Duodenal ulcer complicated by obstruction

Duodenal Ulcer Complicated

by Obstruction

Results of Medical Treatment

CHARLES H. BRO~rN. M.D.*

B o ~ T ~ I~PaOVE~E~'r in surgical technique and the decrease in mortality for peptic ulcer have been progressive over the

past ten to twenty years. In some medical centers the mortality for elective peptic ulcer surgery has been reduced to approxi- mately 1 per cent. This surgical achievement has encouraged many to conclude that all patients with a complicated peptic Ulcer are surgical candidates. It is timely to recall that Sippy, as early as 1915, reported on ulcer patients with the complication of pyloric obstruction who responded to intensive medical treatment. 1

The enthusiasm engendered by improved surgery and lowered mortality should not overshadow the individual patient who, while a 1 per cent mortality statistic, is none the less 100 per cent dead. That he dies from benign disease is the greater tragedy. In addi- tion, the postoperative complications of dumping syndrome, malnu- trition, anemia, and marginal ulcer acc6unt for a morbidity occur- rence varying from 10 to 20 per cent. The significance of this problem i.s indicated by the fact that one entire afternoon session of the First World Congress of GastroenterologT (Washington, D. C., June, 1958) was devoted to the consequences of gastric resection and its management. In our personal experience we include observations on. severe dumping syndromes, hypoglycemia, megalo- blastic anemia, iron-deficiency anemia, psychasthenia, and several suicides that occurred following gastric surgery for duodenal ulcer.

We believe medical treatment warrants a thorofigh trial in every patient, surgery being reserved for established medical intracta- bility and complication. Occasionally, medical treatment of peptic ulcer may be more time-consuming to both the physician and the patient than operation.

*Associate Professor of Gastroenterology, The Frank E. Bunts Educational Inst i tute, Clevelanfi, Ohio.

From the Department of Gastl'~enterology, The Cleveland Clinic Foundat ion and The Frank G. Bunts Educational Inst i tute, C]eve!and, Ohio.

Presented a t the Peptic Ulcer Symposium, Louisiana State University, Nov. 1, 1958.

AMERICAN JOURNAL OF 940 DIGESTIYE DISEASES

Complicated Duodenal Ulcer

While obstruct ion due to duodenal ulcer is r ega rded by many as an indicat ion for surgery, S ippy ' s early repor t s ~ of successful medical t r ea tmen t of obst ruct ion have been conf i rmed/ ' 3.4

CLINICAL EXPERIENCE

We repor ted previously on 36 pat ients with severe obstruct ion due to ulcer, all of whom were t rea ted medically. ~ The average dura t ion of ulcer symptoms was 11.7 years. Six had had symptoms f rom 22 to 39 years. There is the inference tha t scarr ing and eieatricial stenosis could have occurred in such pro longed illness. F o u r of the pa t ien ts had had hemorrhage , and one had a h is tory of gast r ic ulcer. The dura t ion of follow-up var ied f rom 31/~ months in 1 pa t ien t who was t r ea ted surgically, to 10 years , wi th an average follow-up of 56 months . Th i r ty pa t ien ts were hospital ized at the onset of t rea tment , while 6 were t rea ted as outpat ients .

THERAPEUTIC'METHODS AND PRINCIPLES

The t r ea tmen t of" tile obst ruct ion employed in this group of pa t ien t s is divided into four per iods : (1) the first 24 hours, (2) the first 14 days, (3) the first 6 weeks, and (4) the p r o g r a m to p reven t recurrence thereaf te r .

I m m e d i a t e T r e a t m e n t

The therapeut ic objectives of the first 24 hours include o'astric decompress ion and correct ion of dehydra t ion and electrolytic imbalance. Af te r tho rough aspiratino" and lavaging the s tomach wi th a large Ewald tube, a Levin tube is inser ted and cont inuous suction mainta ined. Dehydra t ion , alkalosis, and electrolyte imbalance are corrected by pa ren te ra l fluids. T rans fus ions are given if indicated.

