The Management of Gastric Ulcers
A Current Review
R. BENTON ADKINS, JR., M.D., F.A.C.S., JOSEPH B. DELOZIER III, M.D.,
H. WILLIAM SCOTT, JR., M.D., F.A.C.S., JOHN L. SAWYERS, M.D., F.A.C.S.
In the past 10 years, 163 patients with documented gastric
ulcers were treated at Vanderbilt University and Metropolitan
Nashville General Hospitals. One hundred thirty-five were
initially managed medically. Medical therapy was successful
in 58 patients (43%) in this group. Twenty-eight (17%) patients
required surgical treatment initially. An additional 77 patients
(57%) became candidates for surgical management when their
medical management failed. Of this group, 40 now have been
surgically treated and 37 still have symptoms while on medical
treatment. Three patients being treated for benign ulcers, two
for as long as six years each, were found to have carcinoma of
the stomach diagnosed by subsequent endoscopy and biopsy in
one and by laparotomy with gastrectomy to include the ulcer
in two. We consider subtotal gastrectomy or surgical resection
of the antrum, including the ulcer site, to be the preferred
surgical treatment for gastric ulcers, and this was done in 50
cases. Vagotomy was done in addition to the antrectomy in 31
of these, and in addition to the subtotal resection in 11. Two
patients who had vagotomy and resection subsequently devel-
oped a marginal ulcer. One of these who had a subtotal
resection and vagotomy healed with medical treatment. The
one who had a vagotomy and antrectomy required a second
vagotomy for a missed vagus nerve. Gastrointestinal endoscopy
in the past 10 years has improved to the point that very few
malignant ulcers are missed by endoscopic biopsy. Large
ulcers, those that perforate or continue to bleed, and those
that fail to heal on medical treatment for a maximum of 2 to
3 months should be submitted to an antrectomy that includes
the ulcer. Vagotomy should be added in selected cases.
T HE PATHOGENESIS of gastric ulcer disease is multi-
factorial. Gastric irritants, gastritis, gastric stasis,
hypersecretion, duodenal reflux, and hereditary factors
are all likely contributors to the ulceration of gastric
mucosa.' With improved technology of upper gastroin-
testinal endoscopy and biopsy, the accuracy of deter-
mining benign from malignant gastric ulcer has greatly
improved. This has allowed us to employ more safely a
trial of medical management to see if the gastric ulcer
Presented at the 96th Annual Meeting of the Southern Surgical
Association, December 3-5, 1984, Palm Beach, Florida.
Reprint requests: R. Benton Adkins, Jr., M.D., Department of
Surgery, Vanderbilt University School of Medicine, Nashville, TN
37232.
Submitted for publication: January 11, 1985.
741
From the Surgical Services of Metropolitan Nashville
General Hospital, Vanderbilt University Medical Center, and
the Section of Surgical Sciences, Vanderbilt University
School of Medicine, Nashville, Tennessee
will heal. Elective operations are now done for those
uncomplicated gastric ulcers that fail to heal or that
recur after healing. Urgent and emergency operations
are done for bleeding, perforation, and gastric outlet
obstruction. We have previously reported our experience
with the management of gastric ulcer prior to modem
gastroscopy.2 This report reviews our results over the
past 10 years in patients with Type I, II, and III gastric
ulcer disease and evaluates our current method of man-
agement.
Materials and Methods
One hundred sixty-three patients who were treated at
the Metropolitan Nashville General and the Vanderbilt
University Hospitals from January 1973 to January
1984 with documented gastric ulcers were identified
through a medical record and surgical pathology record
search. Approximately 250 pyloric channel ulcers and
50 acute stress ulcers were treated during this time but
were excluded from this review. Each patient's record
was reviewed for initial symptoms, site and size of ulcer,
treatment, and outcome. Patients were categorized as
having Type I, II, or III ulcers based on a modification
of Johnson's3 classification. The classifications we have
used are as follows:
Type I: An ulcer in the body of the stomach without
abnormality of the duodenum, pylorus, or prepyloric
region.
Type II: An ulcer in the body of the stomach combined
with an ulcer or its scar in the duodenum or at the
pylorus.
Type III (without duodenal ulcer): A gastric ulcer
close to the pylorus (within 3 cm) in the absence of a
duodenal ulcer or scar.
 742 ADKINS AND OTHERS Ann. Surg. * June 1985

TABLE 1. Signs and Symptoms blockers, antacids, and diet. Forty of these 135 eventually
Successful Failed Initial required surgical treatment of their gastric ulcer disease.
Medical Medical Surgical Twenty-eight patients with complicated gastric ulcers
Management Management Management were managed surgically without a trial of conservative
n = 58 n = 77 n = 28
treatment because of bleeding, perforation, severe pain,
Pain 34 (59%) 56 (74%) 21 (75%) or large ulcer size (Table 2).
Burning 13 (22%) 20 (26%) 5 (18%) Three patients (1.8%), two of whom had been treated
Vomiting 26 (45%) 42 (55%) 16 (57%)
Weight loss 11 (19%) 17 (22%) 5 (18%) medically for 6 years each, were found to have gastric
Anorexia 7 (12%) 11 (14%) 4 (14%) carcinoma at the time of laparotomy in two and by
Bleeding 34 (59%) 44 (58%) 20 (71%) repeated endoscopic biopsy in one. Two of these were
originally considered to be benign gastric ulcerations
and were in the failed-medical-management group. The
Type III (with duodenal ulcer): A gastric ulcer close other, who was in the initial-surgical-management group,
to the pylorus (within 3 cm) with an associated, but was considered benign by endoscopic biopsy but had
separate, duodenal ulcer. early, planned, surgical treatment because of a large
ulcer with bleeding.
