If a patient has ''peptic ulcer disease', you can usually treat him by medical treatment with diet and antacids, and by persuading him to abandon alcohol and cigarettes. Unfortunately, you are unlikely to be able to give him the expensive H[,2] receptor antagonists, cimetidine or ranitidine, because he cannot afford them. So, if inexpensive medical treatment fails, the only way you can help a poor patient may be to operate. If he has uncontrollable pain and dyspepsia, or if his quality of life has been spoilt over the years by nagging pain, heartburn, and indigestion, do a truncal vagotomy and gastroenterostomy or pyloroplasty (11.4), as an elective procedure, especially if he is older and has atypical symptoms. He may have a gastric ulcer, with its higher rate of complications and recurrence. Don't wait until he has a severe bleed, or the overwhelming vomiting of pyloric obstruction. You will not have an endoscope, and may not be able to do barium studies, so you will only be able to confirm the diagnosis at laparotomy.
The absolute indications for operation are: (1) perforation, (2) a continuing or recurrent haematemesis, (3) pyloric stenosis, (4) suspicions of carcinoma[md]if he is fit enough. Otherwise, he is likely to be the best judge as to whether he should undergo surgery or not[md]provided he is not neurotic!
Your methods for investigating him will be limited, so when you do a laparotomy, expect to find that your preoperative diagnosis was wrong. What you thought was a duodenal ulcer may be chronic cholecystitis, carcinoma of his stomach, chronic pancreatitis, or some other abdominal condition.
Fig. 11-7 GASTROSTOMY. A, the incision. B, the patient's stomach exposed. C, picking up his stomach in Allis forceps. D, introducing the catheter through his abdominal wall. E, the incision in his stomach. F, the catheter introduced. G, the purse string sutures. H, how his stomach wall is invaginated.