أسئلة التاسعة جراحة ثالثة الدلتا

• Peptic ulcers have acute and chronic complications.

Acute Complications

• Bleeding
• Perforation

Chronic Complications

• Obstruction
• Malignant transformations

Bleeding

Etiology

• Work
• Worry
• Weather
• Ulcerogenic drugs

Pathology

• Mild: Erosion of granulation tissue in the ulcer floor through trauma from solid food
• Moderate: Erosion of a vessel in the ulcer floor
• Severe/Fatal: Erosion of a large extragastric vessel, like the splenic or gastroduodenal artery

Complications of Continued Bleeding

• Acute renal failure
• Acute tubular necrosis
• Hypovolemic shock
• Unless the bleeding stops within 48 hours, the patient often passes into these complications

Clinical Picture

• Bleeding is more common in middle-aged males.
• There may be a history of chronic ulcer dyspepsia or the presence of an ulcer.
• Bleeding may be the first presentation.

Severity

• Mild: Iron deficiency anemia
• Moderate: Melena alone with pallor
• Severe:
  • Hypovolemic shock
  • Hematemesis
  • Melena
  • Red clotted blood per rectum

Investigations

• Fibreoptic Endoscopy
• Selective coeliac angiography barium meal examination.
• Radioisotope scanning with 51 Cr labelled with RBCs
• Blood examination to exclude purpura and blood diseases.

Differential Diagnosis

• Peptic ulcers account for 26% of upper Gastrointestinal bleeding
• Gastritis/Erosions account for 16%
• Oesophagitis account for 17%
• 12% No cause found
• Erosive Duodenitis account for 9%
• Malignancy account for 3%
• Mallory-Weiss Tear account for 3%
• Varices accout for 8%
• Portal Hypertensive Gastropathy account for 4%
• Vascular Ectasia account for 2%

Treatment

• Resuscitation includes hospitalization, absolute rest, warmth, fresh blood transfusion, sedation using Morphia 10 mg IV if the liver is not cirrhotic, Vitamin K injection, Ryle's tube for assessment and irrigation, CVP catheter and Foley's catheter.
• Constant observation to keep track of pulse, BP, temperature, CVP, urinary output, and the amount of bleeding
• Perform a diagnosis once the patient stabilizes

Subsequent Medical Management

• Administer routine treatment for peptic ulcers like cimetidine IV.
• Start a light diet at frequent intervals after 12 hours.
• Prophylactic antibiotics prevent pulmonary complications.
• Daily stool sample to detect further blood loss through melena.
• Observation chart for a minimum of 3 days after apparent cessation of hemorrhage.

Interventional Treatment

• Trans-endoscopic control of bleeding points can be mechanical with sclerosants, thermal-chemical, or laser photocoagulation
• Selective infusion of bleeding vessels through angiography, use Gelfoam embolization of the bleeding artery

Surgical treatment

• Failure of conservative treatment
• Development of other complications
• Patients over the age of 45

Surgical interventions according to general condition

• If in bad general condition (stop bleeding): erodes extra-gastric vessel, bleeding from the ulcer base, ligate the vessel outside the stomach or obliterate ulcers by deep sutures
• If in good general condition (definitive ulcer surgery): Gastric ulcer or Duodenal ulcer, partial gastrectomy including ulcer or vagotomy & pyloroplasty suture of the bleeding vessel

Perforation

Acute Perforation Etiology

• Factors causing exacerbation of an ulcer
• Increase in intragastric pressure

Pathology of Perforation

• More common in the Duodenum than the Gastric Ulcer
• More common in antero-superior wall

Stages of Peritonitis

• Peritonism
• Reaction
• Septic peritonitis

Peritonism

• The patient experiences a sudden and severe epigastric pain which may be referred to the shoulder, along with vomiting (once)
• Pallor
• Shallow rapid respiration
• Tachycardia
• Hypotension
• Hypothermia
• There will be no abdominal movements on inspection
• Rigidity and tenderness on palpation
• Shifting dullness on percussion
• Absent intestinal sounds on auscultation

Reaction

• Pain is relieved and the patient feels better
• Tachycardia
• Tenderness and rigidity persist
• Shifting dullness may be elicited

Complications

• Shock
• Fluid & electrolyte imbalance
• Toxaemia
• Paralytic ileus

Septic peritonitis

• Pain returns
• Tachycardia
• Distension abdominally
• Hyperthermia
• Dead silent on auscultation

