Peptic Ulcer

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

• Crows feet
• N of Latarjet
• Criminal Nerve of Grassi
• Antral pump mechanism

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Applied Anatomy Stomach

• Pressure studies
• Endoscopic Chromo-endoscopic
• Contrast ( Ba meal with air)
• Intra-luminal USG
• Electron microscopy
• USG
• CT/ MR
• Surgical

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APD Acid Peptic Disease

• Peptic Ulcer
• Gastric Ulcer
• Duodenal Ulcer
• Hyperacidity
• ZE Syndrome

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APD Acid Peptic Disease

• Acute Ulcer
• Stress Ulcer
• Curlings
• Cushings

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APD

• Incidence
• Aetiology
• CP
• Investigations
• DD
• Rx

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Peptic Ulcer

• 10 population affected
• Gastric ulcer in elderly 5-6th decade
• Duodenal ulcer in adults 4th decade
• DU also in young

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Duodenal Ulcer

• Proximal duodenum
• 1 - 2 cm of pylorus
• ? acid
• Distal duodenum ZE

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Type 1 Gastric Ulcer

• most common (among gastric Ulcers)
• proximal antrum
• ? mucosal defense
• ? acid

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Type II Gastric Ulcer

• Secondary to DU pyloric stenosis

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Type III Gastric Ulcer

• Prepyloric and pyloric canal ulcer
• acid ?
• common etiology with DU

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GU Benign Vs CA

• Rugae upto margins
• Small , lt2cm
• Sticking of barium
• Accompanying spasm
• ? Acid
• Crater beyond the normal stomach on a barium

• Rugae-short of
• Small-Big
• -
• -
• Achlorhydria
• Limited to Stomach

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APD

• Incidence
• Aetiology
• CP
• Investigations
• DD
• Rx

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APD

• Hurry
• Worry
• Curry

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Pathogenesis

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

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H.pylori

• 95 - duodenal ulcer
  
• 80 - gastric ulcer
• ? mucosal resistance hydrophobicity
• eradication reduces ulcer recurrence

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NSAID

• Suppress prostaglandins
• prostaglandin ?
• ? acid secretion
• ? ? mucosal blood flow
• ? mucus bicarbonate secretion
• 10 -30 in chronic users

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ZE Zollinger Ellison Syndrome

• Recurrent
• Recalcitrant
• Resistant
• Unusual sites
• Multiple
• Malignant

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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

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ZE Syndrome

• 20 multiple
• 66 malignant
• slow growing indolent tumor
• parietal cell mass increased
• genetic basis
• massive hyper-secretion of acid

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ZE Syndrome

• MEN - I
• hyperparathyroidism
• islet cell tumor
• pituitary tumors

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A/ DU

• NSAIDs
• Acid hypersecretion
• Rapid gastric emptying
• Impaired acid disposal
• Smoking

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Duodenal Ulcer

• Increased secretion of acid
• More rapid gastric emptying
• Decreased prostaglandin
• Chronic duodenitis with H.pylori
• Smoking

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Gastric Ulcer

• H.pylori
• NSAIDs
• Duodenogastric reflux
• Impaired gastric mucosal defense

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Gastric Ulcer

• Acid secretion - normal to low
• Reflux of duodenal contents ? gastritis ? ulcer
• Pylorus sphincter disorder
• Smoking
• Disturbed mucosa with low grade gastritis

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APD

• Incidence
• Aetiology
• CP
• Investigations
• DD
• Rx

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CP

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

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CP

• Periodic chronic recurrent pain
• Nausea vomiting
• Weight loss
• Epigastric tenderness

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APD

• Incidence
• Aetiology
• CP
• Investigations
• DD
• Rx

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Investigations

• Endoscopy
• 90 sensitivity
• must in all pts. with severe pain
• excludes malignancy
• biopsy can be taken
• test for H.pylori

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Investigations

• Barium Meal double (air) contrast
• 90 sensitivity

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H Pylori detection

• Breath test
• Blood test
• Tissue test

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APD

• Incidence
• Aetiology
• CP
• Investigations
• DD
• Rx

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DD

• Cholecystitis
• Hiatus hernia
• Pancreatitis
• MI
• Pneumonia
• Dissecting aneurysm
• Worm Infestations

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APD

• Incidence
• Aetiology
• CP
• Investigations
• DD
• Rx

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Rx - Medical

• Stop smoking, NSAIDs
• Stop alcohol
• Antacids - acid neutralisation
• H2 receptor antagonist -Ranitidine - secretion
  inhibition

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Rx- Medical

• H pump inhibition - H/Kase inhibition -
  Omeprazole
• Anticholinergic - secretory inhibition
• Prostaglandin - Misoprostol - mucosal
  protection

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Proton Pump Blockers

• Omeperazole
• Eso-meperazole
• Rabi-meperazole

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Rx - Medical

• Sucralfate - protective coating
• Colloidal Bismuth
• eradicate H.pylori
• protective coating
• Antibiotics - H.pylori
• Kit for H Pylori

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H2 Receptor Antagonists

• On parietal cells
• Decrease basal stimulated acid secretion
• Pepsin output decreased
• Decreased gastric blood flow
• Competitive inhibitor of parietal cell

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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

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Rx - Duodenal Ulcer

• Indications for surgery Compl
• Hemorrhage
• Obstruction
• Perforation
• Intractability of pain
• Intractable pain ? HSV / TV GJ

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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

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Rx - DU

• Indication of surgery in hemorrhage
• bleeding of gt than 6 units
• recurrent bleed after endoscopic control
• pyloro-duodenotomy and control of bleeding
• HSV or TV GJ

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Rx - DU

• Perforation - simple closure with omental
  patch -Grahams patch
• definitive surgery
• HSV
• TV pyloroplasty
• parietal cell vagotomy
• TVGJ

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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

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Rx - GU

• Type I - Distal Gastrectomy with vagotomy G-D
  or GJ
• proximal ulcer- total gastrectomy
• parietal cell vagotomy - high recurrence

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Hemorrhage

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

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Perforation

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

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Obstruction

• Chronic ulcer disease with edema and scarring
• in 5 cases of DU
• nausea, vomiting, abdominal distension
• metabolic alkalosis, paradoxical aciduria

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Obstruction

• Endoscopy
• Ba study
• Scintigraphy
• Rx V G-J / G-D