Thirlby R C
University of Washington, Seattle.
Gastroenterol Clin North Am. 1994 Jun;23(2):295-311.
Figure 2 summarizes my evaluation of most patients with postoperative recurrent ulcers. First, serum gastrin and calcium levels should be determined in all patients. At the initial endoscopy, any silk sutures should be removed, and gastric ulcers biopsied. The presence of gastric ulcers or evidence of delayed gastric emptying should influence the surgical procedure. Ideally, a Congo red test should be performed at the initial endoscopy. The only caveat is that excessive sedation may invalidate the test results. If the initial diagnostic endoscopy does not include a Congo red test and serum gastrin and calcium levels are normal, it is reasonable to proceed with medical management without vagotomy testing. I believe that if medical management fails and operative treatment is planned, all patients should undergo vagotomy testing. If the Congo red test is definitively positive, sham feeding is not necessary. On the other hand, if the Congo red test suggests hyposecretion, I believe that sham feeding is mandatory prior to proceeding with operation. Conversely, sham feeding tests may be falsely negative in postoperative patients. Therefore, many of our patients undergo both Congo red testing and sham feeding prior to reoperation. Finally, if delayed gastric emptying is believed to be part of the clinical syndrome, a radionuclide scan should be performed to assess gastric emptying. It can be either a solid-meal study or an acetanilidoiminodiacetic acid scan, which measures bile reflux as well as determines emptying of bile from the fasted stomach (see introductory article in this issue).
图2总结了我对大多数术后复发性溃疡患者的评估。首先，应测定所有患者的血清胃泌素和钙水平。在初次内镜检查时，应取出所有丝线缝合线，并对胃溃疡进行活检。胃溃疡的存在或胃排空延迟的证据应影响手术方式。理想情况下，应在初次内镜检查时进行刚果红试验。唯一需要注意的是，过度镇静可能会使检查结果无效。如果初次诊断性内镜检查未包括刚果红试验且血清胃泌素和钙水平正常，则在不进行迷走神经切断试验的情况下进行药物治疗是合理的。我认为，如果药物治疗失败并计划进行手术治疗，所有患者都应接受迷走神经切断试验。如果刚果红试验明确为阳性，则无需进行假饲试验。另一方面，如果刚果红试验提示分泌减少，我认为在进行手术前必须进行假饲试验。相反，假饲试验在术后患者中可能会出现假阴性结果。因此，我们的许多患者在再次手术前都要进行刚果红试验和假饲试验。最后，如果认为胃排空延迟是临床综合征的一部分，则应进行放射性核素扫描以评估胃排空情况。可以是固体餐研究或乙酰苯胺亚氨基二乙酸扫描，该扫描可测量胆汁反流并确定空腹胃中胆汁的排空情况（见本期的介绍性文章）。
