Peptic ulcer

0
1261
  • Stomach – Blood Supply (Basic MCQ in every MD Entrance)
    • Greater curvature: Right and left gastroepiploic arteries
    • Lesser curvature: Right and left gastric arteries
    • Pylorus: Gastroduodenal artery
    • Fundus: Short gastric arteries
  • Stomach – Innervation (MCQ)
    • Anterior gastric wall: Left vagus nerve
    • Posterior gastric wall: Right vagus nerve
    • Sympathetic afferents from level T5 (below nipple line) to T10 (umbilicus) are responsible for sensation of gastroduodenal pain.
  • Peptic ulcer disease
    • PUD consists of duodenal ulcers (DUs) and gastric ulcers (GUs).
    • Two times more common in men.
    • Incidence increases with age.
    • Smoking and EtOH increase risk.
    • Pathophysiology
      • Parietal cells secrete HCl into the gastric lumen and bicarbonate into the gastric venous circulation (alkaline tide) and into the protective gastric mucous gel.
      • A proton pump exchanges potassium in the gastric lumen for protons.
      • The parietal cells are stimulated by gastrin, the vagus nerve, and histamine.
      • Gastrin release (MCQ)
        • stimulated by gastrin-releasing peptide
        • inhibited by somatostatin.
      • Histamine receptors on parietal cells also stimulate HCl secretion.
      • Gastric bicarbonate secretion into the mucous gel is inhibited (MCQ)
        • NSAIDs
        • Acetazolamide
        • Alpha blockers,
        • Alcohol.
      • Gel thickness is increased by prostaglandin E (PGE) and reduced by steroids and NSAIDs.
    • Complications
      • Bleeding: 20% incidence
      • Perforation: (MCQ)
        • Incidence: 7%.
        • Posterior perforation of a duodenal ulcer will cause pain that radiates to the back and can cause pancreatitis or cause GI bleeding.
        • A chest or abdominal film will not show free air because the posterior duodenum is retroperitoneal.
        • Anterior perforation will show free air under the diaphragm in 70% of cases.
      • Gastric outlet obstruction, due to scarring and edema.
    • DUODENAL ULCER (DU))
    • Pathophysiology – Increased acid production. (MCQ)
    • Etiology
      • Helicobacter pylori: (MCQ)
        • A bacterium that produces urease,
        • breaks down the protective mucous lining of the stomach
        • 10% to 20% of persons with H. pylori develop PUD.
      • NSAIDs/steroids: (MCQ)
        • Inhibit production of PGE, which stimulates mucosal barrier production.
      • Zollinger–Ellison (ZE) syndrome: (MCQ)
        • A gastrin-secreting tumor in or near the pancreas.
        • 0.1–1% of patients with ulcer.
        • 20% of ZE patients have associated multiple endocrine neoplasia 1(MEN-1). (MCQ)
        • Two thirds are malignant. (MCQ)
        • Diarrhea is common.
        • Can see jejunal ulcers(MCQ)
    • Clinical features
      • Burning gnawing epigastric pain that occurs with an empty stomach:
      • Pain is relieved within 30 minutes by food.
      • Nighttime awakening (when stomach empties) (MCQ)
      • Nausea, vomiting.
      • Associated with blood type O. (MCQ)
    • Diagnosis –
      • DU
        • Via endoscopy
          • Most symptomatic cases of DU are easily diagnosed clinically
          • If patient responds to DU therapy, there is no need to do the biopsy. (MCQ)
        • H. pylori:
          • Endoscopy with biopsy—allows C&S for H. pylori
          • organism is notoriously hard to culture(MCQ)
          • multiple specimens required during biopsy
        • Serology:
          • Anti-H. pylori immunoglobulin G (IgG) indicates current or prior infection.
        • Urease breath test:
          • C13/14 labeled urea is ingested. (MCQ)
          • If gastric urease is present, the carbon isotope can be detected as CO2 isotopes in the breath.
      • ZE:
        • A fasting serum gastrin level > 1,000 pg/mL is pathognomonic for gastrinoma. (MCQ)
        • Secretin stimulation test: (MCQ)
          • Secretin, a gastrin inhibitor, is delivered parenterally (usually with Ca2+) and its effect on gastrin secre- tion is measured.
          • In ZE syndrome, there is a paradoxical astronomic rise in serum gastrin.
        • Over 90% of patients with ZE have PUD.
      • H. pylori may colonize 90% of the population— infection does not necessitate disease. (MCQ)
      • Most common location for DU: Posterior duodenal wall within 2 cm of pylorus treatment(MCQ)
    • Medical Management
      • Discontinue NSAIDs, steroids, smoking.
      • Proton pump inhibitors (omeprazole, lansoprazole, pantoprazole):
      • 90% cure rate after 4 weeks. (MCQ)
      • Eradication of H. pylori: (MCQ)
        • Proton pump inhibitor, clarithromycin, and amoxicillin/metronidazole × 14 days
          • ∼90% cure rate
        • Bismuth, metronidazole, tetracycline × 14 days:
          • ∼85% cure rate
        • H2 blockers (cimetidine, ranitidine, famotidine, nizatidine):
          • 85–95% cure rate after 8 weeks.
        • Prostaglandin analogues (e.g., misoprostol) work because of their anti- secretory effect
        • Not as efficacious as H2 blockers, so no longer recommended.
      • Antacids:
        • Over the counter, good for occasional use for all causes of dyspepsia, but better drugs are available for active ulcer disease.
    • Surgical Management
      • Since the advent of highly effective medical therapy, elective surgery for PUD is quite rare.
      • Surgery is indicated (MCQ)
        • when ulcer is refractory to 12 weeks of medical treatment
        • if hemorrhage, obstruction, or perforation is present.
      • Truncal vagotomy and selective vagotomy (MCQ)
