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SU28.8 | Pyloric Stenosis, Peptic Ulcer Disease and Carcinoma Stomach — SDL Guide (Part 2)

Principles of Surgical and Medical Management

Management follows directly from the diagnosis, and the guiding principle differs for each. In infantile hypertrophic pyloric stenosis, the cardinal rule is that the operation is not an emergency — resuscitation is. The infant is first rehydrated and the hypochloraemic hypokalaemic metabolic alkalosis is corrected with intravenous fluids and potassium; only once electrolytes and acid-base status are normal is the definitive procedure performed: a Ramstedt pyloromyotomy, in which the hypertrophied pyloric muscle is split down to (but not through) the mucosa, relieving the obstruction with an excellent prognosis. In peptic ulcer disease, most patients are managed medically — H. pylori eradication (a course of a proton pump inhibitor with two antibiotics) and acid suppression with a proton pump inhibitor, together with stopping NSAIDs. Surgery is now largely reserved for complications: a perforated ulcer is treated by resuscitation and operative closure, classically an omental (Graham) patch repair (open or laparoscopic) plus peritoneal lavage; a bleeding ulcer is treated first by endoscopic haemostasis, with surgery for failure; and gastric outlet obstruction from scarring may need drainage or resection. In gastric carcinoma, the principle is stage, then treat with curative intent only when resectable: localised, operable disease is treated by gastrectomy (partial or total) with D2 lymphadenectomy, usually combined with perioperative chemotherapy, while advanced disease — signalled by the metastatic signs or by imaging — is treated palliatively (chemotherapy, relief of obstruction or bleeding, and nutritional support). The recurring theme is that one organ demands three quite different strategies.

Provided image

Disease	Typical age & presentation	Main cause	Key investigation	Principle of management
Infantile hypertrophic pyloric stenosis	Neonate ~3–6 wk; non-bilious projectile vomiting, hungry	Pyloric muscle hypertrophy	Ultrasound (+ electrolytes/blood gas)	Correct alkalosis FIRST, then Ramstedt pyloromyotomy
Peptic ulcer disease	Adults; epigastric pain or a complication	H. pylori, NSAIDs	Endoscopy + biopsy + H. pylori test	Eradication + PPI; surgery (Graham patch) for perforation
Gastric carcinoma	>50 yr; weight loss, mass, anaemia	Adenocarcinoma (intestinal/diffuse)	Endoscopy + biopsy + CT staging	Gastrectomy + D2 ± chemo if resectable; else palliation

Check Your Understanding

Bring the threads together by reasoning back through the three patients in the hook. The three-week-old first-born boy with non-bilious projectile vomiting who stays hungry has infantile hypertrophic pyloric stenosis: confirm with ultrasound (and palpate the olive), check the hypochloraemic hypokalaemic metabolic alkalosis, correct it first, then perform a Ramstedt pyloromyotomy. The 45-year-old with sudden severe pain, a rigid abdomen and free gas under the diaphragm has a perforated peptic ulcer: resuscitate and repair, classically with a Graham omental patch, and treat the underlying H. pylori. The 62-year-old with months of weight loss and an epigastric mass has gastric carcinoma: endoscopy and biopsy for the diagnosis, CT to stage, and curative gastrectomy with D2 lymphadenectomy only if resectable — otherwise palliation. Use these to self-test the competency. First, can you give the aetiology, cardinal clinical features, key investigation and management principle for each of the three conditions, keeping them distinct? Second, can you state the characteristic biochemical disturbance of pyloric stenosis and why resuscitation precedes surgery? Third, can you describe the complications of peptic ulcer disease and how each is managed, and outline the types and spread of gastric adenocarcinoma? The questions that follow check exactly these links.