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Peptic ulcer disease

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Peptic ulcer disease:
Pathogenesis, clinical features, investigation, management, complications

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Peptic ulcer disease

  1. 1. PEPTIC ULCER DISEASE Pukar K.C Kathmandu University School of Medical Sciences
  2. 2. Normal Esophagus & Stomach
  3. 3. DEFINITIONS  Ulcer Breach in the mucosa of the GI tract that extends through the muscularis mucosa into submucosa or deeper  Erosion Epithelial disruption without breach of the muscularis mucosa  Peptic Ulcer disease Circumscribed ulcer that occurs in any part of the GI tract due to the aggressive action of acid and peptic juices.
  4. 4. SITES OF ULCERS  First part of Duodenum  Lesser curve of stomach  Stoma following gastric surgery  Oesophagus  Gastric mucosa within Meckel’s Diverticulum
  5. 5. ETIOLOGY  Helicobacter pylori infection  Chronic NSAIDs and Corticosteroids use  Cigarette smoking  Alcohol consumption  Zolinger-Ellison syndrome  Hyperparathyroidism and chronic renal failure
  6. 6. PATHOGENESIS
  7. 7.  Zollinger- Ellison syndrome  Uncontrolled secretion of gastrin by tumor resulting massive acid production  NSAIDs use  Direct chemical irritation  Suppressing prostaglandin synthesis  Cigarette smoking  Impaired mucosal blood flow and healing  Hyperthyroidism and chronic renal failure  Hypercalcemia induced excessive gastrin secretion
  8. 8. H. PYLORI  Flagella  Urease  Generates ammonia from endogenous urea and elevates pH  Adhesins  Enhance bacterial adherance to surface cells  Toxins  CagA gene
  9. 9. H. PYLORI
  10. 10. ETIOLOGIC FACTORS OF PUD
  11. 11. Features Gastric ulcers Duodenal ulcers Incidence Less common More common Common Location Antrum, lesser cuvature Anterior wall*, 1st part Age group Middle age Middle or old age Male: Female ratio 1:1 4:1 Association with H. Pylori 65% 85%-100% Level of gastric acid secretion Mostly normal Mostly increased Malignancy Common Rare *Kissing ulcers: Both anterior and posterior wall ulcer of duodenum
  12. 12. TYPES OF GASTRIC ULCER DAINTREE JOHNSON •Type I In the antrum, near lesser curvature Normal acid level •Type II Combined gastric and duodenal ulcer High acid level •Type III Prepyloric High acid level •Type IV Ulcer in the proximal stomach and Cardia Normal acid level 55% 25% 15% 5%
  13. 13. FEW MORE ULCERS!!!  Stress ulcer  In association with shock, sepsis or severe trauma  Curling ulcer  In association with severe burns or trauma  Cushing’s ulcer  In patients with intracranial disease oor after neurosurgery
  14. 14. CLINICAL PRESENTATION  Symptoms  Pain  Epigastric region, burning or aching type  May radiate to back  Heartburn, Nausea, vomiting, bloating, belching, water- brash  Alteration in weight  Haematemesis or Maelena  presents as anemia  Periodicity of symptoms  Significant past history  Clinical examination  Tender epigastrium  Features of complication, if present
  15. 15. Gastric Ulcer Duodenal Ulcer Pain increased after food intake Pain relieved after food intake Periodicity less common Periodicity more common Haematemesis more common Melaena more common Weight loss common Weight gain occurs Equal in both sexes More in males
  16. 16. INVESTIGATIONS  Esophagogastrodeodenoscopy (EGD)  Barium swallow  Urea Breath Testing
  17. 17. ESOPHAGOGASTRODEODENOSCOPY It is fundamental that any gastric ulcer should be regarded as being Malignant, no matter how classically it resemble a benign gastric ulcer Multiple biopsies should be taken, as many as 10 well targeted biopsies
  18. 18. ESOPHAGOGASTRODEODENOSCOPY  Endoscopic procedure  Visualizes ulcer crater  Ability to take tissue biopsy to R/O cancer and diagnose H. pylori
  19. 19. BENIGN GASTRIC ULCER MUCOSAL FOLDS Converging folds Margin Regular Floor Granulation tissue in floor Edges NOT everted ,punched Surrounding Area Normal Size and Extent Small deep up to muscle layer
  20. 20. MALIGNANT GASTRIC ULCER MUCOSAL FOLDS Effacing Mucosal folds Margin Irregular margin Floor Necrotic Slough in the floor Edges Everted Edges Surrounding Area Shows nodules, ulcers and irregularities Size and Extent Large and Deep
  21. 21. BARIUM SWALLOW  Outpouching of ulcer crater beyond the gastric contour (exoluminal)  Overhanging mucosa at the margins of a benign gastric ulcer, project inwards towards the ulcer  Regular/ Round Margin of the Ulcer Crater  Converging mucosal folds towards the base of ulcer  STOMACH SPOKE WHEEL PATTERN  HAMPTON LINE: A thin millimetric radiolucent line seen at the neck of a gastric ulcer in barium studies  Deformed or absent duodenal cap
