Peptic Ulcer Fatimah Abdullah 6 th year MS, KFU
May 27, 2015
Peptic Ulcer
Fatimah Abdullah
6th year MS, KFU
Objectives Definition.
Pathophysiology.
Etiology.
Clinical Picture.
Management.
DEFINITIONBreak in the gastrointestinal mucosa exposed to the aggressive action of acid-peptic juices.
Common sites are the first part of the
duodenum and the lesser curve of the
stomach.
The gastroduodenal mucosal integrity is determined by protective (defensive) & damaging (aggressive) factors.
PATHOPHYSIOLOGY
Pathophysiology• Bicarbonate• Mucus layer• Prostaglandins• Mucosal blood flow• Epithelial renewal
Defensive
• Helicobacter pylori• NSAIDs• Pepsins• Bile acids• Smoking and alcohol
Aggressive
Mucosal damage erosions & ulcerations
ETIOLOGY H. Pylori Infection
NSAIDs
Smoking & Alcohol
Acid Hypersecretion
Stress
Family History of PUD.
Clinical Presentation
Gastric ulcer Duodenal Ulcermiddle age 50-60 Any age specially 30-40 Age
More in male More in male Sex
Same Stress job eg. Manager Occupation
Epi. Can radiate to back
Epigastric , discomfort Pain
Immediately after eating
2-3 hours after eating & midnight
Onset
Eating Hunger Agg.by
Gastric ulcer Duodenal UlcerLying down or vomiting Eating Relived by
Few weeks 1-2 months Duration
Common(to relieve the pain)
Uncommon Vomiting
Pt. afraid to eat Good Appetite
Avoid fried food Good , eat to relieve the pain Diet
wt. Loss No wt. loss Weight
60% 40% Hematemesis
40% 60% Melena
Stool fecal occult blood.
CBC CBL.
Rapid Urease test, urea breath test H. Pylori.
Upper GI Endoscopy.
Barium meal X-Ray.
INVESTIGATIONS
In all patients with “Alarming symptoms” endoscopy is required.
Dysphagia.Weight loss.Vomiting.Anorexia.Hematemesis or Melena.
INVESTIGATIONS
Any patient >50 y/o with new onset of symptoms
UGT ENDOSCOPY
Management
Life Style Change.
Medical.
Surgical.
LIFE STYLE MODIFICATION
Discontinue NSAIDs
Smoking cessation.
Alcohol cessation.
Stress reduction.
AntacidsH2-receptor blocking
agents. Proton pump inhibitors.Cytoprotective and
antisecretory drugs.Antibiotics.
MEDICATIONS
MEDICATIONSH. pylori Eradication Therapy:• Triple therapy:
Proton pump inhibitor . 2 Antibiotics:
• Metronidazole + Clarithromycin.• Clarithromycin + Amoxicillin.
» In some regimens, H2-receptor blockers, e.g. ranitidine, are used instead of PPI.
Indications:
Failure of medical treatment.
Development of complications
High level of gastric secretion and
combined duednal and gastric ulcer.
SURGICAL
Principle:
Reduce acid and pepsin
secretion.
Vagotomy:
Truncal Vagotomy with drainage.
Highly selective Vagotomy.
Combination of vagal
denervation (vagotomy) +
anterctomy.
SURGICAL
VagotomyTruncal vagotomy with drainage:
Resect the major trunk of the vagus to
the stomach this will lead to:Decrease acid and pepsin secretion.
Impair antral motility and drainage.
–Two types of drainage:Pyloroplasty.Gastrojejnostomy.
Pyloroplasty Drainage
Gastrojejunostomy Drainage
Highly selective vagotomy:
• It is a parietal cells vagotomy.• It can be done with or without
drainage.• It is done by cut a branch
of vagus of the body and the fundus this will lead to decrease HCl production.
Vagotomy
Combination of vagotomy+
anterctomy:Combination of vagal denervation & removal of the major area of gastric production.
Vagotomy
Gastrointestinal continuity is restored by gastroduodenal (Billroth 1) anastomosis OR gastrojejunal (Billroth 2) anastomosis.
Dehiscence.Stenosis of
anastomosis.Bleeding.Injury to neighbour
tissues.Dumping
syndrome
Vagotomy
Hemorrhage
Perforation peptic ulcer
Gastric outlet obstruction
Complications of Disease
Thank you