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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 Endoscopic & Chromo-endoscopic Contrast ( Ba meal with air) Intra-luminal USG Electron microscopy USG CT/ MR Surgical
APD= Acid Peptic Disease Peptic Ulcer Gastric Ulcer Duodenal Ulcer Hyperacidity ZE Syndrome
APD= Acid Peptic Disease Acute Ulcer Stress Ulcer Curling’sCushing’s
Peptic Ulcer 10% population affected Gastric ulcer in elderly 5-6 th decade Duodenal ulcer in adults 4 th decade DU also in young
Duodenal Ulcer Proximal duodenum cm of pylorus ▲ acid Distal duodenum = ZE
Type 1 Gastric Ulcer most common(among gastric Ulcers) proximal antrum mucosal defense acid
Type II Gastric Ulcer Secondary to DU + pyloric stenosis
Type III Gastric Ulcer Prepyloric and pyloric canal ulcer acid ▲ common etiology with DU
GU: Benign Vs CA 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
Pathogenesis Imbalance of acid-pepsin and mucosal defence H. pylori infection NSAID ZE Syndrome Type A personality
H.pylori 95% - duodenal ulcer 80% - gastric ulcer mucosal resistance hydrophobicity eradication reduces ulcer recurrence
NSAID Suppress prostaglandins prostaglandin ► acid secretion ▲ mucosal blood flow mucus & bicarbonate secretion % in chronic users
ZE= Zollinger Ellison Syndrome RecurrentRecalcitrantResistant Unusual sites MultipleMalignant
ZE Syndrome % of peptic ulcer Type I and Type II Gastrin secretion from non-beta cell tumor of pancreas - Gastrinoma MC in pancreas ; duodenum, antrum
ZE Syndrome 20% multiple 66% malignant slow growing indolent tumor parietal cell mass increased genetic basis massive hyper-secretion of acid
ZE Syndrome MEN - I – hyperparathyroidism – islet cell tumor – pituitary tumors
A/ DU NSAIDs Acid hypersecretion Rapid gastric emptying Impaired acid disposal Smoking
Duodenal Ulcer Increased secretion of acid More rapid gastric emptying Decreased prostaglandin Chronic duodenitis with H.pylori Smoking
Gastric Ulcer H.pyloriNSAIDs Duodenogastric reflux Impaired gastric mucosal defense
Gastric Ulcer Acid secretion - normal to low Reflux of duodenal contents gastritis ulcer Pylorus sphincter disorder Smoking Disturbed mucosa with low grade gastritis
CP Duodenal Ulcer – pain relieved by food or alkali – pain several hours after meal Gastric Ulcer - gnawing or burning pain on eating
CP Periodic chronic recurrent pain Nausea & vomiting Weight loss Epigastric tenderness
Investigations Endoscopy – 90% sensitivity – must in all pts. with severe pain – excludes malignancy – biopsy can be taken – test for H.pylori
Investigations Barium Meal double (air) contrast – 90% sensitivity
H Pylori detection: Breath test Blood test Tissue test
DD Cholecystitis Hiatus hernia PancreatitisMIPneumonia Dissecting aneurysm Worm Infestations
Rx - Medical Stop smoking, NSAIDs Stop alcohol Antacids - acid neutralisation H 2 receptor antagonist -Ranitidine - secretion inhibition
Rx- Medical H + pump inhibition - H + /K + ase inhibition - Omeprazole Anticholinergic - secretory inhibition Prostaglandin - Misoprostol - mucosal protection
Proton Pump Blockers OmeperazoleEso-meperazoleRabi-meperazole
Rx - Medical Sucralfate - protective coating Colloidal Bismuth – eradicate H.pylori – protective coating Antibiotics - H.pylori Kit for H Pylori
H2 Receptor Antagonists On parietal cells Decrease basal & stimulated acid secretion Pepsin output decreased Decreased gastric blood flow Competitive inhibitor of parietal cell
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
Rx - Duodenal Ulcer Indications for surgery=Compl –Hemorrhage –Obstruction –Perforation –Intractability of pain Intractable pain ► HSV / TV + GJ
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
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
Rx - DU Perforation - simple closure with omental patch-Graham’s patch definitive surgery –HSV –TV + pyloroplasty –parietal cell vagotomy –TV+GJ
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 weeks - Surgery
Rx - GU Type I - Distal Gastrectomy with vagotomy + G-D or GJ proximal ulcer- total gastrectomy parietal cell vagotomy - high recurrence
Hemorrhage Hemorrhage - potential cause of death % gross bleeding erosion of duodenal ulcer into gastro-duodenal artery Endoscopy –laser, sclerosant oralcohal injection
Perforation In 5-10% of cases pneumo-peritoneum in 75% cases peritonitis, pain, ileus leukocytosis, hypovolumia, IIIrd space loss DD - acute appendicitis, enteric perf.
