1. Gastric and duodenal ulcer disease

2. Anatomy
Arterial blood supply
Lymphatic drainage
Nerve supply

3. Stimulant of Gastric secretion:
PHYSIOLOGY
Function:
Digestion of food, reduce the size of food
Acts as reservoir
Absorption of Vit. 12, iron and calcium
Stimulant of Gastric secretion:
Gastrin -----> (+) parietal cell
Acetylcholine (vagus) ---> (+) gastric cells
Histamine (mast cells) ---> parietal & chief cells

4. PHYSIOLOGY
BAO: 2 – 5 meq of acid/hr. (vagal tone and basal histamine secretion)
MAO:
Cephalic (vagus) ---> (+) parietal & G cell
10 meq acid/hr.
Gastric: ---> (+) vagus & G cell
15 – 25 meq of acid/hr pH = < 2.0
Intestinal:
Chyme enters the duodenum
(-) gastric release
Secretin, gastric inhibitory peptide, peptide YY
ACID condition sterilized the area, except for HELICOBACTER PYLORI

5. Peptic Ulcer Disease Pathogenesis :
Protective factors vs. hostile factors

6. Peptic ulcer Pathogenesis: For both Duodenal & Gastric Ulcers:
Infection w/ H. pylori:
Decreases resistance of mucus layer from acid permeation (hydrophobicity)
Increase acid secretion
Slow duodenal emptying
Reduced both duodenal and gastric bicarbonate secretion

7. Clinical Manifestation
Abdominal pain:
Due to irritation of afferent nerves w/in the ulcer by the acid or due to peristaltic waves passing through the ulcer
Duodenal: colicky or burning pain relieved w/ food intake
Gastric: gnawing or burning usually during or after eating.
N/V
Weight loss
Epigastric tenderness

8. Peptic ulcer Pathogenesis: Effects of NSAIDs
Decreases Prostagladin
Prostaglandin – inhibits acid secretion, stimulates mucus and HCO3 secretion and mucosal blood flow
Zollinger-Ellison Syndrome (1%):
Massive secretion of HCL due to ectopic gastrin production from non-beta islet cell tumor (gastrinoma)
Associated w/ type I (MEN) PPP
20% multiple, 2/3 malignant, w/ slow growing
Parietal cell mass is increased
> gastrin 3-6 x the normal

9. Symptoms of gastric ulcer disease:
epigastric pain after meal or during meal
upper dyspeptic syndrome – loss of appetite, nauzea, vomiting, flatulence
vomiting brings relief
reduced nutrition
loss of weight

10. Comparing Duodenal and Gastric Ulcers

11. Symptoms of duodenal ulcer disease:
epigastric pain 2 hours after meal or on a empty stomach or during night
pyrosis
good nutrition
obstipation
seasonal dependence (spring, autumn)

12. Diagnosis:
UGIS (double contrast)
Endoscopy

13. Therapy: Conservative Surgical regular lifestyle
prohibition of the smoking and alcohol
diet (proteins, milk and milky products)
pharmacology (antagonists of H2 receptors, antacids, anticholinergics
Surgical
BI, BII resection
proximal selective vagotomy
vagotomy with pyloroplastic
suture of perforated or haemorrhagic ulcer

14. Stomach resections:
Billroth I (BI) – gastro-duodenoanastomosis end-to-end
Billroth II (BII) – gastro-jejunoanastomosis end-to-side with blind closure of duodenum
Proximal selective vagotomy – denervation of parietal gastric cells

15. Zeman, M. et al., Speciální chirurgie, ISBN 80-7262-260-9, 2004
Billroth I

16. Zeman, M. et al., Speciální chirurgie, ISBN 80-7262-260-9, 2004
Billroth II

17. Gastro-enteroanastomosis on Roux Y crankle
Zeman, M. et al., Speciální chirurgie, ISBN , 2004
Gastro-enteroanastomosis on Roux Y crankle

19. Zeman, M. et al., Speciální chirurgie, ISBN 80-7262-260-9, 2004
Vagotomy

20. Treatment Primarily medical Surgical indications PPI or H2 blocker
Triple combination (double antibiotic and PPI=amoxicillin, clarithromycin, pantoprazole for 7-14 days)
Surgical indications
Intractibility (after medical therapy)
Hemorrhage
Obstruction
Perforation
Relative: continuous requirement of steroid therapy/NSAIDs
H pylori therapy fails in as many as 20% of patients

21. Treatment: Mechanism of Pharmacologic Therapy:
For eradication of H. pylori:
Bismuth based triple therapy
Bismuth + Tetracycline + Metronidazole
Proton pump inhibitor
Omeprazole + Amoxicillin/Clarithromycin
+ metronidazole

22. Treatment: Surgical Treatment: Indication: Intractability:
Highly selective vagotomy
Low septic complication, (-) dumping and diarrhea
For gastric ulcer:
Total or subtotal gastrectomy w/ or w/o vagotomy

