PEPTIC ULCER DISEASEPEPTIC ULCER DISEASE

PATHOGENYPATHOGENY Low PGE2 secretionLow PGE2 secretion

Low secretion of mucus and bicarbonateLow secretion of mucus and bicarbonate Decreased vascular flow in the mucosaDecreased vascular flow in the mucosa Low epithelial proliferationLow epithelial proliferation

Low resistance to aggresionLow resistance to aggresion Endogenic factors (Endogenic factors (HCl, pepsinHCl, pepsinee, , biliary salts)biliary salts) Exogenic facotrs (Exogenic facotrs (NSAIDs, alcoNSAIDs, alcohhol, etcol, etc))

Helicobacter pyloryHelicobacter pylory 90% in90% in duodenal ulcer and duodenal ulcer and 75% 75% gastric ulcergastric ulcer GG-- bacili bacili Produce ureaProduce ureasissis AsociatAsociated with antrala gastritised with antrala gastritis MecMechhanismanism

Toxic products that produce local injury Toxic products that produce local injury Induces a local imune responseInduces a local imune response Increases the acid secretionIncreases the acid secretion

NSAIDsNSAIDs Low trophicity of the mucus layerLow trophicity of the mucus layer Low synthesis of PGE2Low synthesis of PGE2

SPECIAL SITUATIONSSPECIAL SITUATIONS Gastrinoma - sdr. Zollinger-EllisonGastrinoma - sdr. Zollinger-Ellison

Pancreatic isle tumorPancreatic isle tumor Very high secretion of gastrineVery high secretion of gastrine 25% MEN I25% MEN I

HHyypercalcemia percalcemia Acid hypersecretionAcid hypersecretion Gastrine hypersecretionGastrine hypersecretion

Genetic factorsGenetic factors 3x risk in first degree relatives3x risk in first degree relatives

SmokingSmoking 22x riskx risk

SteressSteress Increases the acidic secretionIncreases the acidic secretion

AlcoAlcohol and diethol and diet

PATHOLOGYPATHOLOGY

UG şi UDUG şi UD

GastrinGastrinee, Calciu, Calciumm, , acid output?acid output? Detection of HPyloriDetection of HPylori

EEndo biopsyndo biopsy Urea breath testUrea breath test Immunological detection AbImmunological detection Ab

TRTREEATMENTATMENT

MEDICALMEDICAL goalsgoals– – relieve symptoms, heal, prevent relieve symptoms, heal, prevent

recurrence and complicationsrecurrence and complications 1. 1. AAvoidvoid substances that induce ulcersubstances that induce ulcer

NSAID, smoking, stress NSAID, smoking, stress 2. Ant2. Antiiacidacide medicatione medication

1-3 ore 1-3 ore after meal and in the evening after meal and in the evening → → buffers buffers acid outputacid output

Mg → diareMg → diareaa; ; CIND in chronic renal disease CIND in chronic renal disease Al → constipaAl → constipationtion → hi → hippoophphosfatemiosfatemiaa Ca → rebound acidCa → rebound acid secretion secretion, hipercalcemie, , hipercalcemie,

hipercalciurihipercalciuriaa

TRATAMENTTRATAMENT 3. 3. Inhibit acid secretionInhibit acid secretion H2 H2 blockers on the parietal cellsblockers on the parietal cells → inhib → inhibition of ition of

acid secretionacid secretion CimetidinCimetidinee , Ranitidin , Ranitidinee → → side effects: side effects: ginecomastiginecomastiaa, ,

impotenimpotencece, antiandrogenic, antiandrogenic effect effect FamotidinFamotidinee,, NizatidinNizatidine – much bettere – much better Healing achieved in Healing achieved in 8-12 8-12 weeks inweeks in 80-90% pa 80-90% pattienientsts Recurrence rate 25-40% at 6 2weeksRecurrence rate 25-40% at 6 2weeks

PPIPPI Omeprazol, Omeprazol, LLansoprazol, ansoprazol, PPantoprazol, antoprazol, RRabeprazol, abeprazol,