E v a l u a t i o n

Afte r the first 24 hours , a period of' evaluat ion f rom 7 to 14 days begins. Continuous gast r ic suction is d iscont inued if response has been sat isfactory, and the pa t ien t is placed on a str ict ulcer sched- ule. Asp i ra t ion with a large Ewald tube at bedt ime is done every night . I f more than 250 ec. are obtained, a Levin tube is re inser ted and cont inuous suction is used dur ing the night. When less than 250 ec. are obtained for seven consecutive nights, the night ly asp i ra t ions are discontinued. Ant ichol inergie d rugs and a t ropine are not given the first 7 to 14 days ; these agents decrease g'astrie

NEW SERIES VOL 4, NO. ;I, 1959 941

Brown

peristaltic activity and motility and may further retention. If the obstruction has been relieved by 7 to i4 days of' medical treatment, anticholinergic drugs may then be used.

After the first three days of treatment, if progressively less is obtained by the nightly aspiration, obstruction is considered relieved. Depending upon the amount of material obtained, a progress roentgenogram of the stomach with a 6-hour retention film may be obtained in the first 10 days. When the obstruction has been relieved and has been established to have occurred on the basis of a duodenal ulcer, the patient is ambulated on a strict ulcer program including antichotinergic drugs2

If patients with obstruction are treated medically, it is essential that the cause of the obstruction--duodenal ulcer versus pyloric carcinoma--be demonstrated roentgenologically before they are discharged from the hospital.

Follow-Up A six-week follow-up with roentgenologic examination-of the

stomach is insisted upon. This examination will usually show healing of the ulcer and no evidence of obstruction.

Ulcer P r o g r a m

The patient is then placed on a simple ulcer program designed to complete healing of his ulcer, to prevent recurrence of obstruction, and ~o mininlize cieatricial stenosis.

ADVANTAGES OF MEDICAL TREATMENT

Improved Diagnosis On the initial roentgen examinatioI1 i n , h e presence of' obstruc-

tion, the pyloroduodenal segment may not be adecinately visualized (Fig. 1A). Consequently, the differential diagnosis between obstruction due to ulcer and carcinoma of the pylorus i(Fig. 1B) may not be established until the obstruction has been relieved and thL~ segment can be adequately evaluated. This is' usually possible within the first 14 days of medical treatment (Fig. 2). In question- able cases gastric cytology may be of diagnostic hssistance. Gastric cytologT, in our lab~)ratory, has proved to be more than '90 per cent accurate in the diagnosis of gastric carcinoma/ If, despite careful evaluation and repeat roentgenograms 10 days after initiation of treatment, there still remains a question of pyloric carcinoma (see Fig. 1B), surgery should be advised.

AMERICAN JOURNAL OF 942 DIGESTIVE DISEASES


Fig. I . A, dilated obst ruct- ed s t o m a c h a f te r b a r i u m swallow. Pa t i en t h a d typi- cal u lcer h i s to ry of 6 yea rs ' du ra t i on . On basis of h is tory , it was a s s u m e d tha t obs t ruc t ion was due to d u o d e n a l ulcer. B, a f t e r 12 days ' in tens ive me d i c a l t r e a t m e n t as out- l ined, s t o m a c h still ob- s t ruc ted . Cause of obst ruc- t ion n o t d e m o n s t r a t e d roen tgenologica l ly . At op- e ra t ion , c a r c i n o m a of pylorus was f o u n d .

There are a number of advan tages of this first 14 days of treat- men t : (1) The obstruct ion is often rel ieved even whell due to pylor ie carcinoma. (2) The di lated s tomach re tu rns to normal size and tone. (3) The electrolytes and hemoglobin are res tored to normal. (4) Different ial diagnosis of the cause of the obs t ruc t ion- - ulcer versus pylorie ca rc inoma- - i s achieved (Pig. 3). (5) The pat imlt is bet ter p r epa red for surgery. Consequently, this period of medical t r ea tmen t for obst ruct ion is indica ted even though surgery may be advisable u l t imate ly (~'ig. 4).

