Powerpoint : Complications

COMPLICATIONS GASTRO-DUODENAL PEPTIC ULCERS

COMPLICATIONS OF GASTRODUODENAL ULCERS 

PERFORATION- PERITONITIS

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BLEEDING- ANEMIA

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STENOSIS- GASTRIC OUTLET OBSTRUCTION

PERFORATION 

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Perforation- ulcer rupture into the peritoneal cavity with spillage of GD contents Penetration- erosion into a solid organ: liver or pancreas Perforation of a chronic ulcer- increasing dyspepsia prior to the perforation Perforation of an acute ulcer- no premonitory symptoms

PERFORATION 

Risk factors:

- drugs: steroids, NSAID - situations of stress: burns, multiple injuries, sepsis, chemotherapy, radiotherapy

CLINICAL FEATURES OF PERFORATED ULCER 

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The moment of perforation is identified by the patient as an excruciating epigastric pain The intensity of sy. depend on the degree of peritoneal soiling and whether the perforation becomes sealed The spillage goes along the right paracolic gutter- pain from epigastrium shifts to RIF , may mimick acute appendicitis Vomiting in delayed cases- ileus

PHYSICAL SIGNS OF PERFORATED PEPTIC ULCER   

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Depend upon the degree and rate of soiling within peritoneal cavity Tenderness with guarding may vary from being localized to the upper abdo- to being generalized Typical signs for generalized peritonitis due to perforated ulcer are: rigid abdomen, no respiratory movements, silent abdomen, As later features: progressive distension, hypotension, tachycardia, cold periphery, decreased urinary output

PHYSICAL SIGNS OF PERFORATED ULCER Any deep inspiration, coughingincreased pain

The patient lies still in the bed, any movement exacerbating the pain

INVESTIGATIONS IN PERFORATED ULCER 

Plain abdominal X Ray in erect position – Pneumoperitoneum- air visible in the right subdiaphragmatic space – Gas/fluid levels in advanced cases – If pneumoperitoneum is not seen, think to a sealed perforation or acute pancreatitis – Do not count on amylase, may be increased in any acute abdomen

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USS of the abdomen- fluid within peritoneal cavity

Plain rx. of the RUQ shows a tiny streak of air under the diaphragm

Pneumoperitoneum in perforated duodenal ulcer

Pneumoperitoneum

Pneumoperitoneum perforated duodenal ulcer

Upright CXR shows a large collection of air under both the diaphragms

MANAGEMENT OF PERFORATED ULCER 

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Correction of hypovolemia, electrolyte disturbances, low urinary output Severe cases- monitoring CVP, hourly UO Colloids, cristaloids – effective Naso-gastric aspiration Antisecretory drugs Planning for operation

OPERATIVE VS CONSERVATIVE TREATMENT   

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Sealed perforated ulcer- Taylor’s method Taylor’s method: NG aspiration, iv fluids, antibiotics, antisecretory drugs Indication: young patients with short history of perforation of acute ulcer and with minimum of pneumo. and fluid under liver Close clinical observation

OPERATIVE VS.CONSERVATIVE TREATMENT  

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If the patient is getting worse within 6-12 hours, the operation is required Operative procedure- simple closure of the perforation, omentoplasty, peritoneal lavage and multiple drainages Peritoneal fluid sent for bacteriological culture Empiric antibiotherapy- broad spectrum antibiotics

Perforated peptic duodenal ulcer. The ulcer was found to be a typically punched out peptic ulcer (arrows) with a diameter of 6 mm

Perforated peptic ulcer

Perforated duodenal ulcer

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A 49-year-old man was admitted with sudden onset of severe pain in the epigastrium. Recently, he had taken a course of a non-steroidal antiinflammatory drug (NSAID). This had caused indigestion, which had worsened in the two days prior to his presentation. On examination, the patient was ill and had a rigid abdomen. The operative photograph shows a perforated duodenal ulcer. This was oversewn.

Closure of perforated duodenal ulcer & omental patching.  

PYLORIC STENOSIS 

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Chronic scarring from ulceration in the pyloric region- gastric outlet obstruction or pyloric stenosis Occurs in a patient with longstanding ulcer disease ignored, neglected or bad treated Be aware that pyloric stenosis might be due to a malignant antral tumor

PYLORIC STENOSIS CLINICAL FEATURES 

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Pain in the upper abdomen, relieved by the vomiting Vomiting is efortless, projectile with partially digested food and bile is absent Naso-gastric aspiration reveals only gastric fluid with thick partially digested food For gastric decompresion- gastric lavage and aspiration

PYLORIC STENOSIS CLINICAL FEATURES 

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Underweight patient, dehydrated with persistent skin fold, anemic Gastric stasis revealed by succusion splash on percusion Visible peristalsis, passing across the upper abdomen from left to right

