1. Gastric and duodenal ulcer disease

2. Ulcer disease
ulcer is a defect of gastric or duodenal mucosa which interfere over lamina muscularis mucosae, submucosa or penetrates across whole gastric or duodenal wall
rise of ulcer is conditioned by presence of acid gastric content
frequent disease, men are afected 3-4x more than women

3. Pathogenesis: multifactorial
dysbalance between protective and aggressive factors
Protective f.: saliva, food, alcalic duodenal fluid, mucus - mucine, fast regeneration of gastric epithelial cells, well perfused gastric mucosa
Aggressive f.: HCl, pepsin, bile acids (reflux), helicobacter pylori, drugs (analgetics, aspirin, korticoids), nicotine, alcohol

4. Classification: Acute ulcer (ulcus acutum)
smooth non-elevated borders and smooth base
major bleeding into upper GIT
Chronic ulcer (ulcus chronicum)
rushed and elevated boders, inflammation with hypertrophic and fibrotic proliferation is present
the most frequent form of ulcer disease
Ulcus chronicum mediogastricum
Ulcus chronicum ventriculi et duodeni
Ulcus chronicum praepyloricum
Ulcus chronicum duodeni

5. Symptoms of gastric ulcer disease:
epigastric pain after meal or during meal
upper dyspeptic syndrome – loss of appetite, nauzea, vomiting, flatulence
vomiting brings relief
reduced nutrition
loss of weight

6. Symptoms of duodenal ulcer disease:
epigastric pain 2 hours after meal or on a empty stomach or during night
pyrosis
good nutrition
obstipation
seasonal dependence (spring, autumn)

7. Complications: Bleeding - chronic (minor, cause anaemia)
- acute (major, form affected vessel)
Perforation - mostly bulbus duodeni, anterior gastric wall
- acute violent pain
- bleeding can be present
Penetration - of the ulcer deeply through whole wall into
neighbor organ (pancreas, liver)
Stenosis - narrow of the lumen caused by scar, oedema or
inflammatory infiltration after healing of the ulcer
- rise only at pyloric localization
- vomiting of huge volume of gastric content

8. A – penetration B – perforation C – bleeding D - stenosis
Zeman, M. et al., Speciální chirurgie, ISBN , 2004
A – penetration B – perforation
C – bleeding D - stenosis

9. Therapy: Conservative Surgical regular lifestyle
prohibition of the smoking and alcohol
diet (proteins, milk and milky products)
pharmacology (antagonists of H2 receptors, antacids, anticholinergics
Surgical
BI, BII resection
proximal selective vagotomy
vagotomy with pyloroplastic
suture of perforated or haemorrhagic ulcer

10. Stomach resections:
Billroth I (BI) – gastro-duodenoanastomosis end-to-end
Billroth II (BII) – gastro-jejunoanastomosis end-to-side with blind closure of duodenum
Proximal selective vagotomy – denervation of parietal gastric cells

11. Zeman, M. et al., Speciální chirurgie, ISBN 80-7262-260-9, 2004
Billroth I

12. Zeman, M. et al., Speciální chirurgie, ISBN 80-7262-260-9, 2004
Billroth II

13. Gastro-enteroanastomosis on Roux Y crankle
Zeman, M. et al., Speciální chirurgie, ISBN , 2004
Gastro-enteroanastomosis on Roux Y crankle

14. Zeman, M. et al., Speciální chirurgie, ISBN 80-7262-260-9, 2004
Vagotomy

15. Complications after stomach resection:
Early – dehiscence, stenosis of anastomosis, bleeding, pancreatitis, obstructive icterus, affection of neighbour tissues
Late - days, weeks
- early dumping syndrome
- late dumping syndrome
- incoming crankle syndrome
- outcoming crankle syndrome
- ulcer in anastomosis or in outcoming crankle

16. Early dumping syndrome:
group of symptoms approved shortly after meal
appears after BII resection
vasomotoric sy. - face redness, fall of blood pressure, dizziness
GI sy. - vomiting, diarrhoea
Th.: diet, no sugar, low quantities of food, change BII to BI resection

17. Late dumping syndrome:
hypoglycaemia (sugar is not enough digested)
appears after BII resection
weakness, perspiration, dizziness, tremor cca 3h after meal
Th.: no sugar, change BII to BI resection

18. Incoming crankle syndrome:
stasis of the content at incoming crankle increase intraluminal pressure
appears after BII resection
Th.: diet, change BII to BI resection

19. Outcoming crankle syndrome:
chronic or acute closure of outcoming crankle
appears after BII resection
vomiting after meal, convulsive pain
Th.: change BII to BI resection

25. Haemorrhagic mediogastric ulcer

27. Chronic gastric ulcer

34. Pylorostenosis and gastrectasia

35. Duodenal ulcer

36. Stress ulcers

38. Benign stomach tumors rise from all layers of stomach wall
often asymptomatic
Polypus, Leiomyoma, Lipoma, Fibroma, Neurofibroma, Neurinoma, Hemangioma, Karcinoids, Lymfoma
Diagnostic: endoscopy, X – ray
Therapy: local excision, stomach resection

39. Stomach cancer Symptoms: Diagnosis: long-time asymptomatic
feeling of full stomach, odour from mouth, tiredness, anaemia, occasional vomiting, loss of appetite, loss of weight
Diagnosis:
gastrofibroscopy – biopsy - histology
X-ray, USG, CT - metastasis
Wirchow´s nodule – enlargement of left supraclavicular nodule

40. Stomach cancer Etiopathogenesis: Division:
Praecancerosis: adenomatous polypus, chronic atrofic gastritis, foveolar hyperplasia (Ménétrier disease), stub of the stomach after BII resection
Division:
Macroscopic: exofytic polypoid form, diskyform ulcerous form, diffused infiltrating form
Histopathologic: adenocarcinoma, papilar, tubular, gelatinous cancer, round cell cancer, flagstone cell cancer, etc.

41. Stomach cancer Therapy:
Zeman, M. et al., Speciální chirurgie, ISBN , 2004
Therapy:
Currative – total gastrectomy, sub-total gastrectomy
Paliative – gastrostomy, jejunostomy

49. Gastric cancer

50. Gastric stub cancer after B II resection

52. Schwanoma fundi vetriculi

56. Than you for your attention!!!