Peptic ulcer

Benign Gastric and Duodenal Ulcers

Dr.Sujith Mathew JosePG in General Surgery

Coimbatore Medical College Coimbatore

Anatomy of GI Tract

Peptic Ulcers• Defined

– Ulcerated lesion in the mucosa of the stomach or duodenum

• Types

GastricDuodenal

Gastric and Duodenal Ulcers

Gastric Ulcers

• Due to the imbalance between protective and damaging factors of Gastric Mucosa

Stomach Defense Systems

• Mucous layer– Coats and lines the stomach– First line of defense

• Bicarbonate– Neutralizes acid

• Prostaglandins– Hormone-like substances that keep blood vessels

dilated for good blood flow– Thought to stimulate mucus and bicarbonate

production

CAUSES of GASTRIC ULCER

Atropic GastritisDuodenogastric bile refluxGastric StasisSmokingNSAIDSSteroidsHELICOBACTER PYLORI (70%)Lower Socioeconomic group

Benign Gastric Ulcer

MUCOSAL FOLDS

Converging folds

SITE 95% in Lesser curvature

Margin Regular

Floor Granulation tissue in floor

Edges NOT everted ,punched

Surrounding Area

Normal

Size and Extent

Small deep up to muscle layer

Malignant Gastric Ulcer

MUCOSAL FOLDS

Effacing Mucosal folds

SITE Greater curvature

Margin Irregular margin

Floor Necrotic Slough in the floor

Edges Everted Edges

Surrounding Area

Shows nodules, ulcers and irregularities

Size and Extent

Large and Deep

Types of Gastric Ulcer Type Iin the andrum, near lesser curvature

Type IICombined gastric and duodenal ulcer

Type IIIPrepyloric

Type IVUlcer in the proximal stomach and Cardia

55% 25%

15% 5%

Gastric Ulcers

• Pain occurs 1-2 hours after meals• Pain usually does not wake patient• Accentuated by ingestion of food• Risk for malignancy• Deep and penetrating and usually

occur on the lesser curvature of the stomach

Gastric ulcer >3cm is called GIANT GASTRIC ULCER

Gastric Ulcers isequal in both sexesaffect older populationless common than duodenal ulcers

Duodenal Ulcers

AetiologyHELICOBACTER PYLORI (90%)NSAIDS, SteroidsZollinger Ellison SyndromeAlcohol, SmokingBlood Group OMEN 1Chronic Pancreatitis

Duodenal Ulcers

• Pain occurs 2-4 hours after meals• Pain wakes up patient• Pain relieved by food• Very little risk for malignancy

• Most Common in first part of duodenum• Chronic Ulcer penetrates the mucosa and

into the muscle coat, leading to fibrosis• Fibrosis ------- Pyloric Stenosis

ANTERIOR ULCER ---- PERFORATE

POSTERIOR ULCER ---- BLEEDS

GASTRIC ULCER erode LEFT GASTRIC VESSELS and SPLENIC VESSELS

DUODENAL ULCER erodes GASTRODUODENAL artery

• Microscopically,Duodenal Ulcer shows,Destruction of Muscular

CoatBase of ulcer with

Granulation TissueArteries in the region

shows ENDARTERITIS OBLITERANS

General Peptic Ulcer Symptoms

PAIN Epigastric ---- Radiating to Back

Periodicity Due to spontaneous Healing of ulcer

Vomiting Present when stenosis occurs

Weight Alteration Gastric loss Duodenal -> Gain

Bleeding May present as anemia

Clinical FeaturesGASTRIC ULCER DUODENAL ULCER

Pain after food Intake Pain before food intake

Periodicity less Common Periodicity more Common

Weight loss +++ Weight Gain+++

Male = Female Male > Female

Hemetemesis more Malena more

INVESTIGATIONS

• Esophagogastrodeodenoscopy (EGD)

• Upper gastrointestinal series (UGI) (Barium swallow)

• Urea Breath Testing

• USG

GASTRODUODENOSCOPY

– Endoscopic procedure

– Visualizes ulcer crater

– Ability to take tissue biopsy to R/O cancer and diagnose H. pylori

It is fundamental that any gastric ulcer should be regarded as being Malignant, no matter how classically it resemble a benign gastric ulcer

Multiple biopsies should be taken, as many as 10 well targeted biopsies

Biopsy can be taken to look for the presence of

Helicobacter Pylori

Rapid Urease TestC13 or C14 breath test

– Client drinks a carbon-enriched urea solution

– Excreted carbon dioxide is then measured

Faecal Antigen Test

BARIUM MEAL X Ray of Benign Gastric Ulcer

• Outpouching of ulcer crater beyond the gastric contour (exoluminal)

