1. Peptic Ulcer & its Complications Prof. Dr. Faisal Ghani Siddiqui FCPS; MCPS-HPE; PGDip-bioethics

2. Preamble Peptic ulcer and its treatment Complications of peptic ulcer disease

3. Peptic Ulcer -Sites Duodenum Stomach Stomas Oesophagus Meckel’s diverticulum

4. Peptic Ulcer -Aetiology Acid Familial Stress NSAIDs Cigarette smoking H.pylori

5. Peptic Ulcer -Investigations Endoscopy Tests for H.pylori 13 C and 14 C breath tests CLO test Histpathology Serology

6. Peptic Ulcer -Treatment Medical treatment (H 2 -receptor antagonists / PPI) Eradication treatment (PPI + Metronidazole + Amoxycillin / clarothromycin) Surgery

7. Peptic Ulcer -Complications Pyloric outlet obstruction Perforation Bleeding

8. Pyloric Outlet Obstruction PerforationBleeding

9. Long history of Long history of peptic ulcer disease Vomiting Vomiting Weight loss Weight loss Dehydration Dehydration Succussion splash Succussion splash Peristalsis Peristalsis Tetany Tetany

10. Hypochloraemic alkalosis & paradoxical alkalosis

11. PARADOXICAL ACIDURIA Renal loss of K + and H + Aldosterone secretion & Na + conservation Renal Excretion of HCO3 with Na+ deficit HYPOCHLORAEMIC ALKALOSIS Vomiting –loss of HCl,

12. Investigations Laboratory investigations Hypochloraemic alkalosis; hyponatremia;hypokalaemia

13. Investigations Imaging Plain X-ray ; Barium meal

16. Investigations Saline load test 700 ml normal saline infused over 3-4 minutes Tube clamped for 30 minutes Stomach aspirated Recovery of >350 ml indicates obstruction

18. Treatment Correction of metabolic abnormalities Dealing with the mechanical problem

19. Treatment Correction of fluid & electrolyte imbalance Rehydration with isotonic saline and potassium supplements

20. Treatment Medical treatment Gastric lavage and suction (5-7 days) Surgical treatment Truncal vagotomy with gastrojejunostomy Endoscopic treatment Balloon dilatation

21. … in summary Most commonly associated with PUD and carcinoma stomach Hypochloraemic alkalosis & paradoxical aciduria Medical / endoscopic dilatation effective in less severe cases Operation with a drainage procedure usually required

22. Perforation of peptic ulcer

23. Most perforated ulcers are located anteriorly absence of protective viscera | major blood vessels

24. Pain Pain Pain Distressed Distressed Shallow breath Shallow breath Rigidity Rigidity Absent gut sounds Absent gut sounds Tympanitic note over liver Tympanitic note over liver

25. Investigations Laboratory investigations Leucocytosis ; raised serum amylase High levels of amylase in aspirated fluid Imaging Gas under diaphragm Escape of contrast material from the lumen

27. Tretament Nasogastric tube IV fluids Antibiotics Graham-Steele patch

30. Bleeding peptic ulcer

31. Hematemesis & Shock

32. Hematemesis with shock Initial management Definitive management

33. Upper GI Endoscopy (within 1-2 hours of admission) History & physical examination Stop bleeding by ice-water lavage Assess shock & replace blood loss Pulse | BP | Urine output | Haematocrit | Blood aspirated Initial Management

34. Causes of Upper GI Bleeding Peptic ulcer Acute gastritis Oesophageal varices Oesophagitis Mallory-Weiss syndrome

35. Bleeding Peptic Ulcer -Treatment Endoscopic treatment Emergency Surgery

36. Endoscopic Treatment -Indications Active bleeding at the time of endoscopy Visible vessel at the base of the ulcer

37. Endoscopic Treatment Injection Epinephrine | ethanol Cautery Heat probe | electorcautry Nd:YAG laser

38. Emergency Surgery Hypotension on admission 4 units of blood to achieve circulatory stability Continuous bleeding Subsequent transfusion requirements exceed 1 unit every 8 hours