Stomach surgery for ulcers

The chief goals of treatment are reducing the amount of acid in the stomach, strengthening the protective linings that come in direct contact with gastric acids, and — if your ulcer is caused by bacterial infection — treating the H. pylori infection with medication. Your doctor will likely prescribe triple therapy which is a combination of antibiotics, such as amoxicillin and clarithromycin, along with a proton pump inhibitor, such as omeprazole (Prilosec) or esomeprazole (Nexium). Metronidazole (Flagyl) can be substituted for amoxicillin in patients who are allergic to penicillin. In patients who have been repeatedly exposed to these antibiotics, or in areas where there is resistance to clarithromycin or metronidazole, quadruple therapy with bismuth (Pepto-Bismol), a proton-pump inhibitor, and 2 antibiotics (like metronidazole and tetracycline) is more effective. Regardless of the regimen, all medications should be taken for 10-14 days.

Surgical treatment of peptic ulcers is reserved for ulcer disease unresponsive to medical management or emergency treatment of complications, such as bleeding. If your ulcer is hemorrhaging, the surgeon will identify the source of the bleeding (usually a small artery at the base of the ulcer) and repair it. Perforated ulcers — holes in the entire stomach or duodenal wall — must be surgically closed. This is an emergent procedure.

In some cases, an elective surgery to decrease stomach acid secretion may be necessary. However, you should have an in-depth discussion with your doctor as there are many potential complications associated with the procedures, including ulcer recurrence, liver complications, and ”dumping syndrome,” which causes chronic abdominal pain, diarrhea, vomiting, and/or sweating after eating.

Contents

Summit Medical Group Web Site

What is a perforated ulcer?

A perforated ulcer is a raw place or sore in the lining of the stomach or upper intestine that makes a hole through the tissue. Acids that digest food, bacteria, and food may then move through the hole and into your belly. Blood vessels or other organs, such as your pancreas and liver, may be damaged. This could cause a life-threatening infection.

What is the cause?

The lining of the stomach and intestine normally keeps these organs from being hurt by stomach acid and digestive juices. If this protective layer breaks down, stomach acids can damage the walls of your stomach or intestine and cause an ulcer. If the ulcer gets too big or too deep, it can make a hole in your stomach or intestine.

You may get an ulcer when:

  • You have bacteria called Helicobacter pylori (H. pylori). These bacteria are the most common cause of ulcers. When H. pylori bacteria infect the stomach or intestine, the infection can weaken the lining of these organs.
  • You regularly take nonsteroidal anti-inflammatory drugs (NSAIDS), such as aspirin, ibuprofen, naproxen, or ketoprofen. These medicines irritate the lining of the stomach and upper intestine, making it easier for stomach acid to damage the lining.
  • Your stomach makes too much stomach acid.

What are the symptoms?

When an ulcer makes a hole in the wall of your stomach or intestine, the symptoms may come on very fast. Symptoms may include:

  • Sudden sharp belly pain that doesn’t go away
  • Vomit that is bloody or looks like coffee grounds
  • Weakness or feeling like you’re going to faint
  • Fever and chills

How is it diagnosed?

Your healthcare provider will ask about your symptoms and medical history and examine you. Tests may include:

  • X-rays of your chest and belly
  • Blood tests
  • Urine tests
  • CT scan, which uses X-rays and a computer to show detailed pictures of the intestines

How is it treated?

You will stay at the hospital for treatment. You may be given emergency treatment for blood loss, and you will likely have surgery to close the hole.

A tube may be passed through your nose or mouth and down into your stomach. The tube may be used to give fluids or medicine or to help relieve pressure from air or fluids in your stomach and intestine.

Other treatments usually include:

  • Medicine to lower the acid in your stomach
  • Medicine that coats and protects the lining in your stomach and intestine from acid
  • Antibiotics to prevent or treat infection
  • Pain medicine

When you are able to eat again, you will have a liquid diet for 24 hours or longer. Then you will eat only soft foods until your stomach has healed enough for you to go back to your regular diet.

