Peptic UlcerPeptic Ulcer
Professor Ravi KantFRCS (England), FRCS (Ireland),
FRCS(Edinburgh), FRCS(Glasgow), MS, DNB, FAMS, FACS, FICS,
Professor of Surgery
Surgical AnatomySurgical Anatomy
Crow’s feetCrow’s feet
N of LatarjetN of Latarjet
Criminal Nerve of GrassiCriminal Nerve of Grassi
Antral pump mechanismAntral pump mechanism
Applied Anatomy : StomachApplied Anatomy : Stomach
Pressure studiesPressure studies
Endoscopic & Chromo-endoscopicEndoscopic & Chromo-endoscopic
Contrast ( Ba meal with air)Contrast ( Ba meal with air)
Intra-luminal USGIntra-luminal USG
Electron microscopyElectron microscopy
USGUSG
CT/ MRCT/ MR
SurgicalSurgical
APD= Acid Peptic DiseaseAPD= Acid Peptic Disease
Peptic UlcerPeptic Ulcer
Gastric UlcerGastric Ulcer
Duodenal UlcerDuodenal Ulcer
HyperacidityHyperacidity
ZE SyndromeZE Syndrome
APD= Acid Peptic DiseaseAPD= Acid Peptic Disease
Acute UlcerAcute Ulcer
Stress UlcerStress Ulcer
Curling’sCurling’s
Cushing’sCushing’s
Peptic UlcerPeptic Ulcer
10% population affected10% population affected
Gastric ulcer in elderly 5-6Gastric ulcer in elderly 5-6thth decadedecade
Duodenal ulcer in adults 4Duodenal ulcer in adults 4thth decade decadeDU also in youngDU also in young
Duodenal UlcerDuodenal Ulcer
Proximal duodenumProximal duodenum
1 - 2 cm of pylorus1 - 2 cm of pylorus
▲▲ acidacid
Distal duodenum = ZEDistal duodenum = ZE
Type 1 Type 1 Gastric UlcerGastric Ulcer
most commonmost common (among gastric (among gastric Ulcers)Ulcers)
proximal antrumproximal antrum
mucosal defensemucosal defense
acidacid
Type II Type II Gastric UlcerGastric Ulcer
Secondary to DU + pyloric Secondary to DU + pyloric stenosisstenosis
Type III Type III Gastric UlcerGastric Ulcer
Prepyloric and pyloric Prepyloric and pyloric canal canal ulcerulcer
acid acid ▲▲
common etiology with common etiology with DUDU
GU: Benign Vs CAGU: Benign Vs CA
Rugae upto marginsRugae upto margins
Small , <2cmSmall , <2cm
Sticking of barium +Sticking of barium +
Accompanying spasmAccompanying spasm
↓ ↓ AcidAcid
Crater beyond the Crater beyond the normal stomach on a normal stomach on a bariumbarium
Rugae-short of Rugae-short of
Small-BigSmall-Big
--
--
AchlorhydriaAchlorhydria
Limited to StomachLimited to Stomach
PathogenesisPathogenesis
Imbalance of acid-pepsin Imbalance of acid-pepsin and mucosal defenceand mucosal defence
H. pylori infectionH. pylori infection
NSAIDNSAID
ZE SyndromeZE Syndrome
Type A personalityType A personality
H.pyloriH.pylori
95% - duodenal ulcer95% - duodenal ulcer
80% - gastric ulcer80% - gastric ulcer
mucosal resistance hydrophobicitymucosal resistance hydrophobicity
eradication reduces ulcer eradication reduces ulcer recurrencerecurrence
NSAIDNSAID
Suppress prostaglandinsSuppress prostaglandinsprostaglandin prostaglandin ►► acid secretion acid secretion ▲▲ mucosal blood flowmucosal blood flow mucus & bicarbonate secretionmucus & bicarbonate secretion
10 -30% in chronic users10 -30% in chronic users
ZE= Zollinger Ellison SyndromeZE= Zollinger Ellison Syndrome
RecurrentRecurrent
RecalcitrantRecalcitrant
ResistantResistant
Unusual sitesUnusual sites
MultipleMultiple
MalignantMalignant
ZE SyndromeZE Syndrome
0.1 - 1.0% of peptic ulcer0.1 - 1.0% of peptic ulcer
Type I and Type IIType I and Type II
Gastrin secretion from non-beta cell Gastrin secretion from non-beta cell tumor of pancreas - tumor of pancreas - GastrinomaGastrinomaMC in pancreas ; duodenum, antrumMC in pancreas ; duodenum, antrum
