benign gastric and duodenal ulcers

1. Benign Gastric and Duodenal
Ulcers
Dr.Sujith Mathew Jose
PG in General Surgery
Coimbatore Medical College
Coimbatore

2. Anatomy of GI Tract

3. Peptic Ulcers
• Defined
– Ulcerated lesion in the mucosa of the
stomach or duodenum
• Types
Gastric
Duodenal

4. Gastric and Duodenal Ulcers

5. Gastric Ulcers
• Due to the
imbalance
between
protective and
damaging factors
of Gastric
Mucosa

6. Stomach Defense Systems
• Mucous layer
– Coats and lines the stomach
– First line of defense
• Bicarbonate
– Neutralizes acid
• Prostaglandins
– Hormone-like substances that keep blood vessels
dilated for good blood flow
– Thought to stimulate mucus and bicarbonate
production

7. CAUSES of GASTRIC ULCER
Atropic Gastritis
Duodenogastric bile reflux
Gastric Stasis
Smoking
NSAIDS
Steroids
HELICOBACTER PYLORI (70%)
Lower Socioeconomic group

8. Benign Gastric Ulcer
MUCOSAL
FOLDS
Converging folds
SITE 95% in Lesser curvature
Margin Regular
Floor Granulation tissue in
floor
Edges NOT everted ,punched
Surrounding
Area
Normal
Size and
Extent
Small deep up to
muscle layer

9. Malignant Gastric Ulcer
MUCOSAL
FOLDS
Effacing Mucosal folds
SITE Greater curvature
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

10. Types of Gastric Ulcer
Type I
in the andrum, near
lesser curvature
Type II
Combined gastric and
duodenal ulcer
Type III
Prepyloric
Type IV
Ulcer in the proximal
stomach and Cardia
55% 25%
15% 5%

11. Gastric Ulcers
• Pain occurs 1-2 hours after meals
• Pain usually does not wake patient
• Accentuated by ingestion of food
• Risk for malignancy
• Deep and penetrating and usually
occur on the lesser curvature of the
stomach

12. Gastric ulcer >3cm is called GIANT
GASTRIC ULCER
Gastric Ulcers is
equal in both sexes
affect older population
less common than duodenal ulcers

13. Duodenal Ulcers
Aetiology
HELICOBACTER PYLORI (90%)
NSAIDS, Steroids
Zollinger Ellison Syndrome
Alcohol, Smoking
Blood Group O
MEN 1
Chronic Pancreatitis

14. Duodenal Ulcers
• Pain occurs 2-4 hours after meals
• Pain wakes up patient
• Pain relieved by food
• Very little risk for malignancy

15. • Most Common in first part of duodenum
• Chronic Ulcer penetrates the mucosa and
into the muscle coat, leading to fibrosis
• Fibrosis ------- Pyloric Stenosis

16. ANTERIOR ULCER ---- PERFORATE
POSTERIOR ULCER ---- BLEEDS

17. GASTRIC ULCER
erode LEFT GASTRIC
VESSELS and
SPLENIC VESSELS
DUODENAL ULCER
erodes
GASTRODUODENAL
artery

18. • Microscopically,
Duodenal Ulcer shows,
Destruction of Muscular
Coat
Base of ulcer with
Granulation Tissue
Arteries in the region
shows
ENDARTERITIS OBLITERANS

19. General Peptic Ulcer Symptoms
PAIN Epigastric ---- Radiating
to Back
Periodicity Due to spontaneous
Healing of ulcer
Vomiting Present when stenosis
occurs
Weight Alteration Gastric loss Duodenal -
> Gain
Bleeding May present as anemia

20. Clinical Features
GASTRIC ULCER DUODENAL ULCER
Pain after food Intake Pain before food intake
Periodicity less Common Periodicity more Common
Weight loss +++ Weight Gain+++
Male = Female Male > Female
Hemetemesis more Malena more

21. INVESTIGATIONS
• Esophagogastrodeodenoscopy (EGD)
• Upper gastrointestinal series (UGI) (Barium swallow)
• Urea Breath Testing
• USG

