PEPTIC ULCER DISEASE

(Acid – pepsin ulcer disease)

G JUMBI
 SURGICAL ANATOMY
• ANATOMY (Stomach and duodenum)
-gross anatomy.
- Microscopic anatomy.
- Blood supply.
- Nerve supply.
 PHYSIOLOGY
GASTRIC SECTRETIONS.
• THE PARIETAL CELLS (Acid secretion).
( The proton pump).
• THE CHIEF CELLS (Pepsinogens secretion).
• THE ENDOCRINE CELLS (Hormones
secretions). Eg.
- The G-cells (secretes gastrin hormone) .
- The D-cells (secretes somatostatin hormone).
- The ECL-cells eg. Histamine producing cells.
• THE MUCOUS SECRETING CELLS.
(COLUMNAR CELLS).
 CONTROL OF GASTRIC
SECRETIONS.
• CEPHALIC PHASE (Vagal phase).

• GASTRIC PHASE (hormonal phase).

Stimulatory hormones.
Inhibitory hornones.

• DUODENAL (INTESTINAL PHASE).

Stimulatory hormones.
Inhibitory hormones.
 PATHOPHYSIOLOGY
(Disorders of control of gastric
•
secretion)
EXCESSIVE ACID/PEPSIN SECRETION
(Duodenal ulcers).
• LACK OF MUCOUS PROTECTION.
(Gastric ulcers).
• “12 HOUR OVERNIGHT ACID SECRETION
TEST”.
Normal = 10-20 meq/L.
High acid output = 40-80 meq/L.
Low acid output = 5-15 meq/L.
Very high acid output = 100-300 meq/L.
 PATHOLOGY
• EPIDEMIOLOGY.
Incidence, Age, Sex, Race, Geographical,
Social class etc.
• AETIOLOGY.
H. pylori, NSAIDs, Alcohol, Smoking, Diet,
Genetic factors (eg.blood group O),
Predisposing conditions, Psychosomatic.
• HELICOBACTER PYLORI.
DIAGNOSIS - Urease breadth test,
Brush cytology, Biopsy.
 PATHOLOGY cont.
• MACROSCOPIC APPEARANCE……CONT.
ACUTE ULCERS VS. CHRONIC ULCERS.
SITE, SIZE, SHAPE, EDGES, FLOOR, BASE
CONSISTENCE, SURROUNDINGS.
• MICROSCOPIC APPEARANCE.
ACUTE ULCERS VS. CHRONIC ULCERS.
DEPTH. INFLAMMATORY REACTION. FIBROSIS.
• COMPLICATIONS OF PUD.
ACUTE VS. CHRONIC.
HAEMORRHAGE,
PERFORATION & PENETRATION.
STENOSIS: (OESOPHAGEAL STRICTURE, PYLORIC
STENOSIS, HOUR-GLASS DEFORMITY,TEA-POT
DEFORMITY).
 CLASSIFICATION OF PUD.
• 1. ACUTE PEPTIC ULCERS.
NSAIDs, Alcohol, Acute illnesses.
Superficial. Generalised in location. Small.
• 2. CHRONIC PEPTIC ULCERS.
- Duodenal ulcers. Bulbar, post bulbar
- Gastric ulcers. TYPES I, II, III, IV.
- Anastomotic (jejunal ulcers).
- Oesophageal ulcers.
- Meckel’s.
Deeper. Ocurrs in Specific locations. Larger.
 COMPLICATIONS OF PUD
• HAEMORRAGE.
• Acute ulcers, Chronic ulcers, Penetration.
• PERFORATION.
• Acute, Chronic ulcers, Penetration.
• STENOSIS.
• Pyloric stenosis,
• Hour - glass deformity,
• Tea - pot deformity,
• Oesophageal stricture.
 MANAGEMENT OF PUD

OUTLINE OF MANAGEMENT:
• Hx.
• P/E.
• INVESTIGATIONS.
• TREATMENT
• SUPORTIVE (COMPLICATED ULCERS).
• DEFINITIVE (MEDICAL, SURGICAL).
• COPLICATIONS OF TREATMENT.
• PROGNOSIS.
• FOLLOW UP.
• PREVENTION.
 Mx. CONT.
DIFFERENTIAL DIGNOSIS
• UPPER ABDOMINAL PAIN.
• COMPLICATED ULCERS.
• HAEMORRHAGE.
• ACUTE PERFORATION.
• PYLORIC STENOSIS.
 INVESTIGATIONS
• STOOL - OCCULT BLOOD.
• BARIUM MEAL.
• UPPER GIT. ENDOSCOPY.
• GASTRIN ASSAY.
• COMPLICATED PUD
• PERFORATION – CXR(erect), ABD.(supine de.).
• HAEMORRAGE – EMERGENCY OGD.
EMERGENCY ANGIOGRAPHY.
EMERGENCY RADIO-ISOTOPE SCAN
 TREATMENT OF PUD
SUPPORTIVE TREATMENT
(Complicated PUD).
• HAMORRHAGE.

• PERFORATION.

• PYLORIC STENOSIS.

DEFINITIVE TREATMENT.

• MEDICAL TREATMENT.

• SURGICAL TREATMENT.
 DEFINITIVE TREATMENT.
MEDICAL TREATMENT (TRIPPLERx.)
CLARITHROMYCIN.
PPI OR H2RA.

AMOXICILLIN OR A NITROIMIDAZOLE .

SURGICAL TREATMENT
See below
 SURGICAL MANAGEMENT
• PRE-OPERATIVE MANAGEMENT.
See below
• INTRAOPERATIVE MANAGEMENT.
See below
• POST-OPERATIVE MANAGEMENT.
See below
 PRE-OPERATIVE
MANAGEMENT
• Investigations.
• Supportive treatment.
• Psychological preparation.
• Preparation of local site of operation.
• Evaluation for anaesthesia.
• Informed consent.
• Premedication.
 SURGICAL TREATMENT
INTRA-OPERATIVE TREATMENT
1. OPERATIONS FOR UNCOMPLICATED ULCERS.
DUODENAL ULCERS – HSV, V&D (SV OR TV)
GASTRIC ULCERS - PG (BILROTH I OR II) OR V&D.
2. OPERATIONS FOR COMPLICATED ULCERS
BLEEDING ULCERS – HAEMOSTASIS + MED. Mx.
PERFORATED ULCERS – CLOSURE OF
PERFORATION + MED.Mx.
OPERATIONS FOR STENOSIS.
PYLORIC STENOSIS – V&D (GASTRO-JEJUNOSTOMY).
HOUR-GLASS DEFORMITY – PG.
TEA-POT DEFORMITY – V&D (GASTRO-JEJUNOSTOMY).
 COMPLICATIONS OF
TREATMENT
COMPLICATIONS OF VAGOTOMY.
• POST-VAGOTOMY DIARRHOEA.
• DELAYED GASTRIC EMPTYING.
• “SMALL STOMACH SYNDROME”.
• EARLY DUMPING SYNDROME
• GALLSTONES (Truncal Vagotomy).
COMPLICATIONS OF GASTRECTOMY.
• DUMPING SYNs (BOTH EARLY & LATE).
• BILIOUS VOMITTING (AFFERENT LOOP SYN)
• SMALL STOMACH SYN.
• NUTRITIONAL DEFFICIENCIES (WT. LOSS, Fe, VIT B12,
OSTEOPOROSIS).
• GASTRIC STUMP MALIGNANCY.