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Peptic Ulcer & its Complications Prof. Dr. Faisal Ghani Siddiqui FCPS; MCPS-HPE; PGDip-bioethics
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Preamble Peptic ulcer and its treatment Complications of peptic ulcer disease
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Peptic Ulcer -Sites Duodenum Stomach Stomas Oesophagus Meckel’s diverticulum
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Peptic Ulcer -Aetiology Acid Familial Stress NSAIDs Cigarette smoking H.pylori
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Peptic Ulcer -Investigations Endoscopy Tests for H.pylori 13 C and 14 C breath tests CLO test Histpathology Serology
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Peptic Ulcer -Treatment Medical treatment (H 2 -receptor antagonists / PPI) Eradication treatment (PPI + Metronidazole + Amoxycillin / clarothromycin) Surgery
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Peptic Ulcer -Complications Pyloric outlet obstruction Perforation Bleeding
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Pyloric Outlet Obstruction PerforationBleeding
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Long history of Long history of peptic ulcer disease Vomiting Vomiting Weight loss Weight loss Dehydration Dehydration Succussion splash Succussion splash Peristalsis Peristalsis Tetany Tetany
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Hypochloraemic alkalosis & paradoxical alkalosis
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PARADOXICAL ACIDURIA Renal loss of K + and H + Aldosterone secretion & Na + conservation Renal Excretion of HCO3 with Na+ deficit HYPOCHLORAEMIC ALKALOSIS Vomiting –loss of HCl,
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Investigations Laboratory investigations Hypochloraemic alkalosis; hyponatremia;hypokalaemia
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Investigations Imaging Plain X-ray ; Barium meal
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Investigations Saline load test 700 ml normal saline infused over 3-4 minutes Tube clamped for 30 minutes Stomach aspirated Recovery of >350 ml indicates obstruction
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Treatment Correction of metabolic abnormalities Dealing with the mechanical problem
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Treatment Correction of fluid & electrolyte imbalance Rehydration with isotonic saline and potassium supplements
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Treatment Medical treatment Gastric lavage and suction (5-7 days) Surgical treatment Truncal vagotomy with gastrojejunostomy Endoscopic treatment Balloon dilatation
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… in summary Most commonly associated with PUD and carcinoma stomach Hypochloraemic alkalosis & paradoxical aciduria Medical / endoscopic dilatation effective in less severe cases Operation with a drainage procedure usually required
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Perforation of peptic ulcer
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Most perforated ulcers are located anteriorly absence of protective viscera | major blood vessels
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Pain Pain Pain Distressed Distressed Shallow breath Shallow breath Rigidity Rigidity Absent gut sounds Absent gut sounds Tympanitic note over liver Tympanitic note over liver
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Investigations Laboratory investigations Leucocytosis ; raised serum amylase High levels of amylase in aspirated fluid Imaging Gas under diaphragm Escape of contrast material from the lumen
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Tretament Nasogastric tube IV fluids Antibiotics Graham-Steele patch
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Bleeding peptic ulcer
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Hematemesis & Shock
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Hematemesis with shock Initial management Definitive management
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Upper GI Endoscopy (within 1-2 hours of admission) History & physical examination Stop bleeding by ice-water lavage Assess shock & replace blood loss Pulse | BP | Urine output | Haematocrit | Blood aspirated Initial Management
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Causes of Upper GI Bleeding Peptic ulcer Acute gastritis Oesophageal varices Oesophagitis Mallory-Weiss syndrome
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Bleeding Peptic Ulcer -Treatment Endoscopic treatment Emergency Surgery
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Endoscopic Treatment -Indications Active bleeding at the time of endoscopy Visible vessel at the base of the ulcer
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Endoscopic Treatment Injection Epinephrine | ethanol Cautery Heat probe | electorcautry Nd:YAG laser
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Emergency Surgery Hypotension on admission 4 units of blood to achieve circulatory stability Continuous bleeding Subsequent transfusion requirements exceed 1 unit every 8 hours
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