OUTCOME OF MEDICAL T R E A T M E N T

All of the 36 pat ients we s tudied and t rea ted as out l ined above had significant obstruct ion (in excess of 20 per cent ba r ium retch-

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AMERICAN JOURNAL OF .944 DIGESTIVE DISEASES

C o m p l i c a t e d D u o d e n a l U l c e r

Fig. 3. A, obstruct ion in " h i g h p res su re" executive who had ulcer history of 5 years ' durat ion. Cause of obs t ruct ion not visualized since none of the bari- um has lef t s tomach. B, x-ray fi lm af ter ba r ium swallow a week later clear- ly demons t ra tes large ulcer crater . On medical treat- men t , obs t ruct ion was re- ];eved and ulcer crater dis- appeared . For past 71/_~ years (since episode of obs t ruc t ion) , pa t ient has r e m a i n e d asymptomatic , and repea ted x-rays of the s tomach have shown no re- curreuce of active ulcer despi te tensions associated with his work.

NEW SERIES V O L . 4, N O . i I, 1959 945

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C o m p l i c a t e d D u o d e n a l Ulcer

t ion at 6 hours ) . In 23 individuals ba r ium re ten t ion was in excess of 50 per cent, wi th 10 of these showing almost a complete 6-hour ol)struction. A high degree of obstruct ion was p resen t in the 8 pa t ien ts in whom 6-hour films were not obtained. F o u r of these pa t ien ts had marked gastr ic di la tat ion (see Fig. 4A), 6 showed 24- hour retent ion, in 2 of whom the retent ion was es t imated to ap- p rox imate 50 per cent.

Rel i e f o f Obs truc t ion

The obstruct ion was rel ieved in all 36 pat ients who were t r ea ted as outlined, and progress roeu tgenograms did not demons t ra te 6-hour re ten t ion in any of the pat ients . (The t ime in terval between the ini t ial and progress roen tgenograms averaged 9.2 days but var ied f rom 5 to 21 days.)

R e c u r r e n c e

111 subsequent follow-up examinat ions we observed tha t recur- ren t obst ruct ion occurred in 9 of the 36 pat ients , 27 had no fu r the r obstruct ion, 5 pa t ients died of causes unre la ted to the ulcer.

On 23 pat ients who cont inued with medical t rea tment , the average follow-up was 56 months or a lmost 5 years. Only 1 of the 23 pa t ien t s developed recur ren t obstruct ion and this was rel ieved by f u r t h e r medical t rea tment . Twenty- two of the pa t ien ts had no f u r t h e r episodes of obst ruct ion dur ing this follow-up period.

S u r g e r y

The pa t ien ts subsequent ly undergo ing su rge ry numbered 13 out of the group of 36. All 13 had responded init ial ly to medical t reatment wi th relief of their obstruct ion. The average t ime interval between their episode of obst ruct ion to the t ime of surgery was 47 months and var ied f rom 3~A months to 9 years.

An effort was made to de te rmine the reason for surgical election in these 1:3 eases. In 4 pa t ien ts opera ted upon elsewhere, data were insufficient. E igh t of the 13, however, had recto ' rent obstruct ion (see Fig . '4). We have justification for believing tha t one pa t ien t with recur ren t symptoms of obstruct ion of only 7 days ' durat ion, 6 years af ter the original episode, may have r e sponded to repeti- t ion of medical t rea tment . One pa t ien t had no evidence of recurrent obstruction. Four did not follow medical t r ea tment .

NEW SERIES voL. 4, NO. ~, ~959 947

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Cooperation of Patient This may be the crux of the problem in the t rea tment of peptic

ulcer. Many patients who do not respond to medical t rea tment are individuals who do not adhere to their program. As Dr. Wal ter Pa lmer has asked, " I s it the ulcer that i s intractable or the pa- t i en t ? " In this connection we should note that many operations for ulcer are elective. I~i car ing for his ulcer the patient may prefer the presumably easier method, surgery, to medical treatment, in cases in which the indications for surgery are not defini- tive or absolute. I t is of in te res t that none of the 13 patients who subsequently underwent surgery had a fu r ther t r ia l of n]~dieal t reatment .

