Peptic Ulcer Flashcards
Types of gastric cells
Parietal cells
Chief cells
Mucous cells
G-cells
D-cells
Boey Score 1)Use 2)components 3)interpretation
1) outcome prediction for PPU (30 day mortality)
2) duration of PPU, presence of preoperative shock level, comorbidities
Name several scoring systems for predicting mortality after PPU
Boey
PULP
ASA
Mannheim peritonitis index
APACHEII
Hacateppe score
Jabalpur score
Chief cells secrete?
Pepsinogen
Parietal cells secrete?
HCl
Intrinsic factor
G-cells
1) Secrete
2) Location
1) Gastrin
2) Pylorus
D-cells
1) Secrete
2) Location
1) Somatostatin
2) Antrum
Stimulating gastric acid
Acetylcholine (parasympathetic vagal neural stimulation of parietal cells
Gastrin
Histamine
Inhibition of HCl secretion
Somatostatin
Secretin
CCK
Gastric fluid made up of
Water
Mucus
Ions: HCl, HCO3
Pepsinogen
Intrinsic factor
Hormones (Gastrin, Histamine)
Phases of acid secretion
1) Cephalic phase: vagal activation -> HCl and Gastrin secretion
2) Gastric phase
3) Intestinal phase: food in duodenum => acid secretion then inhibition
Helicobacter pylori
1) Classification
2) Action
1)Gram negative, microaerophilic, spiral bacterium
2)
a. Potent urease activity
b. Direct damage from cytotoxin
c. Dirupt neural pathway by impair inhibitory reflex on acid secretion
Methods of H.pylori detection
Histological
Microbiological culture
Urease breath test
Rapid urease test
Serology for antigen
Stool antigen test
Risks of prolonged PPI use
Vitamin B12 deficiency
Iron deficiency
Reduced calcium absorption (hip fracture, osteoporosis)
Atrophic gastritis
Intestinal metaplasia
Fundic gland polyps
Increase enteric infections (ex CD)
Lap vs Open for PPU surgical intervention
Metanalyses suggest no difference in mortality or postoperative complications, but higher leak rate for ulcers >0.5cm
Conclusion: no evidence lap better than open
Graham-Steele operation
Pedicled omental patch laid over perforation site with full thickness interrupted suture with absorbable with atraumatic needle. Traditionally 3 sutures
Indications to consider NOM (non-operative management) for PPU
Stable without sepsis/periotonitis
Delayed presentation with improving clinical picture
<70 years old
Unfit for surgery (ASA 5)
Patient unwilling for surgery
Reduction in acid secretion
Truncal vagotomy: 60-70%
Antrectomy: 85%
PPI:
- 100% by 6 hours
- 60-70% by 24 hours
Types of pyloroplasty techniques
Heinke-Mikulicz
Jaboulay
Finney
Heineke-Mikulicz Pyloroplasty
Full thickness longitudinal incision from distal antrum to proximal duodenum and closed transversely to increase diameter of pyloric channel
Types of drainage procedure
Pyloroplasty
Gastrojejunostomy
Finney pyloroplasty
- Side to side gastroduodenostomy between anterior surfaces of stomach and duodenum,
- the pylorus is excised
- Single inverted U or V -shaped incision through prepyloric antrum, pylorus and
- Continuous full thickness suture