eMedicine Specialties > Pediatrics: Surgery > General Surgery

Peptic Ulcer: Surgical Perspective: Treatment

Author: Carlos A Angel, MD, Associate Professor of Pediatrics, Division of Pediatric Surgery, University of Tennessee School of Medicine; Consulting Staff, East Tennessee Children's Hospital, East Tennessee Pediatric Surgery Group
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Updated: Jul 19, 2006

Treatment

Medical Therapy

All current recommendations support eradication therapy in all children with peptic ulcers and proven H pylori infection. Eradication therapy has also been suggested for children with MALT lymphoma, atrophic gastritis, and H pylori with a family history of gastric adenocarcinoma. The benefits of eradication therapy in children without ulcers who have gastritis alone are uncertain. Eradication therapy could be considered as an option in children with H pylori infection who also have refractory iron-deficiency anemia or autoimmune thrombocytopenic purpura because complete or partial responses are seen in approximately one half of cases.

The object of therapy is to hasten resolution of the ulcers, ameliorate symptoms, and prevent complications and recurrence. One of the most important goals of treatment is the eradication of H pylori because primary peptic ulcers are likely to recur unless H pylori infection is controlled. Several combinations of therapeutic agents have been recommended. The best success rates are achieved with triple therapy, combining omeprazole with 2 antibiotics (clarithromycin and amoxicillin or metronidazole) for 1-2 weeks.

13C-UBT is a reliable test to confirm successful eradication of H pylori infection and should be performed at least 4 weeks after completion of therapy. Acquired resistance to clarithromycin (up to 45% of H pylori isolates in children) and, to a lesser extent, resistance to metronidazole is cause for concern. If therapy fails, an alternative triple-therapy regimen should be used, substituting one or both of the antibiotics. Bismuth-containing compounds such as bismuth subsalicylate or ranitidine bismuth citrate are optional, but the use of bismuth-containing compounds in children remains controversial.

Secondary ulcers are treated with acid-suppressing medications, such as H2 blockers, proton pump inhibitors, and mucosal protectants (eg, sucralfate). Offending substances (eg, aspirin, NSAIDs, corticosteroids, nicotine, alcohol) should be stopped.

Surgical Therapy

Surgical treatment is indicated for intractable pain, gastric outlet obstruction (rare in children), bleeding, or perforation. Even with significant bleeding, the initial treatment should be medical because most upper GI bleeding in children stops in 24-48 hours. Operation is indicated when blood loss approaches half the blood volume in 8 hours or 1 blood volume in 24 hours. If the rate of bleeding allows the stomach to be lavaged for endoscopy, endoscopic cautery or injection of sclerosants or vasoconstrictors may control the bleeding and prevent further bleeding episodes. Hemorrhagic shock and anemia need to be treated with fluid resuscitation and blood transfusions; monitoring for signs of continuous bleeding or hypovolemia is essential.

Knowledge of surgical treatment for peptic ulcer disease in children is derived from the experience of treating adults. Subtotal and, occasionally, total gastrectomies often become necessary for cases of acute neonatal gastric necrosis. For hemorrhagic ulcers in the stomach, simple oversewing of the ulcer followed by medical therapy is sufficient treatment; resection is seldom required.

In older children, the ulcers may be located in the duodenum, and best outcomes are achieved with ligation of the bleeding ulcer and an acid-reducing procedure, such as a vagotomy with a pyloroplasty or a proximal gastric vagotomy. The treatment of perforated gastric or duodenal ulcers includes simple closure of the perforation with an omental patch followed by medical therapy. Acid-reducing procedures are optional. Gastric outlet obstruction is treated with (1) vagotomy and gastrojejunostomy or with (2) antrectomy, selective or truncal vagotomy, and gastroduodenostomy or gastrojejunostomy. For Dieulafoy lesions, when an endoscopy cannot control bleeding, operative treatment should be as conservative as possible, with simple ligation of the bleeding point. Cases of Zollinger-Ellison syndrome can be cured if the gastrinoma is identified and removed. Even if removal is incomplete, the use of proton pump inhibitors can control the disease.

Preoperative Details

Fluid resuscitation, preoperative blood transfusions, correction of coagulopathy, and intravenous antibiotics may be necessary to prepare for laparotomy for bleeding or perforated ulcers in children.

Intraoperative Details

The Heineke-Mikulicz pyloroplasty is the most commonly used method of drainage. Proximal or highly selective vagotomies are accomplished by dividing the Latarjet nerves from the stomach's lesser curvature, beginning 7 cm proximal to the pylorus and ending at least 5 cm proximal to the gastroesophageal junction. Perforations are treated with simple closure reinforced with omentum (Graham patch), with or without vagotomy and pyloroplasty, or with a highly selective vagotomy. To approach a bleeding duodenal ulcer, a longitudinal incision across the pylorus and duodenum usually exposes the bleeding branch of the gastroduodenal artery.

Suture ligation at 4 quadrants is sometimes needed when oversewing the ulcer. Occasionally, when suture ligation fails to stop the bleeding, ligation of the gastroduodenal artery cephalad and inferior to the duodenum, followed by an acid-reducing operation, yields the best results.

Postoperative Details

Intravenous fluids, nasogastric decompression, intravenous antibiotics, analgesics, and careful monitoring and support of hemodynamics are mandatory in the immediate postoperative period. The nasogastric tube is removed upon return of gastrointestinal transit, and feeding is slowly begun. Proton pump inhibitors are used throughout the perioperative period, and treatment of H pylori should be instituted immediately after the operative procedure and continued for 2-4 weeks when infection with this organism is suspected or documented. Results of treatment are confirmed later (6-8 wk) with upper GI endoscopy.

Complications

Early complications include wound infections, anastomotic leaks, or recurrence of bleeding. However, morbidity and mortality rates in children are quite low, although they seem to be higher in premature infants with acute gastric necrosis when gastric involvement is extensive. Late complications, such as dumping syndrome, postvagotomy diarrhea, and alkaline reflux, have been reported mostly in adults but can occur in children.

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