PEPTIC+ULCERATION

PEPTIC PEPTIC ULCERATIONULCERATION

OTJE HUDAJAOTJE HUDAJA

20072007

FK UKMFK UKM

PEPTIC ULCERATIONPEPTIC ULCERATION THIS OCCURS ANYWHERE WHERE THIS OCCURS ANYWHERE WHERE

PEPSIN AND ACID OCCUR TOGETHERPEPSIN AND ACID OCCUR TOGETHER CAUSED BY AN IMBALANCE BETWEEN CAUSED BY AN IMBALANCE BETWEEN

SECRETION OF ACID AND PEPSIN AND SECRETION OF ACID AND PEPSIN AND MUCOSAL DEFENCE MECHANISMMUCOSAL DEFENCE MECHANISM

NO ACID, NO ULCERNO ACID, NO ULCER OVERSECRETION OF ACID IS ASSOCIATED OVERSECRETION OF ACID IS ASSOCIATED

WITH DUODENAL ULCERATIONWITH DUODENAL ULCERATION BREAKDOWN OF THE MUCOSAL BREAKDOWN OF THE MUCOSAL

DEFENCES OCCURS IN GASTRIC DEFENCES OCCURS IN GASTRIC ULCERATIONULCERATION

EXACERBATING EXACERBATING FACTORSFACTORS

STRESSSTRESS SMOKINGSMOKING ALCOHOLALCOHOL NSAIDsNSAIDs STEROIDSSTEROIDS HYPERPARATHYROIDISMHYPERPARATHYROIDISM ZOLLINGER-ELLISON SYNDROMZOLLINGER-ELLISON SYNDROM

EXACERBATING EXACERBATING FACTORSFACTORS

INFECTION WITH HELICOBACTER INFECTION WITH HELICOBACTER PYLORI MAY IMPAIR MUCOSAL PYLORI MAY IMPAIR MUCOSAL DEFENCES AND HAS RECENTLY DEFENCES AND HAS RECENTLY BEEN ASSOCIATED WITH BEEN ASSOCIATED WITH DUODENAL ULCER AND DUODENAL ULCER AND GASTRITIS AND TO A LESSER GASTRITIS AND TO A LESSER EXTENT GASTRIC ULCEREXTENT GASTRIC ULCER

SITES OF PEPTIC SITES OF PEPTIC ULCERSULCERS

COMMON SITES OF PEPTIC ULCER ARE COMMON SITES OF PEPTIC ULCER ARE STOMACH AND DUODENUMSTOMACH AND DUODENUM

THE ANTERIOR AND THE POSTERIOR THE ANTERIOR AND THE POSTERIOR WALLS OF THE FIRST PART OF THE WALLS OF THE FIRST PART OF THE DUODENUM AND THE LESSER CURVE OF DUODENUM AND THE LESSER CURVE OF THE STOMACH BEING THE MOST THE STOMACH BEING THE MOST COMMON SITESCOMMON SITES

TYPES ( JOHNSON 1964 ) :TYPES ( JOHNSON 1964 ) :- TYPE I . LESSER SAC- TYPE I . LESSER SAC- TYPE II. 2 SITES : DUODENUM AND - TYPE II. 2 SITES : DUODENUM AND DISTALDISTAL PART OF THE ANGULUSPART OF THE ANGULUS- TYPE III. PRAEPYLORIC- TYPE III. PRAEPYLORIC

SYMPTOMS AND SIGNSSYMPTOMS AND SIGNS

DUODENAL ULCER ( DU )DUODENAL ULCER ( DU ) EPIGASTRIC PAIN. MAY RADIATED TO EPIGASTRIC PAIN. MAY RADIATED TO

THE BACK. RELEAVING BY EATING. THE BACK. RELEAVING BY EATING. WORSE AT NIGHTWORSE AT NIGHT

PERIODIC AND LAST ABOUT 14 DAYS PERIODIC AND LAST ABOUT 14 DAYS AND RECUR AT 3 TO 4 MONTHLY AND RECUR AT 3 TO 4 MONTHLY INTERVALSINTERVALS

IF VOMITING OCCURS, PYLORIC IF VOMITING OCCURS, PYLORIC STENOSIS SHOULD BE SUSPECTEDSTENOSIS SHOULD BE SUSPECTED

REVEAL TENDERNESS IN EPIGASTRIUMREVEAL TENDERNESS IN EPIGASTRIUM


GASTRIC ULCER ( GU )GASTRIC ULCER ( GU ) EPIGASTRIC PAIN. NOT PERIODICEPIGASTRIC PAIN. NOT PERIODIC FOOD MAY PRECIPITATE PAINFOOD MAY PRECIPITATE PAIN PAIN MAY BE RELIEVED BY PAIN MAY BE RELIEVED BY

