Duodenum

Question 1

Perforated duodenal ulcer Presentation and work up

Answer 1

Presentation Work up

Question 2

Perforated duodenal ulcer Treatment

Answer 2

Old, high risk pt or advanced peritonitis. Omental patch, lavage abdomen, post op H. Pylori treatment Young, good risk, or early peritonitis: Omental patch and PCV OR if patient has had other complications from PUD…antrectomy and vagotomy

Question 3

Obstructing duodenal ulcer Presentation and work up

Answer 3

Presentation Work up. CT scan/ endoscopy Need to r/o cancer and H.pylori

Question 4

Obstructing duodenal ulcer Treatment

Answer 4

Conservative tx for a week: NGT H2 blockers or PPI and H. Pylori ABX/IVF/TPN upper GI and thin barium after 5-7 days IF still obstructed, go to OR Antrectomy and vagotomy with B2 and Braun Also get biopsy of area of resection

Question 5

Bleeding Duodenal ulcer presentation and work up

Answer 5

presentation work up

Question 6

Bleeding duodenal ulcer treatment

Answer 6

old patient, high surgical risk –vagotomy and pyloroplasty –U stitch to oversew GDA WATCH THE CBD young and good risk –oversew and PCV and a B1 (if ulcer is <2cm) –OR can do B2 with A/V **if patient has been on PPI then do acid-reducing surgery

Question 7

describe parietal cell vagotomy

Answer 7

1. upper midline incision
2. triangular ligament of left liver taken down and retract to right (watch inferior phrenic n.)
3. incise peritoneum over GE junction
4. pass finger behind esophagus, isolate and vessel loop the vagus n. and the anterior vagus
5. ID anterior n. of Laterjet (about 7 cm from pylorus) and just proximal to that point, anterior layer of gastrohepatic omentum is opened
6. divide and take all tissue in anterior leaflet of GH omentum up to vessel loop then do same for posterior leaflet

7 penrose around esophagus and clean up esophagus 5-7cm.

8. divide 1cm of N. of grassi
9. check spleen!!!