When is surgery indicated for PUD?
• Perforation: Closure with an omental or a Graham patch is acceptable for patients without previous history of PUD and for hemodynamically unstable patients. Definitive antiulcer surgery is indicated in hemodynamically stable patients with a prior history or chronic PUD. Resection of the ulcer crater with adequate margins should be performed for gastric ulcers. Definitive gastrectomy is undertaken after recovery if carcinoma is found in the specimen.
• Obstruction: If duodenal obstruction from an ulcer is not relieved by 7 days, surgery is generally indicated. Balloon dilation and stenting are alternatives in patients who are poor surgical candidates.
• Bleeding: Surgery is indicated in any hemodynamically unstable patient or in those requiring greater than 6 units of packed red blood cells within a 24-hour period. Esophagogastroduodenoscopy (EGD) as well as angiography can be very useful in this setting prior to operative intervention.
• Intractability: Despite benign biopsies, recurrent or nonhealing gastric ulcers should be resected because of the risk of underlying carcinoma.
