Peptic ulcer disease

Peptic Ulcer Disease

Done by :

PROF/GOUDA ELLABBAN

What is a peptic ulcer?

A peptic ulcer is a hole in the gut lining of Stomach (gastric ulcer) Duodenum (duodenal ulcer) Esophagus (esophageal ulcer)

Sites duodenum ulcer

the 1st part of the duodenum is the commenest site

peptic ulcer in duodenum There is a stellate appearance to

the posterior wall of the duodenal cap and the appearance is consistent with a healing ulcer crater. There is a normal areae gastricae pattern to the visible portions of the stomach. The prominent medial mucosal fold in the second part of the duodenum marks the ampulla of Vater at the lower end of the common bile duct.

chronic peptic ulceration in duodenum

The normal 'ace of spades' appearance to the duodenal cap has been replaced by a trefoil, three leaved shamrock, appearance, which is classically typical of chronic duodenal ulcer.

Classification of Gastric ulcer :

Type I G.U : (55%) occurs near the junction of the parietal and antral mucosa on the lesser curvature where the inner oblique muscle is absent ( usually near the incisura ) and is associated with normal acid secretion .

Type II G.U : (25%) is located in the gastric body in combination with a duodenal ulcer and is associated with acid hypersecretion .

Type III G.U : (15%) is prepyloric and is also associated with acid hypersecretion .

Type IV G.U : (5%) is located on the lesser curve near the gastroesophageal junction and is associated with normal acid secretion .

peptic ulceration in stomach There is an extension of

gas into the lesser curve and extending beyond its boundary.

peptic gastritis The gastric mucosa in

the body of the stomach shows several small niches of barium, which have a stellate appearance and are surounded by some oedema.

chronic peptic ulceration in stomach

There is pooling of barium in a posterior ulcer that extends beyond the lesser curve margin. There is a distortion of the uninterrupted mucosal folds of the stomach, which are drawn in towards the ulcer.

Causes Etiology of DU and GU is multifactorial . H. pylori gastritis is present in >80% of DU and >60% of

GU. Imbalance between aggressive factors (e.g. gastric acid,

pepsin, bile salts, pancreatic enzymes) and defensive factors maintaining mucosal integrity (e.g. mucus, bicarbonate, blood flow, prostaglandins, cell turnover) which may relate to H. pylori infection

Causes (cont. ) Ulcerogenic drugs (e.g. NSAIDs) Zollinger-Ellison syndrome Other hyper secretory syndromes Retained gastric antrum

H. pylori gram –ve spirochetal bacteriam found in the antral and duodenal macosa Mechanism:

it is urease +ve split urea and lead to formation of ammonia alkaline media around the bacteria 2ry high acid ULCER

also it affect the cells through cytotoxin

Diagnosis

1. histology : Spiral bacteria rod adjacent to gastric epithelium

2. direct culture: only done when an antibiotic resistant organism is

suspected

3. CLO ( urease ) test :4. serology :

High anti – H. pylori

A burning pain in abdomin is the most common symptom

Abdominal pain nausea vomiting weight loss fatigue heartburn chest pain vomiting blood bloody or dark tarry stools

Clinical presentation

Duodenal Ulcer Gastric ulcerAge Any age specially 30-40 middle age 50-60

sex More in male More in male

occupation Stress job eg. Manager Same

Pain Epigastric , discomfort Epi. Can radiate to back

Onset 2-3 hours after eating & midnight Immediately after eating

Agg.by Hunger Eating

Duodenal Ulcer Gastric ulcerRelived by Eating ( milk) Lying down or vomiting

Duration 1-2 months Few weeks

Vomiting Uncommon Common(to relieve the pain)

Appetite Good Pt. afraid to eat

Diet Good , eat to relieve the pain Avoid fried food

Weight No wt. loss Loos wt.

