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Published on : Jul 10, 2021 | Views : 2647 | Downloads : 16

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Slide 1-

Peptic Ulcer Professor Ravi Kant FRCS (England), FRCS (Ireland), FRCS(Edinburgh), FRCS(Glasgow), MS, DNB, FAMS, FACS, FICS, Professor of Surgery
Slide 2-

Surgical Anatomy Crow’s feet N of Latarjet Criminal Nerve of Grassi Antral pump mechanism
Slide 3-

Applied Anatomy : Stomach Pressure studies Endoscopic & Chromo-endoscopic Contrast ( Ba meal with air) Intra-luminal USG Electron microscopy USG CT/ MR Surgical
Slide 4-

APD= Acid Peptic Disease Peptic Ulcer Gastric Ulcer Duodenal Ulcer Hyperacidity ZE Syndrome
Slide 5-

APD= Acid Peptic Disease Acute Ulcer Stress Ulcer Curling’s Cushing’s
Slide 6-

APD Incidence Aetiology CP Investigations DD Rx
Slide 7-

Peptic Ulcer 10% population affected Gastric ulcer in elderly 5-6th decade Duodenal ulcer in adults 4th decade DU also in young
Slide 8-

Duodenal Ulcer Proximal duodenum 1 - 2 cm of pylorus ▲ acid Distal duodenum = ZE
Slide 9-

Type 1 Gastric Ulcer most common (among gastric Ulcers) proximal antrum  mucosal defense  acid
Slide 10-

Type II Gastric Ulcer Secondary to DU + pyloric stenosis
Slide 11-

Type III Gastric Ulcer Prepyloric and pyloric canal ulcer acid ▲ common etiology with DU
Slide 12-

GU: Benign Vs CA Rugae upto margins Small , <2cm Sticking of barium + Accompanying spasm ↓ Acid Crater beyond the normal stomach on a barium Rugae-short of Small-Big - - Achlorhydria Limited to Stomach
Slide 13-

APD Incidence Aetiology CP Investigations DD Rx
Slide 14-

APD Hurry Worry Curry
Slide 15-

Pathogenesis Imbalance of acid-pepsin and mucosal defence H. pylori infection NSAID ZE Syndrome Type A personality
Slide 16-

H.pylori 95% - duodenal ulcer 80% - gastric ulcer  mucosal resistance hydrophobicity eradication reduces ulcer recurrence
Slide 17-

NSAID Suppress prostaglandins prostaglandin ►  acid secretion  ▲ mucosal blood flow  mucus & bicarbonate secretion 10 -30% in chronic users
Slide 18-

ZE= Zollinger Ellison Syndrome Recurrent Recalcitrant Resistant Unusual sites Multiple Malignant
Slide 19-

ZE Syndrome 0.1 - 1.0% of peptic ulcer Type I and Type II Gastrin secretion from non-beta cell tumor of pancreas - Gastrinoma MC in pancreas ; duodenum, antrum
Slide 20-

ZE Syndrome 20% multiple 66% malignant slow growing indolent tumor parietal cell mass increased genetic basis massive hyper-secretion of acid
Slide 21-

ZE Syndrome MEN - I hyperparathyroidism islet cell tumor pituitary tumors
Slide 22-

A/ DU NSAIDs Acid hypersecretion Rapid gastric emptying Impaired acid disposal Smoking
Slide 23-

Duodenal Ulcer Increased secretion of acid More rapid gastric emptying Decreased prostaglandin Chronic duodenitis with H.pylori Smoking
Slide 24-

Gastric Ulcer H.pylori NSAIDs Duodenogastric reflux Impaired gastric mucosal defense
Slide 25-

Gastric Ulcer Acid secretion - normal to low Reflux of duodenal contents  gastritis  ulcer Pylorus sphincter disorder Smoking Disturbed mucosa with low grade gastritis
Slide 26-