PYLORIC STENOSIS METABOLIC FEATURES 

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Prolonged vomiting- electrolyte disturbances and renal failure Hypochloremic alkalosis due to hydrogen and chloride ions losses At a later stage- renal function disturbed To compensate metabolic alkalosis, the kidneys excret bicarbonates at the expense of losing sodium

PYLORIC STENOSIS METABOLIC FEATURES  

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The patient becomes progressively more dehydrated and hyponatremic In an attempt to conserve circulatory volume, sodium is retained by the kidneys and hydrogen plus potassium is excreted preferentially Hence alkalosis becomes more severe and hypokalemia more marked Hypocalcemia- disturbance of consciousness and tetany

PYLORIC STENOSIS METABOLIC FEATURES 

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These electrolyte disturbances in patients with severe pyloric stenosis are termed DARROW’S SYNDROME Lab.findings are:- base excess> - high serum urea, hyponatremia, - hypopotasemia, - hypocalcemia

X-ray after a barium meal will show delayed emptying of the stomach, and often the contour of the stomach will be seen deep in the pelvis

Draining the stomach with a naso-gastric tube (NG tube) will produce thick muddy content (undigested food).

Endoscopic view of normal duodenum

Endoscopic view of pyloric stenosis

PYLORIC STENOSIS MANAGEMENT   

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The priority is correction of fluid and electrolytes abnormalities Rehydration- saline infusion with K supplements Provision of adequate sodium allows excretion of alkaline urine so that the alkalosis becomes correctable Clinical improvement: increased UO, a fall to normal in blood urea and normal electrolytes Gastric lavage until fluid is clear

PYLORIC STENOSIS SURGICAL TREATMENT 

Partial gastric resection with gastroduodenal anastomosis (PEANBILLROTH I)

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Partial gastric resection with gastrojejunal anastomosis (BILLROTH II) For old, frail patients- by pass operation like gastro-jejunostomy

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BLEEDING PEPTIC ULCER      

Acute bleeding is the commonest complication It carries the highest mortality Bleeding results from erosion of the ulcer into a blood vessel The most common sign is melena +/hematemesis One of three pts. have no history of ulcer In major bleeding- GI transit so rapidstool is bright red

BLEEDING PEPTIC ULCER Severity of acute bleeding assessed by: BP, PR, Hb., Ht. if sufficient time passed for compensatory hemodilution Systolic BP< 100, PR>100 with the patient supine, suggest major blood loss (>1 l.)

BLEEDING PEPTIC ULCER 

Adverse clinical factors on outcome: – Severe, continuing bleeding – Early rebleeding within 3-5 days of initial stabilization – Age greater than 60 – Associated diseases: cardio-vascular and liver diseases

BLEEDING PEPTIC ULCER 

The differential diagnosis includes: Rupture of esophago-gastric varices Hemorrhagic gastritis Mallory-Weiss laceration Ulcerated benign and malignant gastric tumors – Vascular anomalies (angiodysplasia) – Aorto-enteric fistula in pts. with a prosthetic aortic graft – – – –

BLEEDING PEPTIC ULCER-ENDOSCOPY

Forrest’s classification of bleeding activity Forrest Ia- active bleeding- arterial spurting Forrest Ib- active bleeding- oozing Forrest II-bleeding ceased- clot lying on ulcer or visible vessel stump Forrest III-bleeding ceased- no signs of recent bleeding

MANAGEMENT 

Three phases in the management of the bleeding: – – –

Resuscitation Diagnosis Definitive treatment

Active bleeding gastric ulcer

Endoscopic view of activ gastric bleeding

Endoscopic view of erosive duodenitis

Active bleedingduodenal ulcer

Bleeding duodenal ulcer

Bleeding erosive gastritis

RESUSCITATION     

Hemorrhagic shock- ICU Do not sedate patient for endoscopy Rapid transfusion BP, PR, CVP, UO monitoring Confusion and restlessness demand attention for oxygenation

DIAGNOSIS   

History- dyspepsia, liver disease, intake of alcohol, aspirin, NSAID Endoscopic examination: the sourse and the gravity of bleeding Endoscopic criteria for early surgery: – – –

Arterial spurter Visible vessel in base of ulcer Adherent clot

MANAGEMENT   

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Bed rest Naso-gastric lavage with cold saline IV antisecretory drugs (H proton pump inhibitors, H2 receptor antagonists) Hemostatic drugs Endoscopic adrenaline injection

INDICATION FOR SURGERY Continuing bleeding  Re-bleeding  The sourse of bleeding  Fitness of the patient Check coagulation parameters 

SURGERY IN BLEEDING ULCER 

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Partial gastrectomy but morbidity and mortality high Underrunning of the bleeding ulcer, followed by the treatment with antiulcer drugs

THE FAILURES OF GASTRIC SURGERY 

Recurrent Ulceration – – – – –

Incomplete vagotomy Inadequate resection Retained gastric antrum Zollinger-Ellison syndrome Hypercalcemia