Complications of ulcer disease

Chief of hospital surgeryChief of hospital surgery

Lection for students of 5 courseLection for students of 5 course

ComplicationsComplications

of ulcer diseaseulcer disease.

Anatomy of the stomachAnatomy of the stomach

1 — lig. hepatogastricum; 2 — lien; 3 — ventriculus; 4 — lig. 1 — lig. hepatogastricum; 2 — lien; 3 — ventriculus; 4 — lig. gastrocolicum; 5 — duodenum; 6 —lig. hepatorenale; 7 — gastrocolicum; 5 — duodenum; 6 —lig. hepatorenale; 7 — foramen epiploicum (Winslovi); 8 — lig. hepatoduodenale; 9 — foramen epiploicum (Winslovi); 8 — lig. hepatoduodenale; 9 — vesica fellea; 10 — hepar; 11 — lig. teres hepatis.vesica fellea; 10 — hepar; 11 — lig. teres hepatis...

Anatomy of the stomachAnatomy of the stomach

1 — lien; 2 — aa. et vv. gastricae breves; 3 — a. et v. gastrica sinistra; 4 — truncus coeliacus; 5 — a. lienalis; 6 — a. hepatica communis; 7 — a. et v. gastro-epiploica sinistra; 8 — ventriculus; 9 — omentum majus; 10 — a. et v. gastro-epiploica dextra; 11 — duodenum; 12 — a. et v. gastrica dextra; 13 — a. et v. gastroduodenalis; 14 — ductus choledochus; 15 — v. cava inferior; 16 — v. portae; 17 — a. hepatica propria; 18 — hepar; 19 — vesica fellea.

Anatomy of the stomachAnatomy of the stomach

1 — ventriculus; 2 — a. et v. gastro-epiploica sinistra; 3 — aa. et vv. gastricae breves; 4 — lien; 5 — truncus coeliacus; 6 — a. et v. gastrica sinistra; 7 — plica gastropancreatica; 8 — a. lienalis; 9 — a. hepatica communis; 10 — pancreas; 11 — radix mesocolici; 12 — a. et v. colica media; 13—-ren dexter; 14 — duodenum; 15 — a. et v. gastro-epiploica dextra; 16 — a. et v. gastroduodenalis; 17 — v. portae; 18 — a. et v. gastrica dextra; 19 — a. hepatica propria; 20 — hepar; 21 — lig. hepatogas-tricum; 22 — vesica fellea.

Peptic ulcer disease (PUD)

is one of the most common diseases affecting the gastro-intestinal tract. It causes inflammatory injuries in the gastric or duodenal mucosa, with extension beyond the submucosa into the muscularis mucosa.

PathophysiologyPathophysiology

The normal stomach maintains a balance The normal stomach maintains a balance between protective factorsbetween protective factors and aggressive and aggressive factors. Gastric ulcers develop when factors. Gastric ulcers develop when patients has disbalanse this patients has disbalanse this factorsfactors. .

Ulcer of stomach this wickless of Ulcer of stomach this wickless of protective protective factors factors

Ulcer of duodenal this strong of Ulcer of duodenal this strong of aggressive aggressive factorsfactors

PProtective factors rotective factors of of stomachstomach

mucus mucus bicarbonate secretionbicarbonate secretion good vasculaturegood vasculature foodfood

AAaggressive factors aggressive factors of of stomachstomach

Helicobacter pylori infectionHelicobacter pylori infection acid secretion acid secretion ppepsinepsin microtrauma microtrauma