Pyloric channel ulcers which extended uninterrupted
across the pylorus and into the duodenum were consid- Results
ered to be more duodenal than gastric and were excluded
from this study. Successful Medical Management
The average age of the patients in this series was 54.2 Fifty-eight of the 135 patients (42.9%) who were
years (range 2 to 87). There were 87 women and 76 managed medically had sustained resolution of symptoms
men. The most common symptom was pain (111 pa- and radiographic and/or endoscopic evidence of reso-
tients) followed by gastrointestinal bleeding (98 patients) lution of the ulcer. Of these 58, 40 were Type I, four
and vomiting in 84 patients (Table 1). Seventy-one were Type II, 12 were Type III without duodenal ulcer,
patients (44%) were cigarette smokers; 23% (37) were and two could be classified as Type III with an associated
classified as alcohol abusers. Thirty-five (21%) were duodenal ulcer. We could detect no pattern for the
habitual aspirin users. likelihood of success of medical management based
One hundred-thirteen patients (69.3%) with ulcers in upon the location of the ulcer within the stomach (Fig.
the cardia, body, and upper gastric antrum and who 1). Forty-nine (83%) of these 58 patients had endoscopy
had no history of or present clinical evidence of duodenal and biopsy of the gastric ulcer prior to or early in the
ulcer disease were classified as Type I. Seventeen patients course of the medical trial. The average duration of
(10.4%) with gastric ulcers in the Type I location who medical treatment was 10.4 months with a range of
had associated duodenal ulcers were categorized as Type three weeks to seven years before the resolution of
II. Fifteen per cent (25) of the patients in this series had symptoms. We have been liberal in our classification as
prepyloric ulcers within 3 cm of the pylorus without "successful" of those seven cases that took two to seven
duodenal ulcers (Type III). The eight remaining patients years to "cure."
(4.9%) had the same type of prepyloric gastric ulcers Most of these 58 ulcers (37) were less than 1 cm. in
with associated but separate duodenal ulcers, and they diameter when originally diagnosed. Eleven patients had
were also classified Type III. The total number of successful medical management who had large ulcers
patients with Type III ulcers by this definition was 33 (greater than 1 cm). The duration of treatment averaged
(20.2%). 13.3 months in these 11 patients (range two months to
One hundred thirty-five patients (83%) were initially seven years) with the large ulcers. Eight of these 11 large
managed medically with combinations of histamine ulcers were secondary to substance abuse and resolved
TABLE 2. Management by Ulcer Type
Failed Medical Management
Successful Initial Without With
Medical Surgical Surgical Surgical
Management Management Treatment Treatment Total
Type I 40 (35%) 19 (17%) 25 (22%) 29 (26%) 113
Type II 4 (24%) 5 (29%) 3 (18%) 5 (29%) 17
Type III, without duodenal ulcer 12 (48%) 4 (16%) 4 (16%) 5 (20%) 25
Type III, with duodenal ulcer 2 (25%) 0 5 (63%) 1 (13%) 8
Total 58 (36%) 28 (17%) 37 (23%) 40 (25%) 163
Vol. 201 * No. 6 MANAGEMENT OF GASTRIC ULCERS
when the contributing substance (alcohol, aspirin, ste-
roids) was finally eliminated. In 10 other cases managed
successfully with medical treatment, the original size of
the gastric ulcer was never accurately documented but
they all healed (Table 2).
Failed Medical Management
Seventy-seven of the 135 patients (57%) who were
initially begun on a medical regimen and treated con-
servatively with combinations of histamine blockers,
antacids, and diet did not have a successful resolution
of symptoms or healing of the ulcer. Of these 77
patients, 54 (70%) had Type I ulcers, eight (10%) had
Type II, nine (12%) had Type III without duodenal
ulcer, and six (8%) had Type III ulcers in association
with a known duodenal ulcer. The duration of treatment
now averages 29 months for these 77 patients (range
one week to 15 years) and continues to grow for those
in the group who are still alive, have not been treated
surgically, and are yet to be called "cured" on continued
medical regimens. The average size of the ulcers in this
group of 77 patients whose ulcers failed to resolve on
medical management was 1.7 cm at the time of diagnosis.
Forty of these 77 patients have subsequently had
surgical management of their ulcer disease. The ulcer
size averaged 1.78 cm in this group. These 40 patients
are discussed in greater detail under Surgical Treatment.
Of the remaining 37 patients, those who are alive remain
symptomatic and are still on medical treatment. The
average ulcer size in this group being managed medically
is 1.54 cm. These patients have been treated medically
an average of 31 months, and some for as long as 12
years. Eight of these 37 have refused surgical treatment,
and 29 for some reason apparently have not been
considered to be surgical candidates by their gastroen-
terologists and/or by their surgeons. (Table 2).
The two patients who developed gastric carcinoma in
this group of 77, whose ulcers failed to resolve with
medical management, had both been treated medically
for 6 years. In one case, the malignancy was discovered
by repeated endoscopic biopsy of a persistent 2.3 X 1.5
6-year-old ulcer on the lesser curvature. The patient had
a radical total gastric resection, creation of a Paulino
pouch, and Roux-en-Y anastomosis. He is alive without
evidence of recurrence 16 months after treatment. The
second patient had been treated with antacids and
cimetidine for 6 years without a biopsy of the Type I
ulcer and with only intermittent relief of her symptoms.
She eventually was referred to the Surgical Service at
age 65 with symptoms of acute small bowel obstruction.
At the time of laparotomy, adbominal carcinomatosis
from the gastric carcinoma (which had been considered
to be a benign ulcer) was found. A side-to-side anasto-
mosis of ileum to distal colon was done to bypass and
743
FIG. 1. The distribution of the 163 gastric ulcers is shown as the
denominator at each site, along with those that responded successfully
to medical management shown as the numerator at each site (58
patients).
to relieve the obstruction. She died approximately 1
month after the operation.
One patient in this group of 77 whose ulcers did not
respond to medical management died. This was an 81-
year-old woman who was treated medically for 9 months
for a 2-cm Type I bleeding ulcer. She had a sudden
cardiac arrest while hospitalized for continued bleeding
(see Mortality).
