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Peptic Ulcer Disease

Peptic Ulcer Disease. 3 月前无明显诱因下出现上腹部疼痛 , 自诉针扎样痛，不剧，多饥饿时好发，进食后可缓解，无他处放射痛，持续 10 多分钟可自行缓解，伴返酸 。 1 月前患者上腹痛加重，为持续性，有夜间发作。未予重视未就诊。 半月前患者无明显诱因下出现黑便， 2 天 1 次。 4 天前患者晚餐后出现呕吐，为胃内容物中带暗红色血块，未见鲜红色血，有头晕乏力，胸闷气促，冒冷汗 , 解黑色大便 2 次。

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Peptic Ulcer Disease

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  1. Peptic Ulcer Disease

  2. 3月前无明显诱因下出现上腹部疼痛,自诉针扎样痛，不剧，多饥饿时好发，进食后可缓解，无他处放射痛，持续10多分钟可自行缓解，伴返酸 。 • 1月前患者上腹痛加重，为持续性，有夜间发作。未予重视未就诊。 • 半月前患者无明显诱因下出现黑便，2天1次。 • 4天前患者晚餐后出现呕吐，为胃内容物中带暗红色血块，未见鲜红色血，有头晕乏力，胸闷气促，冒冷汗,解黑色大便2次。 • 1天前患者再次出现呕血，色鲜红，同时解黑便，伴头晕头痛，呼吸困难，四肢厥冷，遂转我院急诊，急查血常规示血红蛋白3.9g/dl,予静脉补液并输红细胞8u，急诊内镜：“十二指肠球部前壁0.8 X0.8cm溃疡伴出血（A1期）”。

  3. 手术记录2010-3-26 • 远端胃大部切除（毕2式吻合）+ 十二指肠残端造瘘 • 探查：十二指肠球部至胃幽门部有质硬的瘢痕组织。十二指肠球部与周围组织粘连严重。于幽门环下约4cm处切断十二指肠，十二指肠残端内放置蘑菇头引流管，并丝线闭合十二指肠残端，用闭合器断胃，距Treiz韧带12cm处提起空肠，于横结肠前行胃空肠端侧吻合，胃小弯对输入袢，置腹腔引流管2根于十二指肠残端附近。

  4. 十二指肠溃疡术后8天，呕血8小时 • 患者8天前因十二指肠溃疡术后在我院行急诊远端胃大部切除（毕II式吻合）+十二指肠残端造瘘术。术后无呕血不适，无腹痛腹胀，仍有黑便、低热，其余生命体征平稳，术后7天带腹腔引流管及十二指肠造瘘管转至省青春医院继续治疗。8小时前患者无明显诱因下出现大量呕血，腹腔造瘘管及引流管有血性液体流出，伴腹痛，便血。 • 2010-3-26急诊胃镜：十二直肠球部前壁0.8 X 0.8cm溃疡伴出血，A1期

  5. 手术记录 04-03 • 探查：见腹腔内淡红色积液约500ml，腹腔内未见明显新鲜出血，原胃空肠吻合口通畅，未见梗阻，愈合佳，打开残胃前壁，见胃腔内新鲜血液及凝血块约800ml，吸尽血液，检查残胃，未见明显溃疡和出血点，仔细探查见输入袢肠管有新鲜血液流出，输入袢植入胃镜，检查见十二指肠残端内后壁有明显出血点，遂打开十二指肠残端，见残端充血水肿明显，有一活动性出血点，予prolene线缝合止血，后再用胃镜探查整个肠袢无明显出血。冲洗腹腔，彻底止血。置冲洗引流管4根于十二指肠残端附件，一根盆腔引流管，另在胃肠吻合下40cm处置一空肠营养造瘘管，残胃前壁置入蘑菇造瘘管置于输入襻内

  6. 手术记录 04-16 • 探查腹腔：腹腔内脏器粘连水肿严重，小肠及结肠内可见大量血凝块，先行粘连松解后，见空肠部分浆肌层缺损，分离暴露十二指肠残端，切开十二指肠残端，见大量鲜血及血凝块喷涌而出，吸除血液及血凝块，见十二指肠残端有一直径大小约为０.８ｃｍ溃疡，溃疡内可见一动脉断端鲜血喷出。予proline线沿溃疡缝合后未见明显活动性出血，请术中胃镜，探查十二指肠残端、胃及胃肠吻合口未见明显活动性出血，遂予缝合十二指肠切口，并置入24#蘑菇管1根行十二指肠残端造瘘，切除浆肌层缺损肠段约8cm，行肠肠端侧吻合，十二指肠残端处放置引流管3根。