Hematemesis 40% 60%

Melena 60% 40%

Risk Factors

Strongly associated Drugs (NSAIDs)

Family history Smoking

Z-E syndrome ( acid secretion due to gastrin)

Zollinger Ellison syndrome There is an excess of resting juice

with mucosal thickening in the stomach. The duodenum is dilated, contains excess fluid and an ulcer is present in the first part of the duodenum. The thickened gastric mucosa and excess of resting juice can be seen in the stomach. A fluid-filled duodenum delineates the head of the pancreas.

Risk Factors (cont . )

Possibly associated Corticosteroid Blood group O Stress Lower socioeconomic status

COMLICATION :

Hemorrhage : Leading cause of death due to peptic ulcer disease Hypotension , hematemesis , melena bleeding duodenal ulcer : are usually located on

the posterior duodenal wall within 2 cm of the pylorus and typically erode into the gastroduodenal artery.

Perforation peptic ulcer : Sudden onset of severe abdominal pain Result in generalize peritonitis ( or localize

peritonitis when the perforation is walled off by adjacent viscera and structure ).

N.B: G.U. in posterior wall erode to pancreas G.U. in anterior wall erode to liver

Perforation peptic ulcer : By examination : Low grade fever Tachycardia Abdominal wall rigidity Leukocytosis Subdiaphragmatic gas in X-ray

Gastric outlet obstruction Can occur as a chronic process due to fibrosis and

scarring of the pylorus and duodenum from chronic ulcer disease or as a consequence of acute inflammation superimposed on previous scarring of the gastric outlet .

Patient present with recurrent vomiting of poorly digested food, dehydration, and hypochloremic hypokalemic metabolic alkalosis .

Gastric outflow obstruction due to pyloric stenosis

Differential Diagnosis Atrophic gastritis Cholecystitis Pancreatitis Reflex esophagitis

Investigation • Gastroduedenoscopy

Medical Management Goals

relieve symptoms promote mucosal healing by controlling gastric acid prevent or detect complications prevent recurrence by eradicating H. pylori

Management Program diet modification rest medications

Management: Medications Drug Therapy

Antacids H2-receptor blocking agents Anticholinergics Cytoprotective and antisecretory drugs Proton pump inhibitors Antibiotics

Role of Surgery in the Mangement of PUD

Surgery is mainstay for emergency tx of life-threatening complications of aggressive and advanced PUD

Fundamental goals of surgery permit ulcer healing prevent or treat ulcer complications address underlying ulcer diathesis

Indications for surgery in ulcer disease bleeding perforation obstruction Malignant change

Surgical Management for GU Remove ulcer and gastrin secreting zone of the antrum

Types of anastomosis

Antrectomy with anastomosis to duodenum

(Billroth I)

Antrectomy with anastomosis to jejunum Billroth II

Billroth I

Billroth II

Complication of partial gastroctomy Immediate complication:

Bleeding :Bleeding following partial gastroctomy usually occuer frome

gastric side of anastomosis

Complication con. Early complications :

a) Anastomotic leak: which lead toi. Subphrenic abscessii. Pelvic abscess iii. Abdominal collection

b) Obstruction :i. Of afferent loopii. Of efferent loop

c) internal herniation

Complication con. Late complications :

1. Small stomach syndrome

2. Iron deficiency anemia

3. Dumping syndrom

4. Stomal ulcer

5. Stomach cancer

Surgical Management for DU• You can do one of the following procedures:

Truncal vagotomy with drainage High selective vagotomy Partial gastroctomy with G-J anastomosis Truncal vagotomy with antrectomy and G-J anastomosis

Truncal vagotomy

selective vagotomy

High selective vagotomy

Drainage Methods of drainage :

Pyloroplasty gastrojejunostomy

Pyloroplasty makes a small incision into the abdomen and then

makes a cut into the pyloric muscle This can done by two methods :

Finney pyloroplasty Heineke-Mikulicz pyloroplasty

Finney pyloroplasty

Heineke-Mikulicz pyloroplasty

Postvagotomy complications

1. Dysphagia

2. Gall stone

3. Postvagotmy diarrhea

4. Recurrent ulceration

Summary of surgical procedures

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