Gastric Ulcer Course (Titu Maiorescu University of Bucharest) PDF

Titu Maiorescu University of Bucharest Faculty of Medicine Medicine in English Programme COURSE NO. 05 // GASTRIC ULCER © MCA // 2020-2021 // Rev. 01  DEFINITION CLASIFFICATION  Regardless of the gastric or duodenal...

Titu Maiorescu University of Bucharest Faculty of Medicine Medicine in English Programme COURSE NO. 05 // GASTRIC ULCER © MCA // 2020-2021 // Rev. 01  DEFINITION CLASIFFICATION  Regardless of the gastric or duodenal localization, international literature uses the term peptic ulcer. Definition. For ulcers occurring after surgery with ulcerative visa, the term of relapsed peptic ulcer is used.  Acute ulcer is represented by 2 anatomo- pathological forms: A. Erosion is defined as a loss of substance of the gastric mucosa that does not exceed the muscularis mucosae layer, described by Dieulafoy under the designation of Simplex Exulceratio. It heals without leaving scars, often being multiple and hemorrhagic; B. Deep acute ulcer is a round lesion with a maximum diameter up to 1 cm, which penetrates into the depth of the gastric wall, in all its layers, surrounded by an area of edema and hyperemia. Healing leaves a scar of the gastric wall; Chronic ulcer is represented by a lack of Classification substance of the gastric wall, with a diameter of 2 – 3 cm, which progresses in depth throughout the gastric wall, from the mucous (1) to the serous layers, surrounded by a chronic inflammatory tissue, rich in lymph and plasmocytic infiltration, which sometimes develop into a perforated ulcer. Intraoperatively, chronic ulcer is distinguished from the surface of the stomach or duodenum, through a white-pearl star scar. A particular form is the kissing ulcer that consists of two front-facing, mirrored ulcer sites. Stress ulcers occur in conditions of extensive trauma or after laborious operations, having as a physio pathological substrate the theory of the H+ ions retro-diffusion.  Main classification - described by Johnson and has 3 types: Type I is represented by the ulcer located high on the small gastric curvature, accompanied by a lower acid secretion in relation to the decrease in the mass of parietal cells, gastritis and duodenal reflux. Type II is represented by the ulcer located on the small curvature at the level of the gastric body, associated with the pyloric or duodenal ulcer, sometimes stenotic. Gastric acidity values are maintained between medium and high and gastric Classification evacuation is delayed. In this variant gastric ulcer is considered secondary to duodenal ulcer; Type III of gastric ulcer has antral location (2) immediately in the pre-pyloric region, acting very similar to duodenal ulcer, in terms of secretory and symptomatic. The pre-pyloric localization gives it extremely noisy clinical manifestations, and the secretory activity is characterized by a typical acid hypersecretion; Type IV and V. These types were not in the original classification, but American authors Kauffman and Conter added two other types of gastric ulcer. Type IV are ulcers located on a very high position of the stomach, on the small curvature and Type V are ulcers with a random location, anywhere on the gastric mucosa, being consecutive to chronic ingestion of aspirin or other NSAID. Classification (3)  SIGNS and SYMPTOMS  The clinical picture is dominated in duodenal ulcer by the periodicity and rhythm of symptoms. These details can be easily be obtained through anamnesis. Signs and The disease can have the following types of onset: Symptoms Unsystematic dyspeptic syndrome; (1) Onset directly complication through (hemorrhage, a perforation, penetration, stenosis); Systematized dyspeptic syndrome - centered on pain, which is the main element of clinical diagnosis in gastroduodenal ulcer; sometimes this type of onset is too little sustained or significantly suggested by the paraclinical examinations.  Periodicity translates into intermittent painful periods of about 2-4 weeks, separated by long pain-free periods (the free interval), after which the painful period repeats; that corresponds to the reactivation of the ulcerative activity. Periodicity can have a seasonal Signs and character, periods of activity usually occurring in spring and autumn, sometimes without an obvious cause. Symptoms Painful periods may be influenced or (2) triggered by prolonged physical or psychological exertion, fatigue, affective shocks, nervous tension or occasional nutrition. the painful period may stretch for weeks, without painless intervals. ends abruptly, as it began, from one day to the next.  