powerpoint : complications
TRANSCRIPT
COMPLICATIONSCOMPLICATIONS
GASTRO-DUODENAL PEPTIC GASTRO-DUODENAL PEPTIC ULCERSULCERS
COMPLICATIONS OF COMPLICATIONS OF GASTRODUODENAL GASTRODUODENAL ULCERSULCERS PERFORATIONPERFORATION- PERITONITIS- PERITONITIS
BLEEDINGBLEEDING- ANEMIA- ANEMIA
STENOSISSTENOSIS- GASTRIC OUTLET - GASTRIC OUTLET
OBSTRUCTIONOBSTRUCTION
PERFORATIONPERFORATION
PerforationPerforation- ulcer rupture into the - ulcer rupture into the peritoneal cavity with spillage of GD peritoneal cavity with spillage of GD contentscontents
PenetrationPenetration- erosion into a solid organ: liver - erosion into a solid organ: liver or pancreasor pancreas
Perforation of a chronic ulcerPerforation of a chronic ulcer- increasing - increasing dyspepsia prior to the perforationdyspepsia prior to the perforation
Perforation of an acute ulcerPerforation of an acute ulcer- no - no premonitory symptomspremonitory symptoms
PERFORATIONPERFORATION
Risk factors:Risk factors:
- drugs: steroids, NSAID- drugs: steroids, NSAID
- situations of stress: burns, - situations of stress: burns, multiple injuries, sepsis, multiple injuries, sepsis, chemotherapy, radiotherapychemotherapy, radiotherapy
CLINICAL FEATURES OF CLINICAL FEATURES OF PERFORATED ULCERPERFORATED ULCER The moment of perforation is identified The moment of perforation is identified
by the patient as an by the patient as an excruciating excruciating epigastric painepigastric pain
The intensity of sy. depend on The intensity of sy. depend on the the degree degree of peritoneal soiling and whether of peritoneal soiling and whether the perforation the perforation becomes sealedbecomes sealed
The spillage goes along the right The spillage goes along the right paracolic gutter- pain from epigastrium paracolic gutter- pain from epigastrium shifts to RIF , may mimick acute shifts to RIF , may mimick acute appendicitisappendicitis
Vomiting in delayed cases- Vomiting in delayed cases- ileus ileus
PHYSICAL SIGNS OF PHYSICAL SIGNS OF PERFORATED PEPTIC PERFORATED PEPTIC ULCERULCER Depend upon the Depend upon the degree and rate degree and rate of of
soiling within peritoneal cavitysoiling within peritoneal cavity Tenderness with guarding may vary from Tenderness with guarding may vary from
being localized to the upper abdo- to being localized to the upper abdo- to being generalizedbeing generalized
Typical signs for generalized peritonitis Typical signs for generalized peritonitis due to perforated ulcer are: due to perforated ulcer are: rigid rigid abdomenabdomen, no respiratory movements, , no respiratory movements, silent abdomen, silent abdomen,
As later features: progressive distension, As later features: progressive distension, hypotension, tachycardia, cold periphery, hypotension, tachycardia, cold periphery, decreased urinary outputdecreased urinary output
PHYSICAL SIGNS OF PHYSICAL SIGNS OF PERFORATED ULCERPERFORATED ULCER
Any deep inspiration, coughing- Any deep inspiration, coughing- increased painincreased pain
The patient The patient lies still lies still in the bed, any in the bed, any movement exacerbating the painmovement exacerbating the pain
INVESTIGATIONS IN INVESTIGATIONS IN PERFORATED ULCERPERFORATED ULCER Plain abdominal X Ray Plain abdominal X Ray in erect positionin erect position
– PneumoperitoneumPneumoperitoneum- air visible in the right - air visible in the right subdiaphragmatic spacesubdiaphragmatic space
– Gas/fluid levels Gas/fluid levels in advanced casesin advanced cases– If pneumoperitoneum is not seen, think to If pneumoperitoneum is not seen, think to
a sealed perforation or acute pancreatitisa sealed perforation or acute pancreatitis– Do not count on amylase, may be Do not count on amylase, may be
increased in any acute abdomenincreased in any acute abdomen USS of the abdomenUSS of the abdomen- fluid within - fluid within
peritoneal cavityperitoneal cavity
Plain rx. of the RUQ Plain rx. of the RUQ shows a tiny streak of air shows a tiny streak of air under the diaphragmunder the diaphragm
Pneumoperitoneum Pneumoperitoneum in perforated duodenal in perforated duodenal ulcerulcer
PneumoperitoneumPneumoperitoneum
PneumoperitoneumPneumoperitoneumperforated duodenal perforated duodenal ulcerulcer
Upright CXR shows Upright CXR shows a large collection of air under a large collection of air under both the diaphragmsboth the diaphragms
MANAGEMENT OF MANAGEMENT OF PERFORATED ULCERPERFORATED ULCER Correction of hypovolemia, electrolyte Correction of hypovolemia, electrolyte