EEsomeprazolsomeprazol PPI blockage for 24 hoursPPI blockage for 24 hours Also indicated in long term treatment of ZE syndrome Also indicated in long term treatment of ZE syndrome

TRTREEATMENTATMENT 4. 4. agents with barrier effectagents with barrier effect

Sucralfat Sucralfat complex complex ofof AlOH şi AlOH şi sucrosucrose sulfatese sulfate → stimul → stimulates ates

the endogenous synthesis of PGthe endogenous synthesis of PG effecteffect – bar – barrrier ier on the base of the ulceron the base of the ulcer Inhibits the action of pepsinInhibits the action of pepsin Binds pepsin and biliary saltsBinds pepsin and biliary salts NNo neutralizing effecto neutralizing effect SE – prevents absorption of other drugsSE – prevents absorption of other drugs

5. PGE 5. PGE Inhibits secretion of acid and increases the Inhibits secretion of acid and increases the

mucus protection of the duodenal mucosamucus protection of the duodenal mucosa MisoprostoMisoprostoll

TRTREEATMENTATMENT 6. 6. Anti H. Pylori treatment Anti H. Pylori treatment

IPP+claritromIPP+claritromyycincine +e +amoxicilinamoxicilinee ±± metranidazolmetranidazol 7 days + 14/28 days7 days + 14/28 days

IIndicandicationstions H.pyloriH.pylori pozitive pozitive In vitro sensitivity for recurencesIn vitro sensitivity for recurences Test for eradication 4-6 weeks or if requiredTest for eradication 4-6 weeks or if required

TRTREEATMENTATMENT

SURGICALSURGICAL IndicationsIndications

Inefficient medical treatment +/-Inefficient medical treatment +/- ComplicaComplicationstions

perforaperforationtion obstrucobstructiontion bleedingbleeding penetrapenetrationtion

Operative mortality in elective cases Operative mortality in elective cases <1%<1%

10% - 10% - recurence recurence after or during after or during therapy due to therapy due to HPylori HPylori

Not used any moreNot used any more History + patients History + patients

with resections in with resections in PMH PMH

BLEEDING ULCERBLEEDING ULCER 5-20%5-20% > 75% > 75% managed with medical therapymanaged with medical therapy INDICATIONS FOR SURGERYINDICATIONS FOR SURGERY

Massive bleeding with shockMassive bleeding with shock Repeated Repeated 6 unit 6 unitss of blood in of blood in 224 4 hh Recurrent bleeding during therapyRecurrent bleeding during therapy Old persons may require it earlierOld persons may require it earlier

endoscopendoscopyy – – local treatmentlocal treatment Angiography - Angiography - embolisationembolisation SURGERYSURGERY

In situ hemostasisIn situ hemostasis ResectionsResections BiopsyBiopsy Evaluation for other sources of bleedingEvaluation for other sources of bleeding

PERFORAPERFORATIONTION

nonoperatnonoperativeive– Taylor– Taylor Nasogastric tube Nasogastric tube ++ ATB + watch ATB + watch High risk patientsHigh risk patients

operatoperationion Simple sutureSimple suture ±± omentum or omentum or glueglue Excision sutureExcision suture ±± omentum or glueomentum or glue Omental patchOmental patch +/- resection +/- VT+/- resection +/- VT

PENETRPENETRATIONATION

OBSTRUCOBSTRUCTIONTION VVomitingomiting Gastric stasisGastric stasis SSndrndr Darrow Darrow AlcaloAlcalosis, hypoCl, HypoK, HypoNasis, hypoCl, HypoK, HypoNa

MALIGNANT TUMORS MALIGNANT TUMORS OF THE STOMACHOF THE STOMACH

LYMPHOMALYMPHOMA

Gastric location – the most frequentGastric location – the most frequent 2% 2% of allof all <15% <15% of all gastric tumorsof all gastric tumors >50 >50 yy 3 3 typestypes

Difuse B cell lymphomaDifuse B cell lymphoma 55% 55% MALTMALT (mucosa associated lymphatic tissue (mucosa associated lymphatic tissue L) L) – –

40%40% LL Burkitt – 3% Burkitt – 3%

LymphomaLymphoma

PathogenyPathogeny ImunodeficImunodeficiencyiency HpyloriHpylori Epstein BarrEpstein Barr infections infections

