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Peptic Ulcer

Peptic Ulcer. Professor Ravi Kant FRCS (England), FRCS (Ireland), FRCS(Edinburgh), FRCS(Glasgow), MS, DNB, FAMS, FACS, FICS, Professor of Surgery. Surgical Anatomy. Crow’s feet N of Latarjet Criminal Nerve of Grassi Antral pump mechanism. Applied Anatomy : Stomach. Pressure studies

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Peptic Ulcer

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  1. Peptic Ulcer • Professor Ravi Kant • FRCS (England), FRCS (Ireland), FRCS(Edinburgh), FRCS(Glasgow), MS, DNB, FAMS, FACS, FICS, • Professor of Surgery

  2. Surgical Anatomy • Crow’s feet • N of Latarjet • Criminal Nerve of Grassi • Antral pump mechanism

  3. Applied Anatomy : Stomach • Pressure studies • Endoscopic & Chromo-endoscopic • Contrast ( Ba meal with air) • Intra-luminal USG • Electron microscopy • USG • CT/ MR • Surgical

  4. APD= Acid Peptic Disease • Peptic Ulcer • Gastric Ulcer • Duodenal Ulcer • Hyperacidity • ZE Syndrome

  5. APD= Acid Peptic Disease • Acute Ulcer • Stress Ulcer • Curling’s • Cushing’s

  6. APD • Incidence • Aetiology • CP • Investigations • DD • Rx

  7. Peptic Ulcer • 10% population affected • Gastric ulcer in elderly 5-6th decade • Duodenal ulcer in adults 4th decade • DU also in young

  8. Duodenal Ulcer • Proximal duodenum • 1 - 2 cm of pylorus • ▲acid • Distal duodenum = ZE

  9. Type 1 Gastric Ulcer • most common (among gastric Ulcers) • proximal antrum •  mucosal defense •  acid

  10. Type II Gastric Ulcer • Secondary to DU + pyloric stenosis

  11. Type III Gastric Ulcer • Prepyloric and pyloric canal ulcer • acid ▲ • common etiology with DU

  12. Rugae upto margins Small , <2cm Sticking of barium + Accompanying spasm ↓ Acid Crater beyond the normal stomach on a barium Rugae-short of Small-Big - - Achlorhydria Limited to Stomach GU: Benign Vs CA

  13. APD • Incidence • Aetiology • CP • Investigations • DD • Rx

  14. APD • Hurry • Worry • Curry

  15. Pathogenesis • Imbalance of acid-pepsin and mucosal defence • H. pylori infection • NSAID • ZE Syndrome • Type A personality

  16. H.pylori • 95% - duodenal ulcer • 80% - gastric ulcer •  mucosal resistance hydrophobicity • eradication reduces ulcer recurrence

  17. NSAID • Suppress prostaglandins • prostaglandin ► acid secretion ▲ mucosal blood flow  mucus & bicarbonate secretion • 10 -30% in chronic users

  18. ZE= Zollinger Ellison Syndrome • Recurrent • Recalcitrant • Resistant • Unusual sites • Multiple • Malignant

  19. ZE Syndrome • 0.1 - 1.0% of peptic ulcer • Type I and Type II • Gastrin secretion from non-beta cell tumor of pancreas - Gastrinoma • MC in pancreas ; duodenum, antrum

  20. ZE Syndrome • 20% multiple • 66% malignant • slow growing indolent tumor • parietal cell mass increased • genetic basis • massive hyper-secretion of acid

  21. ZE Syndrome • MEN - I • hyperparathyroidism • islet cell tumor • pituitary tumors

  22. A/ DU • NSAIDs • Acid hypersecretion • Rapid gastric emptying • Impaired acid disposal • Smoking

  23. Duodenal Ulcer • Increased secretion of acid • More rapid gastric emptying • Decreased prostaglandin • Chronic duodenitis with H.pylori • Smoking

  24. Gastric Ulcer • H.pylori • NSAIDs • Duodenogastric reflux • Impaired gastric mucosal defense

  25. Gastric Ulcer • Acid secretion - normal to low • Reflux of duodenal contents  gastritis  ulcer • Pylorus sphincter disorder • Smoking • Disturbed mucosa with low grade gastritis