How can I take care of myself?

  • Take your medicines exactly as prescribed.
  • Follow the diet prescribed by your healthcare provider. Avoid any food or drink that seems to bother your stomach, such as spicy foods; acidic foods like oranges or tomatoes; and tea, coffee, and cola.
  • Avoid alcohol, cigarettes, and chewing tobacco because they slow the healing of ulcers. If you smoke, try to quit. Talk to your healthcare provider about ways to quit smoking.
  • Ask your provider if you should avoid NSAIDs and use acetaminophen for pain relief instead. If your provider says it’s OK to take these drugs, try taking them with food to help avoid irritating your stomach.
  • A healthy lifestyle may also help:
    • Try to get at least 7 to 9 hours of sleep each night.
    • Stay fit with the right kind of exercise for you.
    • Learn to manage stress. Ask for help at home and work when the load is too great to handle. Find ways to relax, for example take up a hobby, listen to music, watch movies, or take walks. Try deep breathing exercises when you feel stressed.
  • Ask your healthcare provider:
    • How and when you will hear your test results
    • How long it will take to recover
    • What activities you should avoid and when you can return to your normal activities
    • How to take care of yourself at home
    • What symptoms or problems you should watch for and what to do if you have them
  • Make sure you know when you should come back for a checkup.

What are the other Names for the Procedure?

  • Antrectomy
  • Pyloroplasty
  • Surgery for Peptic Ulcer

What is the Peptic Ulcer Surgery surgical procedure?

The Peptic Ulcer Surgery is a procedure to reduce the accumulation of acid within the stomach, in order to prevent the formation of ulcers.

What part of the Body does the Procedure involve?

A Peptic Ulcer Surgery involves the esophagus, stomach, duodenum, jejunum, and vagus nerves.

Why is the Peptic Ulcer Surgery surgical procedure Performed?

A Peptic Ulcer Surgery is performed for the following reasons:

  • Excessive bleeding from ulcer site
  • Excruciating pain in the abdomen
  • Obstruction of contents within the stomach
  • Ulcer perforation resulting in peritonitis

What are some Alternative Choices for the Procedure?

  • The use of laparoscopic procedure (keyhole surgery) is a recent advancement
  • Advances in medicines used in anesthesia have decreased the risk of complications

What are the Recent Advances in the Procedure?

Alternatives to Peptic Ulcer Surgery include the use of medications to reduce the acid secretion, along with drugs to fight infection by a type of bacteria called H. pylori, if necessary.

What is the Cost of performing the Peptic Ulcer Surgery surgical procedure?

The cost of Peptic Ulcer Surgery procedure depends on a variety of factors, such as the type of your health insurance, annual deductibles, co-pay requirements, out-of-network and in-network of your healthcare providers and healthcare facilities.

In many cases, an estimate may be provided before the procedure. The final amount depends upon the findings during the surgery/procedure and post-operative care that is necessary.

When do you need a Second Opinion, prior to the Procedure?

  • It is normal for a patient to feel uncomfortable and confused by the information regarding Peptic Ulcer Surgery on what needs to be done
  • If the patient needs further reassurance or a second opinion, a physician will almost always assist and also recommend another physician, if required
  • Also, if the procedure involves multiple surgeries or has many alternatives, the patient may take a second opinion to understand and choose the best one. They can also choose to approach another physician independently

What are some Helpful Resources?

http://www.patient.co.uk/doctor/ulcer-surgery-and-its-complications (Accessed on 11/10/2014)

http://heartburn.about.com/cs/articles/a/Ulcer_Surgery.htm (Accessed on 11/10/2014)

How is the Peptic Ulcer Surgery surgical procedure Performed?

