped, gram-negative)
• Urease-producing (splits urea → ammonia + bicarbonate → alkaline microenvironment for survival)
• Gram-negative microaerophilic bacteria
• Adhesins (binds to gastric epithelial cells)

1. Direct mucosal toxin production (VacA, CagA)
2. Stimulation of inflammatory response
3. Disruption of mucosal defense
4. Alteration in gastrin/acid secretion

NSAIDs

• Responsible for most perforations (especially in elderly females)
• Mechanism: inhibit COX-1 → decrease prostaglandin synthesis → decrease mucus + bicarbonate + blood flow

Mnemonic: "NSAID = No Stomach mucosal AID"

Other Causes

• Zollinger-Ellison syndrome (ZES/gastrinoma) - excess gastrin → excess acid
• Systemic mastocytosis
• Burns (Curling's ulcer)
• Head injury (Cushing's ulcer)
• Cocaine, radiation, gastric bypass

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4. SPECIAL ULCERS

Mnemonic: "Burns = Curling (C for Combustion), Head = Cushing (C for Cranium)"

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5. JOHNSON CLASSIFICATION OF GASTRIC ULCERS (Modified)

Mnemonic: "I Low, II High+DU, III Pre-Py High, IV GEJ Normal, V NSAID Anywhere"

Or: "1 = Incisura, 2 = II diseases (gastric+DU), 3 = Three cm from pylorus (prepyloric), 4 = Four (near the fourth part = GEJ), 5 = Five NSAIDs"

• Type I, IV: Gastrectomy (remove ulcer - low acid, so no vagotomy needed)
• Type II, III: Vagotomy + antrectomy (high acid, similar to DU surgery)
• Type V: Stop NSAIDs first; medical treatment

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6. CLINICAL FEATURES

Duodenal Ulcer (DU)

• Epigastric pain relieved by food ("food relieves")
• Pain wakes patient at 2-3 AM (nocturnal pain)
• Periodicity - pain comes and goes in weeks/months
• Right of midline tenderness

Gastric Ulcer (GU)

• Epigastric pain worsened by food ("food hurts")
• Weight loss (fear of food = sitophobia)
• Midline/left of midline tenderness
• Can be malignant - always biopsy!

Mnemonic: "DU = Dangerously Ulcer gets better with food; GU = Gets Uncomfortable with food"

Key DU vs GU comparison:

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7. INVESTIGATIONS

• Gold standard for diagnosis
• GU: Must take multiple biopsies to exclude malignancy
• CLO (Campylobacter-Like Organism) test for H. pylori
• "U manoeuvre" to inspect incisura, lesser curve, and GOJ
• Check pylorus for deformity (chronic DU)

Mnemonic for Hp tests: "CHESS" CLO, Histology, Exhale (urea breath), Stool antigen, Serology

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8. TREATMENT

Medical (First Line - Most Cases)

Mnemonic: "2 + 1 = Eradication"

• 2 antibiotics + 1 PPI

• PPI (omeprazole/lansoprazole) + Clarithromycin + Amoxicillin (or Metronidazole if penicillin allergy)

• Stop smoking (smoking doubles relapse rate)
• Stop NSAIDs/Aspirin if possible
• Avoid alcohol

Surgical (Now Rare - Only for Complications or Failure)

Mnemonic for vagotomies: "T-H-S" (Truncal, Highly Selective, Selective)

• Truncal = most acid reduction, most side effects
• HSV = least acid reduction, fewest side effects, lowest recurrence in right hands

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9. COMPLICATIONS (HIGH-YIELD)

Mnemonic: "BOP-S" - Bleed, Obstruct, Perforate, (malignant) Stenosis

A. BLEEDING (Most common complication)

• Duodenal ulcer bleeds from gastroduodenal artery (GDA) - posterior D1 ulcer
• Gastric ulcer bleeds from left gastric artery branches (lesser curve)

• Age + shock + comorbidity + endoscopic features

Mnemonic: "Forrest I = Fire (active), II = Fading, III = Finished"

1. Resuscitate (IV access x2, fluid, crossmatch)
2. IV PPI (omeprazole 80 mg bolus → 8 mg/hr infusion)
3. Endoscopy within 24 hours - therapeutic (adrenaline injection, clip, thermal)
4. Repeat endoscopy if re-bleed (one attempt)
5. Surgery if endoscopy fails twice: underrun the bleeding vessel (pyloroplasty approach for posterior DU), avoid gastrectomy if possible (high mortality in elderly)
6. Interventional radiology (embolisation) - alternative to surgery in unfit patients

B. PERFORATION

• Incidence: Not decreasing despite PPIs (especially elderly females on NSAIDs)
• Site: Anterior DU perforates most commonly; anterior lesser curvature for GU
• Key physiology: Initially chemical peritonitis → bacterial peritonitis over hours

• Sudden-onset severe generalised abdominal pain (knife-like)
• Board-like rigidity (peritonism)
• Patient lies still, abdomen does not move with respiration
• Tachycardia initially; pyrexia develops hours later
• May have referred shoulder-tip pain (diaphragmatic irritation)

Atypical presentation (elderly/steroids): Milder pain, no rigidity - higher index of suspicion needed

• Erect CXR: Free gas under diaphragm in >50% - but NOT always present
• CT abdomen (best) - more sensitive, diagnostic for both perforation and pancreatitis
• Serum amylase - may be elevated in perforation (but usually not as high as acute pancreatitis)

