Peptic Ulcer Disease Ppt
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PEPTIC ULCER DISEASE (Acid – pepsin ulcer disease)
G JUMBI
SURGICAL ANATOMY • ANATOMY (Stomach and duodenum) -gross anatomy. - Microscopic anatomy. - Blood supply. - Nerve supply.
PHYSIOLOGY GASTRIC SECTRETIONS. • THE PARIETAL CELLS (Acid secretion). ( The proton pump). • THE CHIEF CELLS (Pepsinogens secretion). • THE ENDOCRINE CELLS (Hormones secretions). Eg. - The G-cells (secretes gastrin hormone) . - The D-cells (secretes somatostatin hormone). - The ECL-cells eg. Histamine producing cells. • THE MUCOUS SECRETING CELLS. (COLUMNAR CELLS).
CONTROL OF GASTRIC SECRETIONS. • CEPHALIC PHASE (Vagal phase). • GASTRIC PHASE (hormonal phase). Stimulatory hormones. Inhibitory hornones. • DUODENAL (INTESTINAL PHASE). Stimulatory hormones. Inhibitory hormones.
•
PATHOPHYSIOLOGY (Disorders of control of gastric secretion) EXCESSIVE ACID/PEPSIN SECRETION
(Duodenal ulcers). • LACK OF MUCOUS PROTECTION. (Gastric ulcers). • “12 HOUR OVERNIGHT ACID SECRETION TEST”. Normal = 10-20 meq/L. High acid output = 40-80 meq/L. Low acid output = 5-15 meq/L. Very high acid output = 100-300 meq/L.
PATHOLOGY • EPIDEMIOLOGY. Incidence, Age, Sex, Race, Geographical, Social class etc. • AETIOLOGY. H. pylori, NSAIDs, Alcohol, Smoking, Diet, Genetic factors (eg.blood group O), Predisposing conditions, Psychosomatic. • HELICOBACTER PYLORI. DIAGNOSIS - Urease breadth test, Brush cytology, Biopsy.
PATHOLOGY cont. •
•
•
MACROSCOPIC APPEARANCE……CONT. ACUTE ULCERS VS. CHRONIC ULCERS. SITE, SIZE, SHAPE, EDGES, FLOOR, BASE CONSISTENCE, SURROUNDINGS. MICROSCOPIC APPEARANCE. ACUTE ULCERS VS. CHRONIC ULCERS. DEPTH. INFLAMMATORY REACTION. FIBROSIS. COMPLICATIONS OF PUD. ACUTE VS. CHRONIC. HAEMORRHAGE, PERFORATION & PENETRATION. STENOSIS: (OESOPHAGEAL STRICTURE, PYLORIC STENOSIS, HOUR-GLASS DEFORMITY,TEA-POT DEFORMITY).
CLASSIFICATION OF PUD. • 1. ACUTE PEPTIC ULCERS. NSAIDs, Alcohol, Acute illnesses. Superficial. Generalised in location. Small. • 2. CHRONIC PEPTIC ULCERS. - Duodenal ulcers. Bulbar, post bulbar - Gastric ulcers. TYPES I, II, III, IV. - Anastomotic (jejunal ulcers). - Oesophageal ulcers. - Meckel’s. Deeper. Ocurrs in Specific locations. Larger.
COMPLICATIONS OF PUD • HAEMORRAGE. • Acute ulcers, Chronic ulcers, Penetration.
• PERFORATION. • Acute, Chronic ulcers, Penetration.
• STENOSIS. • • • •
Pyloric stenosis, Hour - glass deformity, Tea - pot deformity, Oesophageal stricture.
MANAGEMENT OF PUD OUTLINE OF MANAGEMENT: • • • •
• • • •
Hx. P/E. INVESTIGATIONS. TREATMENT • SUPORTIVE (COMPLICATED ULCERS). • DEFINITIVE (MEDICAL, SURGICAL). COPLICATIONS OF TREATMENT. PROGNOSIS. FOLLOW UP. PREVENTION.
Mx. CONT. DIFFERENTIAL DIGNOSIS • UPPER ABDOMINAL PAIN. • COMPLICATED ULCERS. • HAEMORRHAGE. • ACUTE PERFORATION. • PYLORIC STENOSIS.
INVESTIGATIONS • • • • •
STOOL - OCCULT BLOOD. BARIUM MEAL. UPPER GIT. ENDOSCOPY. GASTRIN ASSAY. COMPLICATED PUD • PERFORATION – CXR(erect), ABD.(supine de.). • HAEMORRAGE – EMERGENCY OGD. EMERGENCY ANGIOGRAPHY. EMERGENCY RADIO-ISOTOPE SCAN
TREATMENT OF PUD SUPPORTIVE TREATMENT (Complicated PUD). • HAMORRHAGE. • PERFORATION. • PYLORIC STENOSIS.
