MANAGEMENT OF PEPTIC ULCERAND

ITS PEFORATION

DEFINITION

A circumscribed ulceration of the gastrointestinal mucosa occurring in areas exposed to acid and pepsin and most often caused by Helicobacter pylori infection.

Classification BY REGION / LOCATION

Stomach (called gastric ulcer) Duodenum (called duodenal

ulcer) Esophagus (called Esophageal

ulcer) Meckel's Diverticulum (called

Meckel's Diverticulum ulcer)

Modified Johnson Classification of peptic ulcers

Type I: Ulcer along the lesser curve of stomach

Type II: Two ulcers present - one gastric, one duodenal/prepyloric

Type III: Prepyloric ulcer Type IV: Proximal gastroesophageal

ulcer Type V: Anywhere

Duodenal Ulcers duodenal sites are 4x as common as gastric

sites most common in middle age

peak 30-50 years Male to female ratio—4:1 Genetic link: 3x more common in 1st degree

relatives more common in patients with blood group O associated with increased serum pepsinogen H. pylori infection common

up to 95% smoking is twice as common

Gastric Ulcers

common in late middle age incidence increases with age

Male to female ratio—2:1 More common in patients with blood group

A Use of NSAIDs - associated with a three- to

four-fold increase in risk of gastric ulcer Less related to H. pylori than duodenal

ulcers – about 80% 10 - 20% of patients with a gastric ulcer

have a concomitant duodenal ulcer

Comparing Duodenal and Gastric Ulcers

When an imbalance occurs, PUD might develop.

predisposing factors • H pylori• NSAIDs • acid• pepsin. • smoking,• ethanol, • bile acids,• aspirin,• steroids• stress.

protective factors • mucus• bicarbonate• mucosal blood flow• prostaglandins

Etiology

SYMPTOMS

PAIN NAUSEA, VOMITING CHEST DISCOMFORT HEMATEMESIS MELENA

Complications

Perforation & Penetration—into pancreas, liver and retroperitoneal space

Peritonitis Bowel obstruction, Gastric outflow

obstruction, & Pyloric stenosis Bleeding--occurs in 25% to 33% of

cases and accounts for 25% of ulcer deaths.

Gastric CA

Differential Diagnosis

Neoplasm of the stomach Pancreatitis Pancreatic cancer Diverticulitis Cholecystitis Gastritis GERD MI—not to be missed if having chest pain

INVESTIGATIONS

1. BASE LINE INVESTIGATIONS2. H. Pylori can be diagnosed urea breath test blood test(Ig-G) stool antigen assays rapid urease test3. GASTRO-DUODENOSCOPY WITH BIOPSY

4. Stool for fecal occult blood.5. RADIOGRAPHY WITH BARIUM MEAL

Preferred diagnostic test b/c its highly sensitive for dx of ulcers and allows for biopsy to rule out malignancy and rapid urease tests for

testing for H. Pylori.

Peptic Ulcers: Gastric & Dudodenal

MEDICAL TREATMENT

AIMS OF MEDICAL TREATMENT

1.TO RELEIVE THE SYMPTOMS

2.TO HEAL THE ULCER3.TO PREVENT RECURRENCE4.TO PREVENT THE

COMPLICATIONS

GENERAL MEASURESSTOP SMOKINGSTRESS REDUCTIONDIETARY CHANGEAVOID ASPRIN STERIODS NSAIDS ALCOHOL

DRUGSH-2 RECEPTOR ANTAGONSISTSPROTON PUMP INHIBITORSANTACIDSERADICATION THREAPY FOR H.PYORI

INDICATIONS OF SURGICAL TREATMENT

IF MEDICAL TREATMENT FAILS ANY DOUBT ABOUT HISTOLOGY ULCER IN ANTRUM AND PREPYLORIC

R. COMPLICATION

PYLORIC STENOSISHOURGLASS DEFORMITYPERFORATIONBLEEDING

SURGERY

SURGICAL TREATMENT OF UNCOMPLICATED PEPTIC ULCER

1. BILLROTH I GASTRECTOMY2. BILLROTH II GASTRECTOMY3. VAGOTOMY

1. TRUNCAL VAGOTOMY2. HIGHLY SELECTIVE VAGOTOMY

4. DRAINAGE PROCEDURE

1. GASTRO JEJUNOSTOMY2. PYLOROPLASTY3. ANTRECTOMY

BILLROTH GASTRECTOMY

SURGICAL TREATMENT OF UNCOMPLICATED PEPTIC ULCER

1. BILLROTH I GASTRECTOMY2. BILLROTH II GASTRECTOMY3. VAGOTOMY

1. TRUNCAL VAGOTOMY2. HIGHLY SELECTIVE VAGOTOMY

4. DRAINAGE PROCEDURE

1. GASTRO JEJUNOSTOMY2. PYLOROPLASTY3. ANTRECTOMY

VAGOTOMY

SURGICAL TREATMENT OF UNCOMPLICATED PEPTIC ULCER

1. BILLROTH I GASTRECTOMY2. BILLROTH II GASTRECTOMY3. VAGOTOMY

1. TRUNCAL VAGOTOMY2. HIGHLY SELECTIVE VAGOTOMY

4. DRAINAGE PROCEDURE

1. GASTRO JEJUNOSTOMY2. PYLOROPLASTY3. ANTRECTOMY

GASTROENTEROSTOMY

SURGICAL TREATMENT OF UNCOMPLICATED PEPTIC ULCER

1. BILLROTH I GASTRECTOMY2. BILLROTH II GASTRECTOMY3. VAGOTOMY

1. TRUNCAL VAGOTOMY2. HIGHLY SELECTIVE VAGOTOMY

4. DRAINAGE PROCEDURE

1. GASTRO JEJUNOSTOMY2. PYLOROPLASTY(mikulicz & finny)3. ANTRECTOMY

PYLOROPLASTY

SURGICAL TREATMENT OF UNCOMPLICATED PEPTIC ULCER

1. BILLROTH I GASTRECTOMY2. BILLROTH II GASTRECTOMY3. VAGOTOMY

1. TRUNCAL VAGOTOMY2. HIGHLY SELECTIVE VAGOTOMY

4. DRAINAGE PROCEDURE

1. GASTRO JEJUNOSTOMY2. PYLOROPLASTY3. ANTRECTOMY

ANTRECTOMY

PERFORATED GASTRIC ULCER

CLINICAL FETURES SYMPTOMS

SEVERE GENERLIZED ABDOMINAL PAIN ABDOMINAL DISTENSION VOMETING

SIGNS FEEBLE PULSE GENERLIZED TENDERNESS BOARD LIKE RIGIDITY REDUCED LIVER DULLNESS

INVESTIGATIONS RADIOGRAPHY DIAGNOSTIC PERITONEAL

LAVAGE SERUM AMYLASE CT-SCAN

TREATMENT

A ASPIRATION B BLOOD GROUPING C CHARTS D DRUGS E EXPLORATIVE LAPROTOMY F FLUID