Peptic UlcerPeptic Ulcer

Professor Ravi KantFRCS (England), FRCS (Ireland),

FRCS(Edinburgh), FRCS(Glasgow), MS, DNB, FAMS, FACS, FICS,

Professor of Surgery

Surgical AnatomySurgical Anatomy

Crow’s feetCrow’s feet

N of LatarjetN of Latarjet

Criminal Nerve of GrassiCriminal Nerve of Grassi

Antral pump mechanismAntral pump mechanism

Applied Anatomy : StomachApplied Anatomy : Stomach

Pressure studiesPressure studies

Endoscopic & Chromo-endoscopicEndoscopic & Chromo-endoscopic

Contrast ( Ba meal with air)Contrast ( Ba meal with air)

Intra-luminal USGIntra-luminal USG

Electron microscopyElectron microscopy

USGUSG

CT/ MRCT/ MR

SurgicalSurgical

APD= Acid Peptic DiseaseAPD= Acid Peptic Disease

Peptic UlcerPeptic Ulcer

Gastric UlcerGastric Ulcer

Duodenal UlcerDuodenal Ulcer

HyperacidityHyperacidity

ZE SyndromeZE Syndrome

APD= Acid Peptic DiseaseAPD= Acid Peptic Disease

Acute UlcerAcute Ulcer

Stress UlcerStress Ulcer

Curling’sCurling’s

Cushing’sCushing’s

APDAPD

IncidenceIncidenceAetiologyAetiology

CPCP

InvestigationsInvestigations

DDDD

RxRx

Peptic UlcerPeptic Ulcer

10% population affected10% population affected

Gastric ulcer in elderly 5-6Gastric ulcer in elderly 5-6thth decadedecade

Duodenal ulcer in adults 4Duodenal ulcer in adults 4thth decade decadeDU also in youngDU also in young

Duodenal UlcerDuodenal Ulcer

Proximal duodenumProximal duodenum

1 - 2 cm of pylorus1 - 2 cm of pylorus

▲▲ acidacid

Distal duodenum = ZEDistal duodenum = ZE

Type 1 Type 1 Gastric UlcerGastric Ulcer

most commonmost common (among gastric (among gastric Ulcers)Ulcers)

proximal antrumproximal antrum

mucosal defensemucosal defense

acidacid

Type II Type II Gastric UlcerGastric Ulcer

Secondary to DU + pyloric Secondary to DU + pyloric stenosisstenosis

Type III Type III Gastric UlcerGastric Ulcer

Prepyloric and pyloric Prepyloric and pyloric canal canal ulcerulcer

acid acid ▲▲

common etiology with common etiology with DUDU

GU: Benign Vs CAGU: Benign Vs CA

Rugae upto marginsRugae upto margins

Small , <2cmSmall , <2cm

Sticking of barium +Sticking of barium +

Accompanying spasmAccompanying spasm

↓ ↓ AcidAcid

Crater beyond the Crater beyond the normal stomach on a normal stomach on a bariumbarium

Rugae-short of Rugae-short of

Small-BigSmall-Big

--

--

AchlorhydriaAchlorhydria

Limited to StomachLimited to Stomach

APDAPD

IncidenceIncidence

AetiologyAetiologyCPCP

InvestigationsInvestigations

DDDD

RxRx

APDAPD

HurryHurry

WorryWorry

CurryCurry

PathogenesisPathogenesis

Imbalance of acid-pepsin Imbalance of acid-pepsin and mucosal defenceand mucosal defence

H. pylori infectionH. pylori infection

NSAIDNSAID

ZE SyndromeZE Syndrome

Type A personalityType A personality

H.pyloriH.pylori

95% - duodenal ulcer95% - duodenal ulcer

80% - gastric ulcer80% - gastric ulcer

mucosal resistance hydrophobicitymucosal resistance hydrophobicity

eradication reduces ulcer eradication reduces ulcer recurrencerecurrence

NSAIDNSAID

Suppress prostaglandinsSuppress prostaglandinsprostaglandin prostaglandin ►► acid secretion acid secretion ▲▲ mucosal blood flowmucosal blood flow mucus & bicarbonate secretionmucus & bicarbonate secretion

10 -30% in chronic users10 -30% in chronic users

ZE= Zollinger Ellison SyndromeZE= Zollinger Ellison Syndrome

RecurrentRecurrent

RecalcitrantRecalcitrant

ResistantResistant

Unusual sitesUnusual sites

MultipleMultiple

MalignantMalignant

ZE SyndromeZE Syndrome

0.1 - 1.0% of peptic ulcer0.1 - 1.0% of peptic ulcer

Type I and Type IIType I and Type II

Gastrin secretion from non-beta cell Gastrin secretion from non-beta cell tumor of pancreas - tumor of pancreas - GastrinomaGastrinomaMC in pancreas ; duodenum, antrumMC in pancreas ; duodenum, antrum