APD Incidence Aetiology CP Investigations DD Rx
Slide 27-

CP Duodenal Ulcer pain relieved by food or alkali pain several hours after meal Gastric Ulcer - gnawing or burning pain on eating
Slide 28-

CP Periodic chronic recurrent pain Nausea & vomiting Weight loss Epigastric tenderness
Slide 29-

APD Incidence Aetiology CP Investigations DD Rx
Slide 30-

Investigations Endoscopy 90% sensitivity must in all pts. with severe pain excludes malignancy biopsy can be taken test for H.pylori
Slide 31-

Investigations Barium Meal double (air) contrast 90% sensitivity
Slide 32-

H Pylori detection: Breath test Blood test Tissue test
Slide 33-

APD Incidence Aetiology CP Investigations DD Rx
Slide 34-

DD Cholecystitis Hiatus hernia Pancreatitis MI Pneumonia Dissecting aneurysm Worm Infestations
Slide 35-

APD Incidence Aetiology CP Investigations DD Rx
Slide 36-

Rx - Medical Stop smoking, NSAIDs Stop alcohol Antacids - acid neutralisation H2 receptor antagonist -Ranitidine - secretion inhibition
Slide 37-

Rx- Medical H+ pump inhibition - H+/K+ase inhibition - Omeprazole Anticholinergic - secretory inhibition Prostaglandin - Misoprostol - mucosal protection
Slide 38-

Proton Pump Blockers Omeperazole Eso-meperazole Rabi-meperazole
Slide 39-

Rx - Medical Sucralfate - protective coating Colloidal Bismuth eradicate H.pylori protective coating Antibiotics - H.pylori Kit for H Pylori
Slide 40-

H2 Receptor Antagonists On parietal cells Decrease basal & stimulated acid secretion Pepsin output decreased Decreased gastric blood flow Competitive inhibitor of parietal cell
Slide 41-

Rx - Duodenal Ulcer 95% control - medical Rx Surgery-Outdated, Obsolete Omeprazole better thanRanitidine Ulcer heels in 80% by 6 m  recurrence in 95% by H.pylori eradication
Slide 42-

Rx - Duodenal Ulcer Indications for surgery =Compl Hemorrhage Obstruction Perforation Intractability of pain Intractable pain ► HSV / TV + GJ
Slide 43-

Rx - DU H2 blockers heals 75% DU in 4 weeks H/K proton pump inhibitor better results ulcer may recurr in 80% cases on stopping treatment of H.pylori
Slide 44-

Rx - DU Indication of surgery in hemorrhage bleeding of > than 6 units recurrent bleed after endoscopic control pyloro-duodenotomy and control of bleeding HSV or TV + GJ
Slide 45-

Rx - DU Perforation - simple closure with omental patch -Graham’s patch definitive surgery HSV TV + pyloroplasty parietal cell vagotomy TV+GJ
Slide 46-

Rx GU Omeprazole, H2 receptor antagonist - 8 weeks if pain not relieved by 2 weeks - add one more drug repeat endoscopy after 8 weeks if no healing by 12 - 115 weeks - Surgery
Slide 47-

Rx - GU Type I - Distal Gastrectomy with vagotomy + G-D or GJ proximal ulcer- total gastrectomy parietal cell vagotomy - high recurrence
Slide 48-

Hemorrhage Hemorrhage - potential cause of death 15 -20% gross bleeding erosion of duodenal ulcer into gastro-duodenal artery Endoscopy –laser, sclerosant oralcohal injection
Slide 49-

Perforation In 5-10% of cases pneumo-peritoneum in 75% cases peritonitis, pain, ileus leukocytosis, hypovolumia, IIIrd space loss DD - acute appendicitis, enteric perf.
Slide 50-

Obstruction Chronic ulcer disease with edema and scarring in 5% cases of DU nausea, vomiting, abdominal distension metabolic alkalosis, paradoxical aciduria
Slide 51-

Obstruction Endoscopy Ba study Scintigraphy Rx V + G-J / G-D