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APD.ppt
- 1. Peptic Ulcer Professor Ravi Kant FRCS (England), FRCS (Ireland), FRCS(Edinburgh), FRCS(Glasgow), MS, DNB, FAMS, FACS, FICS, Professor of Surgery
- 2. Surgical Anatomy Crow’s feet N of Latarjet Criminal Nerve of Grassi Antral pump mechanism
- 3. Applied Anatomy : Stomach Pressure studies Endoscopic & Chromo-endoscopic Contrast ( Ba meal with air) Intra-luminal USG Electron microscopy USG CT/ MR Surgical
- 4. APD= Acid Peptic Disease Peptic Ulcer Gastric Ulcer Duodenal Ulcer Hyperacidity ZE Syndrome
- 5. APD= Acid Peptic Disease Acute Ulcer Stress Ulcer Curling’s Cushing’s
- 7. Peptic Ulcer 10% population affected Gastric ulcer in elderly 5-6th decade Duodenal ulcer in adults 4th decade DU also in young
- 8. Duodenal Ulcer Proximal duodenum 1 - 2 cm of pylorus ▲ acid Distal duodenum = ZE
- 9. Type 1 Gastric Ulcer most common (among gastric Ulcers) proximal antrum mucosal defense acid
- 10. Type II Gastric Ulcer Secondary to DU + pyloric stenosis
- 11. Type III Gastric Ulcer Prepyloric and pyloric canal ulcer acid ▲ common etiology with DU
- 12. GU: Benign Vs CA Rugae upto margins Small , <2cm Sticking of barium + Accompanying spasm ↓ Acid Crater beyond the normal stomach on a barium Rugae-short of Small-Big - - Achlorhydria Limited to Stomach
- 15. Pathogenesis Imbalance of acid-pepsin and mucosal defence H. pylori infection NSAID ZE Syndrome Type A personality
- 16. H.pylori 95% - duodenal ulcer 80% - gastric ulcer mucosal resistance hydrophobicity eradication reduces ulcer recurrence
- 17. NSAID Suppress prostaglandins prostaglandin ► acid secretion ▲ mucosal blood flow mucus & bicarbonate secretion 10 -30% in chronic users
- 18. ZE= Zollinger Ellison Syndrome Recurrent Recalcitrant Resistant Unusual sites Multiple Malignant
- 19. ZE Syndrome 0.1 - 1.0% of peptic ulcer Type I and Type II Gastrin secretion from non-beta cell tumor of pancreas - Gastrinoma MC in pancreas ; duodenum, antrum
- 20. ZE Syndrome 20% multiple 66% malignant slow growing indolent tumor parietal cell mass increased genetic basis massive hyper-secretion of acid
- 21. ZE Syndrome MEN - I – hyperparathyroidism – islet cell tumor – pituitary tumors
- 22. A/ DU NSAIDs Acid hypersecretion Rapid gastric emptying Impaired acid disposal Smoking
- 23. Duodenal Ulcer Increased secretion of acid More rapid gastric emptying Decreased prostaglandin Chronic duodenitis with H.pylori Smoking
- 24. Gastric Ulcer H.pylori NSAIDs Duodenogastric reflux Impaired gastric mucosal defense
- 25. Gastric Ulcer Acid secretion - normal to low Reflux of duodenal contents gastritis ulcer Pylorus sphincter disorder Smoking Disturbed mucosa with low grade gastritis
- 27. CP Duodenal Ulcer – pain relieved by food or alkali – pain several hours after meal Gastric Ulcer - gnawing or burning pain on eating
- 28. CP Periodic chronic recurrent pain Nausea & vomiting Weight loss Epigastric tenderness
- 30. Investigations Endoscopy – 90% sensitivity – must in all pts. with severe pain – excludes malignancy – biopsy can be taken – test for H.pylori
- 31. Investigations Barium Meal double (air) contrast – 90% sensitivity
- 32. H Pylori detection: Breath test Blood test Tissue test
- 36. Rx - Medical Stop smoking, NSAIDs Stop alcohol Antacids - acid neutralisation H2 receptor antagonist -Ranitidine - secretion inhibition
- 37. Rx- Medical H+ pump inhibition - H+/K+ase inhibition - Omeprazole Anticholinergic - secretory inhibition Prostaglandin - Misoprostol - mucosal protection
- 39. Rx - Medical Sucralfate - protective coating Colloidal Bismuth – eradicate H.pylori – protective coating Antibiotics - H.pylori Kit for H Pylori
- 40. H2 Receptor Antagonists On parietal cells Decrease basal & stimulated acid secretion Pepsin output decreased Decreased gastric blood flow Competitive inhibitor of parietal cell
- 41. Rx - Duodenal Ulcer 95% control - medical Rx Surgery-Outdated, Obsolete Omeprazole better thanRanitidine Ulcer heels in 80% by 6 m recurrence in 95% by H.pylori eradication
- 42. Rx - Duodenal Ulcer Indications for surgery =Compl –Hemorrhage –Obstruction –Perforation –Intractability of pain Intractable pain ► HSV / TV + GJ
- 43. Rx - DU H2 blockers heals 75% DU in 4 weeks H/K proton pump inhibitor better results ulcer may recurr in 80% cases on stopping treatment of H.pylori
- 44. Rx - DU Indication of surgery in hemorrhage bleeding of > than 6 units recurrent bleed after endoscopic control pyloro-duodenotomy and control of bleeding HSV or TV + GJ
- 45. Rx - DU Perforation - simple closure with omental patch -Graham’s patch definitive surgery –HSV –TV + pyloroplasty –parietal cell vagotomy –TV+GJ
- 46. Rx GU Omeprazole, H2 receptor antagonist - 8 weeks if pain not relieved by 2 weeks - add one more drug repeat endoscopy after 8 weeks if no healing by 12 - 115 weeks - Surgery
- 47. Rx - GU Type I - Distal Gastrectomy with vagotomy + G-D or GJ proximal ulcer- total gastrectomy parietal cell vagotomy - high recurrence
- 48. Hemorrhage Hemorrhage - potential cause of death 15 -20% gross bleeding erosion of duodenal ulcer into gastro-duodenal artery Endoscopy –laser, sclerosant oralcohal injection
- 49. Perforation In 5-10% of cases pneumo-peritoneum in 75% cases peritonitis, pain, ileus leukocytosis, hypovolumia, IIIrd space loss DD - acute appendicitis, enteric perf.
- 50. Obstruction Chronic ulcer disease with edema and scarring in 5% cases of DU nausea, vomiting, abdominal distension metabolic alkalosis, paradoxical aciduria
- 51. Obstruction Endoscopy Ba study Scintigraphy Rx V + G-J / G-D