Obstruction Chronic ulcer disease with edema and scarring in 5% cases of DU nausea, vomiting, abdominal distension metabolic alkalosis, paradoxical aciduria
Obstruction Endoscopy Ba study Scintigraphy Rx V + G-J / G-D
Oesophagus and Stomach PHIL THIRKELL + ASFAND BAIG.
Peptic ulcer disease. Factors influencing Aggressor – Acid – Pepsin – NSAIDs – H.Pylori Defense – Bicarbonate – Blood flow – Mucous – Cell junctions –
Upper GI: Esophagus and Stomach. Dysphagia Etiology –Obstructions Intrinsic: tumors, strictures, herniations Extrinsic: tumors, ascites, morbid obesity.
Nur 4206 The Patient with Digestive Disorders By Linda Self.
Gastrointestinal Bleeding Pathophysiology of GI Bleeding Mucosal lesions – Acid-peptic disease, drug-induced (NSAIDs), Infectious (H. pylori), inflammatory.
Gastrointestinal Disorders PN 4. Changes through the lifespan Relatively immature at birth Teeth at 6-7 months Peristalsis slows to allow formed stool.
DRUGS AFFECTING THE DIGESTIVE SYSTEM Chapters 56, 59, 62 By Sandy Kaminski.
Upper GI Bleeding Dr M. Ghanem. Definition Refers to GI bleeding from a source proximal to the Ligament of Treitz.
Group D – Analyst Grp Vigilia, Patrice Villaflor, Irene Villafuerte, Marc Villar, Cherry Villasis, Ramon Vistal, Kristine Yap, Margaux.
Drugs Affecting the Gastrointestinal System and Nutrition Jan Bazner-Chandler MSN, CNS, RN, CPNP.
UGI Bleeding Epidemiology of Upper GI Bleeding Bleeding from a source above the ligament of Treitz 1 case/1,000 adults/year 50% of cases are peptic ulcer.
GI Physiology Resource 1 Problem Solving Exercises - Discussion 9 am Jan 17, 2012 E.S.Prakash, MBBS, MD Division of Basic Medical Sciences Mercer University.
Digestive Diseases Introduction to Human Diseases Chapter 10.
Gastrointestinal Problems Claire Nowlan MD. Peptic Ulcers Ulceration of either the gastric or duodenal mucosa.
Upper GI Bleeding Presenter: Dr. Abdulaziz Almusallam Moderator: Dr. Maher Morris.
Alonzo.Amaro.Amolenda Anacta.Andal. Beginning Data Male, 45 year old Chief Complain: Severe Abdominal Pain.
GI Board Review – Part I Esophagus, Stomach, and Pancreas February 21, 2013.
GI Bleeding in Children Maria Christina H. Ventura, MD, DPPS July 8, 2010.
Role of H.pylori in Peptic Ulcer and drugs used in Treatment Dr. Abdulaziz al-Khattaf.
Distal gastrectomy with B1, B2 anastomsis or Roux-En-Y Jeffrey A. Neale MD 1/31/08.
Drugs Affecting GI Functions ( Summary) Assoc. Prof. Iv. Lambev
Upper GI quiz PBL 28. Helicobacter infection in the stomach is associated with: a)Gastric carcinoma b)Acute gastric ulceration c)Chronic duodenal ulceration.
UPPER GI BLEED Presentation designed by Wendy Gerstein, MD Department of Medicine NMVAHCS.
1 Gastric Diseases. 2 Pay attention Gastric Ulcer Carcinoma of stomach.
GASTROINTESTINA L BLEEDING Part 1 Stephanie Faith C. Bautista.
1Elsevier items and derived items © 2007 by Saunders, an imprint of Elsevier, Inc. Chapter 38 Digestive Tract Disorders.
Agents to Treat Gastric Acidity and Gastroesophageal Reflux Disease (GERD) Presented by Abby Roth.
Elsevier items and derived items © 2013, 2009 by Saunders, an imprint of Elsevier Inc. Chapter 29 Care of Patients with Disorders of the Upper Gastrointestinal.
GASTROINTESTINAL NURSING Digestive Tract Disorders 2013.
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