Peptic Ulcer

Fatimah Abdullah

6th year MS, KFU

Objectives Definition.

Pathophysiology.

Etiology.

Clinical Picture.

Management.

DEFINITIONBreak in the gastrointestinal mucosa exposed to the aggressive action of acid-peptic juices.

Common sites are the first part of the

duodenum and the lesser curve of the

stomach.

The gastroduodenal mucosal integrity is determined by protective (defensive) & damaging (aggressive) factors.

PATHOPHYSIOLOGY

Pathophysiology• Bicarbonate• Mucus layer• Prostaglandins• Mucosal blood flow• Epithelial renewal

Defensive

• Helicobacter pylori• NSAIDs• Pepsins• Bile acids• Smoking and alcohol

Aggressive

Mucosal damage erosions & ulcerations

ETIOLOGY H. Pylori Infection

NSAIDs

Smoking & Alcohol

Acid Hypersecretion

Stress

Family History of PUD.

Clinical Presentation

Gastric ulcer Duodenal Ulcermiddle age 50-60 Any age specially 30-40 Age

More in male More in male Sex

Same Stress job eg. Manager Occupation

Epi. Can radiate to back

Epigastric , discomfort Pain

Immediately after eating

2-3 hours after eating & midnight

Onset

Eating Hunger Agg.by

Gastric ulcer Duodenal UlcerLying down or vomiting Eating Relived by

Few weeks 1-2 months Duration

Common(to relieve the pain)

Uncommon Vomiting

Pt. afraid to eat Good Appetite

Avoid fried food Good , eat to relieve the pain Diet

wt. Loss No wt. loss Weight

60% 40% Hematemesis

40% 60% Melena

Stool fecal occult blood.

CBC CBL.

Rapid Urease test, urea breath test H. Pylori.

Upper GI Endoscopy.

Barium meal X-Ray.

INVESTIGATIONS

In all patients with “Alarming symptoms” endoscopy is required.

Dysphagia.Weight loss.Vomiting.Anorexia.Hematemesis or Melena.

INVESTIGATIONS

Any patient >50 y/o with new onset of symptoms

UGT ENDOSCOPY

Management

Life Style Change.

Medical.

Surgical.

LIFE STYLE MODIFICATION

Discontinue NSAIDs

Smoking cessation.

Alcohol cessation.

Stress reduction.

AntacidsH2-receptor blocking

agents. Proton pump inhibitors.Cytoprotective and

antisecretory drugs.Antibiotics.

MEDICATIONS

MEDICATIONSH. pylori Eradication Therapy:• Triple therapy:

Proton pump inhibitor . 2 Antibiotics:

• Metronidazole + Clarithromycin.• Clarithromycin + Amoxicillin.

» In some regimens, H2-receptor blockers, e.g. ranitidine, are used instead of PPI.

Indications:

Failure of medical treatment.

Development of complications

High level of gastric secretion and

combined duednal and gastric ulcer.

SURGICAL

Principle:

Reduce acid and pepsin

secretion.

Vagotomy:

Truncal Vagotomy with drainage.

Highly selective Vagotomy.

Combination of vagal

denervation (vagotomy) +

anterctomy.

SURGICAL

VagotomyTruncal vagotomy with drainage:

Resect the major trunk of the vagus to

the stomach this will lead to:Decrease acid and pepsin secretion.

Impair antral motility and drainage.

–Two types of drainage:Pyloroplasty.Gastrojejnostomy.

Pyloroplasty Drainage

Gastrojejunostomy Drainage

Highly selective vagotomy:

• It is a parietal cells vagotomy.• It can be done with or without

drainage.• It is done by cut a branch

of vagus of the body and the fundus this will lead to decrease HCl production.

Vagotomy

Combination of vagotomy+

anterctomy:Combination of vagal denervation & removal of the major area of gastric production.

Vagotomy

Gastrointestinal continuity is restored by gastroduodenal (Billroth 1) anastomosis OR gastrojejunal (Billroth 2) anastomosis.

Dehiscence.Stenosis of

anastomosis.Bleeding.Injury to neighbour

tissues.Dumping

syndrome

Vagotomy

Hemorrhage

Perforation peptic ulcer

Gastric outlet obstruction

Complications of Disease

Thank you