A Surgery for Peptic Ulcer is generally performed under general anesthesia. Depending on the surgical procedure being performed, the following may be done:

  • Vagotomy: The surgeon cuts the vagus nerve (the nerve that transmits messages to increase acid secretion)
  • Antrectomy: This involves the removal of the lower portion of the stomach, called the antrum
  • Pyloroplasty: This procedure involves enlarging the passage between the stomach and the duodenum (the first portion of the small intestine)

Where is the Procedure Performed?

A Peptic Ulcer Surgery procedure is performed in a hospital.

Who Performs the Procedure?

A general surgeon or a gastrointestinal surgeon performs the Peptic Ulcer Surgery procedure.

How long will the Procedure take?

The time taken depends on the type of Peptic Ulcer Surgery procedure being performed, and it may take up to a few hours.

What do you need to tell your Physician before the Procedure?

It is very important to provide the following information to your healthcare provider. This enables your healthcare provider in assessing the risks for the Peptic Ulcer Surgery procedure and helps avoid unnecessary complications.

  • Provide a complete list of medications you are currently, taking to your physician. This information is useful for a variety of reasons. For example, it can help your healthcare provider prevent complications due to a drug interaction
  • If you are allergic to any specific medication or food items
  • If you are taking blood thinners, such as aspirin, warfarin, herbal supplements, or any other such medications
  • If you or your family members, have a history of bleeding disorders, or if there is a tendency to bleed more than normal
  • If you have diabetes, high blood pressure, chest pains, or have previously suffered from a heart attack
  • If you have ever been diagnosed with blood clots in your leg (deep vein thrombosis) or lung (embolism of lung)
  • If you have a history of frequent bone fractures (this may affect bone-healing, if bones are involved as part of your procedure)
  • A list of all previous surgical procedures you have undergone, like for example: Removal of appendix, gallbladder, or any other part, of your body; surgical repair of any body part, such as hernia repair, perforation of bowel wall, etc.

What Preparations are needed, prior to the Procedure?

  • The physician may evaluate the individual’s medical history to gain a comprehensive knowledge of the overall health status of the patient including information related to the medications that are being currently taken
  • Some medications increase a person’s chances of bleeding and it may be recommended to discontinue them for a period of time, before the procedure is performed
  • Blood tests may be performed to determine, if there is a bleeding tendency or any other medical conditions that prevents the person from undergoing the procedure
  • Do inform the physician if you are allergic to any local anesthetics, lidocaine, etc.
  • Avoid application of any cosmetics, deodorant, or topical medicines on the area, prior to the procedure
  • It is advisable to quit smoking and the use of any nicotine based products, for a while, before the surgery
  • Consumption of alcoholic drinks must also be avoided for a period of time, as instructed
  • The patient must avoid eating or drinking at least 8 hours prior to the surgical procedure, depending on when the procedure is arranged
  • For persons suffering from diabetes, it is important that the blood sugar stays within the normal range; if not their diabetologist may have to control blood sugar by recommending insulin and/or a combination of oral medicines

What is the Consent Process before the Procedure?

A physician will request your consent for Peptic Ulcer Surgery procedure using an Informed Consent Form.

Consent for the Procedure: A “consent” is your approval to undergo a procedure. A consent form is signed after the risks and benefits of the procedure, and alternative treatment options, are discussed. This process is called informed consent.

You must sign the forms only after you are totally satisfied by the answers to your questions. In case of minors and individuals unable to personally give their consent, the individual’s legal guardian or next of kin, shall give their consent for the procedure.

What Tests are needed, before the Peptic Ulcer Surgery surgical procedure?

Before a Peptic Ulcer Surgery procedure, the patient has to undergo certain tests, such as:

  • Routine blood and urine analysis
  • Abdominal X-ray
  • Endoscopy

What are some Questions for your Physician?