ZE SyndromeZE Syndrome
20% multiple20% multiple
66% malignant66% malignant
slow growing indolent tumorslow growing indolent tumor
parietal cell mass increasedparietal cell mass increased
genetic basis genetic basis
massive hyper-secretion of acidmassive hyper-secretion of acid
ZE SyndromeZE Syndrome
MEN - IMEN - I– hyperparathyroidismhyperparathyroidism
– islet cell tumorislet cell tumor
– pituitary tumorspituitary tumors
A/ DUA/ DU
NSAIDsNSAIDs
Acid hypersecretionAcid hypersecretion
Rapid gastric emptyingRapid gastric emptying
Impaired acid disposalImpaired acid disposal
SmokingSmoking
Duodenal UlcerDuodenal Ulcer
Increased secretion of acidIncreased secretion of acid
More rapid gastric emptyingMore rapid gastric emptying
Decreased prostaglandinDecreased prostaglandin
Chronic duodenitis with H.pyloriChronic duodenitis with H.pylori
SmokingSmoking
Gastric UlcerGastric Ulcer
H.pyloriH.pylori
NSAIDsNSAIDs
Duodenogastric refluxDuodenogastric reflux
Impaired gastric mucosal defenseImpaired gastric mucosal defense
Gastric UlcerGastric Ulcer
Acid secretion - normal to lowAcid secretion - normal to low
Reflux of duodenal contents Reflux of duodenal contents gastritis gastritis ulcer ulcer
Pylorus sphincter disorderPylorus sphincter disorder
SmokingSmoking
Disturbed mucosa with low grade Disturbed mucosa with low grade gastritisgastritis
CPCP
Duodenal UlcerDuodenal Ulcer
– pain relieved by food or alkalipain relieved by food or alkali
– pain several hours after mealpain several hours after meal
Gastric Ulcer - gnawing or Gastric Ulcer - gnawing or burning pain on eating burning pain on eating
CPCP
Periodic chronic recurrent painPeriodic chronic recurrent pain
Nausea & vomitingNausea & vomiting
Weight lossWeight loss
Epigastric tendernessEpigastric tenderness
InvestigationsInvestigations
Endoscopy Endoscopy – 90% sensitivity90% sensitivity
– must in all pts. with severe pain must in all pts. with severe pain
– excludes malignancyexcludes malignancy
– biopsy can be takenbiopsy can be taken– test for H.pyloritest for H.pylori
InvestigationsInvestigations
Barium MealBarium Meal double (air) contrast double (air) contrast – 90% sensitivity 90% sensitivity
H Pylori detection:H Pylori detection:
Breath testBreath test
Blood testBlood test
Tissue testTissue test
DDDD
CholecystitisCholecystitis
Hiatus herniaHiatus hernia
PancreatitisPancreatitis
MIMI
PneumoniaPneumonia
Dissecting aneurysmDissecting aneurysm
Worm InfestationsWorm Infestations
Rx - MedicalRx - Medical
Stop smoking, NSAIDsStop smoking, NSAIDs
Stop alcoholStop alcohol
Antacids - acid neutralisationAntacids - acid neutralisation
HH22 receptor antagonist -Ranitidine receptor antagonist -Ranitidine
- secretion inhibition- secretion inhibition
Rx- MedicalRx- Medical
HH++ pump inhibition - H pump inhibition - H++/K/K++ase ase inhibition - Omeprazoleinhibition - Omeprazole
Anticholinergic - secretory inhibitionAnticholinergic - secretory inhibition
Prostaglandin - MisoprostolProstaglandin - Misoprostol - mucosal - mucosal
protectionprotection
Proton Pump BlockersProton Pump Blockers
OmeperazoleOmeperazole
Eso-meperazoleEso-meperazole
Rabi-meperazoleRabi-meperazole
Rx - MedicalRx - Medical
Sucralfate - protective coatingSucralfate - protective coating
Colloidal Bismuth Colloidal Bismuth – eradicate H.pylorieradicate H.pylori
– protective coatingprotective coating
Antibiotics - H.pyloriAntibiotics - H.pylori
Kit for H PyloriKit for H Pylori