Initial Surgical Management
Twenty-eight patients had surgical treatment of their
gastric ulcers within 1 month of onset of symptoms
without the consideration of a trial of more conservative
measures because of multiple problems related to the
ulcer. They were operated upon without a planned trial
of medical treatment because they were experiencing
bleeding (20 patients), severe pain (21 patients), very
large ulcer size (ten patients), or because of perforation
(five patients). Nineteen of these 28 patients (67.8%)
had Type I ulcers, five (18%) had Type II, and four
(14%) had Type III without duodenal ulcer. The average
ulcer size for this group was 2.2 cm. The largest was 7
X 8 cm. This group is included and discussed in more
detail in the section Surgical Treatment (Table 2).
The patient who developed gastric carcinoma in this
group of 28 was a 62-year-old woman who had a 3-
week history of upper gastrointestinal bleeding. On
upper gastrointestinal radiograph, a deep 2.2 cm X 2.5
cm Type II gastric ulcer on the lesser curvature was
seen in addition to an active duodenal ulcer (Fig. 2).
Endoscopic biopsies were done and interpreted as chronic
inflammation and necrosis. A planned antrectomy to
include the ulcer, vagotomy, and Billroth I procedure
were done within 3 weeks of onset of symptoms because
744 ADKINS AND OTHERS
FIG. 2. UGI series shows a deep, lesser curvature gastric ulcer in the
antral area. The presence of an associated duodenal ulcer
upper
characterizes this lesion as a Type II gastric ulcer. The radiologic,
endoscopic, and gross pathologic appearance of the lesion were all
typical for benign gastric ulcer. Final pathological report of the resected
specimen was that of gastric adenocarcinoma.
of the large ulcer size and bleeding. The unexpected
final pathologic report 5 days later was that of adeno-
carcinoma of the stomach. She did well for 2 years, but
FIG. 3. The distribution of the 163 gastric ulcers is shown as the
denominator at each site, along with those that required elective,
urgent, and emergency surgical management shown as the numerator
at each site. There was no pattern of distribution to distinguish those
requiring elective procedures from those requiring nonelective proce-
dures. (Forty after failed medical management; 28 without medical
trial.)
Ann. Surg. * June 1985
then returned with metastatic involvement of the small
bowel, colon, and pancreas. Endoscopic examination
and biopsy of the stomach and duodenum were benign
at that time. She died 2 years after diagnosis with
abdominal carcinomatosis.
Surgical Treatment
A total of 68 patients in this series of 163 patients
with gastric ulcers were managed with surgical treatment.
Forty of these 68 had failed a trial of medical therapy
that averaged 27 months (range 2 weeks to 15 years).
Twenty-six of these 40 patients had elective procedures
and had failed medical trials averaging 34 months.
Fourteen of the 40 required emergency operations and
had failed medical trials that averaged 7.4 months before
the emergent situations requiring surgical correction
became imminent. Twenty-eight patients required
planned surgical management initially within an average
of 4 weeks of onset of symptoms. Of those 28 operations,
15 were done as emergencies within a few days of onset
of symptoms. The distribution of the 68 gastric ulcers
requiring elective, urgent, and emergency surgical man-
agement was relatively even throughout the stomach
(Fig. 3).
We have judged the Visick rating in the 50 patients
who had distal gastric resection to include the ulcer with
or without vagotomy to be Grade I in 80% and Grade
II in 8%. Five patients (10%) required reoperation and
one patient (2%) died following partial gastric resection.
Type of Operation
The 68 surgically-treated patients have been catego-
rized for review by type of operation. The categories we
have used are (1) antrectomy with or without vagotomy;
(2) subtotal gastrectomy with or without vagotomy; (3)
vagotomy, pyloroplasty, and suture of the ulcer; (4)
suture or closure of ulcer without vagotomy or excision
of the ulcer; (5) proximal gastric or parietal cell vagotomy
alone; and (6) suture or closure of the ulcer with
proximal gastric or parietal cell vagotomy (Table 3).
Antrectomy with or without vagotomy. The gastric
ulcer was managed with a vagotomy and antrectomy,
including the ulcer, in 31 patients (46%). Of these 31,
eight were emergency procedures for gastric outlet ob-
struction (two) and perforation (one) from the initial-
surgical-management group and for bleeding (three) and
gastric outlet obstruction (two) from the failed-medical-
management group. Twenty-five of these 31 patients
have not had complications or recurrence of their uclers.
One of these, however, is the patient discussed previously
in whom gastric adenocarcinoma was discovered by the
pathologist. Three patients have had postoperative gastric
outlet obstruction and required revision of a Billroth I
anastomosis in two and revision of a Roux-en-Y in one.
 Vol. 201 * No. 6 MANAGEMENT OF GASTRIC ULCERS 745
One patient developed both bile reflux gastritis and a TABLE 3. Surgical Treatment and Ulcer Type
microscopic suture line ulcer at the gastroduodenal Type III
anastomosis. She required the takedown of a Billroth I,
a higher gastric resection, completion of the vagotomy Without With
for a missed vagus nerve, and a Roux-en-Y procedure. Duodenal Duodenal
Type I Type II Ulcer Ulcer
Two other patients who had vagotomy, antrectomy, and n=50 n=10 n=9 n=l
Billroth I have had dumping syndrome, but neither of
them has required an additional operation. Partial resection
with Roux-en-
Two patients had an antrectomy to include the ulcer Y without
and Billroth I without vagotomy. One of these two was vagotomy 2
done as an emergency procedure for bleeding in a Partial resection
with Roux-en-
patient from the failed-medical-management group. The Y with
other of these two patients whose operation was done vagotomy 4
electively for a large Type I ulcer developed bile reflux Partial resection
with B-I
gastritis and had revision of the gastroduodenostomy without
only. vagotomy 4
Subtotal gastrectomy with or without vagotomy. Partial Partial resection
with B-I and
gastric resection (50% or greater) to include the ulcer vagotomy 4 2 1
was done in 17 patients with an associated vagotomy in Antrectomy with
eleven of these. Of these 17, seven were done as emer- B-I 2
Vagotomy,
gency procedures for bleeding (one) and gastric outlet antrectomy
obstruction (one) from the initial-surgical-management with B-I 15 6 4 -
group and for bleeding (three) and gastric outlet obstruc- Vagotomy,
antrectomy
tion (two) from the failed-medical-management group. with B-II 2 1
Fourteen of these 17 patients who had subtotal gastric Vagotomy,
resection did well without ulcer recurrence. Two patients antrectomy
with Roux-en-
who had vagotomy and Billroth I procedures for Type Y 2 - 1
I and II ulcers had complications following the proce- Proximal gastric
dures. One developed bile reflux gastritis and the other or parietal cell
vagotomy 1 1 3
had an ulcer at the anastomotic site. Neither of these Vagotomy with
two patients required additional surgical management; suture of ulcer 3
both were managed medically with success. One other Vagotomy,
pyloroplasty,
patient in this group had a third degree atrioventricular and suture of
block intraoperatively, developed renal failure postop- ulcer 4 1
eratively, and died 20 days later. Suture of ulcer
only 5
Vagotomy, pyloroplasty, and suture of the bleeding
ulcer. Five other patients were managed with vagotomy,
pyloroplasty, biopsy, and suture of the bleeding ulcer. of failed-medical-management. Two of these five patients
All five were done as emergency procedures for bleeding had persistent ulcers with bleeding. One of these was
for four Type I and one Type II ulcers. Two had an managed with a vagotomy and antrectomy with Billroth
associated Nissen fundoplication done at the same time I, and the other patient required a subtotal resection
for hiatal hernia. Three of these patients were from the vagotomy, and Billroth I.