Some of the basic questions that you might ask your physician are as follows:

  • What is a Peptic Ulcer Surgery?
  • Why is this procedure necessary? How will it help?
  • How soon should I get it done? Is it an emergency?
  • Who are the medical personnel involved in this procedure?
  • Where is the procedure performed?
  • What are the risks while performing the procedure?
  • What are the complications that might take place, during recovery?
  • How long will it take to recover? When can I resume normal work?
  • How many such procedures have you (the physician) performed?
  • Are there any follow-up tests, periodic visits to the healthcare facility required, after the procedure?
  • What are the costs involved?

What kind of Anesthesia is given, during the Procedure?

General anesthesia by injection and inhalation is administered for the procedure.

How much Blood will you lose, during the Procedure?

There is not much blood loss during an uncomplicated Pyloroplasty procedure.

What are the possible Risks and Complications during the Peptic Ulcer Surgery surgical procedure?

There are general factors that increase the risk of getting complications during surgery and they include:

  • Obesity: Generally greater the degree of obesity, greater is the surgical risk
  • Smoking: Longer the smoking history (in pack years smoked), greater the surgical risk
  • Advancing age
  • Poorly controlled diabetes, as evidenced by a high hemoglobin A1c and a high fasting glucose
  • Poorly functioning kidney, as evidenced by increased BUN (blood urea nitrogen) and blood creatinine
  • Poorly functioning liver, as evidenced by increased blood liver function tests
  • Hypertension (increased blood pressure), especially if it is poorly controlled
  • Poor nutritional status (malnutrition with mineral and vitamin deficiencies)
  • Poor lung function, as evidenced by abnormal lung function tests
  • History of bleeding disorders
  • Longstanding illness, such as autoimmune disorders, chronic infections
  • Poor immune system due to a variety of causes

The possible risks or complications that may arise during the Peptic Ulcer Surgery are:

  • Excessive bleeding
  • Infection in the surgical wound
  • Anesthetic complications
  • Accidental injury to large blood vessels and surrounding nerves within the neck, top of the lungs, thoracic duct, and laryngeal nerve

What Post-Operative Care is needed at the Healthcare Facility after the Peptic Ulcer Surgery surgical procedure?

At the healthcare facility, usually there is no requirement for any post-procedure care, unless any complications arise.

What are the possible Risks and Complications after the Peptic Ulcer Surgery surgical procedure?

Post Peptic Ulcer Surgery, the following complications may arise:

  • Excessive bleeding
  • Infection in the surgical wound
  • Incisional hernia
  • Recurring peptic ulcers
  • Excessive diarrhea
  • Malnutrition
  • The occurrence of symptoms that cause uneasiness, such as flushing, fainting, or diarrhea, after consuming certain foods

What is the Prognosis after the Surgery?

A complete recovery from a Peptic Ulcer surgical procedure is usually achieved, without any serious complications being observed.

When do you need to call your Physician?

Do contact your physician if you notice any of the following symptoms:

  • Pain that worsens and swelling around the surgical wound
  • Bleeding or fluid drainage from the surgical wound
  • The occurrence of any symptom that causes uneasiness, such as nausea, vomiting, constipation, abnormal swelling, or excessive rectal bleeding
  • Signs of an infection
  • Muscle aches, headache
  • Dizziness
  • Fever, feeling sick
  • Complications associated with prescription medications used in treatment

What Post-Operative Care is needed at Home after the Peptic Ulcer Surgery surgical procedure?

At home, the following post-operative care is recommended, after a Peptic Ulcer Surgery:

  • Slowly resume regular/daily activities as early as possible, which aids in faster recovery
  • Use a heat pad or warm compress to relieve pain due to the incision
  • Resume showering and keep the wound clean and dry. Avoid taking baths until the surgical wound is completely healed. Gently wash the surgical wound with unscented soap and re-bandage the wound again
  • Complete the course of prescribed medication under advice of the physician
  • Take antibiotic medication to help combat or prevent infection (per the physician’s advice)
  • Avoid taking nonprescription medications, such as aspirin. However, individuals may take acetaminophen to relieve pain, per the physician’s advise
  • Resume driving after 2 weeks, or only when advised by your physician
  • Individuals are advised to have clear liquids immediately following surgery, until the gastrointestinal tract begins functioning properly. They are then advised to have a well-balanced diet, which can aid in a faster recovery.

