1. Peptic ulcer disease

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

3. 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

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

5. The gastrinoma triangle

6. 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

7. Upper GI series showing ulcer

8. Complications of peptic ulcer Intractability Bleeding Perforation Obstruction

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

10. Ulcer perforation - xray

11. Closure of perforated DU with onlay patch

12. Gastric ulcer excision

13. Closure after excision

14. Intractability

15. Nonspecific vagotomy

16. Antrectomy

17. Completed vagotomy, antrectomy and gastroduodenostomy

18. Selective and highly selective Vagotomy

19. Laparoscopic HSV using clips or harmonic scalpel ClipsHarmonic shears

20. The criminal nerve of Grassi

21. Heineke-Mikulicz Pyloroplasty

22. Finney’s pyloroplasty

23. Biliroth I procedures

24. Biliroth II reconstruction

25. Roux en y gastrojejunostomy

26. 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

27. Exosure of posterior bleeding DU

28. Figure of eight suture for bleeding control

29. Gastric resection

30. Separation of the greater omentum from the entire transverse colon

31. Mobilization of the left lobe of liver and GE junction

32. Mobilization of the greater curvature

33. Transection of the duodenum

34. D2 compartment lymphadencectomy

35. Division of the left gastric vessels

36. Transection of the esophagus

37. Roux en y reconstruction

38. 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

39. Gastrojejunostomy

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

41. Gastrostomy StammWitzel

42. Janeway (permanent stapled gastrostomy

43. Percutaneous endoscopic gastrostomy

44. Laparoscopic gastrostomy

45. Pyloromyotomy