Prognosis The degree of dilatation of the stomach as obse rved initially

was found to have no prognostic value; patients whose stomachs were dilated to several times normal size have responded well to the t rea tment outlined. There is nothing on the initial roentgenogram (severi ty of gastric retention, nar rowing of the channel, retention of food, etc.) that bears prognostic significance in deter- mining whether surgery will be necessary.

SUMMARY

Good results were obtained with medical management in a group o f patients with severe obstruction of the stomach due to duodenal ulcer. The success of the medical approach :ou t l ined suggests the following conclusions:

1. An intensive trial of medical t rea tment is indicated for all patients with obstruct ion due to ulcer.

2. Recurrence of adequately managed obstruction is not fre- quent; 75 per cent of the pat ients had no recurrence in the average follow-up period Of 56 months.

3. A recurrent episode of obstruction may respond to fur ther medical t reatment.

REFERENCES

1. SIPpY, B . W . Gastric and duodenal ulcer: medical cure by effieie~t re'movat of g:~stric juice corrosion. J.A.M.A. 64:1625, 1915.

2. ]3aowN, R. C. " U l c e r of Stomach, Duodenum, and Je junum. ~' In Oxford Medicine.. New York, Oxford Univ. Press, ]949, ¥ol. 3, P a r t I, p. 1°5.

3. Bgow/¢, R. C. Results of medical t reatment of peptic' ulcer. J.A.MiA. 95:11~4, 1930. 4. L~tHEY, F. It. Treatment of gastric and duodenal ulcer. J.A.M.A. 95:313, 1930.

AMERICAN JOURNAL OF 948 DIGESTIVE DISEASES


5. GIglFONE, J. W., and BROW?C, C. I-I. Results of medical treatment of duodenal ulcer complicated by obstruction. GP 18:78, 1958.

6. BROWN, C. H., and H o ~ g , S. O. Treatment of duodel)al ulcer. Postg~'ad. Med. 12:308, 1952.

7. Kug% E. J., et al. Exfoliative cytology as an aid to the diagnosis of gastric carcinoma. Cleveland Clin. Quart. 19:213, 1952.

A m o n g the papers to appear ill the D e c e m b e r i ssue wi l l be:

Twenty-Five Years of Progress (XII ) : The Future of Gastro- enterology

DWIGHT L. WILBUr, M.D.

Studies on Robudin, Extract from Stomach and Duodenum: Its Effect on Gastric Secretion and Clinical Course of Peptic Ulcer

G~o~G~ B. JEI~z¥ GL~ss, M.I)., and Sa~L A. Sc~w~TZ, M.D.

Jaundice Following Iproniazid Administration with Recovery: Serial Biochemical and Histological Observations of Two Patients

S. P. BRALOW, M.D., and HAImY SI-IAY, M.D.

Liver Function Tests in Patients Receiving Iproniazid (Marsilid) LoIJIs ZETZEL, ~ [ . D . , HEI~MAN KAPL.4,N, 5/[_.D., mad K.aRI~ To DUSSIK, ~/[ .D.

Occult Bleeding: Determination of Its Origin J. ~NOLI) B~RG~, M.D.

Precancerous Gastric Disease H. MAm~ POLLARD, ~I.D.

Therapeutic Principles in Manag'ement of Peptic Ulcer: 1, Diet and Antacids

J . ARNOLD BARGEN, M . D .

Therapeutic Principles in Management of Peptic Ulcer: 2. Anti- cholinergic Agents

ARTI~Va P. KLOTZ, M.D.

NEW SERIES VOL. 4, NO. II , I¢/S9 949

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Duodenal ulcer complicated by obstruction