Rhythmicity is the second two essential characteristic of pain, usually constant, being linked with the daily diet schedule Schedule: Immediately post-food intake, approximately 30 minutes, in the high Signs and ulcer of the small gastric curvature (in Johnson type IV); It appears after eating at approximately Symptoms 1-2 hours in the gastric ulcer of the small curvature, located in gastric body (in Johnson type I); (3) It occurs late, after 2-3 hours after eating in the pre-pyloric ulcer, (Johnson Type III) or in the gastric ulcer consecutively to a duodenal ulcer (Johnson type II); It appears very late, after 3-4 hours after eating in the duodenal ulcer, before the next meal, when associated with the subjective sensation of hunger, which gives the impression of “painful hunger”; Sometimes the pain occurs nocturnal, late at night, waking up the patient from sleep or in the early hours of the morning.  Epigastric and retrosternal burns are typically attributed to gastroesophageal reflux but can be signs of an ulcerous disease as well. Vomiting and nausea are not characteristic of uncomplicated gastroduodenal ulcer. However, they are present in the pre-pyloric ulcer or gastric ulcer associated with duodenal ulcer, but Signs and in particular it signals the installation of a stenosis or a Zollinger-Ellison syndrome. Symptoms Dyspeptic symptoms associated with pain, such as postprandial bloating, eructation, feeling of epigastric fullness or (4) epigastric cramps, fall into unlisted ulcerative dyspeptic syndrome, which may occur independently of pain in the periods of activity of the ulcer. Appetite is preserved in uncomplicated duodenal ulcer, even excessively when the patient realizes that nutrition is a gastric dressing that relieves pain. Decreased appetite betrays the installation of a complication, usually gastritis or ulcerous pyrite stenosis.  The objective exam has a relative value in establishing positive diagnosis, since ulcerative disease is extremely poor in clinical signs. The general condition and the state of nutrition are generally Signs and satisfactory. When examining the epigastric Symptoms region, we can be notice by (5) deep palpation a painful area, to the left of the median line in the gastric ulcer and to the right of the median line in the duodenal ulcer. Skin hyperalgesia and epigastric muscular hypertonia are signs that may also occur in ulcerative disease. DIAGNOSIS  Imaging Techniques: Paraclinical Radiological: Barium intake (static); Diagnosis CT Scan; Upper digestive endoscopy  The radiological examination with barium (simple or “double contrast technique”) highlights: how the stomach is filling, the shape and position of the ulcer, Paraclinical the gastric peristalsis and the appearance of the transit, as well as Diagnosis the stomach clearance. Radiological signs: // Direct signs of ulcer: Radiology Haudeck`s niche, which appears in the profile as an added shade, which protrudes from the gastric contour, with a small base of implantation and smooth contour. Seen from the front, it appears as a round stain, surrounded by a clear halo, with which together give the look of the cockade; Indirect signs: the medio-bulbar incision, deformed eccentric pyloric canal. Paraclinical Diagnosis // Ba. Intake Paraclinical Diagnosis // Ba. Intake Paraclinical Diagnosis // Ba. Intake Paraclinical Diagnosis // Ba. Intake Paraclinical Diagnosis // Ba. Intake Paraclinical Diagnosis // Gastrographin Intake  UE is the main method of diagnosis, because: Paraclinical It reveals the ulcerous lesion; Allows identification of Diagnosis // associated lesions; Biopsy to exclude cancer; Upper Allows the histological Endoscopy highlighting of HP; Allows rapid urease test. (UE) Paraclinical Diagnosis // Upper Endoscopy (UE) Paraclinical Diagnosis // Upper Endoscopy (UE) CLINICAL FORMS  There are some standard clinical forms: Juxta-cardial ulcer, immediate post- food pain, pseudo-esophageal syndrome; Post-bulbar ulcer, delayed or tardive pain, reactivity and vagotomy; Ulcers of the small gastric curvature, 2/3 resection without vagotomy, Clinical Pean procedure; Juxta-pyloric gastric ulcer, resembles Forms duodenal ulcer, generates stenoses; Ulcers of the two sides of the stomach; Gastric ulcer that is consecutive and associated with a duodenal one; Bulbar duodenal ulcer with nocturnal pain; Double gastric or duodenal ulcers; Stress ulcer, with a direct onset of hemorrhage or perforation.  Stress ulcers require various conditions of occurrence such as: After infections, peritonitis, Clinical fistulas, sepsis, After large hydro- Forms // electrolytic imbalances, After extensive burns (The Stress Curling ulcer), Ulcers After craniocerebral trauma (The Cushing ulcer), In acute respiratory insufficiency (Sadone), In the course of extrarenal dialysis (Verbanck). TREATMENT  Antisecretory medication intercepts the pathogenic chain of events and mechanisms of acid secretion. H2 receptor blockers prevent the penetration of histamine into secretory parietal cells. Drugs: Cimetidine (Tagamet), 800-1.000 mg/day, Ranitidine (Zantic, Sostril), 300-400 mg/day, Famotidine 40 mg/day. Proton pump inhibitors inhibit the ATP that Treatment exchanges H+ ions with K+ at the