ZE SyndromeZE Syndrome

20% multiple20% multiple

66% malignant66% malignant

slow growing indolent tumorslow growing indolent tumor

parietal cell mass increasedparietal cell mass increased

genetic basis genetic basis

massive hyper-secretion of acidmassive hyper-secretion of acid

ZE SyndromeZE Syndrome

MEN - IMEN - I– hyperparathyroidismhyperparathyroidism

– islet cell tumorislet cell tumor

– pituitary tumorspituitary tumors

A/ DUA/ DU

NSAIDsNSAIDs

Acid hypersecretionAcid hypersecretion

Rapid gastric emptyingRapid gastric emptying

Impaired acid disposalImpaired acid disposal

SmokingSmoking

Duodenal UlcerDuodenal Ulcer

Increased secretion of acidIncreased secretion of acid

More rapid gastric emptyingMore rapid gastric emptying

Decreased prostaglandinDecreased prostaglandin

Chronic duodenitis with H.pyloriChronic duodenitis with H.pylori

SmokingSmoking

Gastric UlcerGastric Ulcer

H.pyloriH.pylori

NSAIDsNSAIDs

Duodenogastric refluxDuodenogastric reflux

Impaired gastric mucosal defenseImpaired gastric mucosal defense

Gastric UlcerGastric Ulcer

Acid secretion - normal to lowAcid secretion - normal to low

Reflux of duodenal contents Reflux of duodenal contents gastritis gastritis ulcer ulcer

Pylorus sphincter disorderPylorus sphincter disorder

SmokingSmoking

Disturbed mucosa with low grade Disturbed mucosa with low grade gastritisgastritis

APDAPD

IncidenceIncidence

AetiologyAetiology

CPCPInvestigationsInvestigations

DDDD

RxRx

CPCP

Duodenal UlcerDuodenal Ulcer

– pain relieved by food or alkalipain relieved by food or alkali

– pain several hours after mealpain several hours after meal

Gastric Ulcer - gnawing or Gastric Ulcer - gnawing or burning pain on eating burning pain on eating

CPCP

Periodic chronic recurrent painPeriodic chronic recurrent pain

Nausea & vomitingNausea & vomiting

Weight lossWeight loss

Epigastric tendernessEpigastric tenderness

APDAPD

IncidenceIncidence

AetiologyAetiology

CPCP

InvestigationsInvestigationsDDDD

RxRx

InvestigationsInvestigations

Endoscopy Endoscopy – 90% sensitivity90% sensitivity

– must in all pts. with severe pain must in all pts. with severe pain

– excludes malignancyexcludes malignancy

– biopsy can be takenbiopsy can be taken– test for H.pyloritest for H.pylori

InvestigationsInvestigations

Barium MealBarium Meal double (air) contrast double (air) contrast – 90% sensitivity 90% sensitivity

H Pylori detection:H Pylori detection:

Breath testBreath test

Blood testBlood test

Tissue testTissue test

APDAPD

IncidenceIncidence

AetiologyAetiology

CPCP

InvestigationsInvestigations

DDDDRxRx

DDDD

CholecystitisCholecystitis

Hiatus herniaHiatus hernia

PancreatitisPancreatitis

MIMI

PneumoniaPneumonia

Dissecting aneurysmDissecting aneurysm

Worm InfestationsWorm Infestations

APDAPD

IncidenceIncidence

AetiologyAetiology

CPCP

InvestigationsInvestigations

DDDD

RxRx

Rx - MedicalRx - Medical

Stop smoking, NSAIDsStop smoking, NSAIDs

Stop alcoholStop alcohol

Antacids - acid neutralisationAntacids - acid neutralisation

HH22 receptor antagonist -Ranitidine receptor antagonist -Ranitidine

- secretion inhibition- secretion inhibition

Rx- MedicalRx- Medical

HH++ pump inhibition - H pump inhibition - H++/K/K++ase ase inhibition - Omeprazoleinhibition - Omeprazole