initial-surgical-management group and two were from Proximal gastric or parietal cell vagotomy alone. A
the failed-medical-management group. One of these has proximal gastric or parietal cell vagotomy alone was
had recurrence of his Type I ulcer with bleeding. This done in five patients. Three of these five were for Type
was subsequently managed with subtotal gastrectomy III ulcers, one was for Type II, and one was done for a
and a Roux-en-Y procedure. Type I ulcer associated with a hiatal hernia. One of
Suture or closure of the ulcer without vagotomy or these five, a chronic aspirin user with the Type II ulcer,
excision. Five patients had emergency laparotomy and --has had recurrence of the gastric ulcer because of
suture repair of a perforated ulcer (four) or suture of a continued aspirin abuse. The other four, including the
bleeding gastric ulcer (one). No resection or vagotomy 1 cm Type I ulcer which was benign by endoscopic
was done in any of these patients. Four of these were biopsy, have done well without any further gastrointes-
done as emergency operations for patients from the tinal complaints.
group managed initially by surgical treatment, and one Suture for bleeding or closure of perforation of the
of the gastric ulcer perforations occurred in the group ulcer with vagotomy. A proximal gastric (parietal cell)
746 ADKINS AND OTHERS Ann. Surg. * June 1985

vagotomy was done in three patients at the time of an
emergency laparotomy for the suture of a bleeding ulcer
(two) or for the repair of a perforated ulcer (one). All
three of these patients were done as emergencies and
were from the initial-surgical-management group. All
three had benign ulcers by biopsy. Two of these patients
did well without recurrence of the ulcer. One, who was
an alcoholic with cirrhosis, presented with massive
bleeding, had an emergency laparotomy, suture of bleed-
ing ulcer, truncal vagotomy, gastrojejunostomy, and had
multiple postoperation problems. He died of liver failure
40 days later (see Mortality).
A vagotomy has been included as part of the surgical
treatment for all of the 20 patients who had Type II or
III ulcers, whether done electively or as emergency
procedures. Fifteen of these 20 also had antrectomy or
partial gastric resection to include the ulcer. Of the
remaining five patients who had Type II and Type III
ulcers, four had proximal gastric (parietal cell) vagotomy
alone; the other had a vagotomy, pyloroplasty, biopsy,
and suture of the bleeding ulcer.
Type of Reconstruction after Resection
Of the 17 patients who had subtotal gastric resection,
six had a Roux-en-Y reconstruction and I1 had a
Billroth I procedure. Similarly, 25 of the 31 patients
who had a vagotomy and antrectomy had a Billroth I
reconstruction, while three each had Roux-en-Y and
Billroth II reconstructions.
Urgent and Emergency Procedures
Of the 40 patients from the failed-medical-manage-
ment group who eventually had surgical treatment, 14
were done as emergencies or urgent procedures (35%).
Nine of these 14 were emergent for bleeding, four were
urgent for gastric outlet obstruction, and one was emer-
gent for perforation.
Fifteen of the 28 patients who had not been treated
medically and who were initially managed with surgical
treatment required emergency or urgent operations
(54%). Seven of these 15 procedures were emergent for
bleeding, five for perforations, and three were urgent for
gastric outlet obstruction.
Morbidity
Thirteen patients (19.1%) who had surgical treatment
for gastric ulcer have had 14 postoperative complications
or some degree of postgastrectomy sequela (Table 4).
Three of these 10 patients developed postoperative gastric
outlet obstruction and required revision of a Billroth I
in two (Type I and III ulcers) and the revision of a
Roux-en-Y in one (Type I).
Bile reflux gastritis was a complication in three other
patients following partial gastrectomy and Billroth I for
the treatment of Type I ulcers. In one of these, revision
of an antrectomy without vagotomy and Billroth I was
done, and in another, who also had a microscopic suture
line ulcer at the anastomosis, a repeat vagotomy for a
missed vagus nerve, a higher gastric resection, and a
Roux-en-Y reconstruction was done after takedown of
the original vagotomy, antrectomy, and Billroth I. The
third patient with bile reflux gastritis following vagotomy,
subtotal resection, and Billroth I has not required a
second operation and is being managed successfully
with medical treatment.
A second patient developed a marginal ulcer at the
anastomotic site following an antrectomy, truncal va-
gotomy, and Billroth I (He had a Type II ulcer.). This
marginal ulcer healed with medical management only.
Two patients have had some degree of postgastrectomy
dumping syndrome; both were managed successfully
without reoperation. One of these patients had a Type
II ulcer and the other had a Type III; both were treated
with truncal vagotomy, antrectomy, and Billroth I re-
construction procedures.

