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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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