22. GASTRODUODENOSCOPY
– Endoscopic procedure
– Visualizes ulcer crater
– Ability to take tissue
biopsy to R/O cancer
and diagnose H. pylori

23. 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

24. Biopsy can be
taken to look for
the presence of
Helicobacter
Pylori

25. Rapid Urease Test
C13 or C14 breath test
– Client drinks a carbon-enriched
urea solution
– Excreted carbon dioxide is then
measured
Faecal Antigen Test

26. BARIUM MEAL X Ray of Benign Gastric Ulcer
• Outpouching of ulcer crater beyond the
gastric contour (exoluminal)

27. HAMPTOMs LINE
• Overhanging mucosa at the margins of a
benign gastric ulcer, project inwards
towards the ulcer
HAMPTOMs LINE

28. • Regular/ Round Margin of the Ulcer Crater
STOMACH SPOKE WHEEL PATTERN

29. • Converging mucosal folds towards the
base of ulcer

30. Complications of Peptic Ulcers
• Hemorrhage
– Blood vessels damaged as ulcer erodes into the
muscles of stomach or duodenal wall
– Coffee ground vomitus or occult blood in tarry stools
• Perforation
– An ulcer can erode through the entire wall
– Bacteria and partially digested fool spill into
peritoneum=peritonitis
• Narrowing and obstruction (pyloric)
– Swelling and scarring can cause obstruction of food
leaving stomach=repeated vomiting

31. Medical 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

32. Anti H Pylori Regimen

33. 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

34. Surgery
• Greatly decreased from 1960 secondary to the
discovery of H. pylori
• Indication for Surgery
– PERFORATION
– OBSTRUCTION
– HEMORRHAGE
– NOT RESPONDING TO MEDICAL TREATMENT

35. Types of Surgical Procedures
2.Gastroenterostomy
allows regurgitation of
alkaline duodenal contents
into the stomach
1.Diversion of Acid Away
from the duodenum
3.Reduce the secretory
Potential of Stomach

36. Vagotomy
Truncal Vagotomy
– Section of the vagus nerve
– Reduces the maximal acid
output by app 50%
Selective Vagotomy
Highly Selective Vagotomy
Fibres supplying the parietal cells
are ligated
Nerve of Latarjet which supplies
andrum is retained
So no drainage proceedure is
required in HSV preserved
Gastric branches are severed
Hepatic branches are preserved

37. Drainage Procedures
• Pyloroplasty
It is a drainage
procedure
Longitudnal Sectioning
of Pyloric Ring
Incision is closed
transversely

38. Gastrojejunostomy
Alternative Drainage
Procedure to Pyloroplasty
Opening the lesser sac
and performing
anastomosis between the
most dependent part of
andrum and first jejunal
loop.

39. Types of Surgical Procedures
• Antrectomy
– Lower half of stomach (antrum) makes most of the
acid
– Removing this portion (antrectomy) decreases acid
production
• Subtotal gastrectomy
– Removes ½ to 2/3 of stomach
• Remainder must be reattached to the rest of the
bowel
– Billroth I
– Billroth II

40. Billroth I Gastrectomy
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

41. Billroth II Gastrectomy
The lower portion of the stomach is
removed and the remainder is
anastomosed to the jejunum
Duodenum is closed off by suture
of staples
High Operative Mortality and
Morbidity

42. 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

43. Dumping Syndrome
EARLY DUMPING
• Rapid emptying of hyperosmolar food and fluids
from the stomach into the jejunum
• Symptoms
– Weakness
– Faintness
– Palpatations
– Fullness
– Discomfort
– Nausea
– diarrhea
Rx
Dietary manipulation
Octreotide before meals
Avoid High Carbohydrate
Content

44. LATE DUMPING
It is reactive hypoglycemia
CHO load in small bowel ===>
rise in blood glucose ===>
Insulin levels to rise ===>
Secondary Hypoglycemia

45. thankyou