GastriculcerDuodenalulcerPancreatitis

Ileus

BarboraKonečnábasa.konecna@gmail.com

Pepticulcersofstomachandduodenum(PUD)

•  Ulcersarechronic,oftensolitarylesions,thatoccurinanypartofGITthatisexposedtoaggresivefactorsofthe

gastricfluids

•  Ulceration–disruptionofmucosaatleasttothe

muscularismucosaelayerduetosecretionofHCl

andactivationofpepsinogen

•  Erosion–superficialdamage(mucosa)

•  10%ofpopulationhaveorwilldevelopanulcer

Pepticulcersofstomachandduodenum(PUD)

•  Occurduetodysbalanceofgastro-duodenalprotectivemechanismsandaggressivefactors,whiletheeffectsare

furtherenhancedbyexternalorimmunologicalfactors

Pepticulcersofstomachandduodenum(PUD)

Protectivefactors•  normal

compositionandproductionofmucin

•  Alk.secretionofHCO3-

•  intactmicrocirculation

•  regenerationofgastricmucosa

•  secretionofendogenousprostaglandins

Agressivefactors

•  Helicobacterpylori•  drugswith

ulcerogenouseffects(NSAIDs)

•  deleteriouseffectsofduodenalfluids

•  smoking,alcohol•  disruptionsof

microcirculationinthemucosaandsubmucosa

PUD–H.pyloriinfection

•  colonizationofgastricmucosa

•  Doesnotentercells,onlymucosa(extracellularpathogens)

•  Urease→ammonium→acidneutralization→reflexive

productionofacid

•  Proteases→disruptionofmucouslayer

•  Weakresistanceofthemucosa

•  Digestionofthemucosabyacidandpepsin

•  Chroniculcerations

PUD–Otherfactors

•  Zollinger–Elissonsyndrome(gastrinoma)

•  Meckel´sdiverticulumandectopicgastric

mucousmembrane

PUD–symptomes

•  Epigastricpain(heatburn)•  Painworseatnightand1-3hoursaftermeal

•  Nauseas,vomiting,lossofweight

•  Complications:anemia,bleeding,perforation

•  Cancerdevelopmentisrareandconnectedtogastritis

PUD–animalmodels

•  NSAIDs•  Aceticacid/aceticacid+H.pylori•  Ethanol•  Histamine

Gastriculcer•  Moreinmen,5th-6thdecade•  Similartoduodenalulcerbutsurroundedbygastritis•  Moreacid,moreprobability–usuallyattheborderofcorpusandantrum

•  Productionofacid–  Normalordecreased–  Sometimesachlorhydria(absenceofHCl)

•  10-20%haveduodenalulcer•  Damageofmucusbarrierdominates•  Epigastricpain–themostoftensymptom•  Healsbutappearsagainonthesamespot

Duodenalulcer

•  4xmoreoftenthangastric•  Chronic,recurrent•  Oval,1cm,•  Intosubmucosisandmuscularispropria•  Bottom–bloodorexsudatewitherythrocytesandcellinfiltration,inflammation

•  Acidsecretion–normaltoincreased,sometimesincreasedsecretionofpepsin–  50%haveincreasedpepsinogeninserum

•  Oftenhereditary•  Increasedincidence– HLA-B5antigens

•  Connectedtosmokingßdecreasedmicrocirculation–  Bicarbonatessecretioninhibition– Quickemptyingofgastertoduodenum

•  Incidence–  Chronickidneydisease– Alcoholiccirrhosis–  COPD

•  80-100%-H.pyloriàbadhealing•  Epigastricpain90min-3hoursafterfood•  Penetrationsometimes

Pancreatitis

•  Inflammationofthepancreasconnectedwithedema,

differentdegreeofautodigestion,necrosisand

haemorrhagia

•  5thdecade

•  Acute(reversible)vschronic(irreversibledamage)

Acute-etiology

•  Gallstones•  Alcohol•  Idiopathic•  Diseasesofduodenum

•  Endocrineormetabolic

disease

•  Immunologicalfacotors

•  Hereditaryfactors•  Drugs•  Infections

Othercauses:

•  Drugsandtoxicsubstances

•  hypercalciemia

•  Renalfailure•  Viralinfections

•  Cysticfibrosis•  Trauma,operations

•  ERCP•  hyperlipidemia

Alcohol

•  Directtoxiceffectonpancreaticcells•  Alcoholismetabolizedbypancreasandcausesoxidativestress

•  Promotessynthesisofdigestiveenzymes•  Destabilizesintracellularmembranes

•  Predisposestoautodigestion

Pancreatitis

Autodigestion

•  Proteolyticenzymesareactivated

inpancreasinsteadofduodenum

•  Endotoxines,viruses,ischemia...

etc.

