Слайд 2Peptic Ulcer
10% population affected
Gastric ulcer in elderly 5-6th decade
Duodenal ulcer in adults
![Peptic Ulcer 10% population affected Gastric ulcer in elderly 5-6th decade Duodenal](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/1168270/slide-1.jpg)
4th decade
DU also in young
Слайд 3Duodenal Ulcer
Proximal duodenum
1 - 2 cm of pylorus
▲ acid
Distal duodenum = ZE
![Duodenal Ulcer Proximal duodenum 1 - 2 cm of pylorus ▲ acid Distal duodenum = ZE](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/1168270/slide-2.jpg)
Слайд 4Type 1 Gastric Ulcer
most common (among gastric Ulcers)
proximal antrum
↓ mucosal defense
↓ acid
![Type 1 Gastric Ulcer most common (among gastric Ulcers) proximal antrum ↓ mucosal defense ↓ acid](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/1168270/slide-3.jpg)
Слайд 5Type II Gastric Ulcer
Secondary to DU + pyloric stenosis
![Type II Gastric Ulcer Secondary to DU + pyloric stenosis](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/1168270/slide-4.jpg)
Слайд 6Type III Gastric Ulcer
Prepyloric and pyloric canal ulcer
acid ▲
common etiology with DU
![Type III Gastric Ulcer Prepyloric and pyloric canal ulcer acid ▲ common etiology with DU](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/1168270/slide-5.jpg)
Слайд 7Incidence
etiology
CP
Investigations
DD
Rx
![Incidence etiology CP Investigations DD Rx](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/1168270/slide-6.jpg)
Слайд 8Pathogenesis
Imbalance of acid-pepsin and mucosal defence
H. pylori infection
NSAID
ZE Syndrome
Type A personality
![Pathogenesis Imbalance of acid-pepsin and mucosal defence H. pylori infection NSAID ZE Syndrome Type A personality](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/1168270/slide-7.jpg)
Слайд 9H.pylori
95% - duodenal ulcer
80% - gastric ulcer
↓ mucosal resistance hydrophobicity
eradication reduces
![H.pylori 95% - duodenal ulcer 80% - gastric ulcer ↓ mucosal resistance](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/1168270/slide-8.jpg)
ulcer recurrence
Слайд 10NSAID
Suppress prostaglandins
prostaglandin ►
↓ acid secretion
↑ ▲ mucosal blood flow
↑ mucus &
![NSAID Suppress prostaglandins prostaglandin ► ↓ acid secretion ↑ ▲ mucosal blood](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/1168270/slide-9.jpg)
bicarbonate secretion
10 -30% in chronic users
Слайд 11A/ DU
NSAIDs
Acid hypersecretion
Rapid gastric emptying
Impaired acid disposal
Smoking
![A/ DU NSAIDs Acid hypersecretion Rapid gastric emptying Impaired acid disposal Smoking](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/1168270/slide-10.jpg)
Слайд 12Duodenal Ulcer
Increased secretion of acid
More rapid gastric emptying
Decreased prostaglandin
Chronic duodenitis with H.pylori
Smoking
![Duodenal Ulcer Increased secretion of acid More rapid gastric emptying Decreased prostaglandin](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/1168270/slide-11.jpg)
Слайд 13Gastric Ulcer
H.pylori
NSAIDs
Duodenogastric reflux
Impaired gastric mucosal defense
![Gastric Ulcer H.pylori NSAIDs Duodenogastric reflux Impaired gastric mucosal defense](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/1168270/slide-12.jpg)
Слайд 14Gastric Ulcer
Acid secretion - normal to low
Reflux of duodenal contents → gastritis
![Gastric Ulcer Acid secretion - normal to low Reflux of duodenal contents](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/1168270/slide-13.jpg)
→ ulcer
Pylorus sphincter disorder
Smoking
Disturbed mucosa with low grade gastritis
Слайд 15Clinical Presentation
Duodenal Ulcer
pain relieved by food or alkali
pain several hours
![Clinical Presentation Duodenal Ulcer pain relieved by food or alkali pain several](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/1168270/slide-14.jpg)
after meal
Gastric Ulcer - gnawing or burning pain on eating
Слайд 16Periodic chronic recurrent pain
Nausea & vomiting
Weight loss
Epigastric tenderness
![Periodic chronic recurrent pain Nausea & vomiting Weight loss Epigastric tenderness](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/1168270/slide-15.jpg)
Слайд 17Investigations
Endoscopy
90% sensitivity
must in all pts. with severe pain
![Investigations Endoscopy 90% sensitivity must in all pts. with severe pain excludes](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/1168270/slide-16.jpg)
excludes malignancy
biopsy can be taken
test for H.pylori
Слайд 18Investigations
Barium Meal double (air) contrast
90% sensitivity
![Investigations Barium Meal double (air) contrast 90% sensitivity](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/1168270/slide-17.jpg)
Слайд 19H Pylori detection:
Breath test
Blood test
Tissue test
![H Pylori detection: Breath test Blood test Tissue test](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/1168270/slide-18.jpg)
Слайд 20Treatment
Stop smoking, NSAIDs
Stop alcohol
