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Investigation and Management Investigation and Management of Complications of Peptic Ulcerof Complications of Peptic Ulcer

Complications of PUComplications of PU

Upper GI BleedingUpper GI Bleeding PerforationPerforationObstruction of lumenObstruction of lumenMalignant ChangeMalignant Change

History of haematemesis Onset, Frequency, Amount revealed, Colour, Odour /

taste, Associated with faintingDifferentiation between haematemesis from haemoptysis Associated with cough Froth?History of melaena. Onset, Frequency, Amount revealed, Associated with

faintingAsking characteristic features of melaena Tarry, Sticky, Smell, Blood colour on washing

•Asking features of liver disease•Alcohol history•Hepatitis ,jaundice•Cirrhosis•Features of portal hypertension•Ascites

•History suggestive of peptic ulceration•Epigastric pain•Hunger pain / nocturnal pain•Food induced pain•Aggravating and relieving factors•History of taking antacids•Any associated symptoms

•History suggestive of gastric erosion•Taking NSAID•Indigenous medicine•Alcohol ,excessive vomiting

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•History suggestive of CA stomach•Mass in epigastrium•Weight loss / loss of appetite

History of bleeding disorder Gum bleeding Epistaxis Blood transfusion

Past medical history –bleeding D/O, VHPast surgical history-PUDrug history NSAIDs, steroids, anticoagulants, including

indigenous medicineFamily history I T P HaemophiliaPersonal history Alcohol Smoking Irregular meal, hard /spicy food

GOOGOO

C/o Vomiting and Feeling of distension after meal x duration

Features of GOO1.Bloating2.Distension after meals.3. Vomiting timing, relation to meals, character, amount and presence or absence of undigested food.

Pain…..site, character, periodicity, severity, relieving and aggravating factors.Change of character and loss of periodicity after onset of GOO

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Weight loss / loss of appetite,

Inquire about a vague lump moving about in the abdomen

Inquire about mass, pallor, asthenia

History of haematemesis and melaenaHistory of obstructive jaundice

Past history of PU

Personal history - alcohol, smoking

Social history-smoked food, irregular meal.

Drug history of antacids and anti-ulcer therapyProlong use of NSAIDs and steroids

MANAGEMENT

1.Resuscitation 2.History taking & physical examination to

know the site & cause of bleeding 3.Investigations

for detecting site & cause of bleeding

4.Definitive treatment arrest of haemorrhage/treatment of underlying

cause

Investigations

Oesophago-gastro-duodenoscopy Barium studies Angiography Specific investigations

Treatment Arrest of haemorrhage first …followed by Treatment of underlying cause of

haemorrhage

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Peptic Ulcers: Peptic Ulcers: Gastric & Duodenal UlcersGastric & Duodenal Ulcers

Benign Gastric UlcerBenign Gastric Ulcer Duodenal UlcerDuodenal Ulcer

Site of Biopsy for H.pylori Test

Antrum

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Liver Haemangioma CT Liver Haemangioma CT A) PreA) Pre--contrastcontrast

B) Arterial phaseB) Arterial phase

C) Portal venous phaseC) Portal venous phase D) Delayed phaseD) Delayed phase

CT – we will not do delayed phase unless haemangioma suspected.Please specify “? haemangioma” on request form.

GUD after perforation of PU Specific investigations

Ultrasound abdomen or CT scan ERCP ~ to detect Peri-ampullary Ca Spleno-portogram Ba meal in Trendelenberg position ~to

detect hiatus hernia Liver function tests Biopsy of enlarged supraclavicular nodes

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Peptic Ulcer DiseasePeptic Ulcer Disease PyloroplastyPyloroplasty

PyloroplastyPyloroplasty Peptic Ulcer DiseasePeptic Ulcer DiseaseSurgical Treatment Surgical Treatment

Fig. 40-16A. Billroth I Procedure B. Billroth II Procedure

PG and GJPG and GJ A. Billroth I ProcedureA. Billroth I Procedure

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B. Billroth II ProcedureB. Billroth II Procedure B. Billroth II ProcedureB. Billroth II Procedure

Investigation andInvestigation andManagement of Management of

Obstructive JaundiceObstructive Jaundice

3 Chief complaint, containing, complaint + duration (Pain in RHC)

4 PainOnsetDurationCharacterSeverityRadiation and referred painRelieving and aggravating factors Any other associated features

5 History of upper GI upsetDyspepsiaNauseaVomitingDistension of abdomen

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History of jaundiceYellow colouration of skin and scleraHigh colour urine Nature of jaundiceColour of stool

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History of obstructive jaundice Pale stoolItchiness Nature of jaundice Intermittent / progressive

8History of feverDurationType of feverChills and rigors.