VOMITINGVOMITING PATIENT MAY BE AFRAID TO EAT PATIENT MAY BE AFRAID TO EAT

AND WEIGHT LOSS RESULTSAND WEIGHT LOSS RESULTS EXAMINATION REVEALS EXAMINATION REVEALS

TENDERNESS IN EPIGASTRIUMTENDERNESS IN EPIGASTRIUM

INVESTIGATIONSINVESTIGATIONS

ENDOSCOPY (OESOPHAGO-GASTRO-ENDOSCOPY (OESOPHAGO-GASTRO-DUODENOSCOPY) AND BIOPSYDUODENOSCOPY) AND BIOPSY

RISK MALIGNANCY WITH GURISK MALIGNANCY WITH GU SEROLOGY FOR H.PYLORISEROLOGY FOR H.PYLORI BARIUM MEAL IS RARELY USED BARIUM MEAL IS RARELY USED

NOWADAYS. NOWADAYS.

HOUR GLASS BY OBSTRUCTION OF HOUR GLASS BY OBSTRUCTION OF THE MIDSTOMACHTHE MIDSTOMACH

TREATMENTSTREATMENTS ANTACIDSANTACIDS PROTON PUMP INHIBITORS (PPI)PROTON PUMP INHIBITORS (PPI) ERADICATION OF H.PYLORIERADICATION OF H.PYLORI TRIPLE THERAPYTRIPLE THERAPY

- PPI (OMEPERAZOLE, - PPI (OMEPERAZOLE, LANSOPERAZOLE)LANSOPERAZOLE)- TWO OF THE FOLLOWING THREE- TWO OF THE FOLLOWING THREE ANTIBIOTICSANTIBIOTICS 1. AMOXYCILLIN1. AMOXYCILLIN

2. CLARITHROMYCIN2. CLARITHROMYCIN3. METRONIDAZOLE3. METRONIDAZOLE

TREATMENTSTREATMENTS

SURGICAL :SURGICAL : FAILED MEDICAL TREATMENTFAILED MEDICAL TREATMENT COMPLICATIONSCOMPLICATIONS

- HEMORRHAGE- HEMORRHAGE

- PERFORATION- PERFORATION

- OBSTRUCTION- OBSTRUCTION

COMPLICATIONSCOMPLICATIONS

HAEMORRHAGEHAEMORRHAGE POSTERIOR DUs ERODE THE POSTERIOR DUs ERODE THE

GASTRODUODENAL ARTERY GASTRODUODENAL ARTERY TREATMENT : TREATMENT : PYLORUS IS OPENED, THE BLEEDING PYLORUS IS OPENED, THE BLEEDING VESSEL IN THE BASE OF THE ULCER IS VESSEL IN THE BASE OF THE ULCER IS OVERSEWN, PYLORUS IS CLOSED AS A OVERSEWN, PYLORUS IS CLOSED AS A PYLOROPLASTY AND VAGOTOMY PYLOROPLASTY AND VAGOTOMY ADDEDADDED

LESSER CURVE GUs ERODE THE LEFT LESSER CURVE GUs ERODE THE LEFT GASTRIC ARTERY. ULCER IS BEST GASTRIC ARTERY. ULCER IS BEST EXCISED (MALIGNACY ?)EXCISED (MALIGNACY ?)


PERFORATIONPERFORATION ANTERIOR DUs AND Gus MAY ANTERIOR DUs AND Gus MAY

PERFORATE CAUSING GENERALIZIED PERFORATE CAUSING GENERALIZIED CHEMICAL PERITONITISCHEMICAL PERITONITIS

SURGERY : EXCISION, SIMPLE SUTURE, SURGERY : EXCISION, SIMPLE SUTURE, OMENTAL PATCHOMENTAL PATCH

PENETERATION ( TO PANCREAS )PENETERATION ( TO PANCREAS )

MALIGNANCYMALIGNANCY


PYLORIC OBSTRUCTIONPYLORIC OBSTRUCTION VOMITING OF LARGE AMOUNTS VOMITING OF LARGE AMOUNTS

OF FOUL-SMELLING VOMIT OF FOUL-SMELLING VOMIT OFTEN CONTAINIG FOOD EATEN OFTEN CONTAINIG FOOD EATEN SEVERAL DAYS PREVIOUSLYSEVERAL DAYS PREVIOUSLY

ERUCTATIONS OF FOUL GASERUCTATIONS OF FOUL GAS SURGERY :SURGERY :

- GASTROJEJUNOSTOMY- GASTROJEJUNOSTOMY- VAGOTOMY- VAGOTOMY

ZOLLINGER-ELLISON ZOLLINGER-ELLISON SYNDROMESYNDROME

PEPTIC ULCER DISEASE CAUSED BY PEPTIC ULCER DISEASE CAUSED BY EXCESSIVE PRODUCTION OF GASTRINEXCESSIVE PRODUCTION OF GASTRIN

ULCERS MAY OCCUR IN UNUSUAL SITES ULCERS MAY OCCUR IN UNUSUAL SITES

e.g. THE THIRD PART OF THE DUODENUMe.g. THE THIRD PART OF THE DUODENUM THERE IS USUALLY A GASTRIN-THERE IS USUALLY A GASTRIN-

SECRETING PANCREATIC TUMOUR SECRETING PANCREATIC TUMOUR (GASTRINOMA). (GASTRINOMA).