H. PYLORIH. PYLORI

Although Although H. pyloriH. pylori is present in the gastroduodenal mucosa is present in the gastroduodenal mucosa in most patients with duodenal ulcers, only a minority (10 to in most patients with duodenal ulcers, only a minority (10 to 15 percent) of patients with 15 percent) of patients with H. pyloriH. pylori infection develop infection develop peptic ulcer disease.6 peptic ulcer disease.6 H. pyloriH. pylori bacteria adhere to the bacteria adhere to the gastric mucosa; the presence of an outer inflammatory gastric mucosa; the presence of an outer inflammatory protein and a functional cytotoxin-associated gene island in protein and a functional cytotoxin-associated gene island in the bacterial chromosome increases virulence and the bacterial chromosome increases virulence and probably ulcerogenic potential.7 Patients with probably ulcerogenic potential.7 Patients with H. pyloriH. pylori infection have increased resting and meal-stimulated infection have increased resting and meal-stimulated gastrin levels and decreased gastric mucus production and gastrin levels and decreased gastric mucus production and duodenal mucosal bicarbonate secretion, all of which favor duodenal mucosal bicarbonate secretion, all of which favor ulcer formation. Eradication of ulcer formation. Eradication of H. pyloriH. pylori greatly reduces the greatly reduces the incidence of ulcer recurrence-from 67 to 6 percent in incidence of ulcer recurrence-from 67 to 6 percent in patients with duodenal ulcers and from 59 to 4 percent in patients with duodenal ulcers and from 59 to 4 percent in patients with gastric ulcers.8patients with gastric ulcers.8

Main symptomsMain symptomsof ulcerous diseaseof ulcerous disease

PainPain NauseaNausea VomitingVomiting

Burning epigastric painBurning epigastric pain Epigastric discomfort Epigastric discomfort

Loss of appetiteLoss of appetite

Characteristic of painCharacteristic of pain

Classic gastric ulcer pain is described as pain occurring Classic gastric ulcer pain is described as pain occurring shortly after meals, for which antacids provide minimal shortly after meals, for which antacids provide minimal relief. relief.

The pain from gastric ulcer is typically located in the The pain from gastric ulcer is typically located in the epigastrium; however, it can also be perceived in the right epigastrium; however, it can also be perceived in the right upper quadrant and elsewhere. upper quadrant and elsewhere.

Duodenal ulcer pain often occurs hours after meals and at Duodenal ulcer pain often occurs hours after meals and at night. Pain is characteristically relieved with food or night. Pain is characteristically relieved with food or antacids. antacids.

Pain with radiation to the back is suggestive of a posterior Pain with radiation to the back is suggestive of a posterior penetrating gastric ulcer complicated by pancreatitis penetrating gastric ulcer complicated by pancreatitis

Endoscopic diagnosticEndoscopic diagnostic and differential with and differential with cancercancer

Gastric ulcerGastric ulcer

Gastric Gastric cancer cancer

ComplicationsComplications of gastric of gastric ulcersulcers

- - perforationperforation,, - - hemorrhage,hemorrhage,- - and gastric outlet obstruction and gastric outlet obstruction - penetration- penetration

PPerforationerforation

Classification by clinical futures Classification by clinical futures Typical perforation (free peritoneal Typical perforation (free peritoneal

perforation)perforation) Atypical perforationAtypical perforation Closed perforationClosed perforation

PPerforationerforation

Clinic Clinic Acute pain (Acute pain (««by knifeby knife»») ) Tension of abdomen (how tree)Tension of abdomen (how tree) Ulcerous anamnesis Ulcerous anamnesis

PPerforationerforation Free peritoneal perforation and resulting chemical and Free peritoneal perforation and resulting chemical and

bacterial peritonitis is a surgical emergency causing bacterial peritonitis is a surgical emergency causing sudden, rapidly spreading, severe upper abdominal pain sudden, rapidly spreading, severe upper abdominal pain exacerbated by movement; the pain may radiate to the exacerbated by movement; the pain may radiate to the right lower abdomen or to both shoulders. Fever, right lower abdomen or to both shoulders. Fever, hypotension, and oliguria suggest sepsis and circulatory hypotension, and oliguria suggest sepsis and circulatory compromise. Generalized abdominal tenderness, rebound compromise. Generalized abdominal tenderness, rebound tenderness, board-like abdominal wall rigidity, and tenderness, board-like abdominal wall rigidity, and hypoactive bowel sounds (clinical signs of peritonitis) may hypoactive bowel sounds (clinical signs of peritonitis) may be masked in older patients and those taking steroids, be masked in older patients and those taking steroids, immunosuppressants, or narcotic analgesics. immunosuppressants, or narcotic analgesics.

