Peptic Ulcer Disease: Surgical Aspects and Treatment PDF

Peptic ulcer disease Surgical Aspect Prof Agodirin medimagsolutions.com medimagsurgerygroup.com Medimagsurgery.com  Peptic Ulcer Disease Part I Definition By medimagsurgery.com Definition: Critical point...

Peptic ulcer disease Surgical Aspect Prof Agodirin medimagsolutions.com medimagsurgerygroup.com Medimagsurgery.com  Peptic Ulcer Disease Part I Definition By medimagsurgery.com Definition: Critical point Acid & Pepsin bathing Mucosa Epithelium Muscularis Mucosa Beyond Muscularis Submucosa Mucosa Muscle Coat  Erosion Mucosa Epithelium Muscularis Mucosa Limited Mucosa, Ulcer Submucosa Heals by Regeneration Beyond mucosa, Muscle Coat Heals by Scar tissue  Peptic Ulcer Disease Epidemiology By medimagsurgery.com  Peptic Ulcer Disease Part II Epidemiology By medimagsurgery.com Incidence of PUD Occurs Globally Incidence: Male Vs female  Incidence: Male Vs female Duodenal More in males Due to the larger Stomach & Parietal Cell mass Incidence: Male Vs female Gastric: Affects Males and Females Equally Incidence: Male Vs female Age distribution Duodenal Most cases Gastric 20-40 40-60 years 40-60  PUD & Social Class High Low  PUD & Social Class High Low Duodenal Ulcer occurs equally  PUD & Social Class Low High Gastric Ulcer More in Low Class More Facts Incidence: Duodenal Vs Gastric Duodenal 4Xs more common Gastric Ulcer Gastric Ulcer More common in Antrum Gastric Ulcer More common in Antrum More common along lesser Curvature Gastric Ulcer More common in Antrum More common along lesser Curvature Associated with blood Group A Duodenal Ulcer Ulcer More common in first Part Duodenal Ulcer Ulcer More common in first Part More common in the upper part Duodenal Ulcer Ulcer More common in first Part More common in the upper part Associated with blood Group O Perforation Vs Bleeding Perforation Vs Bleeding Perforation Vs Bleeding Posteriors Ulcers Bleed Anterior Ulcers Perforate Bleeding most lethal Perforation most complication Dramatic complication Cause and Pathophysiology of PUD medimagsurgery.com There is interaction between mucosa PROTECTORS & AGGRESSORS 5 Protectors Aggressors Repair H. Pylori Acid control Tight Junction NSAIDs Mucus-Bicarb layer Alcohol Perfusion Smoking Acid control Bile reflux Hyperacidity PUD occurs when aggressors overrun protectors 5 Protectors Repair Acid control Tight Junction Mucus-Bicarb layer Aggressors Perfusion H. Pylori NSAIDs Alcohol Smoking Bile reflux Hyperacidity PUD occurs when aggressors overrun protectors Protectors Repair Acid control Tight Junction Mucus-Bicarb layer Aggressors Perfusion H. Pylori NSAIDs Alcohol Smoking Bile reflux Hyperacidity Let’s See How Protection occurs Repair or Restitution Tight Junction between Epithelial Cells Mucus Bicarb Layer Acid Control High perfusion  Pathology Ulceration beyond muscularis mucosa, in mucosa that is bath by acid in pepsin “Beyond the muscularis mucosa “ 5 locations of PUD Lower esophagus Stomach Duodenum Jejunal side of gastrojejunal stoma Meckel’s Diverticulum Relevant anatomy FUNCTIONS OF STOMACH Receptive relaxation /storage of food Digestion-churning and acid/pepsin production Propulsion forward Body armor(frontline defense)- acid Production of intrinsic factor (for B12 absorption) Activation of pepsin  Relevant physiology of acid secretion RECEPTORS THAT CONTROL ACID SECRETION FROM THE PARIETAL/ OXYNTIC CELLS OTHER IMPORTANT SECRETIONS Pepsinogen (chief cells ) Mucus (mucus cells ) Intrinsic factor Functional Innervation FUNCTION OF VAGAL INNERVATION (secreto-motor) SECRETORY Cephalic phase of acid/juice production Motor Receptive relaxation Peristalsis for gastric emptying Functioning of the sphincter  Classical presentation of PUD using “ECG tracing” Precipitator – fasting /feeding Quality- peppery, burning R-radiation (the back when penetrating into pancreas , may radiate right or left Relief – feeding (duodenal) /vomiting (gastric with fear of feeding ), antacid, milk Region- epigastrium Severity- wakes patient midnight Timing – diurnal variation, periodicity Investigations Upper GI endoscopy Direct visualisation of the ulcer Preferred diagnostic test Biopsy & H. pylori Other Upper GI barium series  Complications ACUTE SUBACUTE CHRONIC Perforation Peri-gastric and lesser sac abscess Anemia Penetration into liver GOO Bleeding Penetration into pancreas ❑ Duodenal stenosis Inflammatory phlegmon( cause GOO) ❑ Antral stenosis ❑ Hourglass Fabius conctator’s tradition deformity ❑ Teapot deformity ❑ Malignant transformation ❑ Kissing ulcers Differentiating differentials ❑Duodenal ulcer ❑Gastric ulcer ❑Cholelithiasis ❑Hiatus hernia ❑GERD ❑Carcinoma of stomach ❑Acute pancreatitis (mild) Treatment Non-pharmacologic Pharmacologic (medical ) Surgical  PHARMACOLOGIC  Antacids- magnesium sulphate, aluminium hydroxide, bicarbonate  Antimuscarinic – atropine, pirenzipine, probantelin  H2-blockers:cimetidine,ranitidine,famotidine  Proton pump inhibitors: omeprazole , rabiprazole  Gastrin inhibitor- proglumide  Mucosa-protector Sulcrafate Bismuth Prostaglandin analogue-misoprostol Anti- H.pylori treatment SURGICAL TREATMENT OF DUODENAL ULCER Remove the innervation ( one form of vagotomy or the other ) Ensure drainage Pyloroplasty or gastrojejunostom Anthrectomy + billroth I or II anastomosis ) Combine them Surgical treatment of Gastric ulcer Remove the ulcer with or without reduction of acid production Wedge resection with vagotomy and bypass Antrectomy Distal partial gastrectomy Subtotal gastrectomy  Complications of gastric surgery for PUD Anastomotic bleeding Gastroparesis-delayed emptying Anastomotic leakage Post vagotomy diarrhea Short stomach syndrome Stoma obstruction(edema, stenosis) Abdominal tuberculosis Pernicious anemia Retrograde intussusception Pulmonary tuberculosis Malnutrition Early and late dumping syndrome Bacterial overgrowth-malabsorption Malignant transformation Afferent loop syndrome Phlegmonous Gastritis Efferent loop syndrome Cholelithiasis Blind loop syndrome Lesser curvature necrosis Gastrojejunocolic fistula Recurrence Reflux gastritis Colonic cancer Clinical Application: Managing a patient with abdominal pain suspected to be PUD Biodata Pc HPC ROS Pmhx (o and G) Sohx Fhx Question time questions The end