Anticholinergic - secretory inhibitionAnticholinergic - secretory inhibition

Prostaglandin - MisoprostolProstaglandin - Misoprostol - mucosal - mucosal

protectionprotection

Proton Pump BlockersProton Pump Blockers

OmeperazoleOmeperazole

Eso-meperazoleEso-meperazole

Rabi-meperazoleRabi-meperazole

Rx - MedicalRx - Medical

Sucralfate - protective coatingSucralfate - protective coating

Colloidal Bismuth Colloidal Bismuth – eradicate H.pylorieradicate H.pylori

– protective coatingprotective coating

Antibiotics - H.pyloriAntibiotics - H.pylori

Kit for H PyloriKit for H Pylori

H2 Receptor AntagonistsH2 Receptor Antagonists

On parietal cellsOn parietal cells

Decrease basal & stimulated acid Decrease basal & stimulated acid secretionsecretion

Pepsin output decreasedPepsin output decreased

Decreased gastric blood flowDecreased gastric blood flow

Competitive inhibitor of parietal cellCompetitive inhibitor of parietal cell

Rx - Duodenal UlcerRx - Duodenal Ulcer

95% control - medical Rx95% control - medical Rx

Surgery-Outdated, ObsoleteSurgery-Outdated, Obsolete

Omeprazole better thanRanitidineOmeprazole better thanRanitidine

Ulcer heels in 80% by 6 mUlcer heels in 80% by 6 m

recurrence in 95% by recurrence in 95% by H.pylori eradicationH.pylori eradication

Rx - Duodenal UlcerRx - Duodenal Ulcer

Indications for surgeryIndications for surgery =Compl=Compl–HemorrhageHemorrhage

–ObstructionObstruction

–PerforationPerforation

–Intractability of painIntractability of pain

Intractable pain Intractable pain ►► HSV / TV + GJ HSV / TV + GJ

Rx - DURx - DU

H2 blockers heals 75% DU in 4 H2 blockers heals 75% DU in 4 weeksweeks

H/K proton pump inhibitor better H/K proton pump inhibitor better resultsresults

ulcer may recurr in 80% cases on ulcer may recurr in 80% cases on stoppingstopping

treatment of H.pylori treatment of H.pylori

Rx - DURx - DU

Indication of surgery in hemorrhageIndication of surgery in hemorrhage

bleeding of > than 6 unitsbleeding of > than 6 units

recurrent bleed after endoscopic recurrent bleed after endoscopic controlcontrol

pyloro-duodenotomy and control of pyloro-duodenotomy and control of bleedingbleeding

HSV or TV + GJHSV or TV + GJ

Rx - DURx - DU

Perforation - simple closure with Perforation - simple closure with omental patchomental patch -Graham’s patch-Graham’s patchdefinitive surgery definitive surgery –HSVHSV–TV + pyloroplastyTV + pyloroplasty–parietal cell vagotomyparietal cell vagotomy–TV+GJTV+GJ

Rx GURx GU

Omeprazole, H2 receptor Omeprazole, H2 receptor antagonist - 8 weeksantagonist - 8 weeks

if pain not relieved by 2 weeks - if pain not relieved by 2 weeks - add one more drugadd one more drug

repeat endoscopy after 8 weeksrepeat endoscopy after 8 weeks

if no healing by 12 - 115 weeksif no healing by 12 - 115 weeks - -

SurgerySurgery

Rx - GURx - GU

Type I - Distal Gastrectomy with Type I - Distal Gastrectomy with vagotomy + G-D or GJvagotomy + G-D or GJ

proximal ulcer- total gastrectomyproximal ulcer- total gastrectomy

parietal cell vagotomy - high parietal cell vagotomy - high recurrencerecurrence

Hemorrhage Hemorrhage

Hemorrhage - potential cause of Hemorrhage - potential cause of deathdeath

15 -20% gross bleeding15 -20% gross bleeding

erosion of duodenal ulcer into erosion of duodenal ulcer into gastro-duodenal arterygastro-duodenal artery

Endoscopy –laser, sclerosant Endoscopy –laser, sclerosant oralcohal injectionoralcohal injection

PerforationPerforation

In 5-10% of casesIn 5-10% of casespneumo-peritoneum in 75% casespneumo-peritoneum in 75% casesperitonitis, pain, ileusperitonitis, pain, ileusleukocytosis, hypovolumia, IIIrd leukocytosis, hypovolumia, IIIrd space lossspace lossDD - acute appendicitis, enteric DD - acute appendicitis, enteric perf.perf.

ObstructionObstruction

Chronic ulcer disease with edema Chronic ulcer disease with edema and scarringand scarring

in 5% cases of DUin 5% cases of DU

nausea, vomiting, abdominal nausea, vomiting, abdominal distensiondistension

metabolic alkalosis, paradoxical metabolic alkalosis, paradoxical aciduriaaciduria

ObstructionObstruction

EndoscopyEndoscopy

Ba studyBa study

ScintigraphyScintigraphy

Rx V + G-J / G-DRx V + G-J / G-D