TABLE 4. Surgical Complications

Complication
Gastric outlet obstruction (three patients)
Bile reflux gastritis (three patients)
Marginal ulcer (two patients)
Dumping syndrome (two patients)
Persistence of gastric ulcer (four patients)
Original Operation Treatment for Complication
1) Vagotomy, antrectomy, B-I Revision of anastomosis
2) Vagotomy, antrectomy, B-I Revision of anastomosis
3) Vagotomy, antrectomy, Roux-en-Y Revision of anastomosis
1) Antrectomy, B-I Revision of anastomosis
2) Subtotal gastrectomy vagotQmy, B-I Managed medicaply with success
3) Vagotomy, antrectomy, B-I Repeat vagotomy, higher gastric
resection, Roux-en-Y
I) Subtotal gastrectomy, vagotomy, B-I Managed medically with success
2) Vagotomy, antrectomy, B-I Repeat vagotomy, higher gastric
resection, Roux-en-Y
1) Vagotomy, antrectomy, B-I Managed medically with success
2) Vagotomy, antrectomy, B-I Managed medically with success
1) Vagotomy, pyloroplasty suture of ulcer Subtotal gastrectomy, Roux-en-Y
2) Proximal gastric vagotomy Managed medically with partial success
3) Suture of bleeding ulcer Vagotomy, antrectomy, B-I
4) Closure of perforated ulcer Subtotal gastrectomy, Roux-en-Y
Vol. 201 - No. 6 MANAGEMENT OF GASTRIC ULCERS
Three patients who had emergency operations for
bleeding (two) and perforation (one) had persistence of
their original Type I gastric ulcers. One had had vagot-
omy and pyloroplasty in addition to the suture of a
bleeding Type I ulcer. The other two patients had
emergency operations for the closure of a perforated
Type I ulcer and the suture of a bleeding Type I ulcer
without additional procedures. One of these three patients
required a vagotomy and antrectomy and two required
subtotal gastric resection and vagotomy when the ulcers
persisted and all rebled. One other patient has had a
persistent ulcer with occasional episodes of upper gas-
trointestinal bleeding following a proximal gastric va-
gotomy alone. This Type II ulcer is known to be
stimulated by continued aspirin abuse.
Four (22%) of the 18 gastric ulcers that were surgically
treated without resection to include the ulcer have
persisted, and three of them have required subsequent
resection.
Mortality
Three patients in this series of 163 (1.8%) died of
their gastric ulcer disease or during its treatment. Two
of the 68 surgically treated patients died after treatment
(2.9%). One of these developed a third degree atrioven-
tricular block during a subtotal gastric resection and
vagotomy for a 2 cm Type I ulcer. He survived the
operation but did poorly. He developed renal failure,
and died 20 days later. The other operative death
occurred in a patient with advanced liver cirrhosis who
had an emergency operation and suture of a bleeding
ulcer, vagotomy, and gastrojejunostomy for massive
bleeding. The bleeding was from a large Type I gastric
ulcer. He had multiple cardiac arrhythmias, pulmonary
insufficiency, eventual hepatic failure, and died on the
40th postoperative day. At autopsy, his gastrointestinal
tract, including the gastrojejunostomy, was intact and
without infection or signs of further bleeding. The cause
of death was determined to be far advanced hepatic
cirrhosis.
The third patient who died, an 81-year-old woman,
had been treated medically for nine months for a 2 cm
Type I ulcer. She was readmitted with upper gastroin-
testinal bleeding and was found at endoscopy to have
recurrence of a huge gastric ulcer that had initially
shown some evidence of healing. She continued bleeding
and had a sudden cardiac arrest on the eighth hospital
day before a surgical consult was obtained. She could
not be resuscitated. Permission for autopsy was not
obtained.
Discussion
The incidence of peptic ulcer disease generally and
duodenal ulcer disease in particular has apparently
decreased in recent years. During this same time, the
747
number of admissions of patients with gastric ulcers to
short-term, nonfederal hospitals in the United States has
not changed significantly.5 The percentage of patients
over 60 years of age with gastric ulcer disease did
increase, however, from 40% to 48% between 1970 and
1978. The use of histamine (H2) blockers has been more
effective in the treatment of duodenal ulcer disease than
it has for gastric ulcers. Reported deaths from peptic
ulcer disease have decreased 31% in recent years, and
this decrease includes deaths from both gastric and
duodenal ulcers.5
The diagnosis of gastric ulcer can usually be deter-
mined by the interpretation of an upper gastrointestinal
contrast radiograph. The differentiation between benign
and malignant ulcers depends upon accurate endoscopic
biopsy or the resection and pathological examination of
the ulcer. It is generally agreed that approximately 70
to 80% of gastric ulcers and tumors can be detected by
upper gastrointestinal series (UGI). Silverstein6 suggests
that if UGI shows a benign-appearing gastric ulcer, it is
acceptable to treat the patient medically without an
endoscopic examination. He recommends that a second
UGI in 3 to 4 weeks should be done to determine
whether or not the ulcer is healing. He submits that an
endoscopic examination and biopsy should be done
immediately if UGI shows any evidence suggestive of a
malignant ulcer and if an apparently benign gastric ulcer
has not shown evidence of healing at the time of the
second UGI. Similarly, Lewis7 recommends that while
all patients should undergo endoscopy at some time
during their treatment, most patients with a gastric ulcer
need not have endoscopy as an initial diagnostic proce-
dure.
Despite these recommendations, we advocate early
endoscopic examination and biopsy of all gastric ulcers.
The importance of accurately diagnosing the gastric
lesion is underscored by the improved chance of cure
seen in cases where there is early detection of a gastric
carcinoma.' Of the 58 patients in our series who were
managed successfully with medical treatment, 83% (49)
had endoscopy and biopsy in addition to UGI. Eighty-
six per cent of the patients who failed to improve on
medical management had an endoscopy. The 11 patients
in the failed-medical-management group who did not
have an endoscopy either refused the procedure or
required an emergency operation for a bleeding or
perforated gastric ulcer before an endoscopy was done.