Mnemonic: "FED" for perforation workup Free gas on CXR, Erect CXR first, Diagnose with CT

1. Resuscitate + analgesia (do NOT withhold - it clarifies signs)
2. NG tube, catheter, IV fluids, antibiotics
3. Surgery (primary treatment)
   • Upper midline laparotomy OR laparoscopy
   • Graham Omental Patch repair - most common: suture + omentum over perforation
   • Lavage of peritoneum
   • Check for malignancy (biopsy if GU perforation)
4. Conservative (Taylor's method) - selected fit young patients with small sealed perforations, diagnosed within 6 hours, hemodynamically stable:
   • NGT, IV fluids, antibiotics, close monitoring
   • Used if water-soluble contrast shows no leak OR perforation self-seals

C. GASTRIC OUTLET OBSTRUCTION (GOO)

• Caused by Type II or III GU, or chronic DU with pyloric scarring
• Presents: Projectile non-bilious vomiting, visible gastric peristalsis, succussion splash
• Metabolic consequence: Hypochloraemic, hypokalaemic metabolic alkalosis (loss of HCl + K+ in vomit)

Mnemonic: "GOO = Going Out Obstructed; Vomit H+Cl- = Alkalosis"

1. IV fluid resuscitation (0.9% saline + K+ replacement)
2. NG tube drainage
3. H. pylori eradication + PPI
4. Endoscopy - biopsy to exclude malignancy; balloon dilation for benign
5. Surgery if medical fails: pyloroplasty or gastrojejunostomy

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10. POST-GASTRECTOMY SYNDROMES (Exam Favourite!)

Mnemonic: "DARED BAR" for postgastrectomy complications: Dumping, Afferent loop, Roux stasis, Efferent loop obstruction, Diarrhoea (postvagotomy), Bile reflux gastritis, Anaemia, Recurrent ulcer

Dumping Syndrome

• Early dumping (15-30 min after food): Hyperosmotic meal enters small bowel rapidly → fluid shift → hypovolemia + GI distress. Symptoms: flushing, tachycardia, sweating, diarrhoea
• Late dumping (1-3 hrs after food): Reactive hypoglycaemia from excess insulin release

Mnemonic: "Early = Emptying too fast = Fluid shift; Late = Late hypoglycaemia"

Alkaline Reflux Gastritis

• Bile enters stomach via GJ anastomosis → burns mucosa
• Triad: epigastric pain + vomiting bile + weight loss (Bile, Burn, Bilious vomit)
• Treatment: Roux-en-Y reconstruction

Afferent Loop Syndrome

• Obstruction of afferent limb after Billroth II
• Bile/pancreatic juice accumulates → postprandial epigastric pain that resolves after bilious vomiting

Postvagotomy Diarrhoea

• Episodic watery diarrhoea, often explosive and nocturnal
• More common after truncal vagotomy

Small Stomach Syndrome

• Early satiety after any gastric resection (loss of reservoir)

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11. STRESS ULCERATION

• Occurs in ICU patients: major surgery, burns, sepsis, head injury
• Curling's ulcer = burns >20-30% BSA → gastric ischemia
• Cushing's ulcer = head injury / raised ICP → vagal over-stimulation → excess acid
• Prevention: PPIs or sucralfate in all ICU patients (now standard)
• Endoscopic treatment may fail → surgery may be needed

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12. GASTROCOLIC FISTULA

• Rare complication: anastomotic ulcer penetrates into transverse colon
• Classic triad: severe diarrhoea (every meal) + foul breath + feculent vomiting
• Rapid weight loss, may mimic malignancy
• Diagnosis: CT with oral contrast or barium enema
• Treatment: correct nutrition first, then revisional surgery

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13. ZOLLINGER-ELLISON SYNDROME (ZES)

• Gastrinoma (usually in pancreas or duodenum) → excess gastrin → massive acid production
• Suspect when: multiple ulcers, ulcers in unusual locations (D3/D4, jejunum), refractory to PPIs
• Part of MEN-1 syndrome (Pancreas, Pituitary, Parathyroid)
• Fasting gastrin > 1000 pg/mL + low gastric pH = diagnostic
• Secretin stimulation test: gastrin paradoxically rises (unlike normal)
• Treatment: PPIs (high dose) + surgical resection of tumour if localizable

Mnemonic: "ZES = Zero End point (never heals) + Excess acid + Suspect MEN-1"

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14. MEGA-SUMMARY TABLE: EXAM AT A GLANCE

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15. ONE-LINER EXAM BOMBS

• "Board-like rigidity + sudden epigastric pain" = Perforated peptic ulcer
• "Free gas under diaphragm" = Perforation (present in >50% only - CT is better)
• "Posterior D1 ulcer bleeds" = Gastroduodenal artery
• "Projectile non-bilious vomiting + succussion splash" = Gastric outlet obstruction
• "Episodic diarrhoea every meal + foul breath" = Gastrocolic fistula
• "Multiple ulcers + refractory to PPIs" = ZES (gastrinoma)
• "Ulcer in Meckel's diverticulum" = Ectopic gastric mucosa
• "Head injury → ulcer" = Cushing's (Cranium); "Burns → ulcer" = Curling's (Combustion)
• "Type I GU at incisura + low acid" = Not acid-related; do gastrectomy without vagotomy
• "Type II/III GU + high acid" = Treat like DU (vagotomy + antrectomy)
• "Type V GU anywhere" = NSAIDs - stop the drug first

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