StaStagingging Std I – T limitStd I – T limited to digestive tracted to digestive tract Std II– Std II– regional LNregional LN Std III – extraregionalStd III – extraregional LN LN Std IV – Std IV – other intraabdominal other intraabdominal

organs/extraabdominal extensionorgans/extraabdominal extension

LymphomaLymphoma DiagnosticDiagnostic ClinicClinicalal

NNonspecificonspecific ParaclinicParaclinic EndoscopEndoscopyy+biops+biopsyy CT, RMN, CT, RMN,

echoendoscopechoendoscopyy – – stastagege

ImunohistochImunohistochemistremistryy – – characterization characterization of phenotypeof phenotype

LymphomaLymphoma TRATAMENTTRATAMENT CHT + RXT + biological therapyCHT + RXT + biological therapy SurgerySurgery

NO – only in emergency or missdiagnosticNO – only in emergency or missdiagnostic HPylori eradicationHPylori eradication

MALT MALT early stageearly stage Limited extension diffuse Limited extension diffuse B B cell cell

lymphomalymphoma PROPROGGNOSTICNOSTIC

55y survivaly survival 95% - std I95% - std I 75% - std II75% - std II

SARCOMASARCOMA 3% din TM gastrice3% din TM gastrice GISTGIST more frequent – special more frequent – special

characterscharacters 60-70%60-70% of all sarcomas of all sarcomas

PATOGENIEPATOGENIE CajalCajal cells cells (pacemaker(pacemakers)s)

In the muscle layerIn the muscle layer Expresses Expresses protooncogenprotooncogenicic KIT (CD117) CD34 KIT (CD117) CD34

mutationmutation

Staging of GISTStaging of GIST Mitotic indexMitotic index

<5 <5 mitosis/mitosis/ 50 50 HPFHPF – benign – benign behavior behavior > 5 > 5 mitosis/mitosis/ 50 50 HPFHPF – – malignant behaviormalignant behavior >50 >50 mitosis/mitosis/ 50 50 HPFHPF – – very aggressivevery aggressive

MalignMalignant behaviorant behavior T>5 cmT>5 cm Cellular atypies Cellular atypies NecroNecrosissis Local invasionLocal invasion c-KITc-KIT mutation mutation

Benign:malign=3-5:1Benign:malign=3-5:1 Even “benign” phenotype can produce Even “benign” phenotype can produce

metastasismetastasis

GISTGIST DiagnosticDiagnostic dispepsiadispepsia, , bleedingbleeding EndoscopEndoscopyy+biops+biopsyy CTCT ImunohistochImunohistochemistryemistry TrTreeatmentatment Surgical (excision) Surgical (excision) RXT + CHT not goodRXT + CHT not good Imatinib mesylateImatinib mesylate

Competitor inhibition of Competitor inhibition of tirozine kinaze associated tirozine kinaze associated with KITwith KIT

INDICATIONS:INDICATIONS: High riskHigh risk Non resectable Non resectable MetastaticMetastatic

BENIGN BENIGN TUMORSTUMORS

3-5% 3-5% from all gastric from all gastric tumorstumors

Any originAny origin 40% muco40% mucosasa şi 40% şi 40%

muscularismuscularis TTypesypes

PolPolypsyps sporadicsporadic PolPolyps associated with yps associated with

genetic diseases (FAP, genetic diseases (FAP, sdr. sdr. Peutz-JegersPeutz-Jegers))

LeiomiomLeiomiomaa GISTGIST FibromFibromaa, fibromiom, fibromiomaa LipomLipomaa Ectopic pancreasEctopic pancreas Vascular, neurogenicVascular, neurogenic CystsCysts Mucocel Mucocel