As one would expect, a lower percentage (71%) of those
28 patients who required initial surgical management
had preoperative endoscopy. The eight patients who had
initial surgical treatment and who did not have endo-
scopic examination had gastric outlet obstruction, se-
verely bleeding ulcers, or perforated ulcers.
In this study, three of 163 patients developed gastric
carcinoma in what was originally considered by us or

748 ADKINS AND OTHERS
our medical colleagues to be a benign gastric ulcer.
However, this low incidence (1.8%) of malignancy may
be somewhat misleading. From our recent report of a
23-year experience with 213 patients treated for gastric
cancer,9 we again reviewed the case histories and found
that 26 of those patients (12.2%) had a history of having
had intermittent periods of treatment for a benign
gastric ulcer for as long as 12 years in one case. Eighteen
of those 26 were treated before 1970. Of the remaining
eight patients from that report, five were referred to us
with the diagnosis of gastric carcinoma after varying
periods of treatment for "benign" ulcer. Only three of
those eight patients were treated after 1980. The three
cases of gastric carcinoma in this current report are
common to both series and were all actually considered
by us to be benign at some time in their treatment.
Only one of those three cases was misdiagnosed by us
since 1980, and this patient was managed with planned
surgical resection of a large, bleeding, Type II gastric
ulcer within 3 weeks of onset of symptoms. This apparent
decrease in the incidence of malignant disease existing
in a gastric ulceration being treated medically as a
benign ulcer illustrates the effectiveness and accuracy of
recent advances with endoscopic examination and biopsy
in the diagnoses of gastric cancer. We insist that all of
our patients have endoscopic examination and multiple
biopsies before or early in the trial of medical manage-
ment for gastric ulcer. If the ulcers fail to respond after
a reasonable 6- to 8-week medical trial, repeated evalu-
ation and biopsies are done. We have had little experience
with endoscopic brushings for cytological examination.
Since the advent of H2 blockers, it appears to us that
there has been a tendency to prolong the use of cimeti-
163 PATIENTS
28
INITIAL SURGICAL MANAGEMENT
15 (54%) 13 (46%)
EMERGENCY OPERATIONS ELECTIVE OPERATII ONS
FOR 8LEEDING OR FOR LARGE ULCER SIZIE
PERFORATION OR SEVERE PAIN
40 (52%)
SURGICAL
MANAGEMENT
14 (35%)
EMERGENCY OPERATIONSS
FOR BLEEDING OR
PERFORATION
Ann. Surg. * June 1985
dine in the treatment of patients with peptic ulcer
disease including those who have gastric ulcers. Recent
controlled trials have produced evidence that cimetidine
is more effective than originally believed for the treatment
of gastric ulcer. It is still reported by some, however, to
be no more effective than placebo in relieving the
symptoms of gastric ulcer disease.'0 Medical treatment
with diet, antacid, and an H2 blocker for as long as 15
weeks is still recommended by some clinicians for the
initial treatment of gastric ulcers.7 This trial time seems
long to us if complete healing has not occurred.
Others""2 have recommended that shorter medical trials
of 4 to 8 weeks are more reasonable and current medical
textbooks'3" 4 support this regimen. The 16 patients in
our series who are alive and still under medical treatment
for symptomatic or unhealed after 2 to 7 years of
therapy obviously deserve surgical consideration.
The long-term medical management pursued by the
gastroenterologists in the treatment of many of the
patients in our series has been a source of great concern
to us. The duration of medical treatment averaged 29
months in those patients whose ulcers failed to heal and
10 months in those patients who achieved successful
healing of the ulcer with medical therapy alone (Fig. 4).
The high percentage (35%) of emergency procedures
required in patients whose ulcers fail to resolve with
medical management is alarming and could be reduced
with earlier surgical intervention. In light of the increasing
percentage of older patients being treated for gastric
ulcer,' the advantage of elective operations over emer-
gency procedures in the elderly is an even greater
consideration. We have found that elective operations
of all types and of all degrees of magnitude are extremely
135
INITIAL MEDICAL MANAGEMENT
FIG. 4. This algorithm shows
77 (57) 58 (43%) the distribution of the entire
FAILED MEDICAL SUCCESSFUL MEDICAL patient group into each
MANAGEMENT MANAGEMENT management category. The
percentage of each treatment
group is shown along with
the duration of symptoms
and period of treatment for
37 (48%) each subgroup.
CONTINUE ON MEDICAL
TREATMENT WITH NON-HEALING ULCER
26 (65%)
ELECTIVE OPERATIONS
FOR NON-HEALING ULCER
Vol. 201 * No.6 MANAGEMENT OF GASTRIC ULCERS
well-tolerated in the elderly but that urgent and emer-
gency procedures are less well-tolerated.'5
Although most side effects of cimetidine are minor,
they are varied and reported with differing frequency.
Several authors have suggested that a relationship exists
between the prolonged use of cimetidine and the devel-
opment gastric carcinoma.'6-20 It has been postulated
(with documented instances) that cimetidine can cause
incomplete or total healing of an ulcerated malignant
gastric lesion resulting in the misdiagnosis and the
prolongation of inappropriate treatment.'7"18 While, to
us, there is no convincing evidence at this time that
cimetidine can cause cancer, this question remains
unanswered. One hypothesis used to explain this possibly
hazardous mechanism of action of the H2 blockers is
that cimetidine can be converted to a carcinogenic
nitrosamine in the stomach.'9'20 Another theory is that
cimetidine-induced hypochlorhydria fosters bacterial
overgrowth in the stomach which increases the formation
of the carcinogenic nitrosamine.'9'20 This bacterial factor
may also be at work in patients who have vagotomy-
induced hypochlorhydria, as there are reports of an
increased incidence of gastric carcinoma developing in
these patients.2"22 We suggest that all of these postulations
require much further study before any conclusions are
drawn. Our concern remains that the introduction of
cimetidine into the medical regimen for the management
of gastric ulcers, while useful as a short-term treatment,
has tended to prolong unnecessarily the decision for
definitive surgical management in many instances.