  7. 手术记录 05-01 • 探查腹腔：腹腔内脏器粘连水肿严重，腹腔内结构显示不清，十二指肠水肿明显，先行粘连松解后，沿造瘘管分离暴露十二指肠残端，切开十二指肠残端，见鲜血及血凝块喷涌而出，吸除血液及血凝块，见十二指肠残端后壁内侧有一动脉出血，术中病人心跳骤停，经心肺复苏，心跳恢复，压迫止血，迅速补液输血，予proline线缝合十二指肠出血部位后未见明显活动性出血，肠壁水肿炎症严重无法缝合，予开放，拔除十二指肠残端造瘘管，十二指肠残端处放置引流管4根 。

  8. Pathogenesis “ self-digestion” — Peptic ulcer no acid, no ulcer (no HP, no ulcer?)

  9. Types of Ulcer • I Incisura • II Gastric + Duodenal • III Prepyloric • IV High lesser curve

  10. 胃十二指肠溃疡的外科适应证 • ①内科治疗无效的十二指肠溃疡(Refractory ulcer)； • ②各种情况的胃溃疡和胃溃疡恶变； • ③急性穿孔； • ④溃疡大出血； • ⑤痕性幽门梗阻； • ⑥应激性溃疡； • ⑦胰源性溃疡。 • Giant Gastric Ulcers >3cm

  11. Causes of Refractory or Recurrent Peptic Ulcer

  12. Causes of Refractory or Recurrent Peptic Ulcer

  13. DuodenalUlcer (DU) Clinical features：节律性、周期性饥饿痛(夜间痛) ca. 30 in age，man＞women Acid dyspepsia: the classic ulcer symptom; Burning epigastric pain: Hunger pain (episodic) (2 to 3 hrs after meal)，Night pain, Food and alkali relief, Periodicity of the pain: Autumn- early spring； Belching，Heartburn。

  14. 十二指肠溃疡 1 、外科手术适应证 （1）严重并发症：急性穿孔、大出血和瘢痕性 幽门梗阻； （2）内科治疗无效(Intractability)：顽固性溃疡 病理：慢性穿透性溃疡，球后溃疡。 临床：节律性消失，症状严重，不易止痛， GI：龛影较大(Giant Gastric Ulcers >3cm )、 球部严重变形、穿透出肠 壁外或位于球后 部溃疡者。

  15. 十二指肠溃疡 2 、外科手术方法 胃大部切除术 迷走神经切断术

  16. GastricUlcer (GU) • ①小弯溃疡，>50%； • ②高位溃疡； • ③后壁溃疡，多慢性穿透 深入胰腺； • ④复合溃疡 • ⑤幽门前溃疡

  17. GastricUlcer (GU) • Irritable stomach: Indigestion, Dysgastria, • Rule out malignancy, dyspepsia. • >40 years, female:male = 2:1 (sabiston) • 胃痛节律性较不明显。 40～50岁，男性较多 • 进餐后不能很好止痛，餐后1小时疼痛即可开始，持续1～2小时。对抗酸药物疗效不明显。较十二指溃疡容易复发，容易引起大出血、急性穿孔等严重并发症。约有5％胃溃疡可以发生恶变。

  18. Dyspepsia • Pain or Discomfort centred in the upper abdomen

  19. Major structural causes of dyspepsia • Chronic peptic ulcer (duodenal or gastric) • Gastro-oesophageal reflux disease (>50% have no oesophagitis) • Gastric or oesophageal adenocarcinoma (rare but of concern for patient and doctor)

  20. 胃溃疡治疗 • 经过8～12周内科治疗无效或愈合后复发； • 年龄 >45岁； • 经X线或胃镜证实为较大(>2.5cm)或高位溃疡； • 不能排除或已证实有恶变者； • 合并或曾有急性穿孔、大出血或梗阻。