How long does it normally take to fully recover, from the Procedure?

It usually takes about 4-6 weeks to fully recover from a Peptic Ulcer Surgery.

What happens to tissue (if any), taken out during the Procedure?

The tissue is taken for further examination and later disposed as per the standard medical procedure.

When should you expect results from the pathologist regarding tissue taken out, during the Procedure?

  • The tissue removed is processed in the laboratory under a pathologist’s supervision
  • Slide(s) are prepared once the tissue is processed and is examined by a pathologist and a pathology report issued
  • Depending on the complexity of the case, issue of the report may take anywhere between 72 hours to a week’s time

Who will you receive a Bill from, after the Peptic Ulcer Surgery surgical procedure?

It is important to note that the number of bills that the patient may receive depends on the arrangement the healthcare facility has with the physician and other healthcare providers.

Sometimes, the patient may get a single bill that includes the healthcare facility and the consultant physician charges. Sometimes, the patient might get multiple bills depending on the healthcare provider involved. For instance, the patient may get a bill from:

  • A hospital
  • An anesthesiologist (if anesthesia was administered)
  • A pathologist (if the tissue is sent for analysis)
  • A general surgeon or gastrointestinal surgeon

The patient is advised to inquire and confirm the type of billing, before the Peptic Ulcer Surgery procedure is performed.

Thanks and Gratitude:

We sincerely acknowledge and thank Dr. Douglas J. Jones for reviewing the article. His valuable input and feedback has helped enrich the contents of this article.

Douglas J. Jones, MD FACS
Board Certified General Surgeon and Faculty Member
University of Illinois, College of Medicine at Urbana-Champaign
506 S. Mathews Ave., Urbana, IL 61801, USA

Emergent laparoscopy in treatment of perforated peptic ulcer: a local experience from a tertiary centre in Saudi Arabia

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Patient Education

Bleeding Peptic Ulcer: Treatment

A peptic ulcer is a sore in the lining of your stomach or duodenum (the first part of the small intestine). Your ulcer is bleeding or at high risk of bleeding. This means that you need treatment right away. Treatment can include medicines. It may also include a procedure such as endoscopy, angiography, or surgery. Your provider will work with you to decide which treatments are best for you. Read on to learn more about each type of treatment.

Treatment with medicines

Medicines will be prescribed as part of your treatment. Combinations of medicines are needed. These can include:

  • Antibiotics. These medicines kill the H. pylori (Helicobacter pylori) bacteria if it is present. An H. pylori infection is the most common cause of a peptic ulcer. You will have to take several antibiotics at the same time.

  • Proton pump inhibitors. These block your stomach from making any acid.

  • H2 blockers. These reduce the amount of acid your stomach makes.

  • Bismuth subsalicylate. This helps protect the lining of your stomach and duodenum from acid.

When taking medicines, be aware of the following:

  • Each medicine has risks and side effects. Your healthcare provider will tell you more about these, based on the medicines that are prescribed for you.

  • Treatment with antibiotics lasts about 7 to 14 days. You may need to take other types of medicines for a longer time. Be sure to take all of the medicines exactly as instructed. Don’t stop taking the medicines even if you are feeling better.

  • During treatment, avoid nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin and ibuprofen. Also avoid blood thinners and anticoagulants. Overuse of these drugs is another possible cause of ulcers. Using them can make your symptoms worse. If you take aspirin because of a heart condition, blood clot, or stroke, you must talk with your healthcare provider first before you stop taking aspirin.

  • Your provider may also advise you to avoid cigarettes, alcohol, and caffeine. These may make your symptoms worse. They may also affect how well your ulcer heals.

