Gastric and duodenal ulcer disease

1. Gastric and duodenal ulcer disease

2. Ulcer disease • ulcer is a defect of gastric or duodenal mucosa which interfere over lamina muscularis mucosae, submucosa or penetrates across whole gastric or duodenal wall • rise of ulcer is conditioned by presence of acid gastric content • frequent disease, men are afected 3-4x more than women

3. Pathogenesis: • multifactorial • dysbalance between protective and aggressive factors • Protective f.: saliva, food, alcalic duodenal fluid, mucus - mucine, fast regeneration of gastric epithelial cells, well perfused gastric mucosa • Aggressive f.: HCl, pepsin, bile acids (reflux), helicobacter pylori, drugs (analgetics, aspirin, korticoids), nicotine, alcohol

4. Classification: Acute ulcer (ulcus acutum) • smooth non-elevated borders and smooth base • major bleeding into upper GIT Chronic ulcer (ulcus chronicum) • rushed and elevated boders, inflammation with hypertrophic and fibrotic proliferation is present • the most frequent form of ulcer disease • Ulcus chronicum mediogastricum • Ulcus chronicum ventriculi et duodeni • Ulcus chronicum praepyloricum • Ulcus chronicum duodeni

5. Symptoms of gastric ulcer disease: • epigastric pain after meal or during meal • upper dyspeptic syndrome – loss of appetite, nauzea, vomiting, flatulence • vomiting brings relief • reduced nutrition • loss of weight

6. Symptoms of duodenal ulcer disease: • epigastric pain 2 hours after meal or on a empty stomach or during night • pyrosis • good nutrition • obstipation • seasonal dependence (spring, autumn)

7. Complications: • Bleeding - chronic (minor, cause anaemia) - acute (major, form affected vessel) • Perforation - mostly bulbus duodeni, anterior gastricwall - acute violent pain - bleeding can be present • Penetration- of the ulcer deeply through whole wall into neighbor organ(pancreas, liver) • Stenosis - narrow of thelumencaused by scar, oedema or inflammatory infiltration after healing of the ulcer - rise only at pyloric localization - vomiting of huge volume of gastric content

8. Zeman, M. et al., Speciální chirurgie, ISBN 80-7262-260-9, 2004 A – penetration B – perforation C – bleeding D - stenosis

9. Therapy: • Conservative • regular lifestyle • prohibition of the smoking and alcohol • diet (proteins, milk and milky products) • pharmacology (antagonists of H2 receptors, antacids, anticholinergics • Surgical • BI, BII resection • proximal selective vagotomy • vagotomy with pyloroplastic • suture of perforated or haemorrhagic ulcer

10. Stomach resections: • Billroth I (BI) – gastro-duodenoanastomosis end-to-end • Billroth II (BII) – gastro-jejunoanastomosis end-to-side with blind closure of duodenum • Proximalselective vagotomy – denervationof parietal gastric cells

11. Zeman, M. et al., Speciální chirurgie, ISBN 80-7262-260-9, 2004 Billroth I

12. Zeman, M. et al., Speciální chirurgie, ISBN 80-7262-260-9, 2004 Billroth II

13. Zeman, M. et al., Speciální chirurgie, ISBN 80-7262-260-9, 2004 Gastro-enteroanastomosis on Roux Y crankle

14. Zeman, M. et al., Speciální chirurgie, ISBN 80-7262-260-9, 2004 Vagotomy

15. Complications after stomach resection: • Early – dehiscence, stenosis of anastomosis, bleeding, pancreatitis, obstructive icterus, affection of neighbour tissues • Late - days, weeks - early dumping syndrome - late dumping syndrome - incoming crankle syndrome - outcoming crankle syndrome - ulcer in anastomosis or in outcoming crankle

16. Early dumping syndrome: • group of symptoms approved shortly after meal • appears after BII resection • vasomotoric sy. - face redness, fall of blood pressure, dizziness • GI sy. - vomiting, diarrhoea • Th.: diet, no sugar, low quantities of food, change BII to BI resection

17. Late dumping syndrome: • hypoglycaemia(sugar is not enough digested) • appears after BII resection • weakness, perspiration, dizziness, tremor cca 3h aftermeal • Th.: no sugar, change BII to BI resection

18. Incoming crankle syndrome: • stasis of the content at incoming crankle increase intraluminal pressure • appears after BII resection • Th.:diet, change BII to BI resection

19. Outcoming crankle syndrome: • chronic or acute closure of outcoming crankle • appears after BII resection • vomiting after meal, convulsive pain • Th.: change BII to BI resection

25. Haemorrhagic mediogastric ulcer

27. Chronic gastric ulcer

34. Pylorostenosis and gastrectasia

35. Duodenal ulcer

36. Stress ulcers

38. Benign stomach tumors • rise from all layers of stomach wall • often asymptomatic • Polypus, Leiomyoma, Lipoma, Fibroma, Neurofibroma, Neurinoma, Hemangioma, Karcinoids, Lymfoma • Diagnostic: endoscopy, X – ray • Therapy: local excision, stomach resection

39. Stomach cancer • Symptoms: • long-time asymptomatic • feeling of full stomach, odour from mouth, tiredness, anaemia, occasional vomiting, loss of appetite, loss of weight • Diagnosis: • gastrofibroscopy – biopsy - histology • X-ray, USG, CT - metastasis • Wirchow´s nodule – enlargement of left supraclavicular nodule

40. Stomach cancer • Etiopathogenesis: • Praecancerosis: adenomatous polypus, chronic atrofic gastritis, foveolar hyperplasia (Ménétrier disease), stub of the stomach after BII resection • Division: • Macroscopic: exofytic polypoid form, diskyform ulcerous form, diffused infiltrating form • Histopathologic: adenocarcinoma, papilar, tubular, gelatinous cancer, round cell cancer, flagstone cell cancer, etc.

41. Stomach cancer • Therapy: • Currative – total gastrectomy, sub-total gastrectomy • Paliative – gastrostomy, jejunostomy Zeman, M. et al., Speciální chirurgie, ISBN 80-7262-260-9, 2004

49. Gastric cancer

50. Gastric stub cancer after B II resection