Benign Gastric Ulcer

Abstract

Benign gastric ulcer is usually a consequence of Helicobacter infection, nonsteroidal antiinflammatory drug (NSAID) or aspirin use, and/or smoking. Most patients are treated as outpatients and never see a surgeon. The most common indication for operation in benign gastric ulcer is perforation; other indications include bleeding, obstruction, and (least commonly) intractability. Although resection is the ideal surgical treatment for gastric ulcer since it rules out cancer and gets rid of the diseased mucosa at risk for ulcer formation (locus minoris resistentiae), many surgical patients nowadays are high risk or too unstable for resection, and some of the gastric ulcers are inconveniently located. Thus biopsy (cancer must be ruled out) with patch (for perforation), oversew (for bleeding), or bypass (for obstruction) are acceptable nonresective options. Distal gastrectomy with Billroth 1 or 2 reconstruction is the operation of choice for low-risk, stable patients with type 1 gastric ulcer. Vagotomy should be strongly considered in stable patients with type 2 (gastric with duodenal ulcer) or type 3 (prepyloric) gastric ulcer, whether they are treated with distal gastric resection or loop gastrojejunostomy. Roux-en-Y gastrojejunostomy should be used when the proximal gastric remnant is small, such as after re-resection for recurrent gastric ulcer, or after excision of high juxtacardia (type 4) gastric ulcer; this prevents bile esophagitis. Recurrent ulcer after operation for gastric ulcer, or marginal ulcer after Roux-en-Y gastric bypass, is common in the presence of Helicobacter infection, NSAID use, smoking, and/or hyperacidity.