peptic ulcer disease bernard m. jaffe, md professor of surgery emeritus
TRANSCRIPT
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PEPTIC ULCER DISEASE
BERNARD M. Jaffe, MDProfessor of Surgery
Emeritus
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PEPTIC ULCER DISEASE• 8% Annual Incidence in the
Population• 500,000 New Cases/Year• 4,000,000 Recurrences/Year• 130,000 Operations/Year• 9,000 Deaths/Year
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PEPTIC ULCER DISEASE• Elective Admissions Declining, for
Complications Unchanging• Gastric Ulcer More Common in Elderly• Admissions for Bleeding GU Increasing• Decreasing Incidence in Males,
Increasing in Females• ? Due to Changes in Smoking
Patterns
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CAUSES OF PUD• H. Pylori Infection• NSAID’s • Acid Hypersecretion• Zollinger- Ellison Syndrome• Acid Plays a Role in All Four
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GASTRIC CELLS• Acid- Fundus Parietal Cells• Gastrin- Antrum G Cells• Pepsinogen- Diffuse Chief Cells• Histamine- Diffuse
Enterochromaffin-Like Cells
• Somatostatin- Diffuse D Cells
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H. Pylori INFECTION• 90% Duodenal, 75% Gastric Ulcers• Nearly 100% Have Antral Gastritis• Eradication Prevents Recurrence• Strong Association with MALT
Lymphoma• Microaerophilic, Urease Producing• Can Live in Gastric Epithelium
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GASTROINTESTINAL INJURY• Production of Toxic Products• Ammonia, Cytokines, Mucinases,
Phospholipases, Platelet Activating Factor
• Induction in Local Mucosal Immune Responses• Increases Gastrin → Increasing Acid
Secretion
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H. Pylori INFECTION• World-Wide Pandemic• Usually Acquired in Childhood• Inverse Relationship Between Infection
Rates and Socio Economic Status• Transmission Mouth-to-Mouth• Higher Rate in Developing Countries-
Sanitation is a Real Issue
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NSAID’S• Second Most Common Cause of PUD• Increased Use in Women >50 Years Old• Risk of Ulcers/Bleeding Parallels Drug
Use• 10% of Patients Taking NSAID’s
Develop Acute Ulcer• 2-4% Develop GI Complications/Year
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ACID- INCREASED• Nocturnal Acid 70%Daytime Acid
50%• Duodenal Acid Load Maximal Acid
65% 40%• Gastrin Sensitivity Basal Gastrin• 35% 35%• Gastric Emptying 30% Parietal Cells 30%
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GASTRIC ULCERS• Type I- Lesser Curvature Near Incisura• 60%• Low Levels of Acid• Type II- Combination Type I Plus DU• 15%• Excess Acid Secretion
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GASTRIC ULCERS (2)• Type III- Pre-Pyloric• 20%• Behave Like DU’s • Excess Acid Secretion• Type IV- High on Lesser Curvature• <10%• Low Acid Secretion• <5% Greater Curvature
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GASTRIC ULCER• Rare Before Age 40, Common 55-65
Years• Caused By NSAID’s• Acid, Pepsin Abnormalities• Co-Existing DU• Delayed Gastric Emptying• Duodenal-Gastric Reflux• Gastritis• H. Pylori Infection
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DU PREDISPOSITION• Chronic Alcohol Intake• Smoking• Long-Term Steroid Use• Infection
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SYMPTOMS• Mid-Epigastric Pain• Relieved By Pain• Spring > Fall• Relapses with Stress• Constant Pain- Deeper Penetration• Back Pain- Penetration Into Pancreas
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COMPLICATIONS• Perforation• Bleeding• Obstruction• Chronicity
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PERFORATION• Sudden Abdominal Pain, Fever• Tachycardia, Ileus, Dehydration• Exquisite Abdominal Tenderness,
Rebound, Rigidity• Free Air Under the Diaphragm, Can
Verify by Gastrograffin Swallow• Surgical Emergency
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PERFORATION• Treat with Gramm Patch Omental Closure• Simultaneous Definitive Procedure IF• PUD with NO Symptoms • Failure to Respond to Medical Therapy• Best Definitive Procedure for Perforation-
Parietal Cell Vagotomy• Non-Operative Therapy Reserved for Late
Presentation with No Acute Abdomen
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BLEEDING• Most Common Cause of PUD Death• Bleeding Accounts for 25% of All Upper
GI Bleeds• Can Present with Melena,
Hematemesis, or Bright Red Rectal Bleeding• Gastroduodenal Artery Lies Posterior
to Duodenal Bulb- “Visible Vessel”
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OBSTRUCTION• Chronic Scarring Can Occlude Pylorus• Acute Inflammation Also Causes
Obstruction• Anorexia, Nausea, Vomiting• Hypochloremic, Hypokalemic Metabolic
Alkalosis, Dehydration, Malnutrition• Stomach Becomes Massivel Dilated and
Loses Muscular Tone
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GASTRIC ULCER• Must Distinguish Benign From Malignant• Causes Same Complications as DU• 8-20% Need Operation for Complications• Bleeding Occurs in 35-40%• Perforation is Most Life-Threatening• Obstruction Occurs in Types I and II
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ZOLLINGER-ELLISON SYNDROME• Triad- Gastric Acid Hypersecretion, Severe
PUD, Non-β Islet Cell Tumors• Gastrinomas in Head of Pancreas,
Duodenum • 50% Multiple, 65% Malignant, 25%
Associated with MEN Syndrome• Abdominal Pain, Diarrhea, Steatorrhea• Elevated Basal, Stimulated Gastrin Levels• Treatment Focuses on Tumor Resection
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ELEVATED GASTRIN LEVELS• Z-E Syndrome• Antral G Cell Hyperplasia• Retained Gastric Antrum• Hypercalcemia• Gastric Outlet Obstruction• Anti-Secretory Drugs
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ELEVATED GASTRIN LEVELS• Previous Ulcer Operation• Atrophic Gastritis• Pernicious Anemia• Chronic Renal Failure• H. Pylori Infection
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PEPTIC ULCER DIAGNOSIS• EGD, Barium Swallow• H. Pylori Testing• Serology- ELISA 90% Sensitive• Urea Breath Test- Uses 14C
Specificity, Sensitivity >95%• Rapid Urease- Endoscopic Biopsy, Tissue
Placed in Urea, >90% Sensitive• Histology, Biopsy of Antrum- Best Test• Culture is Slow, Expensive
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MEDICAL MANAGEMENT• Avoid Smoking, Caffeine, Alcohol, NSAID’s• Antacids- Large Frequent Doses Needed• H2 Receptor Antagonists- 70-80% Healing in
4 Weeks, 80-90% in 8 Weeks• Proton Pump Inhibitors- Most Complete
Acid Inhibition- Healing 85% in 4 Weeks, 90% in 8 Weeks
• Sucralfate- Aluminum Salt of Sulfated Sucrose- Protective Coating
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OPERATIVE MANAGEMENT• Subtotal Gastrectomy- Highest
Complication Rate• Vagotomy and Antrectomy- Most
Efficacious• Vagotomy and Pyloroplasty- Major
Indication is Bleeding Gastritis• Parietal Cell Vagotomy- Most
Physiologic