DEFINITIVE TREATMENT. • MEDICAL TREATMENT. • SURGICAL TREATMENT.
DEFINITIVE TREATMENT. MEDICAL TREATMENT (TRIPPLERx.) CLARITHROMYCIN. PPI OR H2RA. AMOXICILLIN OR A NITROIMIDAZOLE
SURGICAL TREATMENT See below
.
SURGICAL MANAGEMENT • PRE-OPERATIVE MANAGEMENT. See below • INTRAOPERATIVE MANAGEMENT. See below • POST-OPERATIVE MANAGEMENT. See below
PRE-OPERATIVE MANAGEMENT • • • • • • •
Investigations. Supportive treatment. Psychological preparation. Preparation of local site of operation. Evaluation for anaesthesia. Informed consent. Premedication.
SURGICAL TREATMENT INTRA-OPERATIVE TREATMENT 1. OPERATIONS FOR UNCOMPLICATED ULCERS. DUODENAL ULCERS – HSV, V&D (SV OR TV) GASTRIC ULCERS - PG (BILROTH I OR II) OR V&D. 2. OPERATIONS FOR COMPLICATED ULCERS BLEEDING ULCERS – HAEMOSTASIS + MED. Mx. PERFORATED ULCERS – CLOSURE OF PERFORATION + MED.Mx. OPERATIONS FOR STENOSIS. PYLORIC STENOSIS – V&D (GASTRO-JEJUNOSTOMY). HOUR-GLASS DEFORMITY – PG. TEA-POT DEFORMITY – V&D (GASTRO-JEJUNOSTOMY).
COMPLICATIONS OF TREATMENT COMPLICATIONS OF VAGOTOMY. • • • • •
POST-VAGOTOMY DIARRHOEA. DELAYED GASTRIC EMPTYING. “SMALL STOMACH SYNDROME”. EARLY DUMPING SYNDROME GALLSTONES (Truncal Vagotomy).
COMPLICATIONS OF GASTRECTOMY. • • • •
DUMPING SYNs (BOTH EARLY & LATE). BILIOUS VOMITTING (AFFERENT LOOP SYN) SMALL STOMACH SYN. NUTRITIONAL DEFFICIENCIES (WT. LOSS, Fe, VIT B12, OSTEOPOROSIS). • GASTRIC STUMP MALIGNANCY.
G JUMBI
SURGICAL ANATOMY • ANATOMY (Stomach and duodenum) -gross anatomy. - Microscopic anatomy. - Blood supply. - Nerve supply.
PHYSIOLOGY GASTRIC SECTRETIONS. • THE PARIETAL CELLS (Acid secretion). ( The proton pump). • THE CHIEF CELLS (Pepsinogens secretion). • THE ENDOCRINE CELLS (Hormones secretions). Eg. - The G-cells (secretes gastrin hormone) . - The D-cells (secretes somatostatin hormone). - The ECL-cells eg. Histamine producing cells. • THE MUCOUS SECRETING CELLS. (COLUMNAR CELLS).
CONTROL OF GASTRIC SECRETIONS. • CEPHALIC PHASE (Vagal phase). • GASTRIC PHASE (hormonal phase). Stimulatory hormones. Inhibitory hornones. • DUODENAL (INTESTINAL PHASE). Stimulatory hormones. Inhibitory hormones.
•
PATHOPHYSIOLOGY (Disorders of control of gastric secretion) EXCESSIVE ACID/PEPSIN SECRETION
(Duodenal ulcers). • LACK OF MUCOUS PROTECTION. (Gastric ulcers). • “12 HOUR OVERNIGHT ACID SECRETION TEST”. Normal = 10-20 meq/L. High acid output = 40-80 meq/L. Low acid output = 5-15 meq/L. Very high acid output = 100-300 meq/L.
PATHOLOGY • EPIDEMIOLOGY. Incidence, Age, Sex, Race, Geographical, Social class etc. • AETIOLOGY. H. pylori, NSAIDs, Alcohol, Smoking, Diet, Genetic factors (eg.blood group O), Predisposing conditions, Psychosomatic. • HELICOBACTER PYLORI. DIAGNOSIS - Urease breadth test, Brush cytology, Biopsy.
PATHOLOGY cont. •
•
•
MACROSCOPIC APPEARANCE……CONT. ACUTE ULCERS VS. CHRONIC ULCERS. SITE, SIZE, SHAPE, EDGES, FLOOR, BASE CONSISTENCE, SURROUNDINGS. MICROSCOPIC APPEARANCE. ACUTE ULCERS VS. CHRONIC ULCERS. DEPTH. INFLAMMATORY REACTION. FIBROSIS. COMPLICATIONS OF PUD. ACUTE VS. CHRONIC. HAEMORRHAGE, PERFORATION & PENETRATION. STENOSIS: (OESOPHAGEAL STRICTURE, PYLORIC STENOSIS, HOUR-GLASS DEFORMITY,TEA-POT DEFORMITY).
