Management of Complicated Peptic Ulcer Disease

O ur understanding of the pathophysiological features of peptic ulcer disease has rapidly evolved during the last century. Early understanding of gastric physiologic characteristics led to logical and time-tested surgical procedures aimed at acid reduction and a lowering of ulcer recurrence rates. A dramatic shift in treatment occurred with the recognition and growing knowledge of Helicobacter pylori (HP). Where once surgery dominated therapy for ulcer diathesis, medical therapy has now superseded. Just as gastric resection seemed radical to Dr Mayo, thus was medical treatment of peptic ulcer disease similarly approached with skepticism. What was the balance of medical and surgical management of peptic ulcer disease as we entered the 21st century? Complications of peptic ulcer disease requiring operative intervention have remained important. However, the absolute number of procedures performed has significantly diminished in recent years. The reason for the decrease in surgical intervention, both emergent and elective, is multifactorial. Improvements in therapeutic endoscopy, the introduction of effective antacid therapy, and the recognition and treatment of HP infection have all greatly contributed to the successful nonoperative treatment of patients with peptic ulcer disease. With respect to complicated ulcer disease, treatment and eradication of HP infection have arguably led to a shift from treating patients operatively to treating them nonoperatively. This changing management scheme has occurred despite a relative paucity of data regarding the incidence and contribution of HP infection to the etiology of complicated peptic ulcers. Indeed, reports in the literature regarding the incidence of HP infection in a surgical cohort have been sparse. From a surgeon’s perspective, data relative to HP infectionand theclassic indications for surgery—perforation,bleeding, andgastricoutletobstruction(GOO)— have until recently been largely inferential based on treatment of those with uncomplicated peptic ulcers. Deviation from traditional surgical management might prove detrimental should other nonoperative modalities be used. The purpose of this discussion is to review the known pathophysiological features of peptic ulcer disease with a focus on those complications encountered by the surgeon.