Complications to peptic ulcer and peptic ulcer surgery

Abstract: Long term effects after peptic ulcer surgery still exert an influence on some patient groups. Partial gastrectomy increases the risk of gastric carcinoma more than 20 years after surgery and enterogastric reflux is regarded as the main ethiological factor. Partial gastrectomy also gives increased risk of other malignancies as well as smoking related disease. Parietal cell vagotomy (PCV) is considered a more physiological procedure but data of long-term morbidity and mortality after PCV is limited. Peptic ulcer incidence is declining probably due to a decreasing prevalence of Helicobacter pylori, but at the same time prescription rates of drugs with ulcerogenic and bleeding promoting side-effects are increasing. There is diverting reports of hospitalizations of peptic ulcer bleeding (PUB). The aim of this thesis was to (I) investigate if bile diversion could prevent the malignant transformation in the gastric remnant, (II) investigate long-term cancer incidence and mortality after PCV, (III) evaluate hospitalizations of and mortality from PUB in a nation-wide population-based cohort study and (IV and V) assess the impact of aspirin, non-steroidal anti-inflammatory drugs (NSAIDs), steroids, warfarin and selective serotonin re-uptake inhibitors (SSRIs) on outcome after PUB and on localization of gastrointestinal (GI) bleed by evaluation of all hospitalizations of GI bleed at the Department of Surgery in Lund 1984, 1994 and 2004. I) A progression was found of premalignant changes (atrophy, intestinal metaplasia, dysplasia), independent of H. pylori infection, after diversion of enterogastric reflux from the resected stomach. The transformation might have passed a point of no return. II) Patients after PCV do not have an increased overall mortality nor an increased risk of gastrointestinal carcinoma. An increased incidence and mortality in prostate carcinoma and smoking-related disease were however found. III) There has been a 40% decline in hospitalization rates for PUB in Sweden between 1987 and 2005. Mortality in PUB is low in our country but is increasing after duodenal ulcer bleeding. IV, V) Bleeding promoting drugs has had no impact on incidence and fatal outcome of GI bleed although the severity of bleedings has increased. Aspirin was found to decrease the risk of in-hospital mortality after PUB. Aspirin was stronger associated with PUB while steroids and SSRIs were associated to a greater extent with non-ulcer GI bleed.