Fever, hypotension, and oliguria suggest sepsis and circulatory compromise. Generalized abdominal tenderness, rebound tenderness, board-like abdominal wall rigidity, and hypoactive bowel sounds clinical signs of peritonitis may be masked in older patients and those taking steroids, immunosuppressants, or narcotic analgesics. Upright or lateral decubitus abdominal radiography or erect chest radiography may demonstrate pneumoperitoneum; however, the absence of this finding does not rule out perforation.
Initial resuscitation with large-volume crystalloids; nasogastric suction; and administration of intravenous broad-spectrum antibiotics against gram-negative rods, anaerobes, and oral flora are usually followed by laparotomy and placement of an omental patch Graham patch plication in patients with perforated duodenal ulcers.
In otherwise healthy patients with a history of chronic ulcer and minimal peritoneal contamination, a concurrent, definitive, anti-ulcer procedure e. Perforated gastric ulcers are treated with an omental patch, wedge resection of the ulcer, or a partial gastrectomy and reanastomosis. Peptic ulcer disease is the underlying cause in less than 5 to 8 percent of patients presenting with gastric outlet obstruction.
Patients with recurrent duodenal or pyloric channel ulcers may develop pyloric stenosis as a result of acute inflammation, spasm, edema, or scarring and fibrosis. Symptoms suggesting obstruction include recurrent episodes of emesis with large volumes of vomit containing undigested food; persistent bloating or fullness after eating; and early satiety. Weight loss, dehydration, and a hypo-chloremic, hypokalemic metabolic alkalosis may result; a tympanitic epigastric mass representing the dilated stomach with visible gastric peristalsis also may be observed.
EGD or gastroduodenography using diatrizoate meglumine and diatrizoate sodium [Gastrografin] or barium is recommended to determine the site, cause, and degree of obstruction. Malignancy, a more common cause of obstruction responsible for more than 50 percent of cases , should be ruled out. Prokinetic agents should be avoided. Endoscopic pyloric balloon dilatation or surgery vagotomy and pyloroplasty, antrectomy, or gastroenterostomy are options to relieve chronic obstruction.
Already a member or subscriber? Log in. Interested in AAFP membership? Learn more. He received his medical degree and his master's degree in surgery from the Jawaharlal Institute, Pondicherry, India, and was awarded the Fellowship of the Royal College of Surgeons of Edinburgh, Scotland.
Ramakrishnan completed a family practice residency at the University of Oklahoma Health Sciences Center. Salinas completed a family medicine residency and a fellowship in geriatrics at the University of Oklahoma Health Sciences Center.
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Ann Surg. But certain foods can irritate the stomach further in certain individuals. Your doctor will start by asking about your medical history and symptoms. Let your doctor know when and where you most often have symptoms. Gastric and duodenal ulcers can cause pain in different parts of your abdomen. A variety of tests will usually be recommended since abdominal pain has many causes.
If your doctor thinks H. An EGD test involves passing a lighted flexible instrument with a camera on its end, known as a scope, through your mouth and down into the esophagus, stomach, and small intestine. Your doctor will be able to look for ulcers and other abnormal areas, as well as take a tissue sample biopsy. They may even be able to treat certain conditions. Your doctor may also order a test called a barium swallow or an upper GI series.
This test involves drinking a solution with a small amount of liquid material that easily shows up on an X-ray. Your doctor will then take several X-rays to see how the solution moves through your digestive system. This allows them to look for conditions that affect the esophagus, stomach, and small intestine.
Treatment for gastric and duodenal ulcers depends on the causes and how severe your symptoms are. For example, your doctor may prescribe histamine receptor blockers H2 blockers or proton pump inhibitors PPIs to reduce the amount of acid and protect your stomach lining.
For H. If the ulcer is actively bleeding, your doctor can use special tools to stop the bleeding through an endoscope during the EGD procedure. If the ulcer becomes deep enough to cause a hole through the wall of your stomach or duodenum, this is a medical emergency and surgery is most often required to fix the problem. An untreated gastric or duodenal ulcer can develop into a serious problem, especially if you have certain existing medical conditions. In some cases, gastric ulcers can increase your risk for cancerous tumor growth.
Your doctor will typically recommend repeating an EGD after treatment to confirm that the ulcers are healing. Most gastric and duodenal ulcers will go away with time and proper medical treatment. Learn about possible natural and home remedies for ulcers.
You may not be able to completely remove your risk for developing an ulcer, but there are things you can do to lower your risk and prevent them:. But certain foods may help fight the cause of your stomach ulcer. Both gastritis and duodenitis have the same causes and treatments. Prolonged obstruction may result from peptic scarring and may respond to endoscopic pyloric balloon dilation.
