peptic ulcer disease. factors influencing aggressor – acid – pepsin – nsaids – h.pylori...
TRANSCRIPT
Peptic ulcer disease
Factors influencing
• Aggressor– Acid– Pepsin– NSAIDs– H.Pylori
• Defense – Bicarbonate– Blood flow– Mucous– Cell junctions– Apical resistance
• Repair– Restitution– Proliferation– Mucous cap– Growth factors
H.Pylori
• Acid hypersecretion1. Inhibits antral D cells
• Decreased somatostatin• Increased gastrin• Increased acid
2. Local alkalization of the antrum• Increased gastrin• Increased acid
• Toxins – Cag A– Vac A
• Cytokines – IL-8
• These cause inflammation -> direct damage to epithelium
Other etiological factors
• NSAIDs• Gastrinoma (zollinger allison syndrome)• Smoking• Stress
The gastrinoma triangle
Clinical features
• Abdominal pain• Nausea• Bloating• Stool positive for occult
blood
• ALARM symptoms– Wt loss– Recurrent vomitting– Dysphagia– Bleeding– Anemia
• If any alarm symptom present, UGI endoscopy should be done
Upper GI series showing ulcer
Complications of peptic ulcer
• Intractability• Bleeding• Perforation• Obstruction
Perforation
• Acute abdomen – Sudden excruciating pain• Fluid sequestration into third space• Peritoneal signs– Guarding, tenderness, rebound tenderness
• Free air under domes of diaphragm
Ulcer perforation - xray
Closure of perforated DU with onlay patch
Gastric ulcer excision
Closure after excision
Intractability
Nonspecific vagotomy
Antrectomy
Completed vagotomy, antrectomy and gastroduodenostomy
Selective and highly selective Vagotomy
Laparoscopic HSV using clips or harmonic scalpel
Clips Harmonic shears
The criminal nerve of Grassi
Heineke-Mikulicz Pyloroplasty
Finney’s pyloroplasty
Biliroth I procedures
Biliroth II reconstruction
Roux en y gastrojejunostomy
Bleeding
• Melena/hematemesis• Nasogastric aspiration confirmatory• ShockNPO, acid supressionAggressive resuscitation with fluids and bloodUrgent endoscopyIf endoscopic Rx fails, or re-bleed, Surgery
Exosure of posterior bleeding DU
Figure of eight suture for bleeding control
Gastric resection
Separation of the greater omentum from the entire transverse colon
Mobilization of the left lobe of liver and GE junction
Mobilization of the greater curvature
Transection of the duodenum
D2 compartment lymphadencectomy
Division of the left gastric vessels
Transection of the esophagus
Roux en y reconstruction
Post operative complications of gastrectomy
• Short term:– Intra-abdominal bleeding– Subphrenic abscess– Anastomotic leak– Pancreatic fistula– Duodenal stump leak
• Long term:– Weight loss, decreasing nutritional status (reservoir capacity)– Diarrhea– Dumping syndrome– Alkaline reflux
Gastrojejunostomy
Complications of gastrojejunostomy
• Gastric hemorrhage• Anastomotic bleeding• Anastomotic leak• Obstruction (anastomotic or functional)• Anastomotic stenosis (long term)
Gastrostomy
Stamm Witzel
Janeway (permanent stapled gastrostomy
Percutaneous endoscopic gastrostomy
Laparoscopic gastrostomy
Pyloromyotomy