POLYPSPOLYPS HiperplasticHiperplastic

28-75%28-75% <1,5 cm<1,5 cm Associated with atrophic Associated with atrophic

gastritis with HPgastritis with HP 2% 2% can develop can develop malignmalign

FundiFundicc 47%47% Sesil, 2-3 mmSesil, 2-3 mm Never transform malignantNever transform malignant On healthy mucosaOn healthy mucosa AsociaAsociated with ted with FAP, GardnerFAP, Gardner

sdrsdr)) AdenomatoAdenomatoss

10%10% RisRisk to develop cancerk to develop cancer – 21% – 21% > 4 cm 40%> 4 cm 40% risc of ADK risc of ADK If present: high risk for cancer If present: high risk for cancer

on any part of stomachon any part of stomach

DiagnosticDiagnostic ClinicClinicalal

AsimptomaticAsimptomatic Endoscopy: by chanceEndoscopy: by chance Can produce Can produce

obstruction, torsion, obstruction, torsion, bleeding bleeding

ParaclinicParaclinicalal EndoscopEndoscopyy +biops +biopsyy EchoendoscopEchoendoscopyy IImunohistochmunohistochemistryemistry

TrTreeatamentatament ObservaObservationtion EEndoscopic excisionndoscopic excision

SmallSmall<2 cm<2 cm AdenomatoAdenomatoss, ,

hiperplastichiperplastic PolipPolips associated with s associated with

sdr. Peutz-Jegers, sdr. Peutz-Jegers, Gardner, Cronkhite-Gardner, Cronkhite-Canada, Canada, juvenile juvenile poliposis) poliposis)

Small Small stromalstromal tumors tumors SurgicalSurgical

ExciExcisionsion ComplicateComplicated tumorsd tumors Unclear diagnosticUnclear diagnostic

RezecRezectiontion

GASTRIC VOLVULUSGASTRIC VOLVULUS VolvereVolvere (lat)= (lat)= rotated around axisrotated around axis PatPathholoologygy To be able to rotate with To be able to rotate with 180º180º only if only if

significant laxity.significant laxity. Special anatomy Special anatomy ClasificaClasification tion etethhiologiologyy

idiopaticidiopatic secundarsecundaryy(75%):(75%):

1.1.associated with HHassociated with HH 2.2.associated with other diaphragmatic hernias associated with other diaphragmatic hernias 3.pyloric obstructi3.pyloric obstructi

GASTRIC GASTRIC VOLVULUSVOLVULUS

ClassificationClassification organoaxialorganoaxial-- axis = axis =

cardia-pyloruscardia-pylorus More frequent More frequent Majority with acute Majority with acute

presentationpresentation Associated with HH or Associated with HH or

diaphragmatic diaphragmatic deffectsdeffects

mezentericoaxialmezentericoaxial--axis perpendicular on axis perpendicular on the preciousthe precious More often partialMore often partial Not very frequentNot very frequent

GASTRIC VOLVULUSGASTRIC VOLVULUS How muchHow much::

totaltotal partialpartial

Severity Severity acute: acute: obstructio + vascular problems obstructio + vascular problems

(gangrene) – very unusual ischemic due (gangrene) – very unusual ischemic due to complex irrigation to complex irrigation

cchhronic, recurrentronic, recurrent more frequent more frequent

DIAGNOSTICDIAGNOSTIC ClinicClinicalal:: cchhronic: ronic:

Asymptomatic – discovered during barium Asymptomatic – discovered during barium mealmeal

Light unspecific symptoms: meteorism, Light unspecific symptoms: meteorism, burping, vomiting, pain. burping, vomiting, pain.

acutacutee:: Major emergencyMajor emergency 1.1.severe pain with abdominal distensionsevere pain with abdominal distension 2.2.try to vomit but vomiting is impossible try to vomit but vomiting is impossible 3.3.impossible to pass a naso-gastric tubeimpossible to pass a naso-gastric tube NecroNecrosis, bleeding, respiratory failure, sis, bleeding, respiratory failure,

shockshock

TREATMENTTREATMENT

Only if simptomaticOnly if simptomatic CChhronic:ronic:

Careful for associated problem or anything Careful for associated problem or anything that can mimicthat can mimic

Laparoscopy: local evaluationLaparoscopy: local evaluation

Primary (idiopatic) gastropexy – Primary (idiopatic) gastropexy – fixation of stomach to the diaphragm fixation of stomach to the diaphragm

and mediogastric, in order to prevent and mediogastric, in order to prevent further volvulusfurther volvulus

