Gastric and Duodenal Ulcer

Gastric and Gastric and duodenal ulcer duodenal ulcer

diseasedisease

Ulcer diseaseUlcer disease

ulcer is a defect of gastric or duodenal mucosa ulcer is a defect of gastric or duodenal mucosa which interfere over lamina muscularis which interfere over lamina muscularis mucosae, submucosa or penetrates across mucosae, submucosa or penetrates across whole gastric or duodenal wallwhole gastric or duodenal wall

rise of ulcer is conditioned by presence of acid rise of ulcer is conditioned by presence of acid gastric content gastric content

frequent disease, men are afected 3-4x more frequent disease, men are afected 3-4x more than women than women

Pathogenesis:Pathogenesis:

mmultifactorialultifactorial ddysbalance between protective andysbalance between protective and

aaggressive factorsggressive factors

- Protective f.:Protective f.: saliva, food, alcalic duodenal fluid, saliva, food, alcalic duodenal fluid, mmucus - mucine, fast regeneration of gastric ucus - mucine, fast regeneration of gastric epithelial cells, well perfused gastric mucosaepithelial cells, well perfused gastric mucosa

- Aggressive f.:Aggressive f.: HCl, pepsin, bile acids (reflux), HCl, pepsin, bile acids (reflux), helicobacter pylori, drugshelicobacter pylori, drugs (analgetics (analgetics,, aspirin, aspirin, korticoids),korticoids), nicotine, alcohol nicotine, alcohol

Classification: Classification:

Acute ulcer (ulcus acutum)Acute ulcer (ulcus acutum) smooth non-elevated borders and smooth smooth non-elevated borders and smooth

basebase major bleeding into upper GITmajor bleeding into upper GIT

Chronic ulcer (ulcus chronicum)Chronic ulcer (ulcus chronicum) rushed and elevated boders, inflammation rushed and elevated boders, inflammation

with hypertrophic and fibrotic proliferation with hypertrophic and fibrotic proliferation is presentis present

tthe most frequent form of ulcer diseasehe most frequent form of ulcer disease

• Ulcus chronicum mediogastricumUlcus chronicum mediogastricum• Ulcus chronicum ventriculi et duodeniUlcus chronicum ventriculi et duodeni• Ulcus chronicum praepyloricumUlcus chronicum praepyloricum• Ulcus chronicum duodeniUlcus chronicum duodeni

SymptomsSymptoms of gastric ulcer of gastric ulcer diseasedisease::

eepigastric pain after meal or during mealpigastric pain after meal or during meal

uupper dyspeptic syndrome – loss of pper dyspeptic syndrome – loss of appetite, nauzea, vomiting, flatulenceappetite, nauzea, vomiting, flatulence

vvomiting brings relief omiting brings relief

rreduced nutritioneduced nutrition

lloss of weightoss of weight

Symptoms of duodenal ulcer Symptoms of duodenal ulcer disease:disease:

epigastric pain 2 hours after meal or epigastric pain 2 hours after meal or on a empty stomach or during nighton a empty stomach or during night

pyrosispyrosis

good nutritiongood nutrition

obstipationobstipation

seasonal dependence (spring, autumn)seasonal dependence (spring, autumn)

Complications:Complications:

BleedingBleeding - chronic (minor, cause anaemia) - chronic (minor, cause anaemia) - acute (major, form affected vessel)- acute (major, form affected vessel)

PerforationPerforation - mostly bulbus duodeni, anterior gastric - mostly bulbus duodeni, anterior gastric wallwall

- acute violent pain- acute violent pain - bleeding can be present- bleeding can be present

PenetrationPenetration -- of the ulcer deeply through whole wall of the ulcer deeply through whole wall into into

neighbor organneighbor organ (pancreas, liver)(pancreas, liver)

StenosisStenosis - narrow of - narrow of thethe lumenlumen causedcaused by by scar, scar, oedema oedema oror

inflammatory infiltration after healing of inflammatory infiltration after healing of the ulcerthe ulcer

- - rise only at pyloric localizationrise only at pyloric localization - - vomiting of huge volume of gastric contentvomiting of huge volume of gastric content

Zeman, M. et al., Speciální chirurgie, ISBN 80-7262-260-9, 2004

A – penetration B – perforation

C – bleeding D - stenosis

Therapy:Therapy:

Conservative Conservative • regular lifestyleregular lifestyle• prohibition of the smoking and alcoholprohibition of the smoking and alcohol• ddiet (proteins, milk and milky products)iet (proteins, milk and milky products)• pharmacology (antagonistspharmacology (antagonists of of H2 H2

receptors, antacids, anticholinergics receptors, antacids, anticholinergics

Surgical Surgical • BI, BII BI, BII resectionresection• proximal selective vagotomyproximal selective vagotomy• vagotomy with pyloroplasticvagotomy with pyloroplastic• suture of suture of perforatedperforated or haemorrhagic or haemorrhagic

ulcerulcer

Stomach Stomach resections:resections:

BillrothBillroth I (BI) I (BI) – – gastro-gastro-duodenoanastomosis end-to-endduodenoanastomosis end-to-end

Billroth II (BII)Billroth II (BII) – gastro- – gastro-jejunoanastomosis end-to-side with blind jejunoanastomosis end-to-side with blind closure of duodenumclosure of duodenum