        • not commonly performed anymore due to associated morbidity (high rate of dumping syndrome) despite good protection against recurrence.
      • Procedure of choice is highly selective vagotomy (parietal cell vagot- omy, proximal gastric vagotomy) (MCQ)
        • Individual branches of the anterior and posterior nerves of Latarjet in the gastrohepatic ligament going to the lesser curvature of the stomach are divided from a point 6 cm proximal from the pylorus to a point 6 cm proximal to the esophagogastric junction.
        • The terminal branches to the pylorus and antrum are spared, preserving pyloroantral function and thus obviating the need for gastric drainage.
        • Preferred due to its lowest rate of dumping; however, it does have the highest rate of recurrence.
      • Recurrence depends on site of ulcer preop(MCQ)
        • Prepyloric ulcers have the highest recurrence rate at 30%.
      • Laparoscopic option :
        • A posterior truncal vagotomy coupled with an anterior seromyotomy is being done laparoscopically in select centers.
      • For ZE:
        • The tumor is resected.
        • Occasionally, when focus of tumor cannot be found, a total gastrectomy may be considered in severe cases.
  • GASTRIC ULCER (GU)
    • Decreased protection against acid(MCQ)
    • Normal or low acid production(MCQ)
    • Can be caused by reflux of duodenal contents (pyloric sphincter dysfunction) and decreased mucus and bicarbonate production
    • Causes
      • NSAIDs and steroids inhibit production of PGE.
      • PGE stimulates production of the gastric mucosal barrier.
      • H. pylori produces urease, which breaks down the gastric mucosal barrier.
    • Classification (MCQ)
      • Type I: Ulcer in lesser curvature at incisura angularis
      • Type II: Simultaneous gastric and duodenal ulcer
      • Type III: Prepyloric ulcer
      • Type IV: Ulcer in gastric cardia
    • Signs and symptoms
      • Burning, gnawing epigastric pain that occurs with anything in the stomach: Pain is worst 30 minutes after food.
      • Anorexia/weight loss
      • Vomiting
      • Associated with blood type A (MCQ)
    • Diagnosis
      • Via endoscopy.
      • Three percent of GUs are associated with gastric cancer so all GU are biopsied. (MCQ)
    • Treatment
      • Medical options same as for duodenal ulcers
      • Surgical options: (MCQ)
        • Antrectomy for types I and II
        • Highly selective vagotomy for type III
        • Subtotal gastrectomy followed by Roux-en-Y esophagogastrojejunostomy for type IV
    • Special Gastric Ulcers
      • Curling’s ulcers:  (MCQ)
        • Gastric stress ulcers in patients with severe burns
      • Cushing’s ulcers:  (MCQ)
        • Gastric stress ulcer related to severe CNS damage
  • Postgastrectomy syndromes
    • Dumping Syndrome (MCQ)
      • Complication of gastric surgery thought to result from unregulated movement of gastric contents from stomach to small intestine. (MCQ)
      • Signs and symptoms
        • Typically occur 5 to 15 minutes (early dumping syndrome) or 2 to 4 hours (late dumping syndrome) after eating: (MCQ)
          • Nausea, vomiting
          • Diarrhea
          • Belching
          • Tachycardia, palpitations
          • Diaphoresis, flushing
          • Dizziness, syncope
      • Treatment
        • Avoid high-sugar food or excessive water intake.
        • Severe cases (1%) that do not respond to dietary modifications can be treated with octreotide. (MCQ)
    • Postvagotomy Diarrhea
      • Seen mostly after truncal vagotomy. (MCQ)
      • Usually self-limited. (MCQ)
      • Treated symptomatically with kaolin–pectin, loperamide, or diphenoxylate as needed.
      • Refractory cases may respond to cholestyramine. (MCQ)
    • Alkaline Reflux Gastritis
      • Diagnosis of exclusion after recurrent ulcer has been ruled out.
      • Presents with chronic abdominal pain and bilous vomiting.
      • Medical treatment is difficult.
      • Surgical management: (MCQ)
        • Roux-en-Y gastrojejunostomy with Roux limb at least 45 to 50 cm long.
        • Recurrence still reported with this procedure.
    • Afferent Loop Syndrome
      • Obstruction of afferent limb following gastrojejunostomy (Bilroth II) (MCQ)
      • Two thirds present in first postoperative week(MCQ)
      • Signs and symptoms
        • Right upper quadrant (RUQ) pain following a meal
        • Bilous vomiting
        • Steatorrhea
        • Anemia
      • Diagnosis
        • Afferent loop will be devoid of contrast on the upper gastrointestinal (UGI) series. (MCQ)
      • Treatment(MCQ)
        • Endoscopic balloon dilatation
        • Surgical revision
  • Gastritis
  • Increased acid: Smoking, alcohol, stress
  • Decreased mucosal barrier: NSAIDs, steroids
  • Direct irritant: Pancreatic and biliary reflux, infection
  • Signs and symptoms
    • Burning or gnawing pain.
    • Pain usually worsened with food and relieved by antacids.
    • Vomiting may relieve the pain after eating.
  • Diagnosis is made by endoscopy.
  • Treatment
    • Halt NSAIDs.
    • Triple therapy to eradicate H. pylori if present.
    • Halt cigarettes and alcohol.
    • H2 blockers (e.g., cimetidine, ranitidine), sucralfate, or misoprostol.
    • Over-the-counter antacids.
  • Complications
    • Chronic gastritis leads to:
      • Gastric atrophy
      • Gastric metaplasia
      • Pernicious anemia (MCQ)
        • decreased production of intrinsic factor from gastric parietal cells due to idiopathic atrophy of the gastric mucosa and subsequent malabsorption of vitamin B12

