This document discusses peptic ulcers and duodenal ulcers. It covers the aggressive and defensive factors involved, pathomorphology, classifications, clinical presentations, complications, diagnosis, and management including conservative and surgical treatments. Specifically, it discusses classifications of ulcers based on location, size, etiology and stage. It also summarizes the signs, symptoms, diagnostic tests and treatments for complications like perforation, stenosis and bleeding. Surgical procedures for treatment include vagotomy, pyloroplasty and gastrojejunostomy.
Abstract— Gastrointestinal stromal tumors (GIST) are rare neoplasms of the gastrointestinal system. A case of 40 year old man having tense tender abdomen with obliterated liver dullness and shifting dullness was presented in emergency, it was further investigated on X rays, where pneumoperitoneum was found. This case was then decided to go for Laparatomy after routine investigations to further explore. On exploratory laparatomy, diffuse peritonitis with brown coloured fluid was observed. A 10 x 5 x 7 cm mass was found having an opening communicating with the gut lumen was present around 10 cm from the ligament of treitz. However, no adjacent structures, liver or parietal peritoneum seemed to be involved. Gross examination of the specimen revealed an outward bulging mass, which was centrally necrotic and contained hemorrhagic-necrotic material. On histo-pathological examination, features suggestive of gastrointestinal stromal tumor (GIST) with mixed spindle and epitheoid pattern was seen. Mitoses were slightly increased (<5 /> HPFs) leading to the conclusion of LOW GRADE GIST with tumor free margins of gut (R0 resection). So it was a case of Gastrointestinal stromal tumors (GIST), which is a rare medical presentation. So it was decided to report this case as a rare case presentation.
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2. AGGRESSIVE FACTORS
• hydrochloric acid
• pepsin
• reverse diffusion of ions of hydrogen
• products of lipid hyperoxidation
3. DEFENSE FACTORS
• mucus and alkaline components of
gastric juice
• property of epithelium of mucous
tunic to permanent renewal
• local blood flow of mucous tunic and
submucous membrane
5. CLASSIFICATION
by Johnson (1965)
• I – ulcers of small curvature (for 3 cm
higher from a goalkeeper);
• II– double localization of ulcers
simultaneously in a stomach and
duodenum;
• III – ulcers of goalkeeper part of
stomach (not farther as 3 cm from a
goalkeeper)
8. DIAGNOSIS PROGRAM
• 1. Anamnesis and physical examination.
• 2. Endoscopy.
• 3. X-Ray examination of stomach.
• 4. Examination of gastric secretion by the
method of aspiration of gastric contents.
• 5. Gastric pH metry.
• 6. Multiposition biopsy of edges of ulcer and
mucous tunic of stomach.
• 7. Gastric Dopplerography.
• 8. Sonography of abdominal cavity organs.
• 9. General and biochemical blood analysis.
• 10. Coagulogram.
9. X-Ray examination
THE DIRECT SIGNS:
• symptom of “Haudek's niche”
• ulcerous billow and convergence of folds of mucous
tunic.
INDIRECT SIGNS:
• symptom of “forefinger” (circular spasm of muscles)
• segmental hyperperistalsis,
• pylorospasm,
• delay of evacuation from a stomach
• duodenogastric reflux
• disturbance of function of cardial part
(gastroesophageal reflux).
16. CONSERVATIVE THERAPY
a) Omeprazole 20 mg 2 time per day or Н2-
blocker histamine receptor (ranitidine)
— 150 mg in the evening, famotidine —
40 mg at night, roxatidine — 150 mg in
the evening
b) antiacid drugs — in accordance with the
results of pH-metry;
c) reparative drugs (dalargin, solcoseryl,
actovegin) — for 2 ml 1–2 times per days
d) antimicrobial drugs (clarytromicine 500
mg twice daily, de-nol, metronidazole)
17. SURGICAL TREATMEN
• at the relapse of ulcer after the course of
conservative therapy;
• in the cases when the relapses arise during
supporting antiulcer therapy;
• when an ulcer does not heal over during 1,5–2
months of intensive treatment, especially in
families with “ulcerous anamnesis”;
• ulcer with complications (perforation or
bleeding);
• at suspicion on malignization ulcers, in case
of negative cytological analysis.
22. CLASSIFICATION
I. By etiology:
А. True duodenal ulcer.