  22. 22. HAMPTON LINE: A thin millimetric radiolucent line seen at the neck of a gastric ulcer in barium studies STOMACH SPOKE` WHEEL PATTERN
  23. 23. TESTS FOR H. PYLORI  Noninvasive tests  Serum or whole blood antibody tests Immunoglobin G (IgG) Urea breath test  Patient drinks a carbon-enriched urea solution  Excreted carbon dioxide is then measured  Invasive tests  Biopsy of stomach  Rapid urease test
  24. 24. COMPLICATION •Hemorrhage •Perforation •Penetration •Narrowing and obstruction
  25. 25. HEMORRHAGE  Blood vessels damaged as ulcer erodes into the muscles of stomach or duodenal wall  Coffee ground vomitus or occult blood in tarry stools  Posterior wall duodenal ulcer  Arteries involved  GASTRIC ULCER erode LEFT GASTRIC VESSELS and SPLENIC VESSELS  DUODENAL ULCER erodes GASTRODUODENAL artery
  26. 26. PERFORATION  Can erode through the entire wall  Spillage of gastric/duodenal content and bacteria into peritoneum leading to peritonitis  Mostly associated with NSAIDs ulcers  Anterior wall duodenal ulcer
  27. 27. PENETRATION  Ulcers may erode through the entire thickness of the gastric or duodenal wall into adjacent abdominal organs  Can involve the pancreas, bile ducts, liver, and the small or large intestine.  The pancreas is the most common site of penetration
  28. 28. NARROWING AND OBSTRUCTION  Hour glass contracture  Cicatricial contracture of lesser curvature ulcer, dividing the stomach in two compartments  Teapot deformity  Cicatrisation and shortening of lesser curve  Pyloric stenosis  Scarring and cicatrisation of first part of duodenum  Persistent vomiting
  29. 29. MANAGEMENT  Non-pharmacological  Pharmacological  Surgical
  30. 30. PHARMACOLOGICAL MANAGEMENT  Provide pain relief  Antacids and mucosa protectors  Eradicate H. pylori infection  Two antibiotics and one acid suppressor  Heal ulcer  Eradicate infection  Protect until ulcer heals  Prevent recurrence  Decrease high acid stimulating foods in susceptible people  Avoid use of potential ulcer causing drugs  Stop smoking AIM
  31. 31. NON-PHARMACOLOGICAL • Avoid spicy food. • Avoid Alcohol. • Avoid Smoking. • Avoid heavy meals. • Encourage small frequent low caloric meals. • Avoid ulcerating drugs e.g. NSAIDs, corticosteroids
  32. 32. HYPOSECRETORY DRUGS  Proton Pump Inhibitors  Suppress acid production  H2-Receptor Antagonists  Block histamine-stimulated gastric secretions  Antacids  Neutralizes acid and prevents formation of pepsin  Give 2 hours after meals and at bedtime  Prostaglandin Analogs  Reduce gastric acid and enhances mucosal resistance to injury  Mucosal barrier fortifiers  Forms a protective coat  Sucralfate
  33. 33. MEDICAL TREATMENT
  34. 34. ERADICATION THERAPY  Directed against H. pylori  Regimens  Triple therapy for 2 weeks  Omeprazole 20 mg twice daily or lansoprazole 30 mg twice daily or pantoprazole 40 mg twice daily or esomeprazole 40 mg daily or rabeprazole 20 mg daily  Clarithromycin 500 mg twice daily  Amoxicillin 1 g twice daily  Quadruple therapy for 2 weeks  Omeprazole 20 mg twice daily or pantoprazole 40 mg twice daily or esomeprazole 40 mg daily or rabeprazole 20 mg daily  Bismuth subsalicylate 525 mg twice daily  Metronidazole 250–500 mg three times daily  Tetracycline 500 mg four times daily  The PPIs should be continued for 6 more weeks
  35. 35. SURGERY  Indication  Complicated ulcers  Not responding to medical treatment
  36. 36. TYPES OF SURGICAL PROCEDURES 2.Gastroenterostomy allows regurgitation of alkaline duodenal contents into the stomach • Gastrojejunostomy 1.Diversion of Acid Away from the duodenum •Billroth II 3.Reduce the secretory Potential of Stomach •Billroth I (gastric ulcer) •Truncal vagotomy and drainage •Highly selective vagotomy •Truncal vagotomy and antrectomy
  37. 37. BILLROTH I GASTRECTOMY Gastric ulcers Distal portion of the stomach is mobilised and resected The cut edge of the remnant is partially closed from Lesser Curvature aspect Stoma at greater curvature aspect Gastroduodenal anastomosis done
  38. 38. BILLROTH II GASTRECTOMY The lower portion of the stomach is removed along with the ulcer and the remainder is anastomosed to the jejunum Recurrent ulceration is low High Operative Mortality and Morbidity
  39. 39. SEQUELAE OF PEPTIC ULCER SURGERY  Recurrent Ulceration  Small Stomach Syndrome  Bile Vomiting  Early and Late Dumping  Post Vagotomy Diarrhoea  Malignant Transformation  Nutritional Consequences  Gall Stones
  40. 40. OTHER TYPES OF ULCER  NSAIDs induced ulcers  Antisecretory agents  Stomal ulcers  Prolonged course of antisecretory agents  Zollinger- Ellison syndrome  Proton pump inhibitors unless tumor can be managed by surgery
  41. 41. MANAGEMENT OF COMPLICATIONS

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