Systemic Surgery Eindra
PEPTIC ULCER
DEFINITION
Ulceration in any part of GI tract due to acid-pepsin digestion
PATHOLOGY
Sites
1. Duodenum ( 1st inch of 1st pat of duodenum )
2. Stomach , usually antrum ( lesser curvature, prepyloric ulcer )
3. Gastro-esophageal junction ( in GERD )
4. Stomal ulcer ( in Gastrojejunostomy )
5. Duodenum, stomach & jejunum ( in Zollinger- Ellison $ )
6. Within or adjacent to Meckel’s diverticulum
Aetiology
1. Infection
H.pylori infection ( 90% of DU ) ( 75% of GU )
2. Drugs
Asprin & NSAIDs – chemical ulcerogen by inhibiting mucosal Pg synthesis
Corticosteroids – in high dose & repeated use – promote ulcer formation
3. Life-style
Smoking – impaired mucosal blood flow & healing
Alcohol – social & physical stress
4. Endocrine diseases
Zollinger-Ellison $
Cushing’s $
Hyperparathyroidism ( hypercalcemia gastrin acid secretion )
5. Blood Group
Blood group O
Pathology of DU
Site – commonest 1st inch of 1st part of duodenum
Anterior ulcer tend to perforate
Posterior ulcer tend to penetrate bleeding
Chronic fibrosis GOO
No malignant change
Pathology of GU
Site – Lesser curvature ( Junction of antrum & body )
Chronic deformity ( hour-glass OR teapot )
May perforate & penetrate ( bleeding )
associated malignant change
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Systemic Surgery Eindra
CLINICAL FEATURES
Symptoms
GU DU
1. Abdominal Pain
Character acute epigastric pain acute epigastric pain
Aggrevating food-induced Hunger pain/ Nocturnal
Relieving
induced vomiting food & antacids
Periodicity
less common
2. Vomiting + +
3. Appetite decrease increase
4. Body weight wt loss wt gain
Signs
epigastric tenderness (+)
INVESTIGATIONS
1. OGDS
1st line of Invx
Advantages – direct visualization, biopsy taking , H.pylori status
For DU
No need to take biopsy from ulcer ( always benign )
Biopsy from antrum for establishing H.pylori status
For GU
Multiple biopises to exclude biopsy
2. Barium Meal X-ray
DU deformed duodenal cap ( Spade-shape OR trifoliate deformity )
GU Ulcer crater, ulcer niche & notch , mostly on lesser curvature
3. H.pylori detection tests
CLO test
Urea breath test
Rapid urease test
Culture of antral biopsy
TREATMENT
General
Stop smoking, avoid NSAID, reduce stress
Specific
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Systemic Surgery Eindra
1. Medical Tx
a) For Reducing acid
Neutralization Antacids
Anti-secretory PPI ( eg: Omeprazole, Lanzoprazole, Pantoprazole) , H2 blocker
(eg: Ranitidine, Cimetidine )
b) For increasing mucosal defense
Sucralfate, Bismuth,Misoprostol
c) For H.pylori eradication
( PPI + Clarithromycin + Amoxicillin OR metronidazole ) x 7days
2. Surgical Tx
Indications for Sx
Em Perforation & Bleeding
Elective GOO, Chronicity
Operations for DU
a) Vagotomy
Double Truncal Vagotomy + Drainage ( Pyroloplasty or GJ )
Highly selective Vagotomy
b) Gastrectomy
Billroth I operation ( PG + GD )
Billroth II operaition ( PG + GJ )
Operations for GU
Standard Treatment – Billroth I gastrectomy
Distal gastric resection & ulcer
Restoration of intestinal continuity by Gastroduodenostomy
