Peptic Ulcer & its Complications Prof. Dr. Faisal Ghani Siddiqui FCPS; MCPS-HPE; PGDip-bioethics
Preamble Peptic ulcer and its treatment Complications of peptic ulcer disease
Peptic Ulcer -Sites Duodenum Stomach Stomas Oesophagus Meckel’s diverticulum
Peptic Ulcer -Aetiology Acid Familial Stress NSAIDs Cigarette smoking H.pylori
Peptic Ulcer -Investigations Endoscopy Tests for H.pylori 13 C and 14 C breath tests CLO test Histpathology Serology
Peptic Ulcer -Treatment Medical treatment (H 2 -receptor antagonists / PPI) Eradication treatment (PPI + Metronidazole + Amoxycillin / clarothromycin) Surgery
Peptic Ulcer -Complications Pyloric outlet obstruction Perforation Bleeding
Pyloric Outlet Obstruction PerforationBleeding
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
Hypochloraemic alkalosis & paradoxical alkalosis
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,
Investigations Laboratory investigations Hypochloraemic alkalosis; hyponatremia;hypokalaemia
Investigations Imaging Plain X-ray ; Barium meal
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
Treatment Correction of metabolic abnormalities Dealing with the mechanical problem
Treatment Correction of fluid & electrolyte imbalance Rehydration with isotonic saline and potassium supplements
Treatment Medical treatment Gastric lavage and suction (5-7 days) Surgical treatment Truncal vagotomy with gastrojejunostomy Endoscopic treatment Balloon dilatation
… 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
Perforation of peptic ulcer
Most perforated ulcers are located anteriorly absence of protective viscera | major blood vessels
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
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
Tretament Nasogastric tube IV fluids Antibiotics Graham-Steele patch
Bleeding peptic ulcer
Hematemesis & Shock
Hematemesis with shock Initial management Definitive management
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
Causes of Upper GI Bleeding Peptic ulcer Acute gastritis Oesophageal varices Oesophagitis Mallory-Weiss syndrome
Bleeding Peptic Ulcer -Treatment Endoscopic treatment Emergency Surgery
Endoscopic Treatment -Indications Active bleeding at the time of endoscopy Visible vessel at the base of the ulcer
Endoscopic Treatment Injection Epinephrine | ethanol Cautery Heat probe | electorcautry Nd:YAG laser
Emergency Surgery Hypotension on admission 4 units of blood to achieve circulatory stability Continuous bleeding Subsequent transfusion requirements exceed 1 unit every 8 hours