Chief of hospital surgery   Lection for students of 5 course Complications   of  ulcer disease .
Anatomy of the stomach <ul><li>1 — lig. hepatogastricum; 2 — lien; 3 — ventriculus; 4 — lig. gastrocolicum; 5 — duodenum; ...
Anatomy of the stomach 1 — lien; 2 — aa. et vv. gastricae breves; 3 — a. et v. gastrica sinistra; 4 — truncus coeliacus; 5...
Anatomy of the stomach 1 — ventriculus; 2 — a. et v. gastro-epiploica sinistra; 3 — aa. et vv. gastricae breves; 4 — lien;...
Peptic ulcer disease (PUD) <ul><li>is one of the most common diseases affecting the  gastro-intestinal  tract. It causes i...
Pathophysiology   <ul><li>The normal stomach maintains a balance between protective factors   and aggressive factors. Gast...
P rotective factors  of  stomach   <ul><li>mucus  </li></ul><ul><li>bicarbonate secretion </li></ul><ul><li>good  vasculat...
A aggressive factors  of  stomach   <ul><li>Helicobacter pylori infection   </li></ul><ul><li>acid secretion  </li></ul><u...
H. PYLORI <ul><li>Although  H. pylori  is present in the gastroduodenal mucosa in most patients with duodenal ulcers, only...
Main symptoms of ulcerous disease <ul><li>Pain </li></ul><ul><li>Nausea </li></ul><ul><li>Vomiting </li></ul><ul><li>Burni...
Characteristic of pain   <ul><li>Classic gastric ulcer pain is described as pain occurring shortly after meals, for which ...
Endoscopic diagnostic   and differential with cancer <ul><li>Gastric ulcer   </li></ul><ul><li>Gastric  cancer  </li></ul>
Complications   of gastric ulcers   <ul><li>-  perforation ,   </li></ul><ul><li>-  hemorrhage, </li></ul><ul><li>-  and g...
P erforation <ul><li>Classification by clinical futures  </li></ul><ul><li>Typical perforation (free peritoneal perforatio...
P erforation <ul><li>Clinic  </li></ul><ul><li>Acute pain ( « by knife » )  </li></ul><ul><li>Tension of abdomen (how tree...
P erforation <ul><li>Free peritoneal perforation and resulting chemical and bacterial peritonitis is a surgical emergency ...
P erforation <ul><li>Three period of clinic </li></ul><ul><li>Firstly shock (6  hours)  </li></ul><ul><li>Loose safely (6-...
P erforation <ul><li>X-Ray diagnostic  </li></ul><ul><li>Upright or lateral decubitus abdominal radiography or erect chest...
Operative treatment of perforation of ulcer patch of omentum
GASTRIC OUTLET OBSTRUCTION <ul><li>Peptic ulcer disease is the underlying cause in less than 5 to 8 percent of patients pr...
GASTRIC OUTLET OBSTRUCTION <ul><li>Symptoms suggesting obstruction include recurrent episodes of emesis with large volumes...
GASTRIC OUTLET OBSTRUCTION (stenos). Classification  <ul><li>I. Compensation stenos :   episode vomiting, wait barii in st...
GASTRIC OUTLET OBSTRUCTION <ul><li>Treatment of stenos only operative </li></ul><ul><li>Compensation stenos may be use pyl...
BLEEDING <ul><li>Upper gastrointestinal bleeding occurs in 15 to 20 percent of patients with peptic ulcer disease. It is t...
BLEEDING <ul><li>Clinic </li></ul><ul><li>Hematemesis (bright red or &quot;coffee ground&quot;) </li></ul><ul><li>Melena <...
BLEEDING.   Classification.   <ul><li>I. Compensative hemorrhage :  loose of blood to 20% VOL (to 1000 ml), pulse, AP, Hb ...
BLEEDING <ul><li>Patient with stopping  hemorrhage and stable hemostasis treat conservative  </li></ul><ul><li>Patient wit...