9 History of passing of worm , bleeding tendency

10 History of LOW, LOA & mass in RHC

11 Past medical history-bleeding D/O, malaria, worm infestation , similar attack

12 Past surgical history-operation like laparotomy & bypass or resection and anastomosis

13 Personal history Smoking Alcohol drinking.

14 Drug history cholesterol lowering agent, weight reducing agent, androgens

Examination of Obstructive Jaundice

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3 General examination Pallor, Jaundice (Depth of J ) ,Fever, Left SupraclavicularLN enlargement, Palmarerythema, clubbing and oedema, Scratch marks, Cachexia

4 Local examinationInspection General contour of abdomenMove with respiration, visible mass in GBAAny previous surgical scars, distended veinHernia orifices, Condition of umbilicus

5 Any localized visible mass (describe)

6 PalpationLight palpation & deep palpation.Tenderness in RHC, soft.

7 Mass present or notIf present description of mass (5 S)Consistency Rising test.Moves with respiration or not.

8 Liver enlargement & tenderness.Palpable gall bladder

9 Feature of GOO10 Percussion & Auscultation

Shifting dullness & any upward enlargement of the liver.

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11 Mention that you would like to do PR examination-melaena stool, clay color stool

Causes of Obstructive Causes of Obstructive JaundiceJaundice

IntraluminalIntraluminal causescauses Intramural causesIntramural causesExtraluminalExtraluminal causescauses

IntraluminalIntraluminal causescauses

Common Common bile duct stonesbile duct stonesAscarisAscaris lumbricoideslumbricoidesHydatidHydatid cyst of cyst of biliarybiliary treetree

Intramural causeIntramural cause CBD stricturesCBD strictures

IatrogenicIatrogenicTraumaticTraumatic

PeriampullaryPeriampullary carcinomacarcinoma CholedochalCholedochal cystcyst CholangiocarcinomaCholangiocarcinoma SclerosingSclerosing cholangitischolangitis

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Extramural causesExtramural causes:: Carcinoma head of pancreasCarcinoma head of pancreas Chronic pancreatitisChronic pancreatitis Malignant lymph nodes in the porta Malignant lymph nodes in the porta

hepatishepatis

Others:Others: Liver secondariesLiver secondaries Biliary atresiaBiliary atresia

Imaging Ultrasound:Imaging Ultrasound:• shows the size of the bile ducts• defines the level of the obstruction• identifies the cause (in some cases)• gives other information related to the

disease (e.g. hepatic metastases, gallstones, hepatic parenchymal change)

• The echo-texture of the liver, splenomegaly, ascites, and signs of portal hypertension

Imaging Ultrasound:Imaging Ultrasound:

• The level of biliary obstruction will help to guide further investigation if the cause of the obstruction is not apparent.

Distal obstructionDistal obstruction Dilation of the intraDilation of the intra-- and and extrahepaticextrahepatic bile bile

ducts is present; most patients will have a ducts is present; most patients will have a gallstone in the common bile duct or gallstone in the common bile duct or carcinoma of the head of pancreas . carcinoma of the head of pancreas .

Both diagnoses may be apparent on Both diagnoses may be apparent on ultrasound, but often the distal bile duct is ultrasound, but often the distal bile duct is poorly seen with ultrasound due to overlying poorly seen with ultrasound due to overlying bowel gas.bowel gas.

Distal obstruction may also be caused Distal obstruction may also be caused by CBD stones/ Adult by CBD stones/ Adult AscarisAscaris worm/ worm/ Duodenal or Duodenal or PeriampullaryPeriampullary lesion. lesion.

These can be investigated by These can be investigated by duodenoscopyduodenoscopy and biopsied if directly and biopsied if directly seen.seen.

