1. Peptic Ulcer Professor Ravi Kant
FRCS (England), FRCS (Ireland), FRCS(Edinburgh), FRCS(Glasgow), MS, DNB, FAMS, FACS, FICS,
Professor of Surgery

2. Surgical Anatomy
Crow’s feet
N of Latarjet
Criminal Nerve of Grassi
Antral pump mechanism

3. Applied Anatomy : Stomach
Pressure studies
Endoscopic & Chromo-endoscopic
Contrast ( Ba meal with air)
Intra-luminal USG
Electron microscopy
USG
CT/ MR
Surgical

4. APD= Acid Peptic Disease
Peptic Ulcer
Gastric Ulcer
Duodenal Ulcer
Hyperacidity
ZE Syndrome

5. APD= Acid Peptic Disease
Acute Ulcer
Stress Ulcer
Curling’s
Cushing’s

6. APD
Incidence
Aetiology CP
Investigations DD Rx

7. Peptic Ulcer 10% population affected
Gastric ulcer in elderly 5-6th decade
Duodenal ulcer in adults 4th decade
DU also in young

8. Duodenal Ulcer Proximal duodenum 1 - 2 cm of pylorus ▲ acid
Distal duodenum = ZE

9. Type 1 Gastric Ulcer most common (among gastric Ulcers)
proximal antrum
 mucosal defense
 acid

10. Type II Gastric Ulcer
Secondary to DU + pyloric stenosis

11. Type III Gastric Ulcer Prepyloric and pyloric canal ulcer acid ▲
common etiology with DU

12. GU: Benign Vs CA Rugae upto margins Small , <2cm
Sticking of barium +
Accompanying spasm
↓ Acid
Crater beyond the normal stomach on a barium
Rugae-short of
Small-Big -
Achlorhydria
Limited to Stomach

13. APD
Incidence
Aetiology CP
Investigations DD Rx

14. APD
Hurry
Worry
Curry

15. Pathogenesis Imbalance of acid-pepsin and mucosal defence
H. pylori infection
NSAID
ZE Syndrome
Type A personality

16. H.pylori 95% - duodenal ulcer 80% - gastric ulcer
 mucosal resistance hydrophobicity
eradication reduces ulcer recurrence

17. NSAID Suppress prostaglandins prostaglandin ► 10 -30% in chronic users
 acid secretion
 ▲ mucosal blood flow
 mucus & bicarbonate secretion
10 -30% in chronic users

18. ZE= Zollinger Ellison Syndrome
Recurrent
Recalcitrant
Resistant
Unusual sites
Multiple
Malignant

19. ZE Syndrome 0.1 - 1.0% of peptic ulcer Type I and Type II
Gastrin secretion from non-beta cell tumor of pancreas - Gastrinoma
MC in pancreas ; duodenum, antrum

20. ZE Syndrome 20% multiple 66% malignant slow growing indolent tumor
parietal cell mass increased
genetic basis
massive hyper-secretion of acid

21. ZE Syndrome MEN - I hyperparathyroidism islet cell tumor
pituitary tumors

22. A/ DU NSAIDs Acid hypersecretion Rapid gastric emptying
Impaired acid disposal
Smoking

23. Duodenal Ulcer Increased secretion of acid More rapid gastric emptying
Decreased prostaglandin
Chronic duodenitis with H.pylori
Smoking

24. Gastric Ulcer H.pylori NSAIDs Duodenogastric reflux
Impaired gastric mucosal defense

25. Gastric Ulcer Acid secretion - normal to low
Reflux of duodenal contents  gastritis  ulcer
Pylorus sphincter disorder
Smoking
Disturbed mucosa with low grade gastritis

26. APD
Incidence
Aetiology CP
Investigations DD Rx

27. CP Duodenal Ulcer pain relieved by food or alkali
pain several hours after meal
Gastric Ulcer - gnawing or burning pain on eating

28. CP Periodic chronic recurrent pain Nausea & vomiting Weight loss
Epigastric tenderness

29. APD
Incidence
Aetiology CP
Investigations DD Rx

30. Investigations Endoscopy 90% sensitivity
must in all pts. with severe pain
excludes malignancy
biopsy can be taken
test for H.pylori

31. Investigations
Barium Meal double (air) contrast
90% sensitivity

32. H Pylori detection:
Breath test
Blood test
Tissue test

33. APD
Incidence
Aetiology CP
Investigations DD Rx

34. DD Cholecystitis Hiatus hernia Pancreatitis MI Pneumonia
Dissecting aneurysm
Worm Infestations

35. APD
Incidence
Aetiology CP
Investigations DD Rx

36. Rx - Medical Stop smoking, NSAIDs Stop alcohol
Antacids - acid neutralisation
H2 receptor antagonist -Ranitidine - secretion inhibition

37. Rx- Medical H+ pump inhibition - H+/K+ase inhibition - Omeprazole
Anticholinergic - secretory inhibition
Prostaglandin - Misoprostol mucosal protection

38. Proton Pump Blockers
Omeperazole
Eso-meperazole
Rabi-meperazole

39. Rx - Medical Sucralfate - protective coating Colloidal Bismuth
eradicate H.pylori
protective coating
Antibiotics - H.pylori
Kit for H Pylori

40. H2 Receptor Antagonists
On parietal cells
Decrease basal & stimulated acid secretion
Pepsin output decreased
Decreased gastric blood flow
Competitive inhibitor of parietal cell

41. Rx - Duodenal Ulcer 95% control - medical Rx
Surgery-Outdated, Obsolete
Omeprazole better thanRanitidine
Ulcer heels in 80% by 6 m
 recurrence in 95% by H.pylori eradication

42. Rx - Duodenal Ulcer Indications for surgery =Compl
Hemorrhage
Obstruction
Perforation
Intractability of pain
Intractable pain ► HSV / TV + GJ

43. Rx - DU H2 blockers heals 75% DU in 4 weeks
H/K proton pump inhibitor better results
ulcer may recurr in 80% cases on stopping
treatment of H.pylori

44. Rx - DU Indication of surgery in hemorrhage
bleeding of > than 6 units
recurrent bleed after endoscopic control
pyloro-duodenotomy and control of bleeding
HSV or TV + GJ

45. Rx - DU
Perforation - simple closure with omental patch -Graham’s patch
definitive surgery
HSV
TV + pyloroplasty
parietal cell vagotomy
TV+GJ

46. Rx GU Omeprazole, H2 receptor antagonist - 8 weeks
if pain not relieved by 2 weeks - add one more drug
repeat endoscopy after 8 weeks
if no healing by weeks - Surgery

47. Rx - GU Type I - Distal Gastrectomy with vagotomy + G-D or GJ
proximal ulcer- total gastrectomy
parietal cell vagotomy - high recurrence

48. Hemorrhage Hemorrhage - potential cause of death
15 -20% gross bleeding
erosion of duodenal ulcer into gastro-duodenal artery
Endoscopy –laser, sclerosant oralcohal injection

49. Perforation In 5-10% of cases pneumo-peritoneum in 75% cases
peritonitis, pain, ileus
leukocytosis, hypovolumia, IIIrd space loss
DD - acute appendicitis, enteric perf.

50. Obstruction Chronic ulcer disease with edema and scarring
in 5% cases of DU
nausea, vomiting, abdominal distension
metabolic alkalosis, paradoxical aciduria

51. Obstruction
Endoscopy
Ba study
Scintigraphy
Rx V + G-J / G-D