  26. APD • Incidence • Aetiology • CP • Investigations • DD • Rx

  27. CP • Duodenal Ulcer • pain relieved by food or alkali • pain several hours after meal • Gastric Ulcer - gnawing or burning pain on eating

  28. CP • Periodic chronic recurrent pain • Nausea & vomiting • Weight loss • Epigastric tenderness

  29. APD • Incidence • Aetiology • CP • Investigations • DD • Rx

  30. Investigations • Endoscopy • 90% sensitivity • must in all pts. with severe pain • excludes malignancy • biopsy can be taken • test for H.pylori

  31. Investigations • Barium Meal double (air) contrast • 90% sensitivity

  32. H Pylori detection: • Breath test • Blood test • Tissue test

  33. APD • Incidence • Aetiology • CP • Investigations • DD • Rx

  34. DD • Cholecystitis • Hiatus hernia • Pancreatitis • MI • Pneumonia • Dissecting aneurysm • Worm Infestations

  35. APD • Incidence • Aetiology • CP • Investigations • DD • Rx

  36. Rx - Medical • Stop smoking, NSAIDs • Stop alcohol • Antacids - acid neutralisation • H2 receptor antagonist -Ranitidine - secretion inhibition

  37. Rx- Medical • H+ pump inhibition - H+/K+ase inhibition - Omeprazole • Anticholinergic - secretory inhibition • Prostaglandin - Misoprostol - mucosal protection

  38. Proton Pump Blockers • Omeperazole • Eso-meperazole • Rabi-meperazole

  39. Rx - Medical • Sucralfate - protective coating • Colloidal Bismuth • eradicate H.pylori • protective coating • Antibiotics - H.pylori • Kit for H Pylori

  40. H2 Receptor Antagonists • On parietal cells • Decrease basal & stimulated acid secretion • Pepsin output decreased • Decreased gastric blood flow • Competitive inhibitor of parietal cell

  41. Rx - Duodenal Ulcer • 95% control - medical Rx • Surgery-Outdated, Obsolete • Omeprazole better thanRanitidine • Ulcer heels in 80% by 6 m •  recurrence in 95% by H.pylori eradication

  42. Rx - Duodenal Ulcer • Indications for surgery =Compl • Hemorrhage • Obstruction • Perforation • Intractability of pain • Intractable pain ► HSV / TV + GJ

  43. Rx - DU • H2 blockers heals 75% DU in 4 weeks • H/K proton pump inhibitor better results • ulcer may recurr in 80% cases on stopping • treatment of H.pylori

  44. Rx - DU • Indication of surgery in hemorrhage • bleeding of > than 6 units • recurrent bleed after endoscopic control • pyloro-duodenotomy and control of bleeding • HSV or TV + GJ

  45. Rx - DU • Perforation - simple closure with omental patch -Graham’s patch • definitive surgery • HSV • TV + pyloroplasty • parietal cell vagotomy • TV+GJ

  46. Rx GU • Omeprazole, H2 receptor antagonist - 8 weeks • if pain not relieved by 2 weeks - add one more drug • repeat endoscopy after 8 weeks • if no healing by 12 - 115 weeks - Surgery

  47. Rx - GU • Type I - Distal Gastrectomy with vagotomy + G-D or GJ • proximal ulcer- total gastrectomy • parietal cell vagotomy - high recurrence

  48. Hemorrhage • Hemorrhage - potential cause of death • 15 -20% gross bleeding • erosion of duodenal ulcer into gastro-duodenal artery • Endoscopy –laser, sclerosant oralcohal injection

  49. Perforation • In 5-10% of cases • pneumo-peritoneum in 75% cases • peritonitis, pain, ileus • leukocytosis, hypovolumia, IIIrd space loss • DD - acute appendicitis, enteric perf.

  50. Obstruction • Chronic ulcer disease with edema and scarring • in 5% cases of DU • nausea, vomiting, abdominal distension • metabolic alkalosis, paradoxical aciduria

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