34. Diseases of the stomach and duodenum. Peptic ulcer disease. Modern surgical treatment.

Question 1

Innervation of stomach

Answer 1

vagus – Parasympathetic to stomach

• T5-T10 = sympathetic – T5 tract to celiac ganglion in splanchnic nerves – then post ganglionic to stomach
• T5-T10 —(splanchnic)—- celiac ganglion — (postganglionic)—stomach

Question 2

Cells of the stomach

Answer 2

• Parietal cells = IF + HCL
• Chief cells = Pepsinogen
• Pepsinogen + HCL = Pepsin

Question 3

Peptic ulcer disease: Definition

Answer 3

Term used to describe a group of ulceration disorders that occur in areas of upper GI that are exposed to acid-pepsin secretions.

The Defects - in gastric/duodenum mucosa - extend into the submucosa or deeper

Question 4

Peptic ulcer disease: Etiology

Answer 4

Large majority caused by H.pylori (attacks lining – predisposing stomach to acids damage = ulcer) + NSAIDs

Zollinger-Ellison syn: gastrin secreting tumour or hyperplasia of islets calls in pancreas causing overproduction of G acid.

Question 5

Peptic ulcer disease: Pathology

Answer 5

Muscle injury + inhibition of PG (decreased acid secretion) synthesis

Question 6

Peptic ulcer disease: Most Common forms

Answer 6

duodenum (occur at any
age 3x more common) + gastric
(older age group

– affects men >
women)

Question 7

Peptic ulcer disease: Clinical Presentation

Answer 7

Ab pain - non-radiating burning pain located in epigastrium
at night or 2/3 hrs after meal

N/V

weight loss

bleeding

anaemia

Question 8

Peptic ulcer disease: Diagnostic Investigations

Answer 8

History of PUD – use of NSAIDs

Gastroduodenoscopy

All gastric ulcers should be biopsied (change of malignancy – only for gastric ulcer)

Question 9

Peptic ulcer disease: Treatment

Answer 9

PPI’s + Abx (clarithromycin/amoxicillin) for H.pylori

H2 antagonists

cease NSAIDs

smoking

• Surgery (PTO): indicated by bleeding, perforations, obstructing + non-healing

Operations for duodenal ulcers + gastric ulcers:

Highly selective vagotomy is the Surgical gold standard for duodenal ulcers. Part of vagus that supplies parietal cell is denerved – most satisfactory op for duodenal ulceration

1. Billroth I gastrectomy: for gastric ulcer
2. Billroth II gastrectomy: for duodenal ulcer

Gastrojejunostomy: proximal loop of jejunum anastomosed to post wall of stomach

Jejunal loop can be ulcerated due to direct exposure to gastric acid

Question 10

Melena Definition

Answer 10

black colour of stools = caused by hematin – by product of oxidation of heme by intestinal + bacterial enzymes

Question 11

Classification of Ulcers - According to Location

Answer 11

(Daintree-Johnson Classification)

1. Antrum
2. Gastric body + duodenal
3. Pre-pyloric
4. Cardia

Question 12

Truncal vagotomy + drainage:

Answer 12

Secretion of vagus nerve which are highly involved in acid secretion leads to denervation of antropyloroduodenal segment

Because vagus nerve are conductors of motor impulses to stomach, denervation results in gastric stasis when vagotomy is done alone

So need drainage

Heineke-Mikulicz pyloroplasty: involves a longitudinal incision across pylorus that is then closed transversely

o Pyloroplasty = destroys pyloric sphincter so gastric content can flow without stopping (drainage)