level of the oxyntic cell, completely blocking acid secretion. // The prototype of these drugs is Omeprazole, with all current variants, (Lansoprazole or Nexium). Prostaglandin-E1 (Cytotec, Misoprostol), 2-4 x 200 Medication mg/day, in addition to the inhibitory effect of acid secretion, also has a cytoprotective action, protection of the gastric mucosa. It is (1) recommended, in contrast, in the prophylaxis of gastric ulcer produced by NSAID. Anticholinergic substances that block muscarinic receptors and thus hinder the direct action of acetylcholine to stimulate the parietal cell (Pirenzepine, Gastrozepine). Eradicating Helicobacter pylori infection is absolutely necessary to obtain a complete healing and to avoid ulcerous relapse.  Triple therapy antisecretory scheme combines and 2-3 antibiotics in the following therapeutic associations: Treatment // Medication (2) Treatment Surgical indications in the G-D Ulcers: // Surgery Absolute indications Relative indications (Gastric) (1) Relative indications (Duodenal)  Absolute indications - Perforated ulcer, - Hemorrhagic ulcer, when hemorrhaging cannot be controlled conservatively; - If endoscopic hemostasis fails to stop Treatment bleeding; // Surgery - - Pyloric stenosis; Gastric ulcer that does not heal after a (2) complete therapy for 3 months; - Suspicion of malignancy of gastric ulcer; - Double or multiple ulcers; - The Zollinger-Ellison syndrome; - Hemorrhagic or stenosis-inducing post- bulbar ulcer.  Relative indications (gastric ulcer): - Persistence of ulcers over 3 months of active drug therapy; - Recurrent and complicated ulcers; - Very large and multiple ulcers that partially respond to conservative treatment. Treatment Relative indications (duodenal ulcer): // Surgery - If pain decreases and relapses after 3-4 months of well-run active medical treatment, accompanied by dietary-dietetic regimen; (3) - If the character of the pain changes, painful crises are more intense, occur during the night and partially respond to treatment; - When small and repeated hemorrhages occur being a cause of anemia; - When the patients have no conditions to follow the drug treatment.  Objectives: Interruption of acid secretion command; Treatment Resection of the ulcer // Surgery Conservation (as much as possible) the gastric reservoir; (4) Re-establishing continuity; the gastro-intestinal tract  Objectives - Interruption of acid secretion command It can be achieved, surgically, by vagotomy; 3 main types of vagotomy: Troncular (branch-level) vagotomy; Selective vagotomy; Supra-selective vagotomy Branch-level vagotomy: Is bilateral, at a very high level; Adv.: - easy to perform and very effective against acid production; Treatment Disadvantages : it destroys the whole vagal muscular activity of the stomach. requires some form of pyloroplasty. // Surgery Selective vagotomy: cuts only the vagus fibers for the stomach, leaving intact (5) the hepatic branch (from the anterior vagus nerve) – for liver, main biliary pathways, duodenum The celiac branch (from the posterior vagus nerve) – for pancreas, small intestine, right colon. It will affect the peristaltic movements of the stomach, in a lesser extent, so it must be paired with a pyloroplasty. Supra (ultra)-selective vagotomy: Proximal (PSV) – or Highly Selective Vagotomy (HSV), Parietal Cell Vagotomy (PCV) – just for the acid secretory parcels of the stomach. It leaves intact the branches for antrum. Does NOT require a pyloroplasty.  Types of vagotomy Treatment // Surgery (6) A B C  Objectives – Drainage pathways 2 main possibilities: Pyloroplasty It translates into a means of enlarging Treatment the pilor; Frequent techniques: Mikulicz, Finney, // Surgery Jaboulay, Burlui (6) Gastro-jejunal anastomosis Principles: must be placed as near to the pilor and to the great curvature as possible, in the lowest part of the stomach.  Objectives – Ulcer Resection Classic resection: 2/3 lower part w Gastro-Duodenal anastomosis (Billroth I - Pean); Classic resection: 2/3 lower part Treatment w Gastro-Jejunal T-L (Billroth II – Reichel-Polya) w Duodenal // Surgery stump closure (manual or (5) stapler) Limited resection: antrectomy w vagotomy + Gastro-Duodenal Anastomosis (Pean); Resection just of the ulcer: limited  Objectives – Reestablishing Continuity of the G-I tract: Gastro-Duodenal T-T Anastomosis (Pean-Billroth I) – maintains in transit the biliary- duodenal-pancreatic block; Treatment Gastro-Jejunal T-L (Billroth II) w // Surgery 2 variants: (5) The whole gastric section (Reichel-Polya) ½ gastric section (Hoffmeister- Finsterer). Gastro-Jejunal L-L w a-la-Roux intestinal loop (45 cm) – to limit the biliary reflux. Treatment // Surgery – Pean- Billroth I Procedure Treatment // Surgery – Pean- Billroth I Procedure Treatment // Surgery – Pean- Billroth I Procedure Treatment // Surgery – Pean- Billroth I Procedure Treatment // Surgery – Pean- Billroth I Procedure Thank you!