GASTRIC OUTLET OBSTRUCTION

  • Common causes
        • Malignant tumors of stomach and head of pancreas.
        • Obstructing gastric or duodenal ulcers.
        • Usually with duodenal ulcer.
        • Chronic ulcer causes secondary edema or scarring, which occludes lumen.
  • SYMPTOMS
        • Early(MCQ)
          • Early satiety ,Gastric reflux ,Weight loss , Abdominal distention
        • Late(MCQ)
          • Vomiting ,Dehydration , Metabolic alkalosis(due to secondary hyperaldosteronism due to repeated vomiting induced dehydration)
  • Diagnosis – Endsocopy or barium swallow x-ray.
  • Treatment
    • Endoscopic balloon dilatation(MCQ)
    • Surgical resection:
      • Truncal vagotomy and pyloroplasty after 7 days of nasogastric decompression and antisecretory treatment(MCQ)
  • Clinical Pearls
  • Typical Clinical  scenario of Gastric Perforation: (MCQ)
    • A patient with known PUD presents with sudden onset of severe epigastric pain. Physical exam reveals guarding and rebound tenderness.
  • Typical Clinical  scenario of Gastric outlet obstruction.: (MCQ)
    • A 56- year-old woman presents due to 3 months of early satiety, weight loss, and non-bilious vomiting
    • Over 90% of patients with ZE have PUD.
  • Typical Clinical  scenario of Duodenal ulcer.. (MCQ)
    • A 38- year-old female presents with burning epigastric pain that is improved after eating a meal.
  • Most common location for DU: Posterior duodenal wall within 2 cm of pylorus (MCQ)
  • Complications of surgery for peptic ulcer disease:
    • Dumping syndrome
    • Afferent loop syndrome
    • Postvagotomy diarrhea
    • Duodenal stump leak
    • Efferent loop obstruction
    • Marginal ulcer
    • Alkaline reflux gastritis
    • Chronic gastroparesis
    • Post gastrectomy stump cancer
  • Gastric ulcers can even occur with achlorhydria. (MCQ)
  • Smoking is a risk factor for GU. (MCQ)
  • Most common location for GU: Lesser curvature(MCQ)
  • Typical Clinical scenario Gastric ulcer.: (MCQ)
    • A 52- year-old male smoker working as Marketing Head of a Multinational company  presents with weight loss and epigastric pain exacerbated by eating.
  • Typical Clinical scenario of Afferent loop syndrome.: (MCQ)
    • A 62- year-old woman who is 7 days postop from a gastrojejunostomy for PUD presents with postprandial RUQ pain and nausea. She reports that vomiting relieves her suffering
  • Cimetidine is a p450 inhibitor, and therefore prolongs the action of drugs cleared by this system.

