Duodenal ulcer disease: treatment by surgery, antibiotics, or both

Peptic ulcer disease is a function of derangements in intraluminal aggressive factors and defects in endogenous defense mechanisms. Some of these previously described abnormalities may be caused by the presence of H pylori colonization of the antral mucosa and antral mucosal metaplasia of the proximal duodenum. In vivo and in vitro data are being accrued that support this concept, particularly with reference to the mechanisms of H pylori-induced aberrations in gastric and duodenal mucosal function. Standard medical therapy for PUD includes antisecretory medications as well as antibiotics designed to eradicate H pylori colonization. It is rare for patients with an asymptomatic but nonhealed DU to come to surgical attention. Those who do, along with those with a symptomatic DU refractory to all forms of medical therapy, should be offered a proximal gastric vagotomy. Life-threatening bleeding from a DU requires secure suture ligation of the base of the ulcer combined with truncal vagotomy and pyloroplasty. Those patients with non-life-threatening hemorrhage most likely will have been treated with intensive medical therapy, including antibiotics, and should be treated with truncal vagotomy and antrectomy. If H pylori is still present histologically in the antral specimen, sensitivity testing of the bacteria should lead to the use of appropriate antibiotic therapy. Both of these populations of patients with bleeding DU will likely have a lower rebleeding rate if H pylori is eradicated than if they are treated with surgery alone. Perforated DU should be treated with omental patch closure and antisecretory medications and antibiotics to eradicate H pylori, particularly when there are comorbid conditions such as shock, perforation for more than 24 hours, or if the patient has not had significant symptoms for 3 months preperforation. Those patients with perforated DU who are appropriate candidates for proximal gastric vagotomy in addition to omental patch closure and antibiotic therapy do well; however, the true benefit of proximal gastric vagotomy over omental patch closure with antibiotic therapy, in this population, has yet to be clearly demonstrated.