PEPTIC ULCER DISEASE- EPIGASTRIC PAIN #surgicaleducator #epigastricabdominalpain #pepticulcerdisease #usmle #babysurgeon #surgicaltutor • Dear Viewers, • Greetings from “Surgical Educator” • Today I have uploaded a video on Peptic Ulcer Disease- a didactic lecture. • It is one of the common surgical problems you see in surgical wards. • I have discussed the various causes for Epigastric pain, epidemiology, etiopathogenesis, clinical features, investigations, complications and treatment of Peptic Ulcer Disease. • I have also included a mind map and a treatment algorithm for Peptic Ulcer Disease. • I hope the video will be very useful and you will enjoy it. • You can watch all my surgical teaching videos in the following link: • youtube.com/c/surgicaleducator • Thank you for watching the video.

1. PEPTIC ULCER
DISEASE
EPIGASTRIC PAIN
AN OVRVIEWDr.B.Selvaraj MS;Mch;FICS;
“Surgical Educator”
Malaysia

2. PEPTIC ULCER DISEASE
 Different causes for epigastric pain
 Applied Basic Sciences
 Etiopathogenesis
 Epidemiology
 Clinical features
 Investigations
 Complications
 Treatment
 Mindmap
 Treatment Algorithm

3. PEPTIC ULCER DISEASE
D/D for Epigastric Pain

4. PEPTIC ULCER DISEASE
Applied Anatomy
Celiac Axis:
 Left Gastric
 Common Hepatic
 Splenic
-Rt Gastric from
Hepatic artery proper
-Rt Gastroepiploic
from Gastroduodenal
-Short Gastric from
Splenic artery

5. PEPTIC ULCER DISEASE
Applied Physiology
 Chief cells
Pepsinogen
 Parietal cells
Hydrochloric acid
and intrinsic factor
 G cells Gastrin
 D cells Somatostatin
 Intrinsic factor is
needed for the
absorption of Vit B12
 Autoimmune
destruction of
parietal cells causes
deficient B12
Pernicious Anemia
1. Gastrin from G cells
2. Acetylcholine from vagus
nerve
3. Histamine from paracrine
release via mast cells

6. PEPTIC ULCER DISEASE
ETIOPATHOGENESIS

7. PEPTIC ULCER DISEASE
ETIOPATHOGENESIS

8. PEPTIC ULCER DISEASE
EPIDEMIOLOGY
 A peptic ulcer is a break in the epithelial
surface of the stomach or duodenum caused
by the action of gastric secretions (acid and
pepsin) and infection with Helicobacter
pylori.
 Mucosal infection with Helicobacter pylori is
a major cause for PUD
 Patients with duodenal ulcers have an
increased capacity for gastric acid secretion
relative to normal people.
 Hemorrhage is the leading cause of death
associated with peptic ulcer.
 Each year, approximately 300,000 t o 500,000
new cases of PUD occur.
 Three to four million patients are self-
medicating for symptoms of PUD
 30,000 surgeries are performed annually for
PUD .
 The incidence and prevalence of PUD varies
based upon the presence of Helicobacter pylori
(H. pylori). Higher rates are found in countries
where H. pylori infection is higher
 DUs occur two decades earlier than GUs,
particularly in males .

9. PEPTIC ULCER DISEASE

10. PEPTIC ULCER DISEASE
Clinical Features
Symptoms of Gastric ulcers
 Male : female 3:1, peak incidence 50+
years.
 Epigastric pain induced by eating.
 Aversion to food because of pain
 Nausea or vomiting.
 Hemetemesis and Melenemesis
common
 Weight loss.
 Dyspepsia: Bloating and early satiety
 Heartburn, which is a burning
sensation in the chest
 Anemia from chronic blood loss.