We, like others,23'24 continue to support distal gastric
resection including the ulcer as our choice for the
definitive surgical treatment of all gastric ulcers which
fail to heal after a 2- to 3-month trial of medical therapy.
Vagotomy should be employed in all cases of Types II
or III ulcers because of their resemblance in behavior to
duodenal ulcers. Vagotomy is also recommended for
patients with Type I gastric ulcers if the patient is an
alcoholic or requires prolonged treatment with ulcero-
genic drugs. We recommend excision of all gastric ulcers
at the time of elective and definitive operations to ensure
that malignant ulcers are not overlooked. We have had
one such case (see Initial Surgical Management).
In 1977, Davis24 and colleagues reported 595 patients
with gastric ulcer treated surgically at the Mayo Clinic.
They too found that antrectomy or subtotal gastric
resection was the preferred surgical procedure. Alternative
procedures, such as vagotomy and pyloroplasty, were
not found to be equally satisfactory methods of treatment.
Others,25 however, have considered vagotomy and py-
loroplasty to be an acceptable alternative to gastric
resection. Some surgeons combine vagotomy and pylo-
roplasty with local excision of the ulcer and report
satisfactory results.26 In a clinical trial of vagotomy and
pyloroplasty,27 we found an incidence of recurrence of
749
the gastric ulcer to be 15% and do not consider it as
satisfactory as an antral resection or subtotal gastrectomy
that includes the gastric ulcer.
The Billroth I anastomosis remains our reconstruction
procedure of choice, and was used in 38 of the 50
patients (76%) who had distal gastric resection to include
the ulcer. We use the Billroth II reconstruction rarely
when a Billroth I is technically difficult but we prefer a
Roux-en-Y gastrojejunostomy under such circum-
stances.28 If bile reflux is felt to be a significant preop-
erative factor seen at endoscopy as the cause of the
associated gastritis with the gastric ulceration, a Roux-
en-Y gastrojejunostomy is used selectively. We recom-
mend the Roux-en-Y reconstruction as a remedial op-
eration when bile reflux becomes a problem following
any type of gastric surgical procedure.
We found in our group of 50 patients, who had distal
gastric resection to include the ulcer with or without
vagotomy, that 80% of them could be classified as Visick
Grade I and eight per cent could be classified as Grade
II. Similarly, Thomas2' et al. found that 84% of their
patients followed after partial gastrectomy for benign
gastric ulcer and Billroth I reconstruction had an excellent
or good result on Visick grading. There seems to be
little disability imposed by this procedure which offers
the best chance of cure for most patients with gastric
ulcer.
Conclusion
We conclude that the preferred plan of management
for patients with gastric ulcer is: (1) careful thorough
diagnosis with multiple gastroscopic biopsies; (2) close
observation during a reasonable 6- to 12-week trial of
medical therapy with repeat gastroscopy to ensure that
the ulcer has healed; and (3) distal gastric resection that
includes the ulcer when medical treatment fails to result
in resolution of symptoms and permanent healing of
the ulcer within 12 weeks. Vagotomy should be added
to the gastric resection for patients who have Type II or
III gastric ulcers, for those with Type I gastric ulcers
who require ulcerogenic drugs, and those who abuse
drugs and alcohol. Nonresective surgical procedures may
be indicated in emergency situations but frequently
more definitive surgical procedures are required later.
References
1. Baron JH. Current views on pathogenesis of peptic ulcer. Scand J
Gastroenterol 1982; 80:1-10.
2. Adams JE, Sawyers JL, Classen KL, Scott HW Jr. Management
of gastric ulcer. Rock Mt Med J 1959; March:81-84.
3. Johnson HD. Gastric ulcer, classification, blood group character-
istics, secretion patterns, and pathogenesis. Ann Surg 1965;
996-1004.
4. Visick AH. A study of the failures after gastrectomy. Ann R Coil
Surg Engl 1948; 3:266-284.
5. Elashoff JD, Grossman MI. Trends in hospital admissions and
death rates for peptic ulcer in the United States from 1970 to
1978. Gastroenterology 1980; 78:280-285.
7iA ADKINS AND OTHERS
6. Silverstein FE. Peptic ulcer: an overview of diagnosis. Hosp Pract
1979; 14(11):78-87.
7. Lewis JH. Treatment of gastric ulcer, what is old and what is new.
Arch Intern Med 1983; 143:264-274.
8. Abe S, Ogawa Y, Nagasue N, et al. Early gastric cancer: results in
a general hospital in Japan. World J Surg 1984; 8:308-314.
9. Scott HW Jr, Adkins RB Jr, Sawyers JL. Results of an aggressive
surgical approach to gastric carcinoma during a twenty-three
year period. Surgery 1985; 97:55-59.
10. Isenberg JI, Peterson WL, Elashoff JD, et al. Healing of benign
gastric ulcer with low-dose antacid or cimetidine. N Engl J
Med 1983; 308:1319-1324.
11. Meyer JH, Schwabe A, Isenberg JI, et al. Treatment of peptic
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12. Piper DW, Greig'M' Coupland GA, et al. Factors relevant to the
prognosis of chronic gastric ulcer. Gut 1975; 16:714-718.
13. Isenberg JI.' Peptic ulcer: medical treatment. In Wyngaarden JB,
Smith LH Jr, eds. Cecil textbook of medicine. Philadelphia:
WB Saunders, 1982: 646-650.
14. Spiro HM. Gastric ulcer. In Clinical gastroenterology. New York:
Macmillan, 1977:292-306.
15. Adkins RB Jr, Scott HiW Jr. Surgical procedures in patients aged
90 years and older. South Med J 1984; 77:1357-1364.
16. Freston JW. Cimetidine: adverse reactions and patterns of use.
Ann Int Med 1982; 97:728-734.
17. Taylor RH, Lovell D, Menzies-Gow N, et al. Misleading response
of malignant gastric ulcers to cimetidine. Lancet '1978; 12:686-
688.