- 60% MALIGNANT- 60% MALIGNANT

- 30% ASSOCIATED WITH MULTIPLE- 30% ASSOCIATED WITH MULTIPLE

ENDOCRINE NEOPLASIAENDOCRINE NEOPLASIA


TYPICAL SIGNS AND SYMPTOMS OF TYPICAL SIGNS AND SYMPTOMS OF PEPTIC ULCERPEPTIC ULCER

DIARRHOEA MAY OCCUR FROM DIARRHOEA MAY OCCUR FROM OVERPRODUCTION OF ACIDOVERPRODUCTION OF ACID

BLEEDINGBLEEDING PERFORATIONPERFORATION ULCERS RESISTANT TO MEDICAL ULCERS RESISTANT TO MEDICAL

TREATMENTTREATMENT MAY BE FAMILY HISTORY OF PEPTIC MAY BE FAMILY HISTORY OF PEPTIC

ULCERULCER

INVESTIGATIONS AND INVESTIGATIONS AND TREATMENTTREATMENT

INVESTIGATIONSINVESTIGATIONS

- FASTING SERUM GASTRIN- FASTING SERUM GASTRIN

- CT SCAN- CT SCAN

- ANGIOGRAPHY- ANGIOGRAPHY

TREATMENTTREATMENT

EXCISION OF TUMOUREXCISION OF TUMOUR

GASTRIC SURGERYGASTRIC SURGERY

VAGOTOMYVAGOTOMY TRUNCAL + PYLOROPLASTYTRUNCAL + PYLOROPLASTY

- VAGOTOMY REDUCES ACID- VAGOTOMY REDUCES ACID SECRETION AND GASTRIC SECRETION AND GASTRIC MOTILITYMOTILITY- PYLOROPLASTY - PYLOROPLASTY TO ALLOW GASTRIC DRAINAGE .TO ALLOW GASTRIC DRAINAGE . PYLORUS IS CUT LONGITUDINALLYPYLORUS IS CUT LONGITUDINALLY AND SEWN UP TRANSVERSALLY. AND SEWN UP TRANSVERSALLY.


HIGHLY SELECTIVE VAGOTOMYHIGHLY SELECTIVE VAGOTOMY

THE VAGUS IS SECTIONED SUCH THAT THE VAGUS IS SECTIONED SUCH THAT ONLY THE BODY OF THE STOMACH IS ONLY THE BODY OF THE STOMACH IS DENERVATEDDENERVATED

THE NERVE OF LATARJET TO THE THE NERVE OF LATARJET TO THE ANTRUM LEFT INTACT THUS ANTRUM LEFT INTACT THUS PRESERVING MOTILITY OF THIS PRESERVING MOTILITY OF THIS REGION AND ALLOWING STOMACH REGION AND ALLOWING STOMACH EMPTY WITHOUT NEED FOR AEMPTY WITHOUT NEED FOR A

PYLOROPLASTYPYLOROPLASTY

GASTRIC SURGERYGASTRIC SURGERY GASTROENTEROSTOMYGASTROENTEROSTOMY

THE MOST DEPENDENT PART OF THE THE MOST DEPENDENT PART OF THE STOMACH IS ANASTOMOSED TO A STOMACH IS ANASTOMOSED TO A LOOP OF JEJUNUMLOOP OF JEJUNUMTHIS DIVERTS ACID AWAY FROM THE THIS DIVERTS ACID AWAY FROM THE DUODENUM AND ALLOWS THE ULCER DUODENUM AND ALLOWS THE ULCER TO HEALTO HEALVAGOTOMY IS CARRIED OUT TO VAGOTOMY IS CARRIED OUT TO REDUCE ACID AND THUS PREVENT REDUCE ACID AND THUS PREVENT STOMAL ULCERATIONSTOMAL ULCERATION


GASTRECTOMY ( PARTIAL OR TOTAL )GASTRECTOMY ( PARTIAL OR TOTAL ) BILLROTH I BILLROTH I

(GASTRODUODENOSTOMY)(GASTRODUODENOSTOMY) BILLROTH II (POLYA GASTRECTOMY)BILLROTH II (POLYA GASTRECTOMY)