Investigations for Perforation

• Lab tests show leukocytosis, increased amylase, and blood electrolyte & gases
• Radiological tests include plain X-ray of the abdomen in an erect position to check for air under the diaphragm, a gastrografin meal to check for the escape of opaque medium through perforation, and abdominal ultrasound to check for free fluid in the peritoneal cavity
• Aspiration, to assess gastric contents

DDx of Perforation

• Acute abdomen
• Air under diaphragm
• Post-operative complication
• Any rupture of a viscous organ
• Intraabdominal sepsis by gas forming organism
• Tubal insufflation test

Treatment

• Resuscitation: NG tube, antibiotics, IV fluids, Sedation, Fresh blood transfusion

Treatment (Urgent Surgical Intervention)

• If the general condition is bad: closure on omental plug + Biopsy if in case of GU
• If the general condition is good:
  • GU: partial gastrectomy
  • DU: vagotomy & pyloroplasty
• Use peritoneal toilet I & good drainage

Subacute Perforation

• Pathology: Gradual slow erosion of the ulcer leading to perigastric or subphrenic abcesses
• Clinical Presentation: History of P.U
• Pain starts in epigastrium before moving to the right iliac fossa, simulating appendicitis.
• Toxic - hectic fever - tachycardia
• Swelling in epigastrium or right hypochondrium
• Rigidity and tenderness
• Intestinal sounds are heard
• Leucocytosis
• Plain X-ray abdomen: shows gas under the diaphragm
• Treatment = drainage of abscess then definitive ulcer treatment

Chronic Perforation

• Pathology: Ulcer base penetrates a nearby organ pancreas, liver, transverse colon & occurs in posterior wall ulcers
• Clinical Presentation: History of P.U with a change in the characteristics of the pain, continuous, unrelated to meals and not relieved by antacids
• If pancreas is penetrated, the pain radiates to the back and is relieved by leaning forward
• If colon is penetrated, gastro-colic fistula
• Fecal vomitus
• Foal eructation
• Severe diarrhea
• Gastrografin meal diagnosis is possible.
• Treatment = Disconnection + partial gastrectomy - colon resection & anastmosis (in gastro-colic fistula)

Obstruction: Pyloric Stenosis (Gastric Outlet Obstruction)

Etiology

• Fibrosis of the duodenal ulcer

Pathology

• The pylorus is fibrosed and stenosed
• Stomach: Becomes hypertrophied, then dilated, and may reach down to the pelvis; mucosa shows hypertrophic then atrophic gastritis with true achlorohydra
• Intestines: Normal and collapsed

Complications of Obstruction

• Malnutrition & weight loss
• Decreased levels of vitamins
• Dehydration
• Electrolyte deficit
• Metabolic alkalosis
• Infection e.g. pneumonia

Clinical Picture

• History of chronic ulcer dyspepsia
• Upper abdominal distension after meals
• Pain that is continuous and exaggerated with eating
• Projectile vomiting containing food from previous meals with a foul odour.
• Progressive constipation
• Loss of appetite and weight
• Dehydration, tetany & mental confusion
• Physical Examination
• Upper abdominal distension with visible peristalsis from left to right
• Tympanic resonance on Percussion
• Succussion splash on Auscultation

Investigations for Obstruction

• Gastric function tests show hypoacidity
• Blood chemistry reveals metabolic alkalosis, hypokalemia, and hyponatremia
• Barium meal shows a soup dish appearance with a hugely dilated stomach that reaches the pelvis
• Delayed gastric emptying
• Hypertrophic mucosal rugae in cases of hypertrophic gastritis during the post-evacuation phase
• Persistent deformity of duodenal cap
• Endoscopy.

Treatment for Obstruction

• Conservative (for mild cases unfit for surgery): Repeated gastric lavage with normal saline through NG tube. The Patient is give NPO or only fluids
• Intravenous fluids, blood, plasma, & vitamins
• Correct any electrolyte or fluid deficit through IV fluids.
• Surgical management. If in bad general condition= Gastrojejunostomy
• Good General condition: definitive ulcer surgery

Hour Glass Stomach & Tea Pot Stomach

Etiology

• Fibrosed GU pulls the greater curve towards the ulcer, forming an hourglass stomach
• Fibrosed ulcer high on the lesser curve shortens the lesser curve, forming a teapot stomach

Pathology

• The stomach divides into 2 compartments connected by a narrow channel
• The upper pouch shows the same pathology as pyloric obstruction
• The lower pouch is normal, collapsed, and empty

Investigations

• Plain X-ray: double gas sign
• Barium Meal: Fixed constriction in the body of the stomach with dilation
• Endoscopy