Helicobacter pylori

  • 90% patients with duodenal ulceration
  • 70% patients with gastric ulceration
  • 60% patients with gastric cancer

30

      • Billroth I gastrectomy (MCQ)
        • Originally described for the resection of distal gastric cancers
        • Still used in gastric cancers if radical gastrectomy is inappropriate
        • Later applied in the treatment of benign gastric ulcers
        • Indications :
        • if ulcer situated high on the lesser curve
        • bleeding ulcer that requires resection
        • Less effective than Polya Gastrectomy for duodenal ulcers
      • Billroth II / Polya gastrectomy(MCQ)
        • Initially described for duodenal ulceration but rarely performed today
        • Some form of vagotomy is the surgical treatment of choice for uncomplicated DU
        • Occasionally used below a high gastric ulcer
        • Ulcer invariably heals after surgery
        • Useful in recurrent ulceration following previous vagotom


Laparoscopic operation for Perforated Peptic Ulcer; Rossen Tushev M. D. Surgeon
Peptic (Stomach) Ulcer
This 3D medical animation on peptic (stomach) ulcers describes common locations of ulcers: esophageal ulcers located in your esophagus, gastric ulcers located in the antrum of your stomach, and duodenal ulcers located in the portion of your stomach connected to your small intestines.

Peptic Ulcer Disease Pathophysiology
Lecture on the pathophysiology of peptic ulcer disease, including an introduction to the physiology of acid production and mucosal barrier defences in the stomach
Peptic Ulcer Disease and H. Pylori
Peptic Ulcer Disease and H. Pylori
Peptic Ulcer 3D Animation
Peptic Ulcer 3D Animation – Medical Videos
What is Peptic Ulcer / Gastric Ulcer
Stomach Ulcer Video
This is a video performed by Joseph S. Galati, Houston, Texas, on a young patient with chronic abdominal pain. After an evaluation with blood work and an ultrasound of the abdomen, an upper endoscopy was performed that revealed a large gastric ulcer in the antrum/pylorus of the stomach. Several smaller erosions were also noted in the stomach.
How a peptic ulcer develops
Peptic ulcers are ulcers of the stomach and small bowel. Find out more about the causes, symptoms and treatments here:
laparoscopic Repair of perforated peptic ulcer with omental patch
This video is a step-by-step approach to the technique of laparoscopic repair of perforated peptic ulcer with omental patch. The operation was carried out on a 49 yr old male patient. He was admitted via our Accident & Emergency Department few hrs earlier.
He developed epigastric pain whilst at home the previous evening. His pain spread to the rest of his abdomen through the night. He had been fit & well with no history of indigestion and was not on any regular medications.

Gastric Ulcers Overture
A peptic ulcer is a hole in the gut lining of the stomach, duodenum, or esophagus. A peptic ulcer of the stomach is called a gastric ulcer; of the duodenum, a duodenal ulcer; and of the esophagus, an esophageal ulcer. An ulcer occurs when the lining of these organs is corroded by the acidic digestive juices which are secreted by the stomach cells. Peptic ulcer disease is common.