3. DEFINITIONS
Ulcer
Breach in the mucosa of the GI tract that extends through
the muscularis mucosa into submucosa or deeper
Erosion
Epithelial disruption without breach of the muscularis
mucosa
Peptic Ulcer disease
Circumscribed ulcer that occurs in any part of the GI tract
due to the aggressive action of acid and peptic juices.
4. SITES OF ULCERS
First part of
Duodenum
Lesser curve of
stomach
Stoma following
gastric surgery
Oesophagus
Gastric mucosa within
Meckel’s Diverticulum
5. ETIOLOGY
Helicobacter pylori infection
Chronic NSAIDs and Corticosteroids use
Cigarette smoking
Alcohol consumption
Zolinger-Ellison syndrome
Hyperparathyroidism and chronic renal failure
11. Features Gastric ulcers Duodenal ulcers
Incidence Less common More common
Common Location Antrum, lesser cuvature Anterior wall*, 1st part
Age group Middle age Middle or old age
Male: Female ratio 1:1 4:1
Association with H.
Pylori
65% 85%-100%
Level of gastric acid
secretion
Mostly normal Mostly increased
Malignancy Common Rare
*Kissing ulcers: Both anterior and posterior wall ulcer of
duodenum
12. TYPES OF GASTRIC ULCER
DAINTREE JOHNSON
•Type I
In the antrum, near lesser
curvature
Normal acid level
•Type II
Combined gastric and
duodenal ulcer
High acid level
•Type III
Prepyloric
High acid level
•Type IV
Ulcer in the proximal
stomach and Cardia
Normal acid level
55% 25%
15% 5%
13. FEW MORE ULCERS!!!
Stress ulcer
In association with shock, sepsis or severe trauma
Curling ulcer
In association with severe burns or trauma
Cushing’s ulcer
In patients with intracranial disease oor after
neurosurgery
14. CLINICAL PRESENTATION
Symptoms
Pain
Epigastric region, burning or aching type
May radiate to back
Heartburn, Nausea, vomiting, bloating, belching, water-
brash
Alteration in weight
Haematemesis or Maelena presents as anemia
Periodicity of symptoms
Significant past history
Clinical examination
Tender epigastrium
Features of complication, if present
15. Gastric Ulcer Duodenal Ulcer
Pain increased after food intake Pain relieved after food intake
Periodicity less common Periodicity more common
Haematemesis more common Melaena more common
Weight loss common Weight gain occurs
Equal in both sexes More in males
18. ESOPHAGOGASTRODEODENOSCOPY
It is fundamental that any gastric ulcer
should be regarded as being
Malignant, no matter how classically it
resemble a benign gastric ulcer
Multiple biopsies should be taken, as many
as 10 well targeted biopsies
20. BENIGN GASTRIC ULCER
MUCOSAL
FOLDS
Converging folds
Margin Regular
Floor Granulation tissue in
floor
Edges NOT everted ,punched
Surrounding
Area
Normal
Size and
Extent
Small deep up to
muscle layer
21. MALIGNANT GASTRIC ULCER
MUCOSAL
FOLDS
Effacing Mucosal folds
Margin Irregular margin
Floor Necrotic Slough in the
floor
Edges Everted Edges
Surrounding
Area
Shows nodules, ulcers
and irregularities
Size and
Extent
Large and Deep
22. BARIUM SWALLOW
Outpouching of ulcer crater beyond the gastric
contour (exoluminal)
Overhanging mucosa at the margins of a benign
gastric ulcer, project inwards towards the ulcer
Regular/ Round Margin of the Ulcer Crater
Converging mucosal folds towards the base of ulcer
STOMACH SPOKE WHEEL PATTERN
HAMPTON LINE: A thin millimetric radiolucent line
seen at the neck of a gastric ulcer in barium studies
Deformed or absent duodenal cap
23. HAMPTON LINE: A thin millimetric radiolucent line seen at
the neck of a gastric ulcer in barium studies
STOMACH SPOKE` WHEEL
PATTERN
24. TESTS FOR H. PYLORI
Noninvasive tests
Serum or whole blood antibody tests
Immunoglobin G (IgG)
Urea breath test
Patient drinks a carbon-enriched urea solution
Excreted carbon dioxide is then measured
Invasive tests
Biopsy of stomach
Rapid urease test
27. HEMORRHAGE
Blood vessels damaged as ulcer
erodes into the muscles of
stomach or duodenal wall
Coffee ground vomitus or occult
blood in tarry stools
Posterior wall duodenal ulcer
Arteries involved
GASTRIC ULCER erode LEFT
GASTRIC VESSELS and
SPLENIC VESSELS
DUODENAL ULCER erodes
GASTRODUODENAL artery
28. PERFORATION
Can erode through the entire wall
Spillage of gastric/duodenal content and bacteria
into peritoneum leading to peritonitis
Mostly associated with NSAIDs ulcers
Anterior wall duodenal ulcer
29. PENETRATION
Ulcers may erode through the entire thickness of
the gastric or duodenal wall into adjacent
abdominal organs
Can involve the pancreas, bile ducts, liver, and the
small or large intestine.