PPerforationerforation

Three period of clinicThree period of clinic Firstly shock (6 hours) Firstly shock (6 hours) Loose safely (6-12 hours)Loose safely (6-12 hours) Peritonitis (more than 12 hours)Peritonitis (more than 12 hours)

PPerforationerforation X-Ray diagnostic X-Ray diagnostic

Upright or lateral decubitus abdominal Upright or lateral decubitus abdominal radiography or erect chest radiography may radiography or erect chest radiography may demonstrate pneumoperitoneum; however, demonstrate pneumoperitoneum; however, the absence of this finding does not rule out the absence of this finding does not rule out perforation.perforation.

Operative treatment of perforation of ulcerOperative treatment of perforation of ulcerpatch of omentumpatch of omentum

GASTRIC OUTLET OBSTRUCTIONGASTRIC OUTLET OBSTRUCTION

Peptic ulcer disease is the underlying cause Peptic ulcer disease is the underlying cause in less than 5 to 8 percent of patients in less than 5 to 8 percent of patients presenting with gastric outlet obstruction. presenting with gastric outlet obstruction. Patients with recurrent duodenal or pyloric Patients with recurrent duodenal or pyloric channel ulcers may develop pyloric stenosis channel ulcers may develop pyloric stenosis as a result of acute inflammation, spasm, as a result of acute inflammation, spasm, edema, or scarring and fibrosis.edema, or scarring and fibrosis.

GASTRIC OUTLET OBSTRUCTIONGASTRIC OUTLET OBSTRUCTION

Symptoms suggesting obstruction include Symptoms suggesting obstruction include recurrent episodes of emesis with large volumes recurrent episodes of emesis with large volumes of vomit containing undigested food; persistent of vomit containing undigested food; persistent bloating or fullness after eating; and early satiety. bloating or fullness after eating; and early satiety. Weight loss, dehydration, and a hypochloremic, Weight loss, dehydration, and a hypochloremic, hypokalemic metabolic alkalosis may result; a hypokalemic metabolic alkalosis may result; a tympanitic epigastric mass representing the dilated tympanitic epigastric mass representing the dilated stomach with visible gastric peristalsis also may stomach with visible gastric peristalsis also may be observed.be observed.

GASTRIC OUTLET OBSTRUCTION GASTRIC OUTLET OBSTRUCTION (stenos).(stenos).

Classification Classification I. Compensation stenosI. Compensation stenos:: episode vomiting, wait barii in episode vomiting, wait barii in

stomach to 6 hours, loose weight to 5 kg. stomach to 6 hours, loose weight to 5 kg.

II. Subcompensation stenosII. Subcompensation stenos:: everyday vomiting, wait barii in everyday vomiting, wait barii in stomach to 12 hours, loose weight to 10 kg, disturbance of stomach to 12 hours, loose weight to 10 kg, disturbance of waiter-electrolyte balance. waiter-electrolyte balance.

III. Decompensation stenosIII. Decompensation stenos:: no evacuation from stomach, no evacuation from stomach, vomiting after every food, wait bari in stomach more than vomiting after every food, wait bari in stomach more than 24 hours, loose weight more than 10 kg, severe 24 hours, loose weight more than 10 kg, severe disturbance of waiter-electrolyte balance, tetanus. disturbance of waiter-electrolyte balance, tetanus.

. .

