Ulcer surgery

Anatomy or system affected: Gastrointestinal system, intestines, stomach

Definition: The removal of areas of the stomach or duodenum that are ulcerated; a procedure often avoided by nonsurgical treatment.

Indications and Procedures

Many people who are host to peptic ulcers have no symptoms. As these ulcers—which may occur as single or multiple eruptions having a diameter between 0.75 centimeters (0.3 inch) and 2.5 centimeters (1 inch) and a depth of about 0.02 centimeter (0.01 inch)—enlarge and multiply; however, symptoms often become apparent. These symptoms include a burning or gnawing pain in the abdominal region, particularly when the stomach is empty. Therefore, people who are asymptomatic during the day when they are ingesting food at regular intervals may become symptomatic at night. One way to allay symptoms, particularly those caused by a duodenal ulcer, is to eat so that the gastric juices feed on the food rather than on the lining of the stomach or duodenum. Symptoms often reappear, however, a few hours after eating.

In some cases, patients experience a loss of appetite. If the ulcer is in the duodenum, however, the opposite may occur, in which case it is best to eat small quantities of food that is not overly spicy. Belching often accompanies ulcer problems, although, in and of itself, this is not categorically indicative of ulcers. People suffering from ulcers sometimes lose weight, largely because they feel bloated and, therefore, tend to eat less. Nausea and vomiting accompany some ulcer problems.

In extreme cases, an ulcer may start to bleed, in which case the patient may vomit blood. Black, tarry stools are also an indication of bleeding in the stomach, although elements in one’s diet, particularly iron, can also produce darkened stools. Where bleeding is profuse, the patient may require a blood transfusion. On rare occasions, an ulcer may eat through the back wall of the digestive tract and involve the pancreas, causing pain that reaches as far as the patient’s back. When ulcers eat through the front of the duodenum, the result may be peritonitis, a life-threatening inflammation of the abdominal lining that requires immediate attention.

If ulcers persist and go untreated, they can cause dangerous scarring of the stomach lining and duodenum. As a result, the passageway between the stomach and duodenum narrows. When this condition, called pyloric stenosis, occurs, patients usually experience vomiting and weight loss.

Some ulcers are malignant (cancerous) and must be removed surgically. Follow-up radiation and/or chemotherapy may be indicated in such cases. The surgical removal of ulcers involves making an incision in the abdomen and removing the portion of the stomach or duodenum that is ulcerated. The area affected is then joined and sutured. Large portions of the stomach may be removed if necessary and will, in time, regenerate.

Uses and Complications

Except where malignancy is suspected, ulcer surgery is a treatment of last resort. Often, changes in diet can control the situation, as can discontinuing smoking and the drinking of alcoholic beverages or beverages that contain caffeine. Aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) can irritate the stomach and are usually not advised for people with ulcers. The appearance of ulcers has been linked to stress, so changes in lifestyle can result in considerable improvement.

The most common early treatment is with nonprescription antacids or with similar prescription drugs that coat the stomach lining and neutralize the acids that are causing the problem. Prescription drugs, such as H2 blockers and proton pump inhibitors, as well as antimicrobial treatment of the ulcerogenic bacteriaHelicobacter pylori, can almost invariably cure gastric and duodenal ulcers, leaving surgery for removal of malignancies and control bleeding that cannot be stopped by endoscopic cautery. Ulcer patients are also generally advised to eat several small meals a day rather than two or three large ones. Doing so helps to keep food in the stomach, and even nibbling through the night produces favorable results in some patients.

Because ulcer surgery is major and is usually done under general anesthesia, it carries the risks associated with any major surgery. The recovery rate after ulcer surgery is good, however, particularly as the areas around the excision begin to return to normal through regeneration. Where a malignancy has been detected early and removed surgically, metastasis can usually be prevented, particularly if follow-up radiation or chemotherapy is employed.

Perspective and Prospects

Ulcers were once treated by bed rest and a bland, boring diet, mostly of soft foods, such as boiled eggs, toast, and custards, accompanied by plenty of milk, which supposedly lined the stomach and protected it from damage by gastric juices. Such treatment is generally considered unnecessary in the twenty-first century. Most ulcer patients can remain active and can eat sensibly but relatively normally. Extremely spicy food, which can irritate an ulcer, should be avoided if ulcer symptoms are present.

In the past, another method of ulcer treatment was to freeze the affected area, which seemed to produce immediate, favorable results. In time, however, many of the ulcers treated in this way returned. This treatment, although appealing for its short-term results, is uncommon in modern medicine because its benefits do not appear to be lasting.

In the twenty-first century, the management of ulcers has become increasingly conservative, with surgery the least frequent and most extreme treatment of all. In the foreseeable future, it is likely that ulcer surgery will become an increasing rarity.

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