disturbances, low urinary outputdisturbances, low urinary output Severe cases- monitoring CVP, hourly Severe cases- monitoring CVP, hourly
UOUO Colloids, cristaloids – effectiveColloids, cristaloids – effective Naso-gastric aspirationNaso-gastric aspiration Antisecretory drugsAntisecretory drugs Planning for operationPlanning for operation
OPERATIVE VS OPERATIVE VS CONSERVATIVE CONSERVATIVE TREATMENTTREATMENT Sealed perforated ulcer- Sealed perforated ulcer- Taylor’s Taylor’s
methodmethod Taylor’s method: NG aspiration, iv Taylor’s method: NG aspiration, iv
fluids, antibiotics, antisecretory fluids, antibiotics, antisecretory drugsdrugs
Indication: young patients with short Indication: young patients with short history of perforation of acute ulcer history of perforation of acute ulcer and with minimum of pneumo. and and with minimum of pneumo. and fluid under liverfluid under liver
Close clinical observationClose clinical observation
OPERATIVE OPERATIVE VS.CONSERVATIVE VS.CONSERVATIVE TREATMENTTREATMENT
If the patient is getting worse within 6-12 If the patient is getting worse within 6-12 hours, the operation is requiredhours, the operation is required
Operative procedure- Operative procedure- simple closure of simple closure of the perforation, omentoplasty, peritoneal the perforation, omentoplasty, peritoneal lavage and multiple drainageslavage and multiple drainages
Peritoneal fluid sent for bacteriological Peritoneal fluid sent for bacteriological cultureculture
Empiric antibiotherapy- broad spectrum Empiric antibiotherapy- broad spectrum antibiotics antibiotics
Perforated peptic duodenal ulcer. The Perforated peptic duodenal ulcer. The ulcer was found to be a typically punched ulcer was found to be a typically punched out peptic ulcer (arrows) with a diameter out peptic ulcer (arrows) with a diameter of 6 mmof 6 mm
Perforated peptic ulcerPerforated peptic ulcer
Perforated duodenal ulcerPerforated duodenal ulcer
A 49-year-old man was A 49-year-old man was admitted with sudden onset of admitted with sudden onset of severe pain in the epigastrium. severe pain in the epigastrium. Recently, he had taken a Recently, he had taken a course of a non-steroidal anti-course of a non-steroidal anti-inflammatory drug (NSAID).inflammatory drug (NSAID).
This had caused indigestion, This had caused indigestion, which had worsened in the two which had worsened in the two days prior to his presentation.days prior to his presentation.
On examination, the patient On examination, the patient was ill and had a rigid was ill and had a rigid abdomen. abdomen.
The operative photograph The operative photograph shows a perforated duodenal shows a perforated duodenal ulcer. This was oversewn. ulcer. This was oversewn.
Closure of perforated duodenal ulcer & Closure of perforated duodenal ulcer & omental patching.omental patching.
PYLORIC STENOSISPYLORIC STENOSIS
Chronic scarring from ulceration in Chronic scarring from ulceration in the pyloric region- gastric outlet the pyloric region- gastric outlet obstruction or obstruction or pyloric stenosispyloric stenosis
Occurs in a patient with Occurs in a patient with longstanding ulcer disease ignored, longstanding ulcer disease ignored, neglected or bad treatedneglected or bad treated
Be aware that Be aware that pyloric stenosis pyloric stenosis might might be due to a be due to a malignant antral tumormalignant antral tumor
PYLORIC STENOSISPYLORIC STENOSISCLINICAL FEATURESCLINICAL FEATURES
PainPain in the upper abdomen, relieved by the in the upper abdomen, relieved by the vomitingvomiting
VomitingVomiting is efortless, projectile with is efortless, projectile with partially digested food and partially digested food and bile is absentbile is absent
Naso-gastric aspiration reveals only gastric Naso-gastric aspiration reveals only gastric fluid with thick partially digested foodfluid with thick partially digested food
For gastric decompresion- gastric lavage For gastric decompresion- gastric lavage and aspirationand aspiration
PYLORIC STENOSISPYLORIC STENOSISCLINICAL FEATURESCLINICAL FEATURES
Underweight patient, dehydrated Underweight patient, dehydrated with persistent skin fold, anemicwith persistent skin fold, anemic
Gastric stasis revealed by Gastric stasis revealed by succusion splash on percusionsuccusion splash on percusion
Visible peristalsisVisible peristalsis, passing across , passing across the upper abdomen from left to the upper abdomen from left to right right
PYLORIC STENOSISPYLORIC STENOSISMETABOLIC FEATURESMETABOLIC FEATURES Prolonged vomiting- electrolyte Prolonged vomiting- electrolyte
