The stomach is host to a variety of benign and malignant conditions that may present acutely, as in the case of a bleeding or a perforated peptic ulcer, or indolently, as is often the case with gastric cancer.
Peptic ulcer disease is among the most common benign conditions, and its natural course has evolved significantly over the years. While antrectomies, vagotomies, and other acid-reducing procedures were common several decades ago, the introduction of acid-suppressing medications and the discovery (and eradication) of Helicobacter pylori have virtually eliminated such operations.1,2,3,4 Nonetheless, gastric and duodenal perforations due to complicated peptic ulcer disease remain a frequent cause for presentation to the emergency room and account for nearly 10% of hospital admissions related to peptic ulcer disease.1 As critical care and supportive treatments have improved, nonoperative approaches can be considered in subsets of patients with high operative risk due to medical comorbidities, or whose perforations appear to be self-contained.5 Similarly, the availability of acid-suppressing medications and therapies eradicating H. pylori have made less radical and less invasive surgical approaches, such as laparoscopic primary and/or omental patch repair, more common.
Acute upper GI hemorrhage is the most common presentation of peptic ulcer disease, although it may represent other etiologies, including Mallory–Weiss tears or varices. A certain proportion of patients will have self-limited episodes of bleeding, but ongoing bleeding requires upper GI endoscopy. There are a number of advanced endoscopic techniques to stop active bleeding, including cauterization, injection sclerotherapy with epinephrine, and clip application.6 As these techniques have evolved, so has the debate as to which endoscopic therapies are most effective, which we will examine in the chapter that follows. Surgical intervention is now reserved for the rare circumstances in which the patient is in shock or in which endoscopic therapies have failed.
Esophageal and gastric varices are a manifestation of an underlying disease process, most commonly cirrhosis. Spontaneous bleeding occurs at a rate of 5–15% per year,7 and studies have shown that variceal size and degree of decompensated cirrhosis (as graded by Child’s score) are strong predictors of bleeding.8 Gastric varices are associated with higher rates of bleeding and are commonly due to splenic vein thrombosis.7 Endoscopy is recommended for screening and monitoring of patients who are likely to develop bleeding varices,7 and endoscopic ligation can be undertaken to either eradicate them or, at a minimum, to reduce their bleeding risk. Prophylactic treatment is often considered for those patients at the highest risk of bleeding.
Gastric adenocarcinoma is the most common malignancy of the stomach, and without endoscopic screening most patients in Western countries present with advanced disease. As a result, the average 5-year survival rate for patients undergoing surgery is less than 30%.9 Comparatively, the incidence of gastric cancer is much higher in the East,10 and routine endoscopic screening ...