BLEEDING <ul><li>Conservative Treatment  </li></ul><ul><li>Eradication of  Helicobacter pylori </li></ul><ul><li>proton pu...
Surgery <ul><li>Duodenal ulcer : truncal vagotomy, selective vagotomy, highly selective vagotomy,  excision of ulcer and p...
Operative treatment of ulcer disease. Method of excision of ulcer and pyloroplastic.
Operative treatment. Method of resection of stomach. resection of stomach by Bilroth-I resection of stomach by Bilroth-II
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Complications of ulcer disease

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Complications of ulcer disease

  1. 1. Chief of hospital surgery Lection for students of 5 course Complications of ulcer disease .
  2. 2. Anatomy of the stomach <ul><li>1 — lig. hepatogastricum; 2 — lien; 3 — ventriculus; 4 — lig. gastrocolicum; 5 — duodenum; 6 —lig. hepatorenale; 7 — foramen epiploicum (Winslovi); 8 — lig. hepatoduodenale; 9 — vesica fellea; 10 — hepar; 11 — lig. teres hepatis. . </li></ul>
  3. 3. Anatomy of the stomach 1 — lien; 2 — aa. et vv. gastricae breves; 3 — a. et v. gastrica sinistra; 4 — truncus coeliacus; 5 — a. lienalis; 6 — a. hepatica communis; 7 — a. et v. gastro-epiploica sinistra; 8 — ventriculus; 9 — omentum majus; 10 — a. et v. gastro-epiploica dextra; 11 — duodenum; 12 — a. et v. gastrica dextra; 13 — a. et v. gastroduodenalis; 14 — ductus choledochus; 15 — v. cava inferior; 16 — v. portae; 17 — a. hepatica propria; 18 — hepar; 19 — vesica fellea.
  4. 4. Anatomy of the stomach 1 — ventriculus; 2 — a. et v. gastro-epiploica sinistra; 3 — aa. et vv. gastricae breves; 4 — lien; 5 — truncus coeliacus; 6 — a. et v. gastrica sinistra; 7 — plica gastropancreatica; 8 — a. lienalis; 9 — a. hepatica communis; 10 — pancreas; 11 — radix mesocolici; 12 — a. et v. colica media; 13—-ren dexter; 14 — duodenum; 15 — a. et v. gastro-epiploica dextra; 16 — a. et v. gastroduodenalis; 17 — v. portae; 18 — a. et v. gastrica dextra; 19 — a. hepatica propria; 20 — hepar; 21 — lig. hepatogas-tricum; 22 — vesica fellea.
  5. 5. Peptic ulcer disease (PUD) <ul><li>is one of the most common diseases affecting the gastro-intestinal tract. It causes inflammatory injuries in the gastric or duodenal mucosa, with extension beyond the submucosa into the muscularis mucosa. </li></ul>
  6. 6. Pathophysiology <ul><li>The normal stomach maintains a balance between protective factors and aggressive factors. Gastric ulcers develop when patients has disbalanse this factors . </li></ul><ul><li>Ulcer of stomach this wickless of protective factors </li></ul><ul><li>Ulcer of duodenal this strong of aggressive factors </li></ul>
  7. 7. P rotective factors of stomach <ul><li>mucus </li></ul><ul><li>bicarbonate secretion </li></ul><ul><li>good vasculature </li></ul><ul><li>food </li></ul>
  8. 8. A aggressive factors of stomach <ul><li>Helicobacter pylori infection </li></ul><ul><li>acid secretion </li></ul><ul><li>p epsin </li></ul><ul><li>microtrauma </li></ul>
  9. 9. H. PYLORI <ul><li>Although H. pylori is present in the gastroduodenal mucosa in most patients with duodenal ulcers, only a minority (10 to 15 percent) of patients with H. pylori infection develop peptic ulcer disease.6 H. pylori bacteria adhere to the gastric mucosa; the presence of an outer inflammatory protein and a functional cytotoxin-associated gene island in the bacterial chromosome increases virulence and probably ulcerogenic potential.7 Patients with H. pylori infection have increased resting and meal-stimulated gastrin levels and decreased gastric mucus production and duodenal mucosal bicarbonate secretion, all of which favor ulcer formation. Eradication of H. pylori greatly reduces the incidence of ulcer recurrence-from 67 to 6 percent in patients with duodenal ulcers and from 59 to 4 percent in patients with gastric ulcers.8 </li></ul>