disturbances and renal failuredisturbances and renal failure Hypochloremic alkalosis Hypochloremic alkalosis due to due to
hydrogen and chloride ions losseshydrogen and chloride ions losses At a later stage- renal function At a later stage- renal function
disturbeddisturbed To compensate metabolic alkalosis, To compensate metabolic alkalosis,
the kidneys excret bicarbonates at the the kidneys excret bicarbonates at the expense of losing sodiumexpense of losing sodium
PYLORIC STENOSISPYLORIC STENOSISMETABOLIC FEATURESMETABOLIC FEATURES
The patient becomes progressively The patient becomes progressively more dehydrated and more dehydrated and hyponatremichyponatremic
In an attempt to conserve circulatory In an attempt to conserve circulatory volume, sodium is retained by the volume, sodium is retained by the kidneys and hydrogen plus potassium kidneys and hydrogen plus potassium is excreted preferentiallyis excreted preferentially
Hence alkalosis becomes more severe Hence alkalosis becomes more severe and and hypokalemiahypokalemia more marked more marked
HypocalcemiaHypocalcemia- disturbance of - disturbance of consciousness and tetanyconsciousness and tetany
PYLORIC STENOSISPYLORIC STENOSISMETABOLIC FEATURESMETABOLIC FEATURES These electrolyte disturbances in These electrolyte disturbances in
patients with severe pyloric stenosis patients with severe pyloric stenosis are termed are termed DARROW’S SYNDROMEDARROW’S SYNDROME
Lab.findings are:- base excess> Lab.findings are:- base excess> - high serum - high serum
urea, urea, - - hyponatremia, hyponatremia, - hypopotasemia, - hypopotasemia,
- hypocalcemia - hypocalcemia
X-ray after a barium meal will show X-ray after a barium meal will show delayed emptying of the stomach, and delayed emptying of the stomach, and often the contour of the stomach will be often the contour of the stomach will be seen deep in the pelvisseen deep in the pelvis
Draining the stomach with a naso-gastric Draining the stomach with a naso-gastric tube (NG tube) will produce thick muddy tube (NG tube) will produce thick muddy content (undigested food). content (undigested food).
Endoscopic viewEndoscopic viewof normal duodenumof normal duodenum
Endoscopic view of Endoscopic view of pyloric stenosispyloric stenosis
PYLORIC STENOSISPYLORIC STENOSISMANAGEMENTMANAGEMENT
The priority is correction of fluid and The priority is correction of fluid and electrolytes abnormalitieselectrolytes abnormalities
RehydrationRehydration- saline infusion with K - saline infusion with K supplementssupplements
Provision of adequate sodium allows Provision of adequate sodium allows excretion of alkaline urine so that the excretion of alkaline urine so that the alkalosis becomes correctablealkalosis becomes correctable
Clinical improvement: increased UO, a fall to Clinical improvement: increased UO, a fall to normal in blood urea and normal electrolytesnormal in blood urea and normal electrolytes
Gastric lavage until fluid is clearGastric lavage until fluid is clear
PYLORIC STENOSISPYLORIC STENOSISSURGICAL TREATMENTSURGICAL TREATMENT Partial gastric resection with gastro-Partial gastric resection with gastro-
duodenal anastomosis (PEAN-duodenal anastomosis (PEAN-BILLROTH I)BILLROTH I)
Partial gastric resection with gastro-Partial gastric resection with gastro-jejunal anastomosis (BILLROTH II)jejunal anastomosis (BILLROTH II)
For old, frail patients- by pass For old, frail patients- by pass operation like gastro-jejunostomyoperation like gastro-jejunostomy
BLEEDING PEPTIC BLEEDING PEPTIC ULCERULCER Acute bleeding is the commonest Acute bleeding is the commonest
complicationcomplication It carries the highest mortality It carries the highest mortality Bleeding results from erosion of the Bleeding results from erosion of the
ulcer into a blood vesselulcer into a blood vessel The most common sign is melena +/- The most common sign is melena +/-
hematemesishematemesis One of three pts. have no history of One of three pts. have no history of
ulcer ulcer In major bleeding- GI transit so rapid- In major bleeding- GI transit so rapid-
stool is bright red stool is bright red
BLEEDING PEPTIC BLEEDING PEPTIC ULCERULCER
Severity of acute bleeding assessed Severity of acute bleeding assessed by:by:
BP, PR, Hb., Ht. if sufficient time BP, PR, Hb., Ht. if sufficient time passed for compensatory passed for compensatory hemodilutionhemodilution
Systolic BP< 100, PR>100 with the Systolic BP< 100, PR>100 with the patient supine, suggest major blood patient supine, suggest major blood loss (>1 l.) loss (>1 l.)