18. Elder JB, Ganguli PC, Gillespie IE. Cimetidine and gastric cancer.
Lancet 1979; 12:1005-1006.
DISCUSSION
DR. PAUL H. JORDAN, JR. (Houston, Texas): Dr. Adkins and his
colleagues have enunciated the principles for treatment of gastric ulcers
and their results. Unfortunately, we have had persistent difficulty
convincing many of our medical colleagues of these principles and, in
fact, we are losing ground, perhaps because, as this study demonstrates,
with the availability of increasingly potent drugs in their arsenal, they
are procrastinating even longer by their prolongation of nonoperative
treatment.
The need for urgent surgery for fear of cancer is almost no longer a
consideration. The major concern now, as Dr. Adkins has shown, is
the high percentage-that is, 35%-of emergency procedures required
in patients whose ulcers failed to resolve with medical treatment and
who have to undergo surgery.
There have been many types of operations for gastric ulcer, including
simple pylorop!asty. The reason for the apparent lack of agreement on
treatment seems to be due to the various causes that have been
suggested for the pathogenesis of gastric ulcer. Dr. Adkins and his
group have concluded that antrectomy, or distal gastric resection, and
Billroth I anastomosis is the gold standard for the Type I gastric ulcer,
and most authors agree with this.
(Slide) As an example, in this compilation of authors V and P had
a mortality of 1.4% and a recurrence rate of 5.2%, while antrectomy
and Billroth I had a mortality of 1.0% and a recurrence rate of 1.5%.
What the authors have emphasized for our benefit is that antrectomy
and Billroth I should be combined with vagotomy when the ulcer is
prepyloric (slide), or for a Type I ulcer that is associated with a
duodenal ulcer.
The fact that this is not a prospective study does not detract from
its value, for it contains a large amount of valuable information that
you will want to refer to from time to time. One of the most'important
points in the study is their emphasis on the response of specific types
of gastric ulcers to different surgical treatments. In much of our
literature, gastric ulcers are treated as if they were all similar in their
behavior. This is certainly not the case, as these authors have demon-
strated.
We have (slide) looked at a very specific type of gastric ulcer, the
Ann. Surg. * June 1985
19. Reed PI, Haines K, Smith PLR, et al. Gastric juice N-Nitrosamines
in health and gastroduodenal disease. Lancet 1981; 11:550-
552.
20. Reed PI, Haines K, Smith PLR, et al. Effect of cimetidine on
gastric juice N-Nitrosamine concentration. Lancet 1981; 11:
553-556.
21. Domellof L, Eriksson S, Janunger KG. Later precancerous changes
and carcinoma of the gastric stump after Billroth I resection.
Am J Surg 1976; 132:26-31.
22. Papachristou DN, Agnanti N, Fortner JG. Gastric carcinoma after
treatment of ulcer. Am J Surg 1980; 139:193-196.
23. Thomas WEG, Thompson MH, Williamson RCN. The long-term
outcome of Billroth I partial gastrectomy for benign gastric
ulcer. Ann Surg 1982; 195:189-195.
24. Davis Z, Verheyden CN, VanHeerden JA, Judd ES. The surgically
treated chronic gastric ulcer: an extended follow-up. Ann Surg
1977; 185:205-209.
25. Kraft RO. Long-term results of vagotomy and pyloroplasty in the
treatment of gastric ulcer disease. Surgery 1984; 95:460-466.
26. Cade D, Allan D. Long-term follow-up of patients with gastric
ulcers treated by vagotomy, pyloroplasty and ulcerectomy. Br
J Surg 1979; 66:46-47.
27. Sawyers JL, Scott HW Jr, Graham C. Clinical trial of vagotomy
and pyloroplasty in the treatment of benign gastric ulcer. Am
J Surg 1971; 121:119-121.
28. Herrington JL Jr, Scott HW Jr, Sawyers JL. Experience with
vagotomy-antrectomy and Roux-en-Y gastrojejunostomy in
surgical treatment of duodenal, gastric, and stomal ulcers. Ann
Surg 1984; 199:590-597.
Type I ulcer located at the incisura (Slide). We have excised these
ulcers intrluminally through a small gastrotomy on the greater curvature
(slide), and performed a PCV. Of the first 22 of these patients followed
for 4 to 7 years, we have had no mortality, one recurrence, and one
patient who died 3 years later from a carcinoma at the EG junction,
in no relationship to the area fromr which the original ulcer was
removed.
With regard to the Type III ulcer-that is, the ulcer within 3 cm of
the pylorus-I feel less secure of the proper treatment than with ulcers
in other locations. Is the ulcer at 31/½ to 4 cm from the pylorus really
so different than the ulcer at 0 to 21/2 cm from the pylorus that we can
confidently say that the second needs.. a vagotomy and the first one
does not?
Would the authors have serious objection to combining a selective
vagotomy with antrectomy for any ulcer between the pylorus and the
junction between the body and the antrum of the stomach?
DR. WILLIAM H. REMINE (Rochester, Minnesota): This manuscript
is an excellent one, and I want to congratulate the authors on a very
fine study. I think gastric ulcer continues to be a very, very dangerous
lesion from the standpoint of diagnosis and the methods of treatment
that are being instituted now. The incidence of carcinoma of the
stomach has gone way down-it is less than four per cent at the
present time-and yet people are still dying of cancer of the stomach
because of the low degree of suspicion on the part of the internists
and some surgeons. I agree with the authors completely that gastroen-
terologists are treating gastric ulcers far too long.
(Slide) Part of the reason for this is that it is extremely difficult for
even a good pathologist to tell grossly when he has it in his hands
what he is dealing with. Both of these were seen by Malcolm Docherty,
who has seen a tremendous' number of gastric ulcers. (Slide) The first
one was a malignant perforating ulcer; this is a benign one. This one
looks malignant, more so6 than the other one. This is part of the
difficulty when we depend on a gastroscopist to give us the answer to
what is going on in the stomach.
(Slide) A while back we reviewed our experience with what were
thought to be benign gastric ulcers. By all of our methods of study,