TREATMENTTREATMENT Secondary: treat the underlying Secondary: treat the underlying

pathology. If easy to fixpathology. If easy to fix

Secondary with difficult to treat Secondary with difficult to treat conditions (ligamentary laxity, conditions (ligamentary laxity, diaphragmatic hernia, etc)diaphragmatic hernia, etc) Partial gastrectomyPartial gastrectomy Fixation of transverse colon Fixation of transverse colon

Acut:Acut: Naso-gastric tube: immediate reduction Naso-gastric tube: immediate reduction

(unusual)(unusual).. SurgerySurgery

necorsisnecorsis = = resections resections Treat de causeTreat de cause Prevent reucrence: gastropexie, etcPrevent reucrence: gastropexie, etc

SURGERY FOR MORBID SURGERY FOR MORBID OBESITYOBESITY

>>300 mili300 milionsons –– 2-7% 2-7% all medic al spendingsall medic al spendings USA >50% of adults are obese or USA >50% of adults are obese or

overweighed, 5% morbid obesity overweighed, 5% morbid obesity

CHIRURGIA OBEZITĂŢII CHIRURGIA OBEZITĂŢII MORBIDEMORBIDE

IMC>40kg/m2IMC>40kg/m2 IMCIMC

Normal 20-24,9Normal 20-24,9 OverweightOverweight 25-29,9 25-29,9 ObeObesitysity 30-34,9 30-34,9 Morbid obesityMorbid obesity 35- 35-

39,939,9

TREATMENTTREATMENT ApproachesApproaches::

Change life styleChange life style medicationmedication surgerysurgery

Life style changesLife style changes Low calory dietLow calory diet (800-1200 kcal/ (800-1200 kcal/dayday)): goal: : goal:

8% loss with a decrease of fat tissue over 6 8% loss with a decrease of fat tissue over 6 monthsmonths

ExerciseExercise, 3-7 , 3-7 sessionssessions//wkwk for for 30-60 min30-60 min 2- 2-3% decrease in body weight3% decrease in body weight

Behavioral therapy: Behavioral therapy: change life style change life style (identification of stimuli, autoevaluation, (identification of stimuli, autoevaluation, support group)support group)

TREATMENTTREATMENT

MedicationMedication When life style changes do not helpWhen life style changes do not help sibutramine, sibutramine, inhibits inhibits serotonineserotonine

reabsorbtionreabsorbtion orlistat, orlistat, inhibits pancreatic lipaseinhibits pancreatic lipase

6-10% 6-10% reduction in body weight in 1 year reduction in body weight in 1 year (rebound after stop)(rebound after stop)

SURGERY SURGERY IndicaIndicationstions

IMC>40 IMC>40 IMC>35 IMC>35 with comorbiditieswith comorbidities AAfter at least one year of medical therapy fter at least one year of medical therapy Obesity should be stable or worsening in the Obesity should be stable or worsening in the

last 5 yearslast 5 years

ContraindicaContraindicationstions PsihiatriPsihiatric problemsc problems Thyroid or adrenal problemsThyroid or adrenal problems Chronic inflammatory pathology of digestive Chronic inflammatory pathology of digestive

tracttract Drug or alcohol abuse Drug or alcohol abuse

SURGERYSURGERY A. A. RRestrictiveestrictive procedures procedures Diminishes the gastric reservoir to Diminishes the gastric reservoir to 15-20 15-20

ml, ml, limiting the ingestion of solids and limiting the ingestion of solids and inducing early feeling of being full inducing early feeling of being full

Two proceduresTwo procedures Gastric bandingGastric banding Calibrated vertical gastroplasty Calibrated vertical gastroplasty .. Resection of the major curvatureResection of the major curvature

B. B. Malabsorbitve proceduresMalabsorbitve procedures Biliopancreatic diversion +/- duodenal Biliopancreatic diversion +/- duodenal

switchswitch

SURGERYSURGERY

C. C. Mixt proceduresMixt procedures Restriction + malabsorbtive procedureRestriction + malabsorbtive procedure Gastric by-pass with Gastric by-pass with „Y”„Y” loop. loop. The The

gold standard in surgical procedure for gold standard in surgical procedure for obesityobesity

