Gastric Ulcers

Gastric Ulcers are open sores or lesions in the gastric mucosa. Causes and treatments are the same as gastritis. Untreated ulcers may lead to perforation or bleeding.

Ulcers vary in shape and size.

Large Ulcers with blood clots and signs of recent bleeding.

Bleeding from ulcers can be a serious, potentially life threatening condition. Cauterization of bleeding can be accomplished safely and effectively through EGD and use of bicap, heater probe, or laser. This cauterization is often sufficient to control bleeding and prevent patient from undergoing surgery. If cauterization is unsuccessful, the sight of bleeding is injected to induce vascular constriction.

Bicap Probe

Example: Patient admitted cool and clammy with complaints of nausea and weakness. On admission CBC results showed HGB 9.8 and HCT 29.5. History indicated medication regime of Naprosyn twice a day and Aspirin once every day. The patient was transfused with two units of packed cells, blood count improved to HGB of 10.9 and HCT 33.3. Repeat H&H showed continued drop - HGB 10.3 and HCT 30.2. The patient was endoscoped and a bleeding ulcer was found. This was cauterized and injected with epinephrine to stop bleeding. The patient stabilized and was sent home two days later.

Patients with large gastric ulcers are rescoped at six to eight weeks after therapy to evaluate healing.

Healed gastric ulcers after eight weeks of Cimetidine (Tagament) and discontinuation of aspirin.

This patient was unresponsive to therapy and referred for gastrectomy.

Helicobacter pylori is as a bacteria which has been associated with chronic gastritis. Treatment includes the use of antibiotics as well as H2 Blockers of proton pump. Ulcer may be present since the bacteria weakens the stomach lining and damage by acid can occur. This bacteria can be detected by biopsy taken during EGD, and recently as a blood test is also available to detect the presence of H-pylori.

Example: Patient presented with ten pounds weight loss, epigastric pain and waterbrash, EGD revealed gastritis with large ulcer present. CLOtest was positive for helicobacter pylori. The patient was treated with Tetracycline, Flagyl, and Pepto Bismol for two weeks and Axid for eight weeks. Follow up EGD showed ulcer and negative CLOtest.

Large Ulcer (above)
Site of healed ulcer after treatment

Surgical intervention for the treatment of ulcer disorders is sometimes necessary to remove diseased areas and prevent reoccurrence of bleeding and persistent symptoms for non healing ulceration.

Vagotomy is simply cutting of the vagus nerve in an attempt to decrease stimulation of parietal cells and decrease impulses to muscles of the stomach, intestine and gallbladder. Parietel cells are responsible for the secretion of HCL acid and are found in the gastric mucosa.

This procedure may impair gastric emptying and therefore is usually performed along with a Pyloroplasty. Pyloroplasty is enlargement of the pylorus to allow adequate emptying of the stomach. Gastrectomy is removal of the stomach or part of the stomach. The procedures are Billroth I or Billroth II.

Billroth I is removal of the gastric antrum with reanastamosis of the stomach remnant to the proximal duodenum.

Billroth II is removal of the antrum with reanastomosis of the stomach remnant to a loop of the proximal jejunum, food bypasses a large portion of the proximal intestine resulting in suboptimal stimulation of bile and pancreatic secretions.

Afferent Loop: ends proximally at the end of the duodenal bulb closure.

Efferent Loop: the anastomosis of the gastric remnant to the jejunum.

This particular patient has recurrent ulcer despite surgery.

From:  Endoscopy: " An Insiders Look" by Krista M. Stayton, RN.  Used with permission.