  10. 10. Main symptoms of ulcerous disease <ul><li>Pain </li></ul><ul><li>Nausea </li></ul><ul><li>Vomiting </li></ul><ul><li>Burning epigastric pain </li></ul><ul><li>Epigastric discomfort </li></ul><ul><li>Loss of appetite </li></ul>
  11. 11. Characteristic of pain <ul><li>Classic gastric ulcer pain is described as pain occurring shortly after meals, for which antacids provide minimal relief. </li></ul><ul><li>The pain from gastric ulcer is typically located in the epigastrium; however, it can also be perceived in the right upper quadrant and elsewhere. </li></ul><ul><li>Duodenal ulcer pain often occurs hours after meals and at night. Pain is characteristically relieved with food or antacids. </li></ul><ul><li>Pain with radiation to the back is suggestive of a posterior penetrating gastric ulcer complicated by pancreatitis </li></ul>
  12. 12. Endoscopic diagnostic and differential with cancer <ul><li>Gastric ulcer </li></ul><ul><li>Gastric cancer </li></ul>
  13. 13. Complications of gastric ulcers <ul><li>- perforation , </li></ul><ul><li>- hemorrhage, </li></ul><ul><li>- and gastric outlet obstruction </li></ul><ul><li>- penetration </li></ul>
  14. 14. P erforation <ul><li>Classification by clinical futures </li></ul><ul><li>Typical perforation (free peritoneal perforation) </li></ul><ul><li>Atypical perforation </li></ul><ul><li>Closed perforation </li></ul>
  15. 15. P erforation <ul><li>Clinic </li></ul><ul><li>Acute pain ( « by knife » ) </li></ul><ul><li>Tension of abdomen (how tree) </li></ul><ul><li>Ulcerous anamnesis </li></ul>
  16. 16. P erforation <ul><li>Free peritoneal perforation and resulting chemical and bacterial peritonitis is a surgical emergency causing sudden, rapidly spreading, severe upper abdominal pain exacerbated by movement; the pain may radiate to the right lower abdomen or to both shoulders. Fever, hypotension, and oliguria suggest sepsis and circulatory compromise. Generalized abdominal tenderness, rebound tenderness, board-like abdominal wall rigidity, and hypoactive bowel sounds (clinical signs of peritonitis) may be masked in older patients and those taking steroids, immunosuppressants, or narcotic analgesics. </li></ul>
  17. 17. P erforation <ul><li>Three period of clinic </li></ul><ul><li>Firstly shock (6 hours) </li></ul><ul><li>Loose safely (6-12 hours) </li></ul><ul><li>Peritonitis (more than 12 hours) </li></ul>
  18. 18. P erforation <ul><li>X-Ray diagnostic </li></ul><ul><li>Upright or lateral decubitus abdominal radiography or erect chest radiography may demonstrate pneumoperitoneum; however, the absence of this finding does not rule out perforation. </li></ul>
  19. 19. Operative treatment of perforation of ulcer patch of omentum
  20. 20. GASTRIC OUTLET OBSTRUCTION <ul><li>Peptic ulcer disease is the underlying cause in less than 5 to 8 percent of patients presenting with gastric outlet obstruction. Patients with recurrent duodenal or pyloric channel ulcers may develop pyloric stenosis as a result of acute inflammation, spasm, edema, or scarring and fibrosis. </li></ul>
