Peptic ulcer, Upper GI bleeding, esophageal varices, Portal hypertension

1. PEPTIC ULCER
&
UPPER GI BLEEDING
By
Dr. Abdul Qadeer
MBBS; FCPS; FICS
Assistant Professor in General Surgery
King Faisal University College of Medicine
Kingdom of Saudi Arabia

2. OBJECTIVES
1. Definition of peptic ulcer
2. Epidemiology of peptic ulcer
3. Causes of peptic ulcer
4. Clinical presentation
5. Investigations
6. Treatment
7. Definition of upper GI bleeding
8. Epidemiology of upper GI bleeding
9. Causes
10. Clinical presentation
11. Investigations
12. Treatment

3. 1. DEFINITION OF PEPTIC ULCER
 A lesion in the lining (mucosa) of the digestive
tract, typically in the stomach or duodenum,
caused by the digestive action of pepsin and
stomach acid.

4. 2. EPIDEMIOLOGY OF PEPTIC ULCER
 10% of the population has ulcers
 Annual incidence of symptomatic peptic ulcer
is about 0.3%
 Duodenal ulcers are 4 times as common as
gastric ulcers and occur at the duodenal cap
 Gastric ulcers mostly occur in the lesser
curvature. Usually benign. 5% are malignant
 May occur on the stoma following gastric
surgery, esophagus & Meckel’s diverticulum
having ectopic gastric tissue

5.  In general, the ulcer occurs at a junction
between different types of epithelia, the ulcer
occurring in the epithelium least resistant to
acid damage
 Gastric malignancy is common in Japan,
Chile, Finland & Iceland due to
environmental & diet factors.

6. 3. CAUSES OF PEPTIC ULCER
 Higher pepsin/gastric acid levels, though the
ulcers have been seen in patients having
normal levels
 Gastrinoma (Zollinger-Ellison syndrome)
 Helicobacter pylori in 80-95% cases
 Consumption of NSAIDs
 Stress i.e. emotional, trauma, surgical
 Injury or death of mucus-producing cells

7. GASTRINOMA TRIANGLE

8. CAUSES OF PEPTIC ULCER
 Smoking
 Alcohol/diet
 Hypercalcemia ( calcium secretion)
 Genetic factor: first-degree relatives
 Blood group O

9. 4. CLINICAL PRESENTATION OF P. ULCER
 Pain: epigastric, may radiate to back,
intermittent, may be relieved by eating
 Periodicity: the symptoms may disappear
for weeks or months (due to spontaneous
healing)
 Vomiting
 Alteration in weight:: Weight loss or gain
 Bleeding: acute (hematemesis or malena) or
chronic (anemia)

10. CLINICAL PRESENTATION OF P. ULCER
 O/E:
 may be normal or epigastric tenderness
 Perforation
 GOO (Gastric outlet obstruction)

11. 5. INVESTIGATIONS IN PEPTIC ULCER
 Gastoduodenoscopy: investigation of
choice, biopsy is taken for histopathology
and tissue for culture, especially H. Pylori
 Radiological: Barium meal
 Laboratory tests:
a. CLO (Campylobacter-like organism) test
b. Urea breath test (UBT)
c. H.Pylori stool antigen (HpSA) test

12. CLO TEST KIT

13. UREA BREATH TEST

14. 6. TREATMENT OF PEPTIC ULCER
 Medical treatment:
a) H2-receptor antagonists: cimetidine,
ranitidine, famotidine, nizatidine
b) PPIs: omeprazole, lansoprazole,
esomeprazole, pantoprazole etc.
c) Eradication therapy: PPIs + antibiotics
 Surgical treatment:
a) Gastrectomy: Billroth I, Billroth II,
Gastrojejunostomy
b) Vagotomy: Truncal, Selective, Highly

15. GASTRECTOMY

16. VAGOTOMY

17. SEQUELAE OF P.ULCER SURGERY
 Recurrent ulceration
 Small stomach syndrome
 Bile vomiting
 Early & late dumping
 Post-vagotomy diarrhea
 Malignant transformation
 Nutritional consequences
 Gallstones

18. DUMPING SYNDROME

19. EARLY & LATE DUMPING SYNDROMES

20. 7. DEFINITION OF UPPER GI BLEEDING
 Where the source of bleeding is in:
 Esophagus
 Stomach
 Duodenum