Treatment with endoscopy, interventional angiography, or surgery

Along with medicines, your treatment may include endoscopy, interventional angiography, or surgery. Endoscopy is usually the first treatment used. Here’s what to expect with each treatment:

Before the treatment

  • You may be told to not eat or drink anything for at least 6 hours before the treatment.

  • Tell your provider about any medicines you are taking. You will have to stop taking some or all of these medicines before treatment. This includes:

    • All prescription medicines

    • Over-the-counter medicines such as aspirin, ibuprofen, and other NSAIDs

    • Street drugs

    • Herbs, vitamins, and other supplements

  • Follow any other instructions from your provider.

During the treatment

A needle is placed in a vein in your hand or arm. It’s attached to an IV (intravenous) line. The IV line gives you fluids. It also gives you medicine to prevent pain. This may include medicine to make you drowsy (sedative) or sleep (anesthesia) during treatment. The provider will then treat your ulcer with one of the following:

  • Endoscopy. This procedure uses a thin, flexible tube called an endoscope (scope). The scope has a tiny camera on the end. This lets the provider find the ulcer. First, your throat may be numbed with a spray or gargle. Then, the scope is put into your mouth and guided down into your stomach or duodenum. Air is used to expand the digestive tract. Once the ulcer is found, tiny tools are passed through the scope to stop any bleeding. These may include clips or devices that use heat or electricity. In some cases, medicine (epinephrine) is injected directly into the ulcer to help reduce bleeding. When the bleeding is stopped, the air is removed. The scope and any tools used are then also removed.

  • Interventional angiography. A long catheter is thread into the arteries near the ulcer. A clot is put into the ulcer to stop the bleeding.

  • Surgery. This can be done in 2 different ways:

    • Open surgery. A cut (incision) is made in your belly (abdomen) to reach the ulcer. This lets the surgeon see and treat the ulcer directly.

    • Laparoscopy. A few small cuts are made in your belly. A scope with a tiny camera is then inserted through one of the cuts. Pictures of the inside of your belly are sent to a screen. This lets the provider find the ulcer. Tiny tools are then passed through the other cuts to treat the ulcer. Nearby nerves, blood vessels, and parts of the stomach may also be treated. Once the surgery is done, the cuts are closed. Any tools used are removed.

After the treatment

You’ll be taken to a recovery room or ICU (intensive care unit). Nurses will watch your condition closely. You’ll be moved to a hospital room when you’re stable. You will be given medicines to help manage pain and to ease symptoms. Tests may be done to see if your ulcer is bleeding again. You’ll stay in the hospital until your provider confirms there are no problems.

Before leaving the hospital, make sure you have all the prescriptions and home care instructions you’ll need. Also make sure you have a contact number for your provider or the hospital. This is in case you have problems or questions after treatment.

New types of treatment are also being studied. Ask your provider about any new treatment options.

Risks and possible complications of treatment

For endoscopy:

  • Bleeding

  • A hole (perforation) in your upper digestive tract (this includes your esophagus, stomach, and duodenum)

  • Risks of sedative or anesthesia used

  • The ulcer coming back

For angiography:

  • Hole (perforation) in a blood vessel

  • Risks of sedative or anesthesia used

  • The ulcer coming back

For surgery:

  • Bleeding

  • Infection

  • Damage to nearby organs and blood vessels

  • Long-term digestive problems such as irregular bowel movements

  • Risks of anesthesia

  • The ulcer coming back

  • Death

Follow-up

Keep all follow-up appointments with your provider. These are needed to check your health and recovery progress.

When to call your healthcare provider

Call your healthcare provider right away if you have any of the following:

  • Trouble breathing or chest pain (call 911)

  • Fever of 100.4°F (38°C) or higher, or as advised by your healthcare provider

  • Increased redness, pain, swelling, bleeding, or drainage from any incisions

  • Trouble swallowing or sore throat that doesn’t go away within 2 days

  • Belly pain that won’t go away

  • Black, tarry, or bloody stools

  • Upset stomach (nausea) and vomiting

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