  21. 21. GASTRIC OUTLET OBSTRUCTION <ul><li>Symptoms suggesting obstruction include recurrent episodes of emesis with large volumes of vomit containing undigested food; persistent bloating or fullness after eating; and early satiety. Weight loss, dehydration, and a hypochloremic, hypokalemic metabolic alkalosis may result; a tympanitic epigastric mass representing the dilated stomach with visible gastric peristalsis also may be observed. </li></ul>
  22. 22. GASTRIC OUTLET OBSTRUCTION (stenos). Classification <ul><li>I. Compensation stenos : episode vomiting, wait barii in stomach to 6 hours, loose weight to 5 kg. </li></ul><ul><li>II. Subcompensation stenos : everyday vomiting, wait barii in stomach to 12 hours, loose weight to 10 kg, disturbance of waiter-electrolyte balance. </li></ul><ul><li>III. Decompensation stenos : no evacuation from stomach, vomiting after every food, wait bari in stomach more than 24 hours, loose weight more than 10 kg, severe disturbance of waiter-electrolyte balance, tetanus. </li></ul><ul><li>. </li></ul>
  23. 23. GASTRIC OUTLET OBSTRUCTION <ul><li>Treatment of stenos only operative </li></ul><ul><li>Compensation stenos may be use pyloroplastic </li></ul><ul><li>Subcompensation and decompensation stenos resection of stomach ore antrectomy </li></ul>
  24. 24. BLEEDING <ul><li>Upper gastrointestinal bleeding occurs in 15 to 20 percent of patients with peptic ulcer disease. It is the most common cause of death and the most common indication for surgery in the disease. In older persons, 20 percent of bleeding episodes result from asymptomatic ulcers. </li></ul>
  25. 25. BLEEDING <ul><li>Clinic </li></ul><ul><li>Hematemesis (bright red or &quot;coffee ground&quot;) </li></ul><ul><li>Melena </li></ul><ul><li>Fatigue caused by anemia </li></ul><ul><li>Pale </li></ul><ul><li>Tahicardia </li></ul><ul><li>Hypotension </li></ul><ul><li>Orthostatic </li></ul><ul><li>Syncope. </li></ul>
  26. 26. BLEEDING. Classification. <ul><li>I. Compensative hemorrhage : loose of blood to 20% VOL (to 1000 ml), pulse, AP, Hb more be normal. </li></ul><ul><li>II. Subcompensative hemorrhage : loose of blood to 30% VOL (to 1500 ml), pulse – tahicardia to100, AP decrease to 100, Hb decrease 100 g/l, olygurine. </li></ul><ul><li>III. Decompensative hemorrhage : loose of blood more than 30% VOL (more than 1500 ml), pulse – tahicardia to120 and more, AP decrease to 80-70, decrease Hb, olygo-unurine. </li></ul>
  27. 27. BLEEDING <ul><li>Patient with stopping hemorrhage and stable hemostasis treat conservative </li></ul><ul><li>Patient with following hemorrhage and unstable hemostasis and recurrent bleeding treat operative </li></ul>
  28. 28. BLEEDING <ul><li>Conservative Treatment </li></ul><ul><li>Eradication of Helicobacter pylori </li></ul><ul><li>proton pump inhibitor or H2 blocker </li></ul><ul><li>Protectors of gastro mucous </li></ul><ul><li>Infusion therapy </li></ul><ul><li>Hemostatic drags </li></ul><ul><li>Hemotransfusion </li></ul>
  29. 29. Surgery <ul><li>Duodenal ulcer : truncal vagotomy, selective vagotomy, highly selective vagotomy, excision of ulcer and pyloroplastic partial gastrectomy </li></ul><ul><li>Gastric ulcer: resection of stomach ore antrectomy </li></ul><ul><li>partial gastrectomy with gastroduodenal or gastrojejunal anastomosis </li></ul>
  30. 30. Operative treatment of ulcer disease. Method of excision of ulcer and pyloroplastic.
  31. 31. Operative treatment. Method of resection of stomach. resection of stomach by Bilroth-I resection of stomach by Bilroth-II

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