POSTGASTRECTOPOSTGASTRECTOMY SINDROMES MY SINDROMES

Long term incidence 20%Long term incidence 20% MechanicalMechanical

Alkaline reflux gastritis Alkaline reflux gastritis Aferent loop syndromeAferent loop syndrome Blind loop syndromeBlind loop syndrome Recurent ulcer diseaseRecurent ulcer disease BezoarBezoarss CarcinomCarcinomaa

FunctionalFunctional Dumping (early or late)Dumping (early or late) DiarDiarhheeaeea MalnutriMalnutritiontion

Alkaline reflux Alkaline reflux

gastritisgastritis CauCausesses Very frequent afterVery frequent after

BillrothIIBillrothII VT+GEAVT+GEA

Not oftenNot often Billroth I Billroth I GEAGEA

UnusualUnusual VT+P:VT+P:

Not afterNot after PCVPCV

Alkaline reflux Alkaline reflux gastritisgastritis

SimptomSimptomss Nausea, vomiting Nausea, vomiting

(bile) epigastric (bile) epigastric pain, loss of weight pain, loss of weight

Not better after Not better after antiacide antiacide medication or food. medication or food. May be better after May be better after vomitingvomiting

DiagnosticDiagnostic EndoscopEndoscopyy

See the refluxSee the reflux Lesions: eritema, Lesions: eritema,

ulcerationsulcerations BiopsBiopsy y

Alkaline reflux gastritisAlkaline reflux gastritis

TrTreeatmentatment MedicalMedical

ProstaglandineProstaglandine Metoclopramid, Metoclopramid,

cisapridcisaprid?????? ColestiraminColestiraminee

SurgicalSurgical GJA Roux (Y)+VTGJA Roux (Y)+VT

Afferent loop Afferent loop syndromesyndrome CauCausese

Billtoth IIBilltoth II SimptomSimptomss

RUQ painRUQ pain SenSensation of abdominal sation of abdominal

fulnessfulness Simptoms better after Simptoms better after

vomiting with bile and vomiting with bile and food food

DiagnosticDiagnostic USUS

Dilated afferent loop Dilated afferent loop and duodenumand duodenum

Rx Rx with bariumwith barium Barium enters the Barium enters the

aferent loop and aferent loop and duodenum which are duodenum which are distended distended TratamentTratament

Treatment: conversion Treatment: conversion Billroth II Billroth II iin Billroth In Billroth I

Blind loop syndrome Blind loop syndrome Complete obstruction of aff Complete obstruction of aff

erent looperent loop Technical errorTechnical error AdAdhesionshesions Internal hernia, invagination, Internal hernia, invagination,

volvulusvolvulus Anastomotic ulcer, cancerAnastomotic ulcer, cancer

Bacterian proliferationBacterian proliferation – – deconjugation of bile salts, deconjugation of bile salts, lipolisis, diarhea, weigh loss, lipolisis, diarhea, weigh loss, malabsorbtion of fat and malabsorbtion of fat and B12 B12

SimptomSimptomss Violent abdoinal painViolent abdoinal pain Vomiting (not with bile) Vomiting (not with bile) Jaundice Jaundice Pancreatitis Pancreatitis

Blind loop syndrome Blind loop syndrome DiagnosticDiagnostic

Rx Rx abdominal plain abdominal plain Rx Rx contrastcontrast EndoscopEndoscopyy USUS

TrTreeatmentatment Atb, pancreatic enzyme Atb, pancreatic enzyme

supplemets supplemets Surgical correction Surgical correction Coversion to Billroth ICoversion to Billroth I

DUMPINGDUMPING CaCauseuse

by-pass or excision of by-pass or excision of piloruspilorus

GEA+VT, GEA+VT, total gastrectomytotal gastrectomy PathogenyPathogeny

Sudden decrease of Sudden decrease of plasmatic volume due to plasmatic volume due to sudden increase of osmotic sudden increase of osmotic pressure in the small bowellpressure in the small bowell