23. A – penetration B – perforation C – bleeding D - stenosis
Zeman, M. et al., Speciální chirurgie, ISBN , 2004
A – penetration B – perforation
C – bleeding D - stenosis

24. GI Bleeding

25. Ulcer with recent bleed

26. Treatment: Surgical Treatment: Indication: Hemorrhage: s/sx
Critically ill
Endoscopy
Surgery: a. continue bleeding for more than 6 units
b. recurrent bleeding after endoscopically controlled
- pyloroduodenostomy + HSV
- pyloroduodenostomy + vagotomy + pyloroplasty

27. Ulcer Perforation

28. Treatment: Surgical Treatment: Indication: Perforation: S/Sx
Graham omental patch only for shock, perforation > 48 hrs or other medical problem
Vagotomy + pyloroplasty; HSV
Vagotomy + Gastrojejunostomy
Obstruction: S/Sx; Saline loading test
Vagotomy + Antrectomy
Vagotomy + Gastroenterostomy

29. Gastric outlet obstruction

30. Elective Surgical Therapy
Rare; most uncomplicated ulcers heal within 12 weeks
If don’t, change medication, observe addition 12 weeks
Check serum gastrin (antral G-cell hyperplasia or gastrinoma)
EGD: biopsy all 4 quadrants of ulcer (rule out malignant ulcer) if refractory

31. Modified Johnson Classification
Type
Location
Acid
Hypersecretion I
Lesser curvature, incisura No II
Body of stomach, incisura, and duodenal ulcer (active or healed)
Yes
III
Prepyloric IV
High on lesser curve, near gastroesophageal junction V
Anywhere (medication induced)

32. Elective Surgical Therapy
Type I

33. Type I Lesser curvature; incisura MOST COMMON
Decreased mucosal protection (no vagotomy)
Distal gastrectomy (INCLUDING UCLER) with BI

35. Billroth I

36. Elective Surgical Therapy
Type II/III

37. Type 2/3 Ulcers Acid hypersecretion
Antrectomy with ulcer and bilateral truncal vagotomy
Billroth II or Billroth I depending on technical difficulty
Parietal cell vagotomy option but higher recurrence

38. Billroth II
Note: this is subtotal gastrectomy

39. R-Y limb (subtotal gastrectomy)
Note: this is subtotal gastrectomy

40. Elective Surgical Therapy
Type IV

41. Type 4 Ulcers Least common (5% of all gastric ulcers)
Ulcers 2-5cm from cardia can be treated with distal gastrectomy, extending resection along the lesser curvature and BI (Pauchet/Shoemaker procedure)
Ulcers closer to GEJ, tongue-shaped resection high onto lesser curve (Csendes’ procedure with Roux-en-Y reconstruction)
Cardia

42. CSENDES RESECTION
(Line of transection; Roux-en-Y anastomosis)

43. Elective Surgical Therapy
Giant Gastric Ulcer

44. Giant Gastric Ulcer Giant gastric ulcer: >3cm; 30% malignancy risk
Subtotal gastrectomy with Roux-en-Y (high morbidity and mortality)
Kelling-Madlener procedure: less aggressive, antrectomy, BI reconstruction, bilateral truncal vagotomy, leave ulcer, multiple biopsies, cautery of ulcer

45. Complications after stomach resection:
Early – dehiscence, stenosis of anastomosis, bleeding, pancreatitis, obstructive icterus, affection of neighbour tissues
Late - days, weeks
- early dumping syndrome
- late dumping syndrome
- incoming crankle syndrome
- outcoming crankle syndrome
- ulcer in anastomosis or in outcoming crankle

46. Early Complications (1)
1. Failure of the stomach or stomach remnant to empty occurs after any procedure. It was formerly common after vagotomy and drainage. Causes are: 
A.      Prolonged paralysis of stomach (doubtful)
B.      Edema at a stoma
C.      Fluid and electrolyte disorder, especially hypokalaemia.
Management is conservative with NG suction, fluid, electrolyte and nutritional replacement.

47. Early Complications (2)
2. Intestinal obstruction.
Causes are:
A. Adhesive.
B. As a consequences:
(a) Twisting of the loop of a gastrojejunostomy after polya gastrectomy.
(b) Herniation of loops through a mesenteric defect.
(c) Retrograde intussusception of the efferent loop of a gastrojejunostomy (rare).
Prophylaxis: avoid causes – such as mesenteric cul de sacs or holes
Treatment: operative

48. Early Complications (3)
3. Fistulae. Can occur after any operation, which involves a suture line. Most usual sites are:
1. After polya gastrectomy
i. Duodenal stump
ii. Pancreases from trying to dissect out a
difficult ulcer
2.  Occasionally at a Pyloroplasty

49. Early Complications (4)
4. Acute pancreatitis. May follow any procedure. Its etiology is unknown, but some cases are traumatic

50. Late Complications (1) Anastomotic and recurrent ulceration Causes:
Inadequate resection of parietal cell mass.
Isolated antrum left after polya gastrectomy.
Zollinger – Ellison syndrome.
Incomplete vagotmy.
Persistent suture in the anastomosis. More usually this is merely a suture exposed as a consequence of ulceration from another cause.
Prophylaxis: adequate primary treatment.
Management is related to cause and requires investigation to ascertain the level of acid secretion or the completeness of vagotomy. Recurrence after vagotomy is best managed by polya gastrectomy.

