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’sCushing’s

6. APD IncidenceAetiologyCPInvestigationsDDRx

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

14. APD HurryWorryCurry

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 ►  acid secretion  ▲ mucosal blood flow  mucus & bicarbonate secretion 10 -30% in chronic users

18. ZE= Zollinger Ellison Syndrome RecurrentRecalcitrantResistant Unusual sites MultipleMalignant

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.pyloriNSAIDs 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 IncidenceAetiologyCPInvestigationsDDRx

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 IncidenceAetiologyCPInvestigationsDDRx

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 IncidenceAetiologyCPInvestigationsDDRx

34. DD Cholecystitis Hiatus hernia PancreatitisMIPneumonia Dissecting aneurysm Worm Infestations

35. APD IncidenceAetiologyCPInvestigationsDDRx

36. Rx - Medical Stop smoking, NSAIDs Stop alcohol Antacids - acid neutralisation H 2 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 OmeperazoleEso-meperazoleRabi-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 12 - 115 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