H2 Receptor AntagonistsH2 Receptor Antagonists
On parietal cellsOn parietal cells
Decrease basal & stimulated acid Decrease basal & stimulated acid secretionsecretion
Pepsin output decreasedPepsin output decreased
Decreased gastric blood flowDecreased gastric blood flow
Competitive inhibitor of parietal cellCompetitive inhibitor of parietal cell
Rx - Duodenal UlcerRx - Duodenal Ulcer
95% control - medical Rx95% control - medical Rx
Surgery-Outdated, ObsoleteSurgery-Outdated, Obsolete
Omeprazole better thanRanitidineOmeprazole better thanRanitidine
Ulcer heels in 80% by 6 mUlcer heels in 80% by 6 m
recurrence in 95% by recurrence in 95% by H.pylori eradicationH.pylori eradication
Rx - Duodenal UlcerRx - Duodenal Ulcer
Indications for surgeryIndications for surgery =Compl=Compl–HemorrhageHemorrhage
–ObstructionObstruction
–PerforationPerforation
–Intractability of painIntractability of pain
Intractable pain Intractable pain ►► HSV / TV + GJ HSV / TV + GJ
Rx - DURx - DU
H2 blockers heals 75% DU in 4 H2 blockers heals 75% DU in 4 weeksweeks
H/K proton pump inhibitor better H/K proton pump inhibitor better resultsresults
ulcer may recurr in 80% cases on ulcer may recurr in 80% cases on stoppingstopping
treatment of H.pylori treatment of H.pylori
Rx - DURx - DU
Indication of surgery in hemorrhageIndication of surgery in hemorrhage
bleeding of > than 6 unitsbleeding of > than 6 units
recurrent bleed after endoscopic recurrent bleed after endoscopic controlcontrol
pyloro-duodenotomy and control of pyloro-duodenotomy and control of bleedingbleeding
HSV or TV + GJHSV or TV + GJ
Rx - DURx - DU
Perforation - simple closure with Perforation - simple closure with omental patchomental patch -Graham’s patch-Graham’s patchdefinitive surgery definitive surgery –HSVHSV–TV + pyloroplastyTV + pyloroplasty–parietal cell vagotomyparietal cell vagotomy–TV+GJTV+GJ
Rx GURx GU
Omeprazole, H2 receptor Omeprazole, H2 receptor antagonist - 8 weeksantagonist - 8 weeks
if pain not relieved by 2 weeks - if pain not relieved by 2 weeks - add one more drugadd one more drug
repeat endoscopy after 8 weeksrepeat endoscopy after 8 weeks
if no healing by 12 - 115 weeksif no healing by 12 - 115 weeks - -
SurgerySurgery
Rx - GURx - GU
Type I - Distal Gastrectomy with Type I - Distal Gastrectomy with vagotomy + G-D or GJvagotomy + G-D or GJ
proximal ulcer- total gastrectomyproximal ulcer- total gastrectomy
parietal cell vagotomy - high parietal cell vagotomy - high recurrencerecurrence
Hemorrhage Hemorrhage
Hemorrhage - potential cause of Hemorrhage - potential cause of deathdeath
15 -20% gross bleeding15 -20% gross bleeding
erosion of duodenal ulcer into erosion of duodenal ulcer into gastro-duodenal arterygastro-duodenal artery
Endoscopy –laser, sclerosant Endoscopy –laser, sclerosant oralcohal injectionoralcohal injection
PerforationPerforation
In 5-10% of casesIn 5-10% of casespneumo-peritoneum in 75% casespneumo-peritoneum in 75% casesperitonitis, pain, ileusperitonitis, pain, ileusleukocytosis, hypovolumia, IIIrd leukocytosis, hypovolumia, IIIrd space lossspace lossDD - acute appendicitis, enteric DD - acute appendicitis, enteric perf.perf.
ObstructionObstruction
Chronic ulcer disease with edema Chronic ulcer disease with edema and scarringand scarring
in 5% cases of DUin 5% cases of DU
nausea, vomiting, abdominal nausea, vomiting, abdominal distensiondistension
metabolic alkalosis, paradoxical metabolic alkalosis, paradoxical aciduriaaciduria