BLEEDING PEPTIC BLEEDING PEPTIC ULCERULCER
Adverse clinical factors on outcome:Adverse clinical factors on outcome:– Severe, continuing bleedingSevere, continuing bleeding– Early rebleeding within 3-5 days of Early rebleeding within 3-5 days of
initial stabilizationinitial stabilization– Age greater than 60Age greater than 60– Associated diseases: cardio-vascular Associated diseases: cardio-vascular
and liver diseasesand liver diseases
BLEEDING PEPTIC BLEEDING PEPTIC ULCERULCER The differential diagnosis includes:The differential diagnosis includes:
– Rupture of esophago-gastric varicesRupture of esophago-gastric varices– Hemorrhagic gastritisHemorrhagic gastritis– Mallory-Weiss lacerationMallory-Weiss laceration– Ulcerated benign and malignant gastric Ulcerated benign and malignant gastric
tumorstumors– Vascular anomalies (angiodysplasia)Vascular anomalies (angiodysplasia)– Aorto-enteric fistula in pts. with a Aorto-enteric fistula in pts. with a
prosthetic aortic graftprosthetic aortic graft
BLEEDING PEPTIC ULCER-ENDOSCOPYBLEEDING PEPTIC ULCER-ENDOSCOPY
Forrest’s classification of bleeding Forrest’s classification of bleeding activityactivity
Forrest Ia- active bleeding- arterial Forrest Ia- active bleeding- arterial spurtingspurting
Forrest Ib- active bleeding- oozingForrest Ib- active bleeding- oozing
Forrest II-bleeding ceased- clot lying on Forrest II-bleeding ceased- clot lying on ulcer or visible vessel stumpulcer or visible vessel stump
Forrest III-bleeding ceased- no signs of Forrest III-bleeding ceased- no signs of recent bleedingrecent bleeding
MANAGEMENTMANAGEMENT
Three phases in the management Three phases in the management of the bleeding:of the bleeding:– ResuscitationResuscitation– DiagnosisDiagnosis– Definitive treatmentDefinitive treatment
Active bleeding gastric Active bleeding gastric ulcerulcer
Endoscopic view Endoscopic view of activ gastric of activ gastric bleedingbleeding
Endoscopic view Endoscopic view of erosive duodenitisof erosive duodenitis
Active bleeding- Active bleeding- duodenal ulcerduodenal ulcer
Bleeding duodenal Bleeding duodenal ulcerulcer
Bleeding erosive Bleeding erosive gastritisgastritis
RESUSCITATIONRESUSCITATION
Hemorrhagic shock- ICUHemorrhagic shock- ICU Do not sedate patient for Do not sedate patient for
endoscopyendoscopy Rapid transfusionRapid transfusion BP, PR, CVP, UO monitoringBP, PR, CVP, UO monitoring Confusion and restlessness demand Confusion and restlessness demand
attention for oxygenationattention for oxygenation
DIAGNOSISDIAGNOSIS
History- dyspepsia, liver disease, History- dyspepsia, liver disease, intake of alcohol, aspirin, NSAIDintake of alcohol, aspirin, NSAID
Endoscopic examination: the sourse Endoscopic examination: the sourse and the gravity of bleedingand the gravity of bleeding
Endoscopic criteria for early surgery:Endoscopic criteria for early surgery:– Arterial spurterArterial spurter– Visible vessel in base of ulcerVisible vessel in base of ulcer– Adherent clotAdherent clot
MANAGEMENTMANAGEMENT
Bed restBed rest Naso-gastric lavage with cold salineNaso-gastric lavage with cold saline IV antisecretory drugs (H proton IV antisecretory drugs (H proton
pump inhibitors, H2 receptor pump inhibitors, H2 receptor antagonists)antagonists)
Hemostatic drugsHemostatic drugs Endoscopic adrenaline injectionEndoscopic adrenaline injection
INDICATION FOR INDICATION FOR SURGERYSURGERY
Continuing bleedingContinuing bleeding Re-bleedingRe-bleeding The sourse of bleedingThe sourse of bleeding Fitness of the patientFitness of the patient
Check coagulation parametersCheck coagulation parameters
SURGERY IN BLEEDING SURGERY IN BLEEDING ULCERULCER
Partial gastrectomy but morbidity Partial gastrectomy but morbidity and mortality highand mortality high
Underrunning of the bleeding Underrunning of the bleeding ulcer, followed by the treatment ulcer, followed by the treatment with antiulcer drugswith antiulcer drugs
THE FAILURES THE FAILURES OF GASTRIC SURGERYOF GASTRIC SURGERY
Recurrent UlcerationRecurrent Ulceration– Incomplete vagotomyIncomplete vagotomy– Inadequate resectionInadequate resection– Retained gastric antrumRetained gastric antrum– Zollinger-Ellison syndromeZollinger-Ellison syndrome– HypercalcemiaHypercalcemia