B. Symptomatic ulcers.
II. By passing of disease:
1. Acute (first exposed ulcer).
2. Chronic:
a) with the rare exacerbation;
b) with the annual exacerbation;
c) with the frequent exacerbation (2 times
per a year and more frequent).
23. CLASSIFICATION
III. By the stages of disease:
1. Exacerbation.
2. Scarring:
a) stage of “red” scar;
b) stage of “white” scar.
3. Remission.
IV. By localization:
1. Ulcers of bulb of duodenum.
2. Low postbulbar ulcers.
3. Combined ulcers of duodenum and stomach.
24. CLASSIFICATION
V. By sizes:
1. Small ulcers up to 0,5 cm.
2. Middle — up 1,5 cm.
3. Large — up to 3 cm;
4. Giant ulcers over 3 cm.
VI. By the presence of complications:
1. Bleeding.
2. Perforation.
3. Penetration.
4. Organic stenosis.
5. Periduodenitis.
6. Malignization.
28. DIAGNOSIS PROGRAM
• 1. Anamnesis and physical examination.
• 2. Endoscopy.
• 3. X-Ray examination of stomach and
duodenum.
• 4. General and biochemical blood
analysis.
• 5. Coagulogram.
29. CONSERVATIVE THERAPY
a) Omeprazole 20 mg 2 time per day or Н2-
blocker histamine receptor (ranitidine) — 150
mg in the evening, famotidine — 40 mg at
night, roxatidine — 150 mg in the evening
b) antiacid drugs — (almagel, maalox or
gaviscon —1 dessert-spoon in a 1 hour after
food intake);
c) reparative drugs (dalargin, solcoseryl,
actovegin) — for 2 ml 1–2 times per days
d) antimicrobial drugs (clarytromicine 500 mg
twice daily, de-nol, metronidazole)
30. INDICATIONS TO THE
ELECTIVE OPERATION
• 1. Passing of duodenal ulcer with the
frequent relapses which could not
treated conservatively.
• 2. Repeated ulcerous bleeding.
• 3. Stenosis of outcome part of stomach.
• 4. Chronic penetration ulcers with the
pain syndrome.
• 5. Suspicion for malignization ulcers.
40. ULCEROUS STENOSIS
CLASSIFICATION
A
I — compensated;
II — subcompensated;
III — decompensated.
B
I — stenosis of goalkeeper;
II — stenosis of bulb of duodenum;
III — postbulbar duodenal stenosis.
41. DIAGNOSIS PROGRAM
• 1. Complaints of patient and anamnesis of
disease.
• 3. Sounding of stomach and examination of
gastric content.
• 4. Fibergastroduodenoscopy, biopsy.
• 5. Intragastric рН-metry.
• 6. Study of motility of stomach.
• 7. Roentgenologic examination of stomach and
duodenum (structural features, passage).
• 8. Sonography.
43. PERFORATED GASTRODUODENAL ULCERS
CLASSIFICATION
1. After etiology:
• ulcerous;
• unulcerous.
2. After localization:
• gastric (small curvature, cardial, antral,
prepyloric, pyloric) ulcer, front and back walls;
• ulcers of duodenum (front and back walls).
3. After passing:
• perforated in an abdominal cavity;
• covered perforations;
• atypical perforations.
44. DIAGNOSIS PROGRAM
• 1. Anamnesis and physical examination.
• 2. Global analysis of blood and urine, biochemical
blood test,
• coagulogram.
• 3. X-Ray examination of abdominal cavity organs
for presence of free gas (pneumoperitoneum).
• 4. Pneumogastrography, contrasting
pneumogastrography.
• 5. Fiber-gastroduodenoscopy.
• 6. Sonography of abdominal cavity organs.
46. Bleeding gastroduodenal ulcers
CLASSIFICATION
• I degree is easy — observed at the loss to
20 % volume of circulatory blood (at a
patient with weight of body 70 kg it is up
to 1000 ml);
• II degree — middle weight is loss from 20
to 30 % volume of circulatory blood (1000–
1500 ml);
• The III degree is heavy — is observed at
loss of blood more than 30 % volume of
circulatory blood (1500–2500 ml).
47. DIAGNOSIS PROGRAM
• Anamnesis and physical examination.
• Finger examination of rectum.
• Gastroduodenoscopy.
• Global analysis of blood.
• Coagulogram.
• 7. Biochemical blood test.
• X-Ray examination of gastrointestinal tract.
• Electrocardiography.