EOR GI part 3- PUD Flashcards
What is peptic ulcer disease?
Gastric and duodenal ulcers
What are the possible consequences of PUD?
Pain
Hemorrhage
Perforation
Obstruction
What percentage of pts with PUD develops bleeding from the ulcer?
~20%
Which bacteria are associated with PUD?
Helicobacter pylori
What is the tx for H. pylori?
Clarithromycin
Ampicillin
PPI
What is the name of the sign with RLQ pain/peritonitis as a result of succus collection from a perforating peptic ulcer?
Valentino’s sign
In what age group are duodenal ulcers most common?
40-65 yoa
What is the ratio of male to female pts with duodenal ulcers?
Men >women (3:1)
What is the MC location of duodenal ulcers?
Most are within 2 cm of the pylorus in the duodenal bulb
What is the classic pain response to food intake in a duodenal ulcer?
Food classically relieves duodenal ulcer pain
What is the cause of a duodenal ulcer?
Increased production of gastric acid
What syndrome must you always think of with a duodenal ulcer?
Zollinger-Ellison syndrome
What are the major sx of a duodenal ulcer?
Epigastric pain
Bleeding
What are the signs of a duodenal ulcer?
Tenderness in epigastric area Guaiac-pos stool Melena Hematochezia Hematemesis
What is the DDx of duodenal ulcer?
Acute abdomen Pancreatitis Cholecystitis All causes of UGI bleeding Zollinger-Ellison syndrome Gastritis MI Gastric ulcer Reflux
How is the dx made of duodenal ulcer?
Hx
PE
EGD
UGI series (if pt is not actively bleeding)
When is surgery indicated with a bleeding duodenal ulcer?
Most surgeons use: >6 units PRBC transfusions
>3 units PRBCs needed to stabilize
OR
for significant need
What is the medical tx for duodenal ulcer?
PPIs or H2 receptor antagonists- heals ulcers in 4-6 wks in most cases
Tx for H. pylori
When is surgery indicated for duodenal ulcers that are not bleeding?
Intractability
Hemorrhage
Obstruction (gastric outlet obstruction)
Perforation
How is a bleeding duodenal ulcer surgically corrected?
Opening of the duodenum through the pylorus
Oversewing of the bleeding vessel
What artery is involved with bleeding duodenal ulcers?
Gastroduodenal artery
What are the common surgical options for truncal vagotomy?
Pyloroplasty
What are the common surgical options for duodenal perforation
Graham patch (poor candidates, shock, prolonged perforation) Truncal vagotomy and pyloroplasty incorporating ulcer Graham patch and highly selective vagotomy Truncal vagotomy and antrectomy (higher mortality rate, but lowest recurrence rate)
What are the common surgical options for duodenal ulcer intractability?
PGV (highly selective vagotomy)
Vagotomy and pyloroplasty
In what age are gastric ulcers most common?
40-70 yoa
How does the incidence of gastric ulcers in men compare with that of women?
Men > women
Which is more common overall: gastric or duodenal ulcers?
Duodenal ulcers are more than twice as common as gastric ulcers
What is the classic pain response to food with gastric ulcers?
Food classically increases gastric ulcer pain
What is the cause of gastric ulcers?
Decreased cytoprotection or gastric protection
What are the associated RFs with gastric ulcers?
Smoking EtOH Burns Trauma CNS tumor/trauma NSAIDs Steroids Shock Severe illness Male gender Advanced age
Is gastric acid production high or low with gastric ulcers?
Normal or low
What are the sx of gastric ulcers?
Epigastric pain
+/- vomiting, anorexia, nausea
How is the dx of gastric ulcer made?
Hx
PE
EGD with multiple bx (looking for gastric CA)
What is the most common location of gastric ulcers?
~70% are on the lesser curvature
~5% are on the greater curvature
When and why should bx be performed for gastric ulcers?
With all gastric ulcers, to r/o gastric CA
If the ulcer does not heal in 6 wks after medical tx, rebiopsy (always bx in OR) must be performed
What is the medical tx for gastric ulcers?
Similar to that of duodenal ulcer- PPIs or H2 blockers, H. pylori tx
When do pts with gastric ulcers need to have an EGD?
For dx with bxs
6 wks postdiagnosis to confirm healing and r/o gastric CA
What are the indications for surgery with gastric ulcers?
Intractability CA (r/o) Hemorrhage Obstruction Perforation
What is the common operation for hemorrhage, obstruction, and perforation in a gastric ulcer?
Distal gastrectomy with excision of the ulcer without vagotomy unless there is duodenal dz
What is a common option for a poor operative candidate with a perforated gastric ulcer?
Graham patch
What must be performed in every operation for gastric ulcers?
Bx looking for gastric CA
What are the sx of a perforated peptic ulcer?
Acute onset of upper abdominal pain
What is the DDx of a perforated peptic ulcer?
Acute pancreatitis Acute cholecystitis Perforated acute appendicitis Colonic diverticulitis MI Any perforated viscus
Which diagnostic tests are indicated for a perforated peptic ulcer?
X-ray: free air under diaphragm or in lesser sac in an upright CXR
What is the initial tx for a perforated peptic ulcer?
NPO: NGT (decreased contamination of the peritoneal cavity)
IVF/Foley cath
Abx/PPIs
Surgery
What is a Graham patch?
Piece of omentum incorporated into the suture closure of perforation
What type of perforated ulcer may present just like acute pancreatitis?
Posterior perforated duodenal ulcer into the pancreas
Truncal vagotomy
Resection of a 1- to 2-cm segment of each vagal trunk as it enters the abdomen on the distal esophagus, decreasing gastric acid secretion
What other procedure must be performed along with a truncal vagotomy?
“Drainage procedure” (pyloroplasty, antrectomy, or gastrojejunostomy) because vagal fibers provide relaxation of the pylorus, and, if you cut them, the pylorus will not open
Vagotomy and pyloroplasty
Pyloroplasty performed with vagotomy to compensate for decreased gastric emptying
Vagotomy and antrectomy
Remove antrum and pylorus in addition to vagotomy; reconstruct as a Billroth I or II
What is the advantage of proximal gastric vagotomy (highly selective vagotomy)?
No drainage procedure is needed
Vagal fibers to the pylorus are preserved
Rate of dumping syndrome is low
What is a Billroth I?
Truncal vagotomy, antrectomy, and gastroduodenostomy
What are the contraindications for a Billroth i?
Gastric CA or suspicion of gastric CA
What is a Billroth II?
Truncal vagotomy, antrectomy, and gastrojejunostomy
