Peptic ulcer disease

Factors influencing Aggressor – Acid – Pepsin – NSAIDs – H.Pylori Defense – Bicarbonate – Blood flow – Mucous – Cell junctions – Apical resistance Repair – Restitution – Proliferation – Mucous cap – Growth factors

H.Pylori Acid hypersecretion 1.Inhibits antral D cells Decreased somatostatin Increased gastrin Increased acid 2.Local alkalization of the antrum Increased gastrin Increased acid Toxins – Cag A – Vac A Cytokines – IL-8 These cause inflammation -> direct damage to epithelium

Other etiological factors NSAIDs Gastrinoma (zollinger allison syndrome) Smoking Stress

The gastrinoma triangle

Clinical features Abdominal pain Nausea Bloating Stool positive for occult blood ALARM symptoms – Wt loss – Recurrent vomitting – Dysphagia – Bleeding – Anemia If any alarm symptom present, UGI endoscopy should be done

Upper GI series showing ulcer

Complications of peptic ulcer Intractability Bleeding Perforation Obstruction

Perforation Acute abdomen – Sudden excruciating pain Fluid sequestration into third space Peritoneal signs – Guarding, tenderness, rebound tenderness Free air under domes of diaphragm

Ulcer perforation - xray

Closure of perforated DU with onlay patch

Gastric ulcer excision

Closure after excision

Intractability

Nonspecific vagotomy

Antrectomy

Completed vagotomy, antrectomy and gastroduodenostomy

Selective and highly selective Vagotomy

Laparoscopic HSV using clips or harmonic scalpel ClipsHarmonic shears

The criminal nerve of Grassi

Heineke-Mikulicz Pyloroplasty

Finney’s pyloroplasty

Biliroth I procedures

Biliroth II reconstruction

Roux en y gastrojejunostomy

Bleeding Melena/hematemesis Nasogastric aspiration confirmatory Shock NPO, acid supression Aggressive resuscitation with fluids and blood Urgent endoscopy If endoscopic Rx fails, or re-bleed, Surgery

Exosure of posterior bleeding DU

Figure of eight suture for bleeding control

Gastric resection

Separation of the greater omentum from the entire transverse colon

Mobilization of the left lobe of liver and GE junction

Mobilization of the greater curvature

Transection of the duodenum

D2 compartment lymphadencectomy

Division of the left gastric vessels

Transection of the esophagus

Roux en y reconstruction

Post operative complications of gastrectomy Short term: – Intra-abdominal bleeding – Subphrenic abscess – Anastomotic leak – Pancreatic fistula – Duodenal stump leak Long term: – Weight loss, decreasing nutritional status (reservoir capacity) – Diarrhea – Dumping syndrome – Alkaline reflux

Gastrojejunostomy

Complications of gastrojejunostomy Gastric hemorrhage Anastomotic bleeding Anastomotic leak Obstruction (anastomotic or functional) Anastomotic stenosis (long term)

Gastrostomy StammWitzel

Janeway (permanent stapled gastrostomy

Percutaneous endoscopic gastrostomy

Laparoscopic gastrostomy

Pyloromyotomy