Antacids - acid neutralisation
H2 receptor antagonist -Ranitidine - secretion inhibition
![Treatment Stop smoking, NSAIDs Stop alcohol Antacids - acid neutralisation H2 receptor](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/1168270/slide-19.jpg)
Слайд 21H+ pump inhibition - H+/K+ase inhibition - Omeprazole
Anticholinergic - secretory inhibition
Prostaglandin -
![H+ pump inhibition - H+/K+ase inhibition - Omeprazole Anticholinergic - secretory inhibition](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/1168270/slide-20.jpg)
Misoprostol - mucosal protection
Слайд 22Proton Pump Blockers
Omeperazole
Eso-meperazole
Rabi-meperazole
![Proton Pump Blockers Omeperazole Eso-meperazole Rabi-meperazole](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/1168270/slide-21.jpg)
Слайд 23Sucralfate - protective coating
Colloidal Bismuth
eradicate H.pylori
protective coating
Antibiotics - H.pylori
Kit
![Sucralfate - protective coating Colloidal Bismuth eradicate H.pylori protective coating Antibiotics -](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/1168270/slide-22.jpg)
for H Pylori
Слайд 24H2 Receptor Antagonists
On parietal cells
Decrease basal & stimulated acid secretion
Pepsin output decreased
Decreased
![H2 Receptor Antagonists On parietal cells Decrease basal & stimulated acid secretion](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/1168270/slide-23.jpg)
gastric blood flow
Competitive inhibitor of parietal cell
Слайд 25Treatment - Duodenal Ulcer
95% control - medical Rx
Surgery-Outdated, Obsolete
Omeprazole better thanRanitidine
Ulcer heels
![Treatment - Duodenal Ulcer 95% control - medical Rx Surgery-Outdated, Obsolete Omeprazole](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/1168270/slide-24.jpg)
in 80% by 6 m
↓ recurrence in 95% by H.pylori eradication
Слайд 26Indications for surgery =Compl
Hemorrhage
Obstruction
Perforation
Intractability of pain
Intractable pain ► HSV / TV + GJ
![Indications for surgery =Compl Hemorrhage Obstruction Perforation Intractability of pain Intractable pain](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/1168270/slide-25.jpg)
Слайд 27H2 blockers heals 75% DU in 4 weeks
H/K proton pump inhibitor better
![H2 blockers heals 75% DU in 4 weeks H/K proton pump inhibitor](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/1168270/slide-26.jpg)
results
ulcer may recurr in 80% cases on stopping
treatment of H.pylori
Слайд 28Indication of surgery in hemorrhage
bleeding of > than 6 units
recurrent bleed after
![Indication of surgery in hemorrhage bleeding of > than 6 units recurrent](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/1168270/slide-27.jpg)
endoscopic control
pyloro-duodenotomy and control of bleeding
HSV or TV + GJ
Слайд 29Perforation - simple closure with omental patch -Graham’s patch
definitive surgery
HSV
TV + pyloroplasty
parietal
![Perforation - simple closure with omental patch -Graham’s patch definitive surgery HSV](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/1168270/slide-28.jpg)
cell vagotomy
TV+GJ
Слайд 30Treatment GU
Omeprazole, H2 receptor antagonist - 8 weeks
if pain not relieved by
![Treatment GU Omeprazole, H2 receptor antagonist - 8 weeks if pain not](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/1168270/slide-29.jpg)
2 weeks - add one more drug
repeat endoscopy after 8 weeks
if no healing by 12 - 115 weeks - Surgery
Слайд 31Type I - Distal Gastrectomy with vagotomy + G-D or GJ
proximal ulcer-
![Type I - Distal Gastrectomy with vagotomy + G-D or GJ proximal](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/1168270/slide-30.jpg)
total gastrectomy
parietal cell vagotomy - high recurrence
Слайд 32Hemorrhage
Hemorrhage - potential cause of death
15 -20% gross bleeding
erosion of duodenal
![Hemorrhage Hemorrhage - potential cause of death 15 -20% gross bleeding erosion](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/1168270/slide-31.jpg)
ulcer into gastro-duodenal artery
Endoscopy –laser, sclerosant oralcohal injection
Слайд 33Perforation
In 5-10% of cases
pneumo-peritoneum in 75% cases
peritonitis, pain, ileus
leukocytosis, hypovolumia, IIIrd space
![Perforation In 5-10% of cases pneumo-peritoneum in 75% cases peritonitis, pain, ileus](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/1168270/slide-32.jpg)
loss
DD - acute appendicitis, enteric perf.
Слайд 34Obstruction
Chronic ulcer disease with edema and scarring
in 5% cases of DU
nausea, vomiting,
![Obstruction Chronic ulcer disease with edema and scarring in 5% cases of](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/1168270/slide-33.jpg)
abdominal distension
metabolic alkalosis, paradoxical aciduria
Слайд 35Obstruction
Endoscopy
Ba study
Scintigraphy
Rx V + G-J / G-D
![Obstruction Endoscopy Ba study Scintigraphy Rx V + G-J / G-D](/_ipx/f_webp&q_80&fit_contain&s_1440x1080/imagesDir/jpg/1168270/slide-34.jpg)