256 Section II / General Surgery
Why irrigate in an upper	To remove the blood clot so you can see
GI bleed?	the mucosa
What test may help identify	Selective mesenteric angiography
the site of MASSIVE UGI
bleeding when EGD fails to
diagnose cause and blood
continues per NGT?

What are the indications for surgical intervention in UGI bleeding?

What percentage of patients require surgery?

What percentage of patients spontaneously stop bleeding?

What is the mortality of acute UGI bleeding?

What are the risk factors for death following UGI bleed?

Refractory or recurrent bleeding and site known, 3 u PRBCS to stabilize or

6 u PRBCs overall

10%

80% to 85%

Overall 10%, 60–80 years of age 15%, older than 80 years of age 25%

Age older than 60 years Shock

5 units of PRBC transfusion Concomitant health problems

PEPTIC ULCER DISEASE (PUD)

What is it?

What is the incidence in the United States?

What are the possible consequences of PUD?

What percentage of patients with PUD develops bleeding from the ulcer?

Gastric and duodenal ulcers

10% of the population will suffer from PUD during their lifetime!

Pain, hemorrhage, perforation, obstruction

20%

Which bacteria are	Helicobacter pylori
associated with PUD?

What is the treatment?

What is the name of the sign with RLQ pain/peritonitis as a result of succus collecting from a perforated peptic ulcer?

DUODENAL ULCERS

Chapter 40 / Upper GI Bleeding 257

Treat H. pylori with MOC or ACO 2-week antibiotic regimens:

MOC: Metronidazole, Omeprazole, Clarithromycin (Think: MOCk)

or

ACO: Ampicillin, Clarithromycin, Omeprazole

Valentino’s sign

In which age group are these ulcers most common?

What is the ratio of male to female patients?

What is the most common location?

What is the classic pain response to food intake?

What is the cause?

What syndrome must you always think of with a duodenal ulcer?

40–65 years of age (younger than patients with gastric ulcer)

Men women (3:1)

Most are within 2 cm of the pylorus in the duodenal bulb

Food classically relieves duodenal ulcer pain (Think: Duodenum Decreased with food)

Increased production of gastric acid

Zollinger-Ellison syndrome

What are the associated	Male gender, smoking, aspirin and other
risk factors?	NSAIDs, uremia, Z-E syndrome,
	H. pylori, trauma, burn injury
What are the symptoms?	Epigastric pain—burning or aching, usually
	several hours after a meal (food, milk,
	or antacids initially relieve pain)
	Bleeding
	Back pain
	Nausea, vomiting, and anorexia
	↓ appetite

258 Section II / General Surgery

What are the signs?

What is the differential diagnosis?

How is the diagnosis made?

When is surgery indicated with a bleeding duodenal ulcer?

What EGD finding is associated with rebleeding?

What is the medical treatment?

Tenderness in epigastric area (possibly), guaiac-positive stool, melena, hematochezia, hematemesis

Acute abdomen, pancreatitis, cholecystitis, all causes of UGI bleeding, Z-E syndrome, gastritis, MI, gastric ulcer, reflux

History, PE, EGD, UGI series

(if patient is not actively bleeding)

Most surgeons use: 6 u PRBC transfusions, 3 u PRBCs needed to stabilize, or significant rebleed

Visible vessel in the ulcer crater, recent clot, active oozing

PPIs (proton pump inhibitors) or H2 receptor antagonists—heal ulcers in 4 to 6 weeks in most cases

Treatment for H. pylori

When is surgery indicated?

How is a bleeding duodenal ulcer surgically corrected?

What artery is involved with bleeding duodenal ulcers?

What are the common surgical options for the following conditions:

Truncal vagotomy?

The acronym “I HOP”:

Intractability

Hemorrhage (massive or relentless) Obstruction (gastric outlet obstruction) Perforation

Opening of the duodenum through the pylorus

Oversewing of the bleeding vessel

Gastroduodenal artery

Pyloroplasty

	Chapter 40 / Upper GI Bleeding 259
Duodenal perforation?	Graham patch (poor candidates, shock,
	prolonged perforation)
	Truncal vagotomy and pyloroplasty
	incorporating ulcer
	Graham patch and highly selective
	vagotomy
	Truncal vagotomy and antrectomy
	(higher mortality rate, but lowest
	recurrence rate)
Duodenal obstruction	Truncal vagotomy, antrectomy, and
resulting from duodenal	gastroduodenostomy (BI or BII)
ulcer scarring (gastric	Truncal vagotomy and drainage procedure
outlet obstruction)?	(gastrojejunostomy)
Duodenal ulcer	PGV (highly selective vagotomy)
intractability?	Vagotomy and pyloroplasty
	Vagotomy and antrectomy BI or BII
	(especially if there is a coexistent
	pyloric/prepyloric ulcer) but
	associated with a higher mortality
Which ulcer operation has	PGV (proximal gastric vagotomy)
the highest ulcer recurrence
rate and the lowest dumping
syndrome rate?
Which ulcer operation has	Vagotomy and antrectomy
the lowest ulcer recurrence
rate and the highest
dumping syndrome rate?

Why must you perform a drainage procedure (pyloroplasty, antrectomy) after a truncal vagotomy?

Which duodenal ulcer operation has the lowest mortality rate?

Pylorus will not open after a truncal vagotomy

PGV (1/200 mortality), truncal vagotomy and pyloroplasty (1–2/200), vagotomy and antrectomy (1%–2% mortality)

Thus, PGV is the operation of choice for intractable duodenal ulcers with the cost of increased risk of ulcer recurrence