ProximalProximal selective vagotomyselective vagotomy – denervation – denervation of parietalof parietal gastric cells gastric cells


Billroth I

Billroth II



Gastro-enteroanastomosis on

Roux Y crankle


Vagotomy

Complications after stomach Complications after stomach resection:resection:

EarlyEarly – dehiscence, stenosis of anastomosis, – dehiscence, stenosis of anastomosis, bleeding, pancreatitis, obstructive icterus, bleeding, pancreatitis, obstructive icterus, affection of affection of neighbourneighbour tissues tissues

LateLate - - days, weeksdays, weeks

- early dumping syndrome- early dumping syndrome

- late dumping syndrome- late dumping syndrome

- incoming crankle syndromeincoming crankle syndrome

- outcoming crankle syndromeoutcoming crankle syndrome

- ulcer in anastomosis or in outcoming - ulcer in anastomosis or in outcoming cranklecrankle

Early dumping syndrome:Early dumping syndrome:

group of symptoms approved shortly after group of symptoms approved shortly after mealmeal

appears after BII resectionappears after BII resection

vasomotoric sy. - face redness, fall of vasomotoric sy. - face redness, fall of blood pressure, dizzinessblood pressure, dizziness

GI sy. - vomiting, diarrhoeaGI sy. - vomiting, diarrhoea

Th.:Th.: diet, no sugar, low quantities of food, diet, no sugar, low quantities of food, change BII to BI resectionchange BII to BI resection

LateLate dumping syndrome: dumping syndrome:

hhypoglycaemiaypoglycaemia (sugar is not enough (sugar is not enough digested)digested)


weakness, perspiration, dizzinessweakness, perspiration, dizziness, , tremor tremor ccacca 3h 3h afterafter mealmeal

Th.:Th.: no sugar, change BII to BI resection no sugar, change BII to BI resection

Incoming crankle syndromeIncoming crankle syndrome::

stasis of the content at incoming crankle stasis of the content at incoming crankle increase intraluminal pressure increase intraluminal pressure


Th.:Th.: dietdiet, change BII to BI resection, change BII to BI resection

Outcoming crankle syndromeOutcoming crankle syndrome::

chronic or acute closure of outcoming chronic or acute closure of outcoming cranklecrankle


vomiting after meal, convulsive painvomiting after meal, convulsive pain

Th.:Th.: change BII to BI resection change BII to BI resection

Haemorrhagic Haemorrhagic mediogastric ulcermediogastric ulcer

Chronic gastric ulcerChronic gastric ulcer

Pylorostenosis and Pylorostenosis and gastrectasiagastrectasia

Duodenal ulcerDuodenal ulcer

Stress ulcersStress ulcers

Benign stomach tumorsBenign stomach tumors rise from all layers of stomach wallrise from all layers of stomach wall

often asymptomaticoften asymptomatic

Polypus, Leiomyoma, Lipoma, Fibroma, Polypus, Leiomyoma, Lipoma, Fibroma, Neurofibroma, Neurinoma, Hemangioma, Neurofibroma, Neurinoma, Hemangioma, Karcinoids, LymfomaKarcinoids, Lymfoma

Diagnostic:Diagnostic: endoscopy, X – ray endoscopy, X – ray

Therapy:Therapy: local excision, stomach resection local excision, stomach resection

Symptoms:Symptoms:

long-time asymptomaticlong-time asymptomatic feeling of full stomach, odour from feeling of full stomach, odour from

mouth, tiredness, anaemia, occasional mouth, tiredness, anaemia, occasional vomiting, loss of appetite, loss of weightvomiting, loss of appetite, loss of weight

Diagnosis:Diagnosis:

gastrofibroscopy – biopsy - histologygastrofibroscopy – biopsy - histology X-ray, USG, CT - metastasis X-ray, USG, CT - metastasis Wirchow´s nodule – enlargement of left Wirchow´s nodule – enlargement of left

supraclavicular nodule supraclavicular nodule

Stomach cancerStomach cancer

Stomach cancerStomach cancer Etiopathogenesis:Etiopathogenesis:

Praecancerosis:Praecancerosis: adenomatous polypus, adenomatous polypus, chronic atrofic gastritis, foveolar chronic atrofic gastritis, foveolar hyperplasia (Ménétrier disease), stub of hyperplasia (Ménétrier disease), stub of the stomach after BII resectionthe stomach after BII resection

Division:Division:

Macroscopic:Macroscopic: exofytic polypoid form, exofytic polypoid form, diskyform ulcerous form, diffused diskyform ulcerous form, diffused infiltrating forminfiltrating form

Histopathologic:Histopathologic: adenocarcinoma, papilar, adenocarcinoma, papilar, tubular, gelatinous cancer, round cell tubular, gelatinous cancer, round cell cancer, flagstone cell cancer, etc. cancer, flagstone cell cancer, etc.

Therapy:Therapy:

Currative – total gastrectomyCurrative – total gastrectomy, sub-total , sub-total gastrectomygastrectomy

Paliative – gastrostomy, jejunostomyPaliative – gastrostomy, jejunostomy

Stomach cancerStomach cancer


Gastric cancerGastric cancer

Gastric stub cancer after B Gastric stub cancer after B II resectionII resection

Schwanoma fundi Schwanoma fundi vetriculivetriculi

Than you for your Than you for your attention!!!attention!!!

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Gastric and Duodenal Ulcer