11. PEPTIC ULCER DISEASE
Clinical Features
Symptoms of Duodenal ulcers and Type 2 Gastric
ulcers
 Male : female 1:1, peak incidence 25–50 years.
 Epigastric pain during fasting (hunger pain),
relieved by food/antacids, often nocturnal, typically
exhibits periodicity (i.e. recurs at regular intervals).
 Nausea or vomiting.
 Weight gain.
 Dyspepsia: Bloating and early satiety
 Boring back pain if ulcer is penetrating posteriorly
 Haematemesis from ulcer penetrating
gastroduodenal artery posteriorly.
 Peritonitis if perforation occurs with anterior DU.
 Vomiting if gastric outlet obstruction (pyloric
stenosis) occurs (note succussion splash and watch
for hypokalaemic, hypochloraemic alkalosis).

12. PEPTIC ULCER DISEASE
Duodenal Ulcer Vs Gastric Ulcer

13. PUD- INVESTIGATIONS
Upper GI Endoscopy
Upper GI Endoscopy
“ Most sensitive and
specific test”

14. PUD- INVESTIGATIONS
Upper GI Endoscopy
Benign Gastric Ulcer Malignant Gastric Ulcer Resected Specimen

15. PUD- INVESTIGATIONS
H.Pylori TestingNON-INVASIVE INVASIVE
 H. pylori is a helical gram-
negative rod with flagella
that resides beneath the
mucous layer of stomach
& duodenum
 Production of the enzyme
urease allows H. pylori to
survive in the acidic
environment of the
stomach.

16. PUD- INVESTIGATIONS
Contrast Radiology
 Upper gastrointestinal radiology is not used
as much as in previous years, as endoscopy
is a more sensitive investigation
 Computed tomography (CT) imaging with
oral contrast has also replaced contrast
radiology where anatomical information is
sought, eg large hiatus hernias of the
rolling type

17. PUD- COMPLICATIONS
 Four major complications of peptic
ulcer disease (PUD)
- Bleeding,
-Perforation,
-Penetration,
-Obstruction.

18. PUD- TREATMENT
 PPls are the gold
standard with80 to-90%
healing at 8 weeks (e.g.
omeprazole,
lansoprazole).
 H2 antagonists have a
high recurrence rate
eg.Cimetidine, Ranitidine
 PPIs need acidic
environment to get
activated. So, shouldn’t
combine with antacids
and H-2 blockers
Acid neutralizing & inhibitory drugs

19. PUD- TREATMENT
Cyto-Protective Drug H.Pylori Eradication
 H.Pylori should be eradicated in all patients with
documented PUD
 No single drug is effective in eradication
 Combination of drugs should be given for 14 days
 Triple therapy: H. pylori eradication (Rx:amoxicillin
500 mg,and clarithromycin 500 mg) and PPI (20 mg
omeprazole or 30 mg lansoprazole b.d.) for 7–14
days. Metronidazole may replace amoxicillin in
penicillin-allergic patients.
 Quadruple therapy: bismuth, metronidazole,
tetracycline and PPI for 7–14 days.
 The test of choice for documenting eradication is
Urea breath test

20. PUD- TREATMENT
- SURGERY
 Elective for intractable GU: Billroth I gastrectomy.
 Normal vagal innervation of stomach

21. PUD- TREATMENT
- SURGERY
 Elective for intractable DU: Highly selective vagotomy
Selective Vagotomy
Truncal Vagotomy

22. PUD- TREATMENT
- SURGERY
Pyloric stenosis: Truncal vagotomy + Gastrojejunostomy
Truncal Vagotomy + Pyloroplasty

23. PUD- TREATMENT
- SURGERY
Gastric & duodenal ulcer perforation
For DU Perforation- Graham’s
omentopexy+Peritoneal toileting For GU Perforation- Graham’s omentopexy
+ Biopsy of the ulcer
+ Peritoneal toileting

24. PUD- TREATMENT
- SURGERY
Gastric & duodenal ulcer bleeding

25. PEPTIC ULCER DISEASE
MINDMAP

26. PEPTIC ULCER DISEASE
TREATMENT ALGORITHM

27. PEPTIC ULCER DISEASE
TREATMENT ALGORITHM

28. Peripheral Arterial Diseases(PAD)