21. 8. EPIDEMIOLOGY OF UPPER GI BLEEDING
 Incidence: 100/100 000 in Western world
 Strongly associated with NSAIDs use
 5-10% in-hospital mortality

22. 9. CAUSES OF UPPER GI BLEEDING
 Ulcers: esophageal, gastric, duodenal
 Erosions: esophageal, gastric, duodenal
 Mallory-Weiss tear
 Esophageal varices
 Tumor
 Vascular lesions e.g. Dieulafoy’s disease
 Aortic-enteric fistula

24. 10. CLINICAL PRESENTATION OF UPPER GI
BLEEDING
 Hematemesis
 Malena
 Associated with GI perforation
 Shock

25. 11. INVESTIGATIONS OF UPPER GI BLEEDING
 Upper GI endoscopy
 Contrast studies
 CXR erect posture: diagnostic of GI
perforation

26. X-RAY CHEST ERECT POSTURE

27. XRAY ABDOMEN LATERAL DECUBITUS

28. ENDOSCOPY

29. BARIUM MEAL

30. 12. TREATMENT OF UPPER GI BLEEDING
 Resuscitation
 Treat the cause

31. EMERGENCY MANAGEMENT OF ACUTE NON-VARICEAL
UPPER GIT HAEMORRHAGE
 I.V access with large bore cannula
 Basic investigations - blood count, routine
biochemistry, cross match blood
 Hourly measurements of BP, pulse and urine
output
 I.V colloids or crystalloids –pt with hypotension
and tachycardia
 Transfuse with blood
 Endoscopy for diagnosis & Rx
 I.V PPI therapy for bleeding peptic ulcer

32. EMERGENCY MANAGEMENT OF ACUTE
VARICEAL UPPER GIT BLEEDING
 0.9 % saline
 Vasopressor(terlipressin)
 Prophylactic antibiotics
 Emergency endoscope
 Variceal band ligation
 Proton pump inhibitor
 Phosphate enema/lactulose enema

33. MANAGEMENT OF PEPTIC ULCER
 ENDOSCOPIC THERAPY with
* Bipolar electro coagulation
* Heater probe
* Injection therapy
- Absolute alcohol
- 1:10000 epinephrine
* Clips
 High dose constant infusion of iv PPI E.g.
Omeprazole – 80 mg bolus & 8 mg/hr infusion

34. PREVENTION OF RECURRENT BLEEDING
 Eradication of H.Pylori infection
 Discontinue NSAIDS & acids
 If NSAIDS have to be used, use along with
PPI
 Use selective COX-2 inhibitors like Coxib or
traditional NSAIDS + Coxib
 Coxib + PPI : further significant decrease in
ulcers and recurrent bleeding.

35. MALLORY-WEISS TEARS
 Mostly bleeding stops
spontaneously
(Recurrence is only 0-7%)
 Endoscopic therapy is only
for actively bleeding
Mallory-Weiss tear.
 Angiographic therapy with embolization &
operative therapy with over sewing of tear can
be done

36. ESOPHAGEAL VARICES

37. ESOPHAGEAL VARICES
I. Vasoconstrictors (somatostatin, octreotide,
terlipressin) i.v terlipressin infusion at 2 mg
6 hourly, generalized vasoconstriction
leading to decreased blood flow to venous
system.
II. Baloon tamponade (Sengastaken–
Blakemore tube): Triple lumen or Four
lumen tube with esophageal and gastric
balloons.
III. Endoscopic variceal ligation (Band ligation)
IV. Sclerotherapy

38. SENGASTAKEN-BLAKEMORE TUBE

39.  Quinolones – for patients with cirrhosis
decreases the bacterial infection & mortality.
 Non selective Beta blockers – Propranolol,
Nadolol
 For recurrent esophageal bleeding –
continue therapy with beta blocker +
endoscopic ligation

40.  If not subsided with medical therapy, Go for
INVASIVE THERAPY:
 TIPSS (Transjugular intrahepatic
portosystemic shunt)
 Other shunts e.g. Danver

41. GASTRITIS
 Avoiding the long-term use
of alcohol, NSAIDs, coffee,
high-fat foods and drugs
 Reducing stress through
relaxation techniques
 Antacids, H2 blockers, PPIs
 Triple therapy: 2 antibiotics + a PPI is commonly
used to treat H. Pylori related gastritis

42. THE END