OVERSEWN THE DUODENAL STUMP OVERSEWN THE DUODENAL STUMP AND THE CONTINUITY RE-AND THE CONTINUITY RE-ESTABLISHED BY ESTABLISHED BY GASTROJEJUNOSTOMYGASTROJEJUNOSTOMY

ENTEROENTEROSTOMY (BRAUN)ENTEROENTEROSTOMY (BRAUN)


BILLTOTH II + ROUX-EN-Y BILLTOTH II + ROUX-EN-Y ANASTOMOSISANASTOMOSIS

- GASTROJEJUNOSTOMY- GASTROJEJUNOSTOMY

- AFFERENT LOOP IS DETACHED AND- AFFERENT LOOP IS DETACHED AND

REANASTOMOSED LOWER DOWN REANASTOMOSED LOWER DOWN THETHE

JEJUNUMJEJUNUM

BILE ENTERS THE GI TRACT LOWER BILE ENTERS THE GI TRACT LOWER DOWN IN THE JEJUNUM DOWN IN THE JEJUNUM

COMPLICATIONS OF COMPLICATIONS OF SURGERYSURGERY

BILIOUS VOMITINGBILIOUS VOMITING

SUDDEN EMPTYING OF THE SUDDEN EMPTYING OF THE AFFERENT LOOP WITH B IIAFFERENT LOOP WITH B II

ASSOCIATED BILIARY GASTRITISASSOCIATED BILIARY GASTRITIS

MAY RESPOND TO MAY RESPOND TO METOCLOPRAMIDEMETOCLOPRAMIDE

SEVERAL CASES NEED ROUX-EN-Y SEVERAL CASES NEED ROUX-EN-Y ANASTOMOSISANASTOMOSIS

COMPLICATIONSCOMPLICATIONS EARLY DUMPING SYNDROMEEARLY DUMPING SYNDROME

- FAINTING, SWEATING AND DIZZINESS SHORTLY- FAINTING, SWEATING AND DIZZINESS SHORTLY AFTER EATINGAFTER EATING- MAY BE REFLEX CAUSED BY OSMOTIC EFFECT OF- MAY BE REFLEX CAUSED BY OSMOTIC EFFECT OF LARGE VOLUMES OF FOOD ‘DUMPED’ INTO THELARGE VOLUMES OF FOOD ‘DUMPED’ INTO THE JEJUNUMJEJUNUM- PATIENT MAY NEED TO LIE DOWN AND REST FOR- PATIENT MAY NEED TO LIE DOWN AND REST FOR AN HOURAN HOUR- SYMPTOMS MAY BE IMPROVED BY EATING SMALL- SYMPTOMS MAY BE IMPROVED BY EATING SMALL DRY MEALS FREQUENTLY AND VOIDING HEAVYDRY MEALS FREQUENTLY AND VOIDING HEAVY CARBOHYDRATE MEALSCARBOHYDRATE MEALS- MAY SUBSIDE SPONTANEOUSLY WITH TIME- MAY SUBSIDE SPONTANEOUSLY WITH TIME


LATE DUMPING SYNDROMELATE DUMPING SYNDROME

DUE TO HYPOGLYCAEMIA AND DUE TO HYPOGLYCAEMIA AND OCCURS 1½ - 3 HOURS AFTER A OCCURS 1½ - 3 HOURS AFTER A MEALMEAL

RESPONDS TO GLUCOSE RESPONDS TO GLUCOSE (SUCKING BARLEY SUGAR)(SUCKING BARLEY SUGAR)

COMPLICATIONSCOMPLICATIONS DIARRHOEA. AFTER VAGOTOMYDIARRHOEA. AFTER VAGOTOMY WEIGHT LOSS. MAY BE DUE TO REDUCED WEIGHT LOSS. MAY BE DUE TO REDUCED

CALORIC INTAKE OR POOR ABSORPTIONCALORIC INTAKE OR POOR ABSORPTION EPIGASTRIC FULLNESSEPIGASTRIC FULLNESS STEATORRHOEASTEATORRHOEA

DUE TU POOR MIXING OF FOOD AND DUE TU POOR MIXING OF FOOD AND ENZYMES, BLIND LOOP SYNDROMEENZYMES, BLIND LOOP SYNDROME

ANAEMIA DUE TO REDUCED ANAEMIA DUE TO REDUCED HYDROCHLORIC ACID WHICH IS HYDROCHLORIC ACID WHICH IS REQUIRED FOR IRON ABSORPTIONREQUIRED FOR IRON ABSORPTION

BOLUS OBSTRUCTION, CARCINOMA BOLUS OBSTRUCTION, CARCINOMA (RARE)(RARE)

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PEPTIC+ULCERATION