ConsequencesConsequences Rapid gastric emtying + Rapid gastric emtying +

rapid intestnial passagerapid intestnial passage Jejunal distensionJejunal distension Low pasmatic volumeLow pasmatic volume TachicardiaTachicardia Low blood pressureLow blood pressure Low serum KLow serum K EKG changesEKG changes

DUMPINGDUMPING SimptomatomsSimptomatoms

gastrointestinal gastrointestinal Epigastric discomfort, fulness, bloating, crampy Epigastric discomfort, fulness, bloating, crampy

abdominal pain, vomiting, diarrhea. abdominal pain, vomiting, diarrhea. neurovegetatitveneurovegetatitve

Weekness, dizziness, pale, vertigo, palpitation Weekness, dizziness, pale, vertigo, palpitation sweatingsweating

Triggered by food rich in carbohydrates Triggered by food rich in carbohydrates

Early Dumping Early Dumping Often symptoms start very early after eating Often symptoms start very early after eating

or during eatingor during eating Relieved within 1 hourRelieved within 1 hour

Late DumpingLate Dumping 1-2 hours after meal 1-2 hours after meal Due to hypoglicemiaDue to hypoglicemia

DUMPINGDUMPING DiagnosticDiagnostic

SimptomSimptomss i.v. glucose makes symptoms betteri.v. glucose makes symptoms better Exclude other diseasesExclude other diseases

TrTreeatmentatment 2/3 will feel better without treatment,2/3 will feel better without treatment, dietdiet

Main alternative for 80% ptMain alternative for 80% pt Meals with lots of proteins and carbohydrates in small quantity Meals with lots of proteins and carbohydrates in small quantity No drinks during meal (not to solve hypertonic liquids) 35-40 No drinks during meal (not to solve hypertonic liquids) 35-40

minutes later minutes later medication medication

antihistaminics, sedative, serotonine antagonists, antihistaminics, sedative, serotonine antagonists, parasimpatomimetics, verapamilparasimpatomimetics, verapamil, , octeotride and somatostatineocteotride and somatostatine

surgicalsurgical Piloric reconstructionPiloric reconstruction ConversiConversionon GEA GEA iin Billroth In Billroth I Jejunal interpositionJejunal interposition

Late dumpingLate dumping Initial hyperglicemia → excess insulin → rapid Initial hyperglicemia → excess insulin → rapid

metabolism → hypoglicemie metabolism → hypoglicemie SimptomsSimptoms

Senzation of hot, sw2eating, tremor, dizinessSenzation of hot, sw2eating, tremor, diziness Often 1 hour after meal for as long as 10-20 minutes , Often 1 hour after meal for as long as 10-20 minutes ,

unusual it can produce convulsionunusual it can produce convulsion DiagnosticDiagnostic

Severe hypoglicemia Severe hypoglicemia TreatmentTreatment

Frequent eating with low content in carbohydratesFrequent eating with low content in carbohydrates Medication: late glucose absorbtion - pectina,Medication: late glucose absorbtion - pectina,

diazoxid, octeotridediazoxid, octeotride SurgerySurgery

Antiperistaltic loop between stomac and duodennum Antiperistaltic loop between stomac and duodennum Pyloric reconstructioPyloric reconstructio ConversiConversionon GEA GEA iin Billroth In Billroth I

Postvagotomy DiarrheaPostvagotomy Diarrhea Not clear mechanism Not clear mechanism After truncal vagotomy After truncal vagotomy DiarrDiarrhheeaa

1-3-8 /zi1-3-8 /zi Explosive diarrhea without worning +/- Explosive diarrhea without worning +/-

incontinenceincontinence May last 3 months potopMay last 3 months potop

TrTreeatmentatment diet: avoid coffee, and foods associated with diet: avoid coffee, and foods associated with

diarrheadiarrhea Medication: :colestiramina,codeine 1-3 hours Medication: :colestiramina,codeine 1-3 hours

before meal, verapamil, octeotridebefore meal, verapamil, octeotride Surgery: Surgery:

Pyloric reconstructionPyloric reconstruction Antiperistaltic loop 48-135 cm from Treitz. Antiperistaltic loop 48-135 cm from Treitz.

