Peptic Ulcer

Peptic Ulcer
10% population affected
Gastric ulcer in elderly 5-6th decade
Duodenal ulcer in adults 4th decade
DU also in young

Duodenal Ulcer
Proximal duodenum
1 - 2 cm of pylorus
▲ acid
Distal duodenum = ZE

Type 1 Gastric Ulcer
most common (among gastric Ulcers)
proximal antrum
↓ mucosal defense
↓ acid

Type II Gastric Ulcer
Secondary to DU + pyloric stenosis

Type III Gastric Ulcer
Prepyloric and pyloric canal ulcer
acid ▲
common etiology with DU

Incidence
etiology
CP
Investigations
DD
Rx

Pathogenesis
Imbalance of acid-pepsin and mucosal defence
H. pylori infection
NSAID
ZE Syndrome
Type A personality

H.pylori
95% - duodenal ulcer
80% - gastric ulcer
↓ mucosal resistance hydrophobicity
eradication reduces ulcer recurrence

NSAID
Suppress prostaglandins
prostaglandin ►
↓ acid secretion
↑ ▲ mucosal blood flow
↑ mucus & bicarbonate secretion
10 -30% in chronic users

A/ DU
NSAIDs
Acid hypersecretion
Rapid gastric emptying
Impaired acid disposal
Smoking

Duodenal Ulcer
Increased secretion of acid
More rapid gastric emptying
Decreased prostaglandin
Chronic duodenitis with H.pylori
Smoking

Gastric Ulcer
H.pylori
NSAIDs
Duodenogastric reflux
Impaired gastric mucosal defense

Gastric Ulcer
Acid secretion - normal to low
Reflux of duodenal contents → gastritis → ulcer
Pylorus sphincter disorder
Smoking
Disturbed mucosa with low grade gastritis

Clinical Presentation
Duodenal Ulcer
pain relieved by food or alkali
pain several hours after meal
Gastric Ulcer - gnawing or burning pain on eating

Periodic chronic recurrent pain
Nausea & vomiting
Weight loss
Epigastric tenderness

Investigations
Endoscopy
90% sensitivity
must in all pts. with severe pain excludes malignancy
biopsy can be taken
test for H.pylori

Investigations
Barium Meal double (air) contrast
90% sensitivity

H Pylori detection:
Breath test
Blood test
Tissue test

Treatment
Stop smoking, NSAIDs
Stop alcohol
Antacids - acid neutralisation
H2 receptor antagonist -Ranitidine - secretion inhibition

H+ pump inhibition - H+/K+ase inhibition - Omeprazole
Anticholinergic - secretory inhibition
Prostaglandin - Misoprostol - mucosal protection

Proton Pump Blockers
Omeperazole
Eso-meperazole
Rabi-meperazole

Sucralfate - protective coating
Colloidal Bismuth
eradicate H.pylori
protective coating
Antibiotics - H.pylori
Kit for H Pylori

H2 Receptor Antagonists
On parietal cells
Decrease basal & stimulated acid secretion
Pepsin output decreased
Decreased gastric blood flow
Competitive inhibitor of parietal cell

Treatment - Duodenal Ulcer
95% control - medical Rx
Surgery-Outdated, Obsolete
Omeprazole better thanRanitidine
Ulcer heels in 80% by 6 m
↓ recurrence in 95% by H.pylori eradication

Indications for surgery =Compl
Hemorrhage
Obstruction
Perforation
Intractability of pain
Intractable pain ► HSV / TV + GJ

H2 blockers heals 75% DU in 4 weeks
H/K proton pump inhibitor better results
ulcer may recurr in 80% cases on stopping
treatment of H.pylori

Indication of surgery in hemorrhage
bleeding of > than 6 units
recurrent bleed after endoscopic control
pyloro-duodenotomy and control of bleeding
HSV or TV + GJ

Perforation - simple closure with omental patch -Graham’s patch
definitive surgery
HSV
TV + pyloroplasty
parietal cell vagotomy
TV+GJ

Treatment GU
Omeprazole, H2 receptor antagonist - 8 weeks
if pain not relieved by 2 weeks - add one more drug
repeat endoscopy after 8 weeks
if no healing by 12 - 115 weeks - Surgery

Type I - Distal Gastrectomy with vagotomy + G-D or GJ
proximal ulcer- total gastrectomy
parietal cell vagotomy - high recurrence

Hemorrhage
Hemorrhage - potential cause of death
15 -20% gross bleeding
erosion of duodenal ulcer into gastro-duodenal artery
Endoscopy –laser, sclerosant oralcohal injection

Perforation
In 5-10% of cases
pneumo-peritoneum in 75% cases
peritonitis, pain, ileus
leukocytosis, hypovolumia, IIIrd space loss
DD - acute appendicitis, enteric perf.

Obstruction
Chronic ulcer disease with edema and scarring
in 5% cases of DU
nausea, vomiting, abdominal distension
metabolic alkalosis, paradoxical aciduria

Obstruction
Endoscopy
Ba study
Scintigraphy
Rx V + G-J / G-D