CLASSIFICATION OF PUD. • 1. ACUTE PEPTIC ULCERS. NSAIDs, Alcohol, Acute illnesses. Superficial. Generalised in location. Small. • 2. CHRONIC PEPTIC ULCERS. - Duodenal ulcers. Bulbar, post bulbar - Gastric ulcers. TYPES I, II, III, IV. - Anastomotic (jejunal ulcers). - Oesophageal ulcers. - Meckel’s. Deeper. Ocurrs in Specific locations. Larger.
COMPLICATIONS OF PUD • HAEMORRAGE. • Acute ulcers, Chronic ulcers, Penetration.
• PERFORATION. • Acute, Chronic ulcers, Penetration.
• STENOSIS. • • • •
Pyloric stenosis, Hour - glass deformity, Tea - pot deformity, Oesophageal stricture.
MANAGEMENT OF PUD OUTLINE OF MANAGEMENT: • • • •
• • • •
Hx. P/E. INVESTIGATIONS. TREATMENT • SUPORTIVE (COMPLICATED ULCERS). • DEFINITIVE (MEDICAL, SURGICAL). COPLICATIONS OF TREATMENT. PROGNOSIS. FOLLOW UP. PREVENTION.
Mx. CONT. DIFFERENTIAL DIGNOSIS • UPPER ABDOMINAL PAIN. • COMPLICATED ULCERS. • HAEMORRHAGE. • ACUTE PERFORATION. • PYLORIC STENOSIS.
INVESTIGATIONS • • • • •
STOOL - OCCULT BLOOD. BARIUM MEAL. UPPER GIT. ENDOSCOPY. GASTRIN ASSAY. COMPLICATED PUD • PERFORATION – CXR(erect), ABD.(supine de.). • HAEMORRAGE – EMERGENCY OGD. EMERGENCY ANGIOGRAPHY. EMERGENCY RADIO-ISOTOPE SCAN
TREATMENT OF PUD SUPPORTIVE TREATMENT (Complicated PUD). • HAMORRHAGE. • PERFORATION. • PYLORIC STENOSIS.
DEFINITIVE TREATMENT. • MEDICAL TREATMENT. • SURGICAL TREATMENT.
DEFINITIVE TREATMENT. MEDICAL TREATMENT (TRIPPLERx.) CLARITHROMYCIN. PPI OR H2RA. AMOXICILLIN OR A NITROIMIDAZOLE
SURGICAL TREATMENT See below
.
SURGICAL MANAGEMENT • PRE-OPERATIVE MANAGEMENT. See below • INTRAOPERATIVE MANAGEMENT. See below • POST-OPERATIVE MANAGEMENT. See below
PRE-OPERATIVE MANAGEMENT • • • • • • •
Investigations. Supportive treatment. Psychological preparation. Preparation of local site of operation. Evaluation for anaesthesia. Informed consent. Premedication.
SURGICAL TREATMENT INTRA-OPERATIVE TREATMENT 1. OPERATIONS FOR UNCOMPLICATED ULCERS. DUODENAL ULCERS – HSV, V&D (SV OR TV) GASTRIC ULCERS - PG (BILROTH I OR II) OR V&D. 2. OPERATIONS FOR COMPLICATED ULCERS BLEEDING ULCERS – HAEMOSTASIS + MED. Mx. PERFORATED ULCERS – CLOSURE OF PERFORATION + MED.Mx. OPERATIONS FOR STENOSIS. PYLORIC STENOSIS – V&D (GASTRO-JEJUNOSTOMY). HOUR-GLASS DEFORMITY – PG. TEA-POT DEFORMITY – V&D (GASTRO-JEJUNOSTOMY).
COMPLICATIONS OF TREATMENT COMPLICATIONS OF VAGOTOMY. • • • • •
POST-VAGOTOMY DIARRHOEA. DELAYED GASTRIC EMPTYING. “SMALL STOMACH SYNDROME”. EARLY DUMPING SYNDROME GALLSTONES (Truncal Vagotomy).
COMPLICATIONS OF GASTRECTOMY. • • • •
DUMPING SYNs (BOTH EARLY & LATE). BILIOUS VOMITTING (AFFERENT LOOP SYN) SMALL STOMACH SYN. NUTRITIONAL DEFFICIENCIES (WT. LOSS, Fe, VIT B12, OSTEOPOROSIS). • GASTRIC STUMP MALIGNANCY.
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