GASTRIC OUTLET OBSTRUCTIONGASTRIC OUTLET OBSTRUCTION

Treatment of stenos only operativeTreatment of stenos only operative Compensation stenos may be use pyloroplasticCompensation stenos may be use pyloroplastic Subcompensation and decompensation stenos Subcompensation and decompensation stenos

resection of stomach ore antrectomyresection of stomach ore antrectomy

BLEEDINGBLEEDING

Upper gastrointestinal bleeding occurs in 15 Upper gastrointestinal bleeding occurs in 15 to 20 percent of patients with peptic ulcer to 20 percent of patients with peptic ulcer disease. It is the most common cause of disease. It is the most common cause of death and the most common indication for death and the most common indication for surgery in the disease. In older persons, 20 surgery in the disease. In older persons, 20 percent of bleeding episodes result from percent of bleeding episodes result from asymptomatic ulcers. asymptomatic ulcers.

BLEEDINGBLEEDING

ClinicClinic Hematemesis (bright red or "coffee ground")Hematemesis (bright red or "coffee ground") MelenaMelena Fatigue caused by anemiaFatigue caused by anemia PalePale TahicardiaTahicardia HypotensionHypotension OrthostaticOrthostatic Syncope.Syncope.

BLEEDING.BLEEDING. Classification.Classification.

I. Compensative hemorrhageI. Compensative hemorrhage:: loose of blood to 20% VOL (to loose of blood to 20% VOL (to 1000 ml), pulse, AP, Hb more be normal. 1000 ml), pulse, AP, Hb more be normal.

II. Subcompensative hemorrhageII. Subcompensative hemorrhage:: loose of blood to 30% VOL loose of blood to 30% VOL (to 1500 ml), pulse – tahicardia to100, AP decrease to 100, (to 1500 ml), pulse – tahicardia to100, AP decrease to 100, Hb decrease 100 g/l, olygurine.Hb decrease 100 g/l, olygurine.

III. Decompensative hemorrhageIII. Decompensative hemorrhage:: loose of blood more than loose of blood more than 30% VOL (more than 1500 ml), pulse – tahicardia to120 30% VOL (more than 1500 ml), pulse – tahicardia to120 and more, AP decrease to 80-70, decrease Hb, olygo-and more, AP decrease to 80-70, decrease Hb, olygo-unurine.unurine.

BLEEDINGBLEEDING

Patient with stopping Patient with stopping hemorrhage and stable hemorrhage and stable hemostasis treat conservative hemostasis treat conservative

Patient with following Patient with following hemorrhage and unstable hemorrhage and unstable hemostasis and recurrent bleeding treat operativehemostasis and recurrent bleeding treat operative

BLEEDINGBLEEDING

Conservative Treatment Conservative Treatment

Eradication of Eradication of Helicobacter pyloriHelicobacter pylori proton pump inhibitor or H2 blocker proton pump inhibitor or H2 blocker Protectors of gastro mucous Protectors of gastro mucous Infusion therapy Infusion therapy Hemostatic dragsHemostatic drags HemotransfusionHemotransfusion

SurgerySurgery

Duodenal ulcerDuodenal ulcer: truncal vagotomy, : truncal vagotomy, selective vagotomy, highly selective selective vagotomy, highly selective vagotomy, vagotomy, excision of ulcer and excision of ulcer and pyloroplasticpyloroplastic partial gastrectomy partial gastrectomy

Gastric ulcer:Gastric ulcer: resection of stomach ore resection of stomach ore antrectomyantrectomy

partial gastrectomy with gastroduodenal or partial gastrectomy with gastroduodenal or gastrojejunal anastomosisgastrojejunal anastomosis

Operative treatment of ulcer disease.Operative treatment of ulcer disease.Method of excision of ulcer and pyloroplastic.Method of excision of ulcer and pyloroplastic.

Operative treatment.Operative treatment.Method of resection of stomach.Method of resection of stomach.

resection of stomach by resection of stomach by Bilroth-IBilroth-I

resection of stomach by resection of stomach by Bilroth-IIBilroth-II