Proximal obstructionProximal obstruction

Proximal Proximal biliarybiliary dilation usually dilation usually results from results from obstruction at the obstruction at the portaporta hepatishepatis (Enlarged (Enlarged Metastatic Lymph nodes / Metastatic Lymph nodes / Klastkin`sKlastkin`s TumourTumour) ) and is recognized by and is recognized by dilation of the dilation of the intrahepaticintrahepatic ductsducts without enlargement of without enlargement of the distal common bile ductthe distal common bile duct..

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Investigations Stones in CBD Malignancy Acute viral hepatitis

Serum Bilirubin(mmol/l)

50–150 Steady rise to >200

Variable

Urobilinogen in Urine Reduced Absent −early (+late)

Alkaline phosphatase >3× >3× <3×

AspartateAminotransferase

<5× <5× >10×

White cell count (differential)

↑/Normal (↑polymorphs)

↑/Normal ↓(↑lymphocytes)

Ultrasound Gallstones Gallstones +/_ Dilated Bile Duct

Dilated ducts + Mass

Ultrasound showing dilation of the common bile duct

Ultrasound showing dilation of the common bile duct

MRCP showing stone in the MRCP showing stone in the common bile ductcommon bile duct

• Contrast enhanced spiral CT and MRCP has revolutionized the management of obstructive jaundice.

• MRCP gives exquisite assessment of the pancreatic duct and bile ducts withoutthe risks which may occur in (ERCP)

• Diagnostic ERCP virtually obsolete.

MRCPMRCP

Noninvasive and effective with excellent imaging quality .

Advantages…good for iodine containing contrast allergic patient.

Quality is currently below that available from ERCP or PTC

Magnetic resonance angiography (MRA)-images of the hepatic artery and portal vein.

Alternative to selective hepatic angiography for diagnosis.

Useful in patients with chronic liver disease and a coagulopathy in whom the patency of the portal vein and its branches is in question.

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MRCP showing ‘double duct MRCP showing ‘double duct dilation’ with pancreatic cancerdilation’ with pancreatic cancer

Same patient after percutaneoustranshepatic cholangiography and

insertion of Wall stent

•• ContrastContrast--enhanced enhanced multislicemultislice CT is the CT is the radiological investigation of choice in most radiological investigation of choice in most UK UK centrescentres for assessment of for assessment of biliarybiliarymalignancies.malignancies.

•• Contrast agents (Contrast agents (p.op.o., ., i.vi.v.) are used and .) are used and imaging done in unenhanced, venous and imaging done in unenhanced, venous and arterial phases.arterial phases.

CT showing tumour encasement of coeliac axis branches byPancreatic cancer (arrow).

Endoscopic ultrasound can further evaluate relationships to vascular

structures. It may help define benign lesions mimicking cancer

(e.g. sclerosing pancreatitis)

Management of Bile duct stonesManagement of Bile duct stones CBD stones management depends on:

physical condition comorbidity and medical history previous attempts at intervention if the patient has had a cholecystectomy availability of

equipment/theatre/anaesthetist/expertise of Interventionist

patient preference.

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ERCPERCP±±sphincterotomysphincterotomy Laparoscopic exploration of the Laparoscopic exploration of the

common bile ductcommon bile duct Open exploration of the common Open exploration of the common

bile ductbile duct StentingStenting

Steps of open exploration of the Steps of open exploration of the common bile ductcommon bile duct

Laparotomy Choledochotomy Choledocholithotomy Exploration of CBD Internal or External Drainage

Biliary stentBiliary stentPercutaneousPercutaneous transhepatictranshepatic

cholangiographycholangiography (PTC)(PTC) PTC is indicated where endoscopic

cholangiography has failed or is impossible, as in patients with previous Polyagastrectomy.

It is often required in patients with hilar bile duct tumours where endoscopic cholangiography fails to visualise the intrahepatic bile ducts.

Sometime, preoperative preparation of obstructive jaundiced pt. to drain bile out.

Percutaneous transhepaticcholangiography and bilobar stent

of Klatskin tumour

Complications of Complications of stentingstentingImmediateImmediate

Sepsis Haemorrhage Acute pancreatitis Perforation and bile leak (peritonitis)

LateLate Recurrent jaundice due to: Displacement Sludging Overgrowth by neoplasm Erosion into adjacent viscus