peptic ulcer disease and its surgical management

1. Peptic Ulcer Disease
Kanchan sharma
Msc(n) 1st year
Medical surgical department

2. Introduction
• A peptic ulcer is an abnormal area of mucosa that has
been damaged by the pepsin and hydrochloric acid of
gastric juice, with consequent inflammation of the
underlying and surrounding tissue.
• Most of peptic ulcer occur either in the duodenum, or in
the stomach

4. Definition
• Peptic ulcers are open sores that develop on the inside lining of
esophagus, stomach and the upper portion of small intestine.

5. Types
Stomach (called gastric ulcer)
Duodenum (called duodenal ulcer)
Oesophagus (called Oesophageal ulcer)

6. Causes
As many as 80% of ulcers
are associated with
Helicobacter pylori.
chronic use of NSAIDs
Zollinger-Ellison
syndrome
Stress — Emotion.
 Injury or death of
mucus-producing cells.
 Smoking
 Alcohol
 Spicy food
 Caffeine
 Excess acid production
in the stomach.

7. Pathophysiology

8. Sign And Symptoms
DUODENAL ULCER
• Pyrosis
• Gnawing,
• Hunger-like pain, (the
epigastric region).
• Pain may occur or worsen
when the stomach is empty,
usually two to five hours after
a meal.
• Feel better when patient eat
or drink and then worse 1 or 2
hours later (duodenal ulcer)
GASTRIC ULCER
• Pyrosis (heart burn)
• Bloating
• Nausea
• water brash
• Unexplained weight loss
• Hematemesis
• Appetite changes
• Blood in the stools
• Low blood cell count
• Feel worst when patient eating
• An early sense of fullness with
eating

9. Gastric and Duodenal Ulcers

10. Gastric Ulcers
• Pain occurs 1-2 hours after meals
• Pain usually does not wake patient
• Accentuated by ingestion of food
• Risk for malignancy
• Deep and penetrating and usually occur on the lesser curvature
of the stomach

11. Duodenal Ulcers
• Pain occurs 2-4 hours after meals
• Pain wakes up patient
• Pain relieved by food
• Very little risk for malignancy

12. General Peptic Ulcer
Symptoms
• Epigastric tenderness
• Sharp, burning, aching, gnawing pain
• Dyspepsia (indigestion)
• Nausea/vomiting
• Belching

13. Diagnostic Tests
• Esophagogastroduodenoscopy (EGD)
• Endoscopic procedure
• CT scan
• Upper gastrointestinal series (UGI)
• Barium swallow
• X-ray that visualizes structures of the upper GI tract
• Urea Breath Testing
• Used to detect H.pylori
• Client drinks a carbon-enriched urea solution
• Excreted carbon dioxide is then measured

14. Endoscope

15. EndoscopicAppearance

16. Complications of Peptic Ulcers
• Hemorrhage
• Blood vessels damaged as ulcer erodes into the muscles of
stomach or duodenal wall
• Coffee ground vomitus or occult blood in tarry stools
• Perforation
Gastric and duodenal ulcers can perforate or bleed. Perforation
occurs when the ulcer becomes so deep that the entire thickness of
the stomach or duodenum is worn away. The gastroduodenal
contents may then empty into the peritoneal cavity. Symptoms of
perforation are sudden, sharp pain, the abdomen is tender, rigid, and
boardlike. The patient assumes the fetal position, knees to chest.
Client can become acutely ill within hours. Peforation is considered
a surgical emergency and can be life threatening. If this occurs the
physician needs to be notified immediatley.

17. Cont…….
• Narrowing and obstruction (pyloric)
• Swelling and scarring can cause obstruction of food leaving
stomach=repeated vomiting

18. Management
• Antacids
• H2-receptor blocking agents
-Ranitidine 150mg at bed time
-Cimetidine 400mg at bed time
• Proton pump inhibitors.
-omeprazole 20 mg daily
- Pantoprazole 40mg/ day
- Lansoprazole 30mg/day
• Antibiotics.
- Clarithromycine 500mg/twice/day + amoxicillin 1000mg/twice/day

19. Surgery
• Greatly decreased in the last 20-30 years
secondary to the discovery of H. pylori
• Required if ulcer in one of these states
• Perforated and overflowed into the abdomen
• Scarred or swelled so that there is obstruction
• Acute bleeding
• Non-responsive to medications

20. Types of Surgical Procedures
• Gastroenterostomy
allows regurgitation of
alkaline duodenal
contents into the stomach
• Creates a passage
between the body of
stomach to small
intestines
• Keeps acid away from
ulcerated area

21. Vagotomy
Cuts vagus nerve
Which eliminates the
acid-secreting stimulus to
gastric cells and
decreases the
responsiveness of parietal
cells.

22. Types of vagotomy
• Truncal
• Selective
• Proximal parietal cell

23. Surgical
Procedure/Pyloroplasty
• Pyloroplasty
• Widens the pylorus to
guarantee stomach
emptying even without
vagus nerve stimulation

24. Types of Surgical Procedures
• Antrectomy/ Subtotal Gastrectomy
• Lower half of stomach (antrum) makes most of the acid
• Removing this portion (antrectomy) decreases acid
production
• Subtotal gastrectomy
• Removes ½ to 2/3 of stomach
• Remainder must be reattached to the rest of the
bowel
• Billroth I
• Billroth II

25. Billroth I
• Distal portion of the
stomach is removed
• The remainder is
anastomosed to the
duodenum

26. Billroth II
• The lower portion of
the stomach is
removed and the
remainder is
anastomosed to the
jejunum

27. Dumping Syndrome
• Rapid emptying of food and fluids from the
stomach into the jejunum
• Symptoms
• Weakness
• Faintness
• Palpatations
• Fullness
• Discomfort
• Nausea
• diarrhea

28. Minimize Dumping Syndrome
• Eat slowly
• Avoid fluids during meals
• Increase fat
• Eat small, frequent meals