Peptic Ulcer (Gastric And Duodenal Ulcer)

Peptic Ulcer (Gastric And Duodenal Ulcer)


PEPTIC ULCER (GASTRIC AND DUODENAL ULCER)

GASTRIC ULCER                                                 

DUODENAL ULCER

Etiology

  • H. pylori (70%)
  • Altered mucosal barrier function (NSAID)
  • Smoking, Alcohol
  • Type B gastritis
  • Lower socioeconomic group
  • Either normochlorhydria or ,I,chlorhydria
  • Cirrhosis
  • Stress, anxiety – ‘hurry, worry, curry’
  • H. pylori (90%)
  • NSAIDs, steroids
  • Blood group O+ve
  • Endocrine: Zollinger-Ellison syndrome, MEN-I Cushing’s syndrome, hyperparathyroidism
  • Alcohol, smoking, vitamin deficiency
  • Chronic pancreatitis, Cirrhosis
 

MC Site: lesser curvature along the incisura angularis

MC site: 1st part of Duodenum (overall me site for peptic

ulcer)

Clinical features

  • Equal in both sexes
  • Pain in the epigastrium after taking food; relieved by vomiting
  • Pain is uncommon during night
  • Hematemesis common
  • Appetite good, but hesitant to eat as eating induces pain
  • that results in loss of weight
  • More common in males
  • Pain is more before food, in early morning, decreases after food (hunger pain)
  • Pain common during night
  • Melena common
  • Appetite good, eats more frequently and there is weight gain
  • Once stenosis develops, loss of weight
 

Barium meal X ray features

  • Niche on lesser curve with notch on greater curve
  • Regular/round margin of ulcer crater – stomach spoke wheel pattern
  • Overhanging mucosa at the margins of a benign gastric ulcer projects inwards towards the ulcer – Hamptom’s line
  • Converging mucosal folds at the base of the ulcer

 

  • Deformed or absent duodenal cap (because of spasm)
  • Appearance of trifoliate duodenum due to secondary duodenal diverticula

Complications

  • Hour glass contracture – exclusively in women due to cicatricial contracture of lesser curve ulcer which leads to loss of periodicity, persistent pain and vomiting
  • Tea pot stomach (hand bag stomach) – cicatrisation and shortening of the lesser curvature
  • Bleeding (splenic A; rarely left gastric A)
  • Perforation (into lesser sac)
  • Malignant transformation to adeno Ca. in 2-5%
  • Bleeding – MC complication, on posterior wall, gastroduodenal artery is the artery of bleed
  • MC site of bleeding from peptic ulcer – First part of duodenum
  • Perforation – more on anterior wall, if posterior –into pancreas
  • Gastric Outlet Obstruction due to pyloric stenosis– least common
  • Duodenal ulcer will never turn malignant
 
  •  Peptic ulcers never occur in association with pernicious anaemia (no acid and pepsin-secreting parietal and chief cells respectively) 

Types of gastric ulcer

  • I – near the incisura on lesser curvature
  • II – associated with active or quiescent duodenal ulcer
  • III – Prepyloric region
  • IV – Near gastro-esophageal junction 

Most important factors causing peptic ulcer

  • H pylori infection
  • NSAID use 

Benign gastric ulcer

Malignant gastric ulcer

  • Converging mucosal folds upto the margin
  • 95% on the lesser curve
  • Regular margins
  • Granulation tissue in the floor
  • Edge not everted; punched or sloping
  • Rugae in the surrounding area are normal
  • Effacing mucosal folds
  • Greater curvature
  • Irregular margins
  • Necrotic slough in the floor
  • Everted edge
  • Nodules, ulcers, irregularities in surrounding area
 
  • Cushing ulcer – due to intracranial injury/increased ICP/after neurosurgical operations
  • Curling ulcer – after burn injury (>35%); in the body and fundus; not in antrum and duodenum
  • Cameron ulcers – linear gastric erosions in hiatal hernias
  • Kissing ulcers – both anterior and posterior duodenal ulcers are present 

Medical treatment: Proton pump inhibitors or H2 blockers; H.pylori eradication 

Surgeries for Duodenal ulcer

  • Highly Selective Vagotomy or Parietal cell Vagotomy or Proximal gastric Vagotomy
  • Procedure of choice
  • Nerves of Latarjet are preserved (and hence gastric motility)
  • Lowest mortality rate and side effects
  • Minimal chances of dumping syndrome
  • Gastrectomy – highest mortality
  • Vagotomy and Antrectomy – lowest recurrence & highest morbidity
  • Gastroenterostomy alone – highest recurrence
  • Billroth II gastrectomy 
  • Duodenal blow out following Billroth II gastrectomy occurs on 4th day (2-7days) 

Surgery for gastric ulcer

  • Partial gastrectomy with Billroth I gastroduodenal anastomosis
  • Type IV ulcer – subtotal gastrectomy 

Sequelae of peptic ulcer surgery

  • Recurrent ulceration
  • Small stomach syndrome
  • Follows most ulcer operations, does not occur following Highly selective vagotomy
  • Due to loss of receptive relaxation
  • Gets better with time
  • Revisional surgery is not necessary

Bile vomiting (Afferent loop syndrome)

  • Following gastrectomy, best treatment is Roux-en-Y diversion
  • In patients with gastroenterostomy, small Pyloroplasty may be performed

Dumping syndrome (Post cibal syndrome)

  • More common after partial gastrectomy with the Billroth II reconstruction.
  • Much less common following the Billroth I gastrectomy or after vagotomy and drainage procedures

Efferent loop obstruction

  • More than 50% of cases occur within the first postoperative month

Alkaline reflux gastritis

  • Although the diagnosis can be made by taking a careful history HIDA scans usually demonstrate biliary secretion into the stomach and even into the esophagus.
  • Most patients had gastric resection and Billroth II anastomosis

Post vagotomy diarrhea

  • Patient managed as for early dumping
  • Octreotide not effective
Exam Question
 

Most important factors causing peptic ulcer

  • H pylori infection
  • NSAID use
  • Sequelae of peptic ulcer surgery
  • Recurrent ulceration

Small stomach syndrome

  • Follows most ulcer operations, does not occur following Highly selective vagotomy
  • Due to loss of receptive relaxation
  • Gets better with time
  • Revisional surgery is not necessary

Bile vomiting (Afferent loop syndrome)

  • Following gastrectomy, best treatment is Roux-en-Y diversion
  • In patients with gastroenterostomy, small Pyloroplasty may be performed

Dumping syndrome (Post cibal syndrome)

  • More common after partial gastrectomy with the Billroth II reconstruction.
  • Much less common following the Billroth I gastrectomy or after vagotomy and drainage procedures

Efferent loop obstruction

  • More than 50% of cases occur within the first postoperative month

Alkaline reflux gastritis

  • Although the diagnosis can be made by taking a careful history HIDA scans usually demonstrate biliary secretion into the stomach and even into the esophagus.
  • Most patients had gastric resection and Billroth II anastomosis

Post vagotomy diarrhea

  • Patient managed as for early dumping
  • Octreotide not effective
Don’t Forget to Solve all the previous Year Question asked on Peptic Ulcer (Gastric And Duodenal Ulcer)

Leave a Reply

%d bloggers like this:
Malcare WordPress Security