Chronic Complications Of Peptic Ulcer

Chronic Complications Of Peptic Ulcer

1. Gastric Outlet Obstruction: Earlier, it was called pyloric stenosis. However, gastric outlet obstruction is a better word. Chronic cicatrisation of a duodenal ulcer or juxtapyloric ulcer results in the narrowing of pyloric antrum, which is described as pyloric stenosis. In India, pyloric stenosis is more common in South Indian patients, who usually present with a long history of duodenal ulcer and a recent history of vomiting.

Gastric Outlet Obstruction Symptoms

• Classical hunger pain of duodenal ulcer disappears. It may be replaced by a dull aching pain because of gastric distension. Colicky pain is due to hyper-peristalsis of stomach.
• Vomiting is profuse, projectile, persistent, foul-smelling (because of stasis) and nonbilious.
• There may be distension of upper abdomen with epigastric fullness.

Gastric Outlet Obstruction Pyloric Stenosis

• Pyloric stenosis in CDU—Misnomer
• Stenosis is very often found in the first part of duodenum
• In cases of pyloric channel ulcer, true pyloric stenosis occurs
• Metabolic changes, such as paradoxical aciduria, are usually seen in patients with ulcer, not in carcinoma because of relative achlorhydria in the latter

Gastric Outlet Obstruction Signs

1. Visible gastric peristalsis (VGP): Stomach that you
   see
   • It is a wave of contraction of the stomach which starts in the left hypochondrium, runs across the umbilicus and ends in the right hypochondrium. These contractions can be felt—stomach that you feel. The presence of VGP is diagnostic of pyloric stenosis (right to left peristalsis is seen in left-sided obstructive colonic tumours). If VGP is not seen, it can be made prominent by:
   • Asking the patient to drink at least 500-1000 ml of water.
   • Stimulating the abdomen by flicking movement.
2. Succession splash
   • Should be done on a ‘fasting’ stomach. This test should be done before asking the patient to drink water.
   • In pyloric stenosis, there is always residual fluid in the stomach, which gives a splashing sound that can be heard with/without a stethoscope—stomach that you hear.
3. Auscultopercussion test/auscultoscraping test to find out the greater curvature of the stomach. Procedure: Keep the “bell” of the stethoscope in the centre of the epigastrium (ask the patient to hold the bell of the stethoscope) and percuss radially. Percussion over the stomach gives a dull note because of the presence of fluid. When the note changes, it indicates the greater curvature of stomach. Mark it on the abdomen (instead of percussion, scraping can be done with a fingernail). A line joining 3 or 4 such marks outlines the greater curvature of stomach.
   • Saline load test: 700 ml of normal saline is infused into stomach for 3 to 5 minutes through a nasogastric tube and is clamped. If a volume more than 350 ml can be aspirated after 30 minutes, it indicates obstruction.

Electrolyte Changes in Gastric Outlet Obstruction

• Hypochloraemic alkalosis
• Hyponatraemia
• Hypokalaemia
• Paradoxical aciduria

Gastric Outlet Obstruction Investigations

1. Barium meal X-ray

• Hugely dilated stomach (large and low stomach).
• Barium does not enter the duodenum. Barium mixed with food residue can give rise to mosaic appearance. Delay in evacuation.

2. Gastroscopy

• The scope will not enter the duodenum. Stomach is full of foul-smelling food residue.
• Gastroscopy is also done to rule out carcinoma of the stomach.

3. Electrolyte study (vide infra)

Gastric Outlet Obstruction Treatment (ABCDEF)

A: Aspiration with Ryle’s tube—good stomach wash, twice a day is given to keep the stomach empty. Saline is used as it decreases oedema of the stomach wall. Stomach wash should be given for at least 3-5 days before surgery.

B: Blood is arranged for surgery. Blood may be required preoperatively to treat anaemia.

C: Charts: Adequate urine output is maintained by infusion of intravenous fluids.

D: Drug: Antibiotics for surgery.

E: Exploratory laparotomy: Vagotomy followed by GJ is done. Pyloroplasty should not be done because the duodenum is scarred, cicatrised, fibroses and narrowed.

F: Fluids to correct electrolyte abnormalities. Pyloric stenosis patients can develop “hyponatraemic, hypochloraemic, hypokalaemic alkalosis”. Normal saline infusion is better initially than ringer lactate because ringer lactate can aggravate metabolic alkalosis.

Postoperatively these patients recover very fast. Dehydration improves and nutritionally they show dramatic improvement. Even the gastric tone may return after a few years.

Differential Diagnosis of Gastric Outlet Obstruction: There are two important causes for gastric outlet obstruction have been given in Table. However, duodenum obstruction in the second part or third part by malignancies, annular pancreas or lymph nodal masses may give rise to persistent vomiting but usually it is bilious.

2. Tea-Pot Deformity Or Handbag Stomach: A long-standing lesser curve gastric ulcer causes shortening of the lesser curvature due to fibrosis. Such stomach resembles a tea-pot. As a result of this, the pylorus becomes nondependent. Hence, stasis occurs.

Tea-Pot Deformity Or Handbag Stomach Treatment: Partial gastrectomy followed by Billroth 1 anastomosis

3. Hourglass Contracture: When a saddle-shaped ulcer in the lesser curvature gets cicatrised, it involves both surfaces of the stomach resulting in conversion of stomach into two compartments.

• Features of stasis such as fullness, distension and persistent vomiting are present.
• Females are affected more often.
• Weight loss is present. Appetite is decreased.
• It is treated by Billroth I partial gastrectomy with removal of 2nd pouch.

4. Penetration Into Pancreas: Posterior gastric ulcer can penetrate into the pancreas, resulting in severe referred pain to the back resembling pancreatic pathology. However, this type of pain is relieved on lying down.