MALNUTRIMALNUTRITIONTION MalabsorbMalabsorbtiontion

Fat, liposoluble vitamines, proteins, B12, Fe, Ca, Po4, folic acidFat, liposoluble vitamines, proteins, B12, Fe, Ca, Po4, folic acid TypicalTypical

Weight loss, steathorea, anemia, osteoporosis, osteomalaciaWeight loss, steathorea, anemia, osteoporosis, osteomalacia CauCausesses

Total/Subtotal gastrectomyTotal/Subtotal gastrectomy Reconstructions that favor rapid transitReconstructions that favor rapid transit

DiagnosticDiagnostic Low serum level of Low serum level of de Ca, Fe, vitaminede Ca, Fe, vitamine SStool - steathoreatool - steathorea Test Schilling Test Schilling B12 absorbtion B12 absorbtion Juejunal biopsy Juejunal biopsy

TrTreeatment atment Diet – vitamine, mineralDiet – vitamine, mineralss, , pancreatic enpancreatic enzimezimess Surgical correctionSurgical correction

Blind loopBlind loop Billroth II Billroth II iin Billroth In Billroth I

Recurent ulcerRecurent ulcer CauCausesses

VT VT (inadequat???)(inadequat???) 1-2% 1-2% afterafter antrectom antrectomyy +VT +VT Antral stasisAntral stasis Incomplet resection???Incomplet resection???

Close to or on the anastomosisClose to or on the anastomosis SimptomSimptomss

Peptic ulcerPeptic ulcer DiagnosticDiagnostic

Rx bariRx barium,um, endoscop endoscopy, serum level ofy, serum level of Ca şi gastrinei Ca şi gastrinei TrTreeatamentatament

Medical – IPP, etc.Medical – IPP, etc. Surgical – not anymoreSurgical – not anymore

BezoarBezoarss Insoluble vegetable fibers - Insoluble vegetable fibers -

fitobezoafitobezoarsrs CausesCauses

Low acid output Low acid output Digestion in stomach limitedDigestion in stomach limited Low proteolitic activityLow proteolitic activity Changes in gastric motilityChanges in gastric motility Dental problem or mastication Dental problem or mastication

insuficientinsuficient

SSimptomsimptoms Up to 10 years from operation, Up to 10 years from operation,

unspecific symptomsunspecific symptoms Eary senzation of fulness bed Eary senzation of fulness bed

odor in respiration odor in respiration May produce intestinal May produce intestinal

obstruction if pasage in small obstruction if pasage in small bowellbowell

Gastric outlet obstruction not Gastric outlet obstruction not possible (floats)possible (floats)

ComplicationComplicationss malnutritionmalnutrition gastritisgastritis ulcerulcer bleedingbleeding Intestnal Intestnal

obstruction obstruction and and perforationperforation

BezoarBezoarss DDiagnosticiagnostic

Rx. + barium: filling defect ~ cancer Rx. + barium: filling defect ~ cancer Endoscopy Endoscopy Obstruction – may mimic adhesions or anything Obstruction – may mimic adhesions or anything

TTratamentratament Conservative Conservative

Gastric lavajGastric lavaj Endoscopic mechanic destruction Endoscopic mechanic destruction Enzimatic disolution Enzimatic disolution

Surgery Surgery Gastrotomy and removal Gastrotomy and removal

ProfilaxisProfilaxis Good dentitionGood dentition Low fiberLow fiber

CaCancer formationncer formation

High incidence after any High incidence after any operation operation

5y after cance 5y after cance roperation = second roperation = second cancer cancer

Risk increases after 10 yRisk increases after 10 y localisationlocalisation

Close to anastomosis, Close to anastomosis, usually without involving usually without involving the jejunumthe jejunum

Proximal part of gastric Proximal part of gastric remnantremnant

Cancer should be Cancer should be searched for for any new searched for for any new symptomssymptoms

DiagnosticDiagnostic Endoscopy: multiple Endoscopy: multiple

biopsies +/- citology biopsies +/- citology with brushwith brush

TrTreeatmentatment Gastric resectionGastric resection