51. Late Complications (1) 2. Gastrojejunocolic fistulae.
Occurs when a recurrent ulcer after gastrojejual anastomosis penetrates into the colon. It should arouse the suspicion of Zollinger-Ellison syndrome.
Clinical features: Severe diarrhea occurs due to enteritis caused by cronic contents passing directly into the small bowel and acidosis, dehydration, potassium loss, anaemia and cachexia will result in death if the fastula is not interrupted surgically.
Treatment:
1. Good risk patient. Excision of the gastric, jejunal and colonic components and the construction of a higher gastrectomy.
2.      Poor risk patient. A staged procedure:
(a)    Stage 1: Proximal colostomy which, diverts the faecal stream from the fistula and thus stops the enteritis.
(b)   Stage 2: Excision of fistula and its visceral components and the construction of a higher gastrectomy and colonic anastomosis.
(c)    Stage 3: Closure of colostomy. 

52. Early dumping syndrome:
group of symptoms approved shortly after meal
appears after BII resection
vasomotoric sy. - face redness, fall of blood pressure, dizziness
GI sy. - vomiting, diarrhoea
Th.: diet, no sugar, low quantities of food, change BII to BI resection

53. Late dumping syndrome:
hypoglycaemia (sugar is not enough digested)
appears after BII resection
weakness, perspiration, dizziness, tremor cca 3h after meal
Th.: no sugar, change BII to BI resection

54. Anemia
Partial gastrectomy and polya reconstruction interferes with duodenal absorption of iron and a macrocytic anemia may result
More rarely, sufficient stomach has been removed to cause failure of release of intrinsic factor and thus a macrocytic anemia
Malnutrition may contribute to both.

55. Weight loss and its complications
Particulary after partial gastrectomy when patients are unwilling to eat sufficiently, weight loss is common
Severe malnutrition is rare, but there is an increased risk of nutrition-associated diseases such as tuberculosis.

56. Bilious vomiting
Any operation which, destroys or bypasses the pylorus allows bile to reach the stomach.
Not only does this produce atrophic gastritis but also it may be associated with bilious vomiting.
This is more likely after a polya gastrectomy where characteristically a patient eats a meal and some to 10 to 20 minutes later vomits bile only.
In severe cases, either normal anatomy should be restored or the bile diverted more distally into the intestine.

57. Diarrhea
Apart from the dumping syndrome, all vagotomies except highly selective ones seem to cause diarrhea
Matters are made worse if cholecystectomy has been done or is subsequently done

58. Acute Gastritis (erosive)
Stress erosions are usually multiple, small punctuate lesion in the proximal acid secreting portion of the stomach
Clinical Settings:
Severe illness, trauma, burns (Cushing ulcer) or sepsis
Due to (-) mucosal defense (ischemia)
Drug and Chemical ingestion
Aspirin / NSAIDs
CNS trauma:
Increase gastrin ---> elevated acid secretion
Curling ulcer

59. Acute Gastritis Pathogenesis: Clinical manifestations: Diagnosis:
Aspirin, bile salts (backflow), alcohol
Mucosal ischemia
Clinical manifestations:
Gastrointestinal bleeding
Abdominal pain
Diagnosis:
Endoscopy / radionuclide scanning / visceral angiography

60. Acute Gastritis Treatment: NPO NGT / Saline lavage
Antacids / omeprazole / sucralfate
Intra-arterial infusion of vasopressin
Surgery --> if 6-8 units over 24 hrs
Mortality ---> 40%
Near total gastrectomy
Vagotomy + pyloroplasty + over sewing of bleeder
Partial gastrectomy + vagotomy

61. Zollinger-Ellison Syndrome (Gastrinoma)
Symptoms tends to be more severe, unrelenting and less responsive to therapy.
Clinical Manifestation:
Pain
Diarrhea
Steatorrhea
Diagnosis:
Acid secreting studies (50meq/hr)
UGIS
Radio-immuno assay for serum Gastrin level
Diff: a) Pernicious anemia
b) Renal insufficiency
c) Antral gastrin hyperplasia or hyperfunction
CT scan and angiography to localize gastrinoma
Venous sampling