The surgery you can do on a patient's stomach or duodenum is limited to: (1) Treating his peptic ulcer if it perforates. (2) Doing a gastroenterostomy or pyloroplasty if his pylorus stenoses. (3) Treating him if his ulcer bleeds. (4) Perhaps doing an elective truncal vagotomy and gastroenterostomy if he has a chronic disabling duodenal ulcer which has resisted medical treatment.
Duodenal ulcers are a common cause of epigastric pain in most parts of the world. You will need to take a careful history to diagnose and manage them. This can be difficult in a villager, so enquire how the patients in your community express their ulcer symptoms. They are unlikely to give you a clear history that their pain is relieved by food, or by antacids, for example, and their physical signs may be minimal. So, in spite of the limitations of the history, it is likely to be the only way you have of making the diagnosis. When a patient presents with the surgical complications of peptic ulcer disease, you may have to enquire carefully to find out that he has had any previous ulcer symptoms.
In India, antacids may be as expensive as cimetidine from a cheap secondary source. The decision to abandon medical for surgical treatment will often depend on how poor he is. If he is rich, he can afford surgery, or cimetidine and antacids; if he is poor, these drugs may cost more than his salary, so you may have to operate. Peptic ulcers, in India in particular, behave differently from those in the West. Operate early, and don't wait to be pressed to do so by the patient.
PEPTIC ULCER DISEASE HISTORY. Has the patient had heartburn, dyspepsia, or epigastric pain? If, so, how long for, and has it recently got worse? Does it have the features of peptic ulcer pain[md]epigastric, dull, boring, worse at night and when his stomach is empty; relieved by food, milk, antacids, vomiting, and belching; and aggravated by coffee, alcohol, and smoking? The periodicity of the symptoms is important at first. Has he any reason for stress, in his family or at work? Has he been drinking? Weight loss? Black stools?
EXAMINATION. Tenderness in his epigastrium will be his only physical sign?
MEDICAL TREATMENT. No smoking, no spices, and frequent small meals help his symptoms. Four weeks treatment with cimetidine 200 mg three times daily, with 400 mg at night will cure 70% of cases temporarily. If this can be followed by 400 mg at night, there will be less chance of recurrence.
Fig. 11-1 SOME COMPLICATIONS OF PEPTIC ULCERATION. A, anterior perforation of a duodenal ulcer. B, penetration into the liver (penetration into the pancreas is more common). C, and D, haematemesis and melaena. E, pyloric obstruction. Note the hyperperistalsis and the old food in the stomach.