Peptic Ulcer Disease for the Acute Care Surgeon

Peptic ulcer disease (PUD) was not well elucidated as a significant contributor to patient morbidity and mortality until the early 1900s. From that time up until the late twentieth century, PUD was felt to be caused by stress and dietary factors, with treatments focusing on dietary modification, bed rest, and later on, acid suppression and neutralization (Friedenwald, Am J Med Sci 144:157–70, 1912; Malfertheiner et al., Lancet 374(9699):1449–61, 2009; Harbison and Dempsey, Curr Probl Surg 42:346–454, 2005). With the discovery of Helicobacter pylori in the 1980s and the subsequent development of improved medical regimens to treat the organism and suppress acid production, the incidence of PUD has decreased dramatically over the past 30 years (Ramakrishnan and Salinas, Am Fam Physician 76(7):1005–12, 2007). Furthermore, data gathered from multiple countries within the same time period reveals a 40–50 % global decline in incidence (Groenen et al., Can J Gastroenterol 23(9):604–8, 2009; Paimela et al., Scand J Gastroenterol 37(4):399–403, 2002; Wang et al., Ann Surg 251(1):51–8, 2010). In accordance with the trend of successful medical management, surgeons have seen a steady decline in the rate of elective surgery for PUD over the past three decades. Procedures that were once common have become a rarity for today’s surgical residents to encounter. However, though the rate of elective interventions has declined dramatically (80–97 %), the rate of emergency surgery related to PUD has remained constant or increased (Paimela et al., Scand J Gastroenterol 37(4):399–403, 2002; Schwesinger et al., J Gastrointest Surg 5(4):438–43, 2001). Wang et al. reported a 44 % increase in emergent operative interventions related to PUD from 1993 to 2006, and in 2006, there were nearly 25,000 operations performed in the USA alone for perforated or bleeding peptic ulcers. With the evolution of therapeutic modalities for the treatment of PUD, including pharmaceutical advancements and continued improvement of endoscopic technology and therapies, surgical interventions have become more salvage in nature. The majority of surgical indications for PUD are now limited to complications from hemorrhage or perforation that have failed medical and minimally invasive interventions. Less frequently, surgical interventions are sought for rare causes of PUD such as gastrinoma or Zollinger–Ellison syndrome (ZES), antral G-cell hyperplasia, trauma, or burns. Elective operative gastric procedures, though rare, are primarily for lesions suspicious for malignancy or refractory PUD due to failed medical therapy, patient intolerance, or noncompliance (Napolitano, Gastroenterol Clin North Am 38:267–88, 2009). Undoubtedly, the next generation of acute care surgeons will be called upon to manage the urgent and emergent complications of PUD, on a much more complicated population of patients, with significantly less experience than generations prior. The goal of this chapter is to provide a brief overview of the pathophysiology, epidemiology, and presentation of PUD with a more in-depth description of the management and operative techniques as they relate to the acute care surgeon in urgent and emergent situations.