•  Activatedproteolyticenzymes

mayactivateother

•  Proteolysis,edema,interstitial

bleeding,vasculardamage,

necrosis

Acute-pathophysiology•  Abnormalactivationofdigestiveenzymeswithinthepancreas(trypsinogen–trypsin)

•  Celldeath–apoptosisandnecrosis

2typesbasedonpredominantresponsetocellinjury1.  Mild–Inflammationandedema2.  Severe–Necrosis-  Nocapsuleoverpancreas–spreadingofinflammationandnecrosis

Acute-symptoms•  Severeupperabdominalpain•  Nauseaandvomiting•  Lossofappetite•  Feverandchills•  Shock•  Tachycardia•  Respiratorydistress•  Peritonitis•  Hiccup

Acute–lesscommonsigns

•  Grey-Turner'ssign(hemorrhagicdiscolorationoftheflanks)

•  Cullen'ssign(hemorrhagicdiscolorationoftheumbilicus)

•  Körte'ssign(painorresistanceinthezonewheretheheadofpancreasislocated)

•  Kamenchik'ssign(painwithpressureunderthexiphoidprocess)

Differentialdiagnosis

•  Perforatedpepticulcer•  Ciliarycolic•  Acutecholecystitis•  Pneumonia•  Peuriticpain•  Myocardialinfarction

BalthazarscoreBalthazargrade AppearanceonCT CTgradepoints

GradeA NormalCT 0points

GradeB Focalordiffuseenlargementofthepancreas 1point

GradeC Pancreaticglandabnormalitiesandperipancreaticinflammation 2points

GradeD Fluidcollectioninasinglelocation 3points

GradeE Twoormorefluidcollectionsand/orgasbubblesinoradjacenttopancreas 4points

Necrosispercentage Points

Nonecrosis 0points

0to30%necrosis 2points

30to50%necrosis 4points

Over50%necrosis 6points

Acute-treatment

•  Fluidreplacement•  Paincontrol•  Bowelrest•  Nutritionalsupport•  Antibiotics•  ERCP•  Surgery

Chronic-causes

•  Alcohol•  Autoimmunedisorders•  Intraductalobstruction•  Tumors•  Ischemia•  Calcificstones•  Idiopathic

Chronic–riskfactors

•  Smoking•  Geneticpredisposition•  Cysticfibrosis

Chronic-symptoms

•  Upperabdominalpain–increasesafterdrinkingandeating

•  Nauseaandvomiting•  Steatorrhea•  Weightlossevenwheneatinghabitsandamountsarenormal

•  Type1diabetes

AnimalmodelsofPancreatitis

•  Caerulein(↑proteolyticenzymessecretion)

•  Lipopolysacharide+ethanol

Ileus

•  intestinaldistensionandslowerornomovementofstoolintheintestinallumen–failureofperistalsis

•  Laparotomy,metabolic/electrolytichypokaliemia

•  Hyponatremia,hypomagnesemia,uremia,diabeticcoma,abdominalinfection,retroperitonealbleeding,intestinalischemia,sepsa,spinalcordinjuries

•  Drugs–opiates,psychotropics,anticholinergics

Ileus•  Mechanical–obstruction(volvulus,gallstone,adhesion)

•  Paralytic–bowelparalysis(surgery,medications,muscleandnervedisorders,cancer,Crohndisease)

•  Signsandsymptoms:–  Abdominalpainthatcomesandgoes–  Lossofappetite–  Constipation–  Vomiting–  Swellingofabdomen

Ileus

•  Complications:– Necrosis– Peritonitis

•  Treatment– Obstruction–diet,surgery– Paralysis–identifyingthecause,surgery

ThankyouJ