The pancreas is the most common site of
penetration
30. NARROWING AND OBSTRUCTION
Hour glass contracture
Cicatricial contracture of lesser curvature ulcer, dividing
the stomach in two compartments
Teapot deformity
Cicatrisation and shortening of lesser curve
Pyloric stenosis
Scarring and cicatrisation of first part of duodenum
Persistent vomiting
32. PHARMACOLOGICAL MANAGEMENT
Provide pain relief
Antacids and mucosa protectors
Eradicate H. pylori infection
Two antibiotics and one acid suppressor
Heal ulcer
Eradicate infection
Protect until ulcer heals
Prevent recurrence
Decrease high acid stimulating foods in susceptible people
Avoid use of potential ulcer causing drugs
Stop smoking
AIM
33. NON-PHARMACOLOGICAL
• Avoid spicy food.
• Avoid Alcohol.
• Avoid Smoking.
• Avoid heavy meals.
• Encourage small frequent low caloric meals.
• Avoid ulcerating drugs e.g. NSAIDs, corticosteroids
34. HYPOSECRETORY DRUGS
Proton Pump Inhibitors
Suppress acid production
H2-Receptor
Antagonists
Block histamine-stimulated
gastric secretions
Antacids
Neutralizes acid and
prevents formation of
pepsin
Give 2 hours after meals
and at bedtime
Prostaglandin Analogs
Reduce gastric acid and
enhances mucosal
resistance to injury
Mucosal barrier
fortifiers
Forms a protective coat
Sucralfate
39. TYPES OF SURGICAL PROCEDURES
2.Gastroenterostomy
allows regurgitation of alkaline duodenal
contents into the stomach
• Gastrojejunostomy
1.Diversion of Acid Away from
the duodenum
•Billroth II
3.Reduce the secretory Potential of
Stomach
•Billroth I (gastric ulcer)
•Truncal vagotomy and drainage
•Highly selective vagotomy
•Truncal vagotomy and antrectomy
40. BILLROTH I GASTRECTOMY
Gastric ulcers
Distal portion of the
stomach is mobilised
and resected
The cut edge of the remnant is partially
closed from Lesser Curvature aspect
Stoma at greater curvature aspect
Gastroduodenal anastomosis done
41. BILLROTH II GASTRECTOMY
The lower portion of the
stomach is removed along
with the ulcer and the
remainder is anastomosed
to the jejunum
Recurrent ulceration is low
High Operative Mortality and
Morbidity
42. SEQUELAE OF PEPTIC ULCER SURGERY
Recurrent Ulceration
Small Stomach
Syndrome
Bile Vomiting
Early and Late
Dumping
Post Vagotomy
Diarrhoea
Malignant
Transformation
Nutritional
Consequences
Gall Stones
43. OTHER TYPES OF ULCER
NSAIDs induced ulcers
Antisecretory agents
Stomal ulcers
Prolonged course of antisecretory agents
Zollinger- Ellison syndrome
Proton pump inhibitors unless tumor can be managed
by surgery