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
Zeman, M. et al., Speciální chirurgie, ISBN 80-7262-260-9, 2004
Billroth I
Billroth II
Zeman, M. et al., Speciální chirurgie, ISBN 80-7262-260-9, 2004
Zeman, M. et al., Speciální chirurgie, ISBN 80-7262-260-9, 2004
Gastro-enteroanastomosis on
Roux Y crankle
Zeman, M. et al., Speciální chirurgie, ISBN 80-7262-260-9, 2004
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 syndrome- incoming crankle syndrome
- outcoming crankle syndrome- outcoming 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)
appears after BII resectionappears after BII resection
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
appears after BII resectionappears after BII resection
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
appears after BII resectionappears after BII resection
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
Zeman, M. et al., Speciální chirurgie, ISBN 80-7262-260-9, 2004
Gastric cancerGastric cancer
Gastric stub cancer after B Gastric stub cancer after B II resectionII resection
Schwanoma fundi Schwanoma fundi vetriculivetriculi
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