When is surgery indicated for the treatment of peptic ulcer-related upper gastrointestinal bleeding (UGIB)?

Updated: Aug 12, 2019
  • Author: Bennie Ray Upchurch, III, MD, FACP, AGAF, FACG, FASGE; Chief Editor: BS Anand, MD  more...
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Answer

If two attempts at endoscopic control of the bleeding vessel are unsuccessful, avoid further attempts (ie, because of increased complication risks and mortality) and pursue surgical intervention. The indications for surgery in patients with bleeding peptic ulcers are as follows:

  • Severe, life-threatening hemorrhage not responsive to resuscitative efforts
  • Failure of medical therapy and endoscopic hemostasis with persistent recurrent bleeding
  • A coexisting reason for surgery, such as perforation, obstruction, or malignancy
  • Prolonged bleeding, with loss of 50% or more of the patient's blood volume
  • A second hospitalization for peptic ulcer hemorrhage

The operative treatment options for a bleeding duodenal ulcer historically include vagotomy, gastric resection, and drainage procedures. Each specific operative option is associated with its own incidence of ulcer recurrence, postgastrectomy syndrome, and mortality. When making an intraoperative judgment on how to best manage the bleeding ulcer, it is extremely important for the surgeon to be aware of these differences. [16]

The three most common operations performed for a bleeding duodenal ulcer are as follows [10] :

  • Truncal vagotomy and pyloroplasty with suture ligation of the bleeding ulcer
  • Truncal vagotomy and antrectomy with resection or suture ligation of the bleeding ulcer
  • Proximal (highly selective) gastric vagotomy with duodenostomy and suture ligation of the bleeding ulcer

The purpose of the vagotomy is to divide the nerves to the acid-producing body and fundus of the stomach. This inhibits acid production that occurs during the cephalic phase of gastric secretion, thereby decreasing the risk for recurrent ulceration.

In addition to having the same effects as a highly selective vagotomy in the proximal stomach, a truncal vagotomy also has marked effects on distal gastric motor function. It weakens distal gastric peristalsis, thus requiring the creation of a pyloroplasty to decrease the resistance to outflow from the stomach. Proximal vagotomy abolishes gastric receptive relaxation and impairs storage in the proximal stomach. As a result, a more rapid gastric emptying of liquids occurs. A drainage procedure is not required, because the innervation of the antrum and pylorus is still intact. Consequently, the gastric emptying of solid food is not altered. The antropyloric mechanism still functions normally and continues to prevent duodenogastric reflux.

Truncal vagotomy and suture ligation of a bleeding ulcer is a frequently used operation for treating upper GI bleeding in elderly patients with life-threatening hemorrhage and shock. The procedure can be performed rapidly, minimizing the time spent in the operating room under general anesthesia.

Much of what is now known about the operations performed for bleeding duodenal ulcers came from the era before the etiologic role for H pylori and nonsteroid anti-inflammatory drugs (NSAIDs) in the development of peptic ulcers was understood. Reducing gastric acidity has been proven to be beneficial, with lower rebleeding rates when using high-dose omeprazole. [6] Although PPIs seem to have an advantage, they have no effect on mortality.

The diagnosis of H pylori infection is important in the management of patients with a complicated bleeding peptic ulcer. If a patient with a bleeding ulcer requires surgery, then knowledge of the patient's H pylori status becomes pertinent, because it may help guide the decision to choose a particular surgical procedure (eg, simply oversewing the ulcer as opposed to performing an antiulcer operation).

Many studies support the decision to manage the bleeding ulcer in conjunction with eradication of H pylori.

The 2008 Scottish Intercollegiate Guidelines Network (SIGN) guideline recommends testing for H pylori in patients with peptic ulcer bleeding. Eradication therapy should be prescribed for those who test positive for an active infection. In those who take NSAIDs, maintenance antisecretory therapy should consist of daily PPI for prevention of recurrent ulceration after successful healing of the ulcer and H pylori eradication, if the NSAIDs cannot be discontinued. [35, 120, 152]


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