Surgery is necessary to relieve obstruction in selected cases. Factors that affect recurrence of ulcer include failure to eradicate H. Less commonly, a gastrinoma may be the cause. Thus, a patient with recurrent disease should be tested for H. Although long-term treatment with H2 blockers, proton pump inhibitors, or misoprostol reduces the risk of recurrence, their routine use for this purpose is not recommended.
However, patients who require NSAIDs after having had a peptic ulcer are candidates for long-term therapy, as are those with a marginal ulcer or prior perforation or bleeding. Patients with H. There is no increased risk of cancer with ulcers of other etiology. Treatment of gastric and duodenal ulcers requires eradication of H. For duodenal ulcers, it is particularly important to suppress nocturnal acid secretion. Methods of decreasing acidity include a number of drugs, all of which are effective but which vary in cost, duration of therapy, and convenience of dosing.
In addition, mucosal-protective drugs eg, sucralfate and acid-reducing surgical procedures may be used. Some drugs are used in regimens for treating Helicobacter pylori Smoking should be stopped, and alcohol consumption should be stopped or limited to small amounts of dilute alcohol.
There is no evidence that changing the diet speeds ulcer healing or prevents recurrence. Thus, many physicians recommend eliminating only foods that cause distress.
With current drug therapy, the number of patients requiring surgery has declined dramatically. Indications include perforation, obstruction, uncontrolled or recurrent bleeding, and, although rare, symptoms that do not respond to drug therapy.
Surgery consists of a procedure to reduce acid secretion, often combined with a procedure to ensure gastric drainage. The recommended operation for duodenal ulcer is highly selective, or parietal cell, vagotomy which is limited to nerves at the gastric body and spares antral innervation, thereby obviating the need for a drainage procedure. This procedure has a very low mortality rate and avoids the morbidity associated with resection and traditional vagotomy. These are typically combined with truncal vagotomy.
Patients who undergo a resective procedure or who have an obstruction require gastric drainage via a gastroduodenostomy Billroth I or gastrojejunostomy Billroth II. The incidence and type of postsurgical symptoms vary with the type of operation. Weight loss is common after subtotal gastrectomy; the patient may limit food intake because of early satiety because the residual gastric pouch is small or to prevent dumping syndrome and other postprandial syndromes.
With a small gastric pouch, distention or discomfort may occur after a meal of even moderate size; patients should be encouraged to eat smaller and more frequent meals. Maldigestion and steatorrhea caused by pancreaticobiliary bypass, especially with Billroth II anastomosis, may contribute to weight loss.
Anemia is common usually from iron deficiency Iron Deficiency Iron Fe is a component of hemoglobin, myoglobin, and many enzymes in the body. Heme iron, contained mainly in animal products, is absorbed much better than nonheme iron eg, in plants and Deficiency causes megaloblastic anemia, damage IM vitamin B12 supplementation is recommended for all patients with total gastrectomy but may also be given to patients with subtotal gastrectomy if deficiency is suspected.
Dumping syndrome may occur after gastric surgical procedures, particularly resections. Weakness, dizziness, sweating, nausea, vomiting, and palpitations occur soon after eating, especially hyperosmolar foods. This phenomenon is referred to as early dumping, the cause of which remains unclear but likely involves autonomic reflexes, intravascular volume contraction, and release of vasoactive peptides from the small intestine.
Dietary modifications, with smaller, more frequent meals and decreased carbohydrate intake, usually help. Reactive hypoglycemia or late dumping another form of the syndrome results from rapid emptying of carbohydrates from the gastric pouch. Early high peaks in blood glucose stimulate excess release of insulin , which leads to symptomatic hypoglycemia several hours after the meal.
A high-protein, low-carbohydrate diet and adequate caloric intake in frequent small feedings are recommended. Mechanical problems including gastroparesis and bezoar formation Bezoars A bezoar is a tightly packed collection of partially digested or undigested material that most commonly occurs in the stomach. Gastric bezoars can occur in all age groups and often occur in Diarrhea is especially common after vagotomy, even without a resection pyloroplasty.
Recurrent ulcers are diagnosed by endoscopy and generally respond to either proton pump inhibitors or H2 blockers. For ulcers that continue to recur, the completeness of vagotomy should be tested by gastric analysis, H. Peptic ulcers affect the stomach or duodenum and can occur at any age, including infancy and childhood. Most ulcers are caused by H.
Burning pain is common; food may worsen gastric ulcer symptoms but relieve duodenal ulcer symptoms. Acute complications include gastrointestinal bleeding and perforation; chronic complications include gastric outlet obstruction, recurrence, and, when H.
The following is an English-language resource that may be useful. American College of Gastroenterology: Guidelines for the treatment of Helicobacter pylori infection. From developing new therapies that treat and prevent disease to helping people in need, we are committed to improving health and well-being around the world.
The Merck Manual was first published in as a service to the community.
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