  21. Surgical Procedures 一、Subtotal gastrectommy 1 ．Billroth-I 2 ．Billroth-II 3 ．Roux-en-Y 4. Others

  22. Surgical Procedures 1 ．Billroth I (1885)

  23. Surgical Procedures 一、Subtotal gastrectomy 1 ． Billroth-II

  24. Surgical Procedures 一、胃大部切除术 1 ． Roux-en-Y

  25. Surgical Procedures 一、Subtotal gastrectomy 1 ．Billroth-I 2 ． Billroth-II 3 ．Roux-en-Y 4. Others

  26. Surgical Procedures 二、 Vagotomy 1．Truncal vagotomy 2．Selective vagotomy 3．Parietal cell vagotomy (High selective vagotomy)

  27. 二、Vagotomy1． Truncal vagotomy迷走神经干切断术2．选择性胃迷走神经 切断木 3．高选择性胃迷走神经 切断术切断：食管裂孔水平左、右二支腹迷走神经干

  28. 二、 Vagotomy 2．Selective vagotomy

  29. 二、 Vagotomy 3． HighSelective vagotomy Parietal cell vagotomy

  30. Perforation • Free perforation Severe peritonitis,tenderness, rigidity, reboundBoardlike abdomen,Shock. • Contained perforation Penetrating ulcer

  31. 胃十二指肠溃疡急性穿孔Differential diagnosis 1．Hallmark of free perforation 2．Acute pancreatitis 3．Acute appentitis

  32. Perforation Medical therapy: • > 24h, • Close surveillance.

  33. 溃疡病急性穿孔治疗 1．非手术治疗 适应证：症状轻、一般情况好的单纯性空腹 较小穿孔。 方法：胃肠减压、输液和抗生素等。 治疗6～8小时后，症状、体征加重者，改手术治疗。

  34. 溃疡病急性穿孔治疗 • 2．手术治疗 • 手术适应证：饱食后穿孔、顽性溃疡穿孔和伴有幽门梗阻、大出血、恶变等并发症者。

  35. Perforation Operative approach: • Emergency closure (Oversewing)单纯穿孔缝合术, • Definitive ulcer operation。

  36. Perforation • Operative approach: Emergency closure (Oversewing), Definitive operations. .

  37. 溃疡病急性穿孔治疗 • 3．手术方法 • 单纯穿孔缝合术：操作简便，危险性较少 • 彻底性手术。

  38. 溃疡病急性穿孔治疗 • 3． 手术方法 • 单纯穿孔缝合术; • 彻底性手术。

  39. Gastric Outlet Obstruction • Surgery: reliefe of obstruction, antiulcer operation.

  40. Gastric Outlet Obstruction • Fibrosis, scarring, deformity, (spasm,edema). • Gastric atony, gastric retention : bloating, anorexia, nausea, vomiting. • Endoscopic balloon dilatation+stent. • Surgery: absolute indication.

  41. Peptic Ulcer HemorrhageBleeding Peptic Ulcer • 40 ％－ 60 ％ of all upper GI Hemorrhage • 6 ％－15％ in DU，2％－5％ in GU • Conservative therapy, Endoscopy 80% • Surgical indication: Severe, persistent or recurrentbleeding; age, general health condition, other ulcercomplications. • Surgery is required in ca. 10% of patients

  42. Self-limited: 80% • Mortality: 8% to 10% • resuscitation • endoscopy

  43. Peptic Ulcer Hemorrhage 手术治疗 • 单纯缝合术; • 彻底性手术。

  44. Postgastrectomy Syndromes • Postoperative Complications for Peptic Ulcer Disease

  45. DUMPING SYNDROME • Dumping syndrome refers to a symptom complex that occurs following ingestion of a meal when a portion of the stomach has been removed or the normal pyloric sphincter mechanism has become disrupted.

  46. DUMPING SYNDROME • Early Dumping syndrome :usually occurs within 20 to 30 minutes following ingestion of a meal; • Late Dumping syndrome:appears 2 to 3 hours after a meal

  47. METABOLIC DISTURBANCES • Iron deficiency anemia • impairment in vitamin B12 metabolism:Megaloblastic anemia

  48. AFFERENT LOOP SYNDROME

  49. EFFERENT LOOP OBSTRUCTION • The most common cause of efferent loop obstruction is herniation of the limb

  50. ALKALINE REFLUX GASTRITIS

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