Peptic ulcer disease
description
Transcript of Peptic ulcer disease
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Peptic ulcer disease
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Factors influencing
• Aggressor– Acid– Pepsin– NSAIDs– H.Pylori
• Defense – Bicarbonate– Blood flow– Mucous– Cell junctions– Apical resistance
• Repair– Restitution– Proliferation– Mucous cap– Growth factors
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H.Pylori
• Acid hypersecretion1. Inhibits antral D cells
• Decreased somatostatin• Increased gastrin• Increased acid
2. Local alkalization of the antrum• Increased gastrin• Increased acid
• Toxins – Cag A– Vac A
• Cytokines – IL-8
• These cause inflammation -> direct damage to epithelium
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Other etiological factors
• NSAIDs• Gastrinoma (zollinger allison syndrome)• Smoking• Stress
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The gastrinoma triangle
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Clinical features
• Abdominal pain• Nausea• Bloating• Stool positive for occult
blood
• ALARM symptoms– Wt loss– Recurrent vomitting– Dysphagia– Bleeding– Anemia
• If any alarm symptom present, UGI endoscopy should be done
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Upper GI series showing ulcer
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Complications of peptic ulcer
• Intractability• Bleeding• Perforation• Obstruction
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Perforation
• Acute abdomen – Sudden excruciating pain• Fluid sequestration into third space• Peritoneal signs– Guarding, tenderness, rebound tenderness
• Free air under domes of diaphragm
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Ulcer perforation - xray
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Closure of perforated DU with onlay patch
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Gastric ulcer excision
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Closure after excision
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Intractability
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Nonspecific vagotomy
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Antrectomy
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Completed vagotomy, antrectomy and gastroduodenostomy
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Selective and highly selective Vagotomy
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Laparoscopic HSV using clips or harmonic scalpel
Clips Harmonic shears
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The criminal nerve of Grassi
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Heineke-Mikulicz Pyloroplasty
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Finney’s pyloroplasty
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Biliroth I procedures
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Biliroth II reconstruction
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Roux en y gastrojejunostomy
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Bleeding
• Melena/hematemesis• Nasogastric aspiration confirmatory• ShockNPO, acid supressionAggressive resuscitation with fluids and bloodUrgent endoscopyIf endoscopic Rx fails, or re-bleed, Surgery
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Exosure of posterior bleeding DU
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Figure of eight suture for bleeding control
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Gastric resection
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Separation of the greater omentum from the entire transverse colon
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Mobilization of the left lobe of liver and GE junction
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Mobilization of the greater curvature
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Transection of the duodenum
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D2 compartment lymphadencectomy
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Division of the left gastric vessels
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Transection of the esophagus
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Roux en y reconstruction
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Post operative complications of gastrectomy
• Short term:– Intra-abdominal bleeding– Subphrenic abscess– Anastomotic leak– Pancreatic fistula– Duodenal stump leak
• Long term:– Weight loss, decreasing nutritional status (reservoir capacity)– Diarrhea– Dumping syndrome– Alkaline reflux
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Gastrojejunostomy
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Complications of gastrojejunostomy
• Gastric hemorrhage• Anastomotic bleeding• Anastomotic leak• Obstruction (anastomotic or functional)• Anastomotic stenosis (long term)
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Gastrostomy
Stamm Witzel
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Janeway (permanent stapled gastrostomy
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Percutaneous endoscopic gastrostomy
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Laparoscopic gastrostomy
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Pyloromyotomy