HAMPTOMs LINE

• Overhanging mucosa at the margins of a benign gastric ulcer, project inwards towards the ulcer

HAMPTOMs LINE

• Regular/ Round Margin of the Ulcer CraterSTOMACH SPOKE WHEEL PATTERN

• Converging mucosal folds towards the base of ulcer

Complications of Peptic Ulcers

• Hemorrhage– Blood vessels damaged as ulcer erodes into the

muscles of stomach or duodenal wall– Coffee ground vomitus or occult blood in tarry stools

• Perforation– An ulcer can erode through the entire wall– Bacteria and partially digested fool spill into

peritoneum=peritonitis• Narrowing and obstruction (pyloric)

– Swelling and scarring can cause obstruction of food leaving stomach=repeated vomiting

Medical Management

• Provide pain relief– Antacids and mucosa protectors

• Eradicate H. pylori infection– Two antibiotics and one acid suppressor

• Heal ulcer– Eradicate infection– Protect until ulcer heals

• Prevent recurrence– Decrease high acid stimulating foods in susceptible people– Avoid use of potential ulcer causing drugs– Stop smoking

AIM

Anti H Pylori Regimen

Hyposecretory Drugs

• Proton Pump Inhibitors– Suppress acid production

• H2-Receptor Antagonists– Block histamine-stimulated gastric secretions

• Antacids– Neutralizes acid and prevents formation of pepsin – Give 2 hours after meals and at bedtime

• Prostaglandin Analogs– Reduce gastric acid and enhances mucosal resistance to injury

• Mucosal barrier fortifiers– Forms a protective coat

• Sucralfate

Surgery

• Greatly decreased from 1960 secondary to the discovery of H. pylori

• Indication for Surgery– PERFORATION

– OBSTRUCTION

– HEMORRHAGE

– NOT RESPONDING TO MEDICAL TREATMENT

Types of Surgical Procedures

2.Gastroenterostomyallows regurgitation of alkaline duodenal contents into the stomach

1.Diversion of Acid Away from the duodenum

3.Reduce the secretory Potential of Stomach

VagotomyTruncal Vagotomy

– Section of the vagus nerve– Reduces the maximal acid

output by app 50%

Selective Vagotomy

dHighly Selective VagotomyFibres supplying the parietal cells are ligated Nerve of Latarjet which supplies andrum is retained So no drainage proceedure is required in HSV preserved

Gastric branches are severedHepatic branches are preserved

Drainage Procedures

• Pyloroplasty

It is a drainage procedure

Longitudnal Sectioning of Pyloric Ring

Incision is closed transversely

Gastrojejunostomy

Alternative Drainage Procedure to Pyloroplasty

Opening the lesser sac and performing anastomosis between the most dependent part of andrum and first jejunal loop.

Types of Surgical Procedures

• Antrectomy– Lower half of stomach (antrum) makes most of the

acid– Removing this portion (antrectomy) decreases acid

production• Subtotal gastrectomy

– Removes ½ to 2/3 of stomach• Remainder must be reattached to the rest of the

bowel– Billroth I– Billroth II

Billroth I Gastrectomy

Distal portion of the stomach is mobilised and resected

The cut edge of the remnant is partially closed from Lesser Curvature aspect

Stoma at greater curvature aspectGastroduodenal anastomosis done

Billroth II Gastrectomy

The lower portion of the stomach is removed and the remainder is anastomosed to the jejunum

Duodenum is closed off by suture of staples

High Operative Mortality and Morbidity

Sequelae of Peptic Ulcer Surgery

• Recurrent Ulceration

• Small Stomach Syndrome

• Bile Vomiting

• Early and Late Dumping

• Post Vagotomy Diarrhoea

• Malignant Transformation

• Nutritional Consequences

• Gall Stones

Dumping Syndrome

EARLY DUMPING• Rapid emptying of hyperosmolar food and fluids

from the stomach into the jejunum• Symptoms

– Weakness– Faintness– Palpatations– Fullness– Discomfort– Nausea– diarrhea

RxDietary manipulationOctreotide before mealsAvoid High Carbohydrate Content

LATE DUMPINGIt is reactive hypoglycemia

CHO load in small bowel ===>rise in blood glucose ===>

Insulin levels to rise ===>Secondary

Hypoglycemia

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