1. Peptic Ulcer disease

2. Anatomy
Stomach
Regions

3. Stomach – cont. Anatomy – cont. Layers of walls Serosa Muscularis
Submucosa
Mucosa

4. Stomach – cont. Anatomy – cont. Glands in mucosa Cardiac glands
Gastric glands
Chief cells
Parietal cells
Mucous neck cells
gastrin

5. Gastric pit mucus neck & surface cells parietal cells (oxyntic)
Mucus & HCO3
parietal cells
(oxyntic)
H+ secretion &
intrinsic factor
Peptic cells
(chief, zymogen)
Pepsinogen secn

6. Functions of gastric secretions
Digestion of proteins ( pepsinogen & HCl)
Protection of stomach ( HCO3- & mucus)
Absorption of vitamin B12 ( intrinsic factor)
Destroy bacteria & other micro-organisms
(HCl)
~ 3 li per day

7. Peptic ulcer disease General consideration
Peptic ulcers result from the corrosive action of acid gastric juice
Ulcers may occur in oesophagus, stomach,duodenum, jejunum or ileum from ectopic gastric mucosa
Can be anywhere in GI tract exposed to acid-pepsin gastric juice
Other factors also contribute
H. pylori
Mucosal bicarbonate secretion
Stress
Genetics

8. GI Pathology Helicobacter pylori

10. Peptic ulcer disease - cont.
Pathogenesis
Two factors prevent stomach from digesting itself
Gastric mucosal barrier
First line of defense
NSAIDS cause in changes mucosa that my facilitate its digestion by pepsin
Destruction of barrier believed to be important factor in pathogenesis of gastric ulcers
Results of back diffusion of H+ injuring underlying tissues
Antrum more susceptible to back diffusion than fundus
Duodenum resistant to ulceration due to Brunner’s glands which produce a highly alkaline secretion

11. Peptic ulcer disease - cont.
Epithelial barrier
Depends of abundant vascular supply and continual, rapid regeneration of epithelial cells (~3 days)

12. Peptic ulcer disease - cont.
Other factors
10-12 % incidence in population
Duodenal ulcers occur in much younger group than gastric years
Males affected 3X as often as women
Duodenal ulcers 10X as common as gastric
>90% of duodenal ulcers are on anterior or posterior wall within 3 cm of pyloric ring
40-60% have family history

13. Peptic ulcer disease - cont.
Clinical features
Principle feature is chronic, intermittent epigastric pain – typically relieved by food
~25% have bleeding (more common with duodenal)
Other signs and symptoms
Vomiting
Red or “coffee-ground” emesis
Nausea
Anorexia
Weight loss
Pain-food-relief pattern may not be typical of gastric ulcers – food sometimes aggravates

14. Diagnostic procedures
Barium radiologic studies
Gastric analysis of acid secretion
Aspirate gastric juices with nasogastric tube
Endoscopy
Photography
Biopsy
Exfoliative
cytology

15. Differential Diagnosis
Gallbladder disease
Pancreatitis
Functional indegestion
Reflux oesphagitis

16. Peptic ulcer disease - cont.
Medical treatment
Primary consideration is to inhibit or buffer acid to relieve symptoms and promote healing
Antacids – increase pH so pepsin isn’t activated
Dietary management – small frequent meals, avoid alcohol and caffeine
Anticholinergics – inhibit vagal stimulation
Antimicrobial therapy
Physical and emotional rest
Ulcers caused by H. pylori are successfully treated with antimicrobial agents, bismuth salts, and H2 blockers
65-95% eradication rates

17. 10 Day Regimen clarithromycin 500 mg bid X 10
amoxicillin 1 gram bid X 10
omeprazole 20 mg bid X 10
in patients with current ulcer, continue omeprazole 20 mg/day for 18 days

18. kPeptic ulcer disease - cont.
Complications
Hemorrhage
Most frequent complication – 15-20%
Most common in ulcers of the posterior wall of duodenal bulb due to proximity of arteries
Symptoms depend on severity
Anemia
Occult blood in stool
Black and tarry stool
Hematemesis
Shock
Mortality up to 10% - higher for patients over 50

19. Peptic ulcer disease - cont.
Perforation
Approximately 5% of all ulcers perforate - accounts for 65% of deaths from peptic ulcers
Usually on anterior wall of duodenum or stomach
Thought to be due to excess acid and often a result of NSAIDS
Characteristic presentation
Sudden onset of excruciating pain in upper abdomen – chemical peritonitis
Patient fears to move or breath
Abdomen becomes silent to auscultation and board like rigidity to palpation
Treatment – immediate surgery

20. Peptic ulcer disease - cont.
Obstruction
Obstruction of gastric outlet in ~5% of patients
Due to inflammation and edema, pylorospasm or scarring
More often with duodenal ulcers
Symptoms
Anorexia
Nausea
Bloating after eating
Pain and vomiting when severe
Treatment
Restore fluids and electrolytes
Decompress stomach with nasogastric tube
Surgical correction - pyloroplasty

21. Peptic ulcer disease - cont.
Intractability
Medical therapy fails to control symptoms adequately, resulting in frequent, rapid recurrences
Typically surgery is recommended

22. Peptic ulcer disease - cont.
Surgical treatment – for patients who do not respond to therapy
For duodenal ulcers aim is to permanently reduce stomach’s capacity to secrete acid and pepsin
Vagotomy
Cut vagal branches to stomach
Eliminates cephalic phase
Several techniques
Antrectomy
Removal of entire antrum
Eliminates gastric phase
Vagotomy plus antrectomy
Eliminates both cephalic and gastric phases

23. Peptic ulcer disease - cont.
Partial gastrectomy
Removal of distal 50-75% of stomach
Gastric remnant anastamosed to duodenum (Billroth I) or jejunum (Billroth II)
For gastric ulcers
Usually partial gastrectomy and a gastroduodenal anastomosis
Normally do not do vagotomy as patients have normal to low acid production

24. Normal Stomach

25. Esophagus & Stomach Normal

26. Gastric Ulcer

27. Peptic ulcer - Endoscopy

28. Duodenal Peptic Ulcer

29. Gastric Ulcer

31. GI Pathology Duodenal Peptic Ulcers, Gross

32. GI Pathology Giant gastric ulcer

33. GI Pathology Gastric Peptic Ulcer
Gross
Lesser curvature is the most common location in the stomach; greatest frequency is in the first part of the duodenum
Less than three centimeters in diameter
Round to oval in shape
Punched-out area with clean base
Margins are usually level with surrounding mucosa or slightly elevated due to edema; the mucosa is undermined at the edges

34. GI Pathology Gastric Peptic Ulcer
Up to 50% of those with gastric peptic ulcer have concurrent duodenal ulcer
These ulcers typically occur at mucosal junctions exposed to acid and pepsin (e.g., body of stomach/antrum)

35. GI Pathology Gastric peptic ulcer
Associations: Chronic gastritis, Helicobacter pylori (50-60%)
Peak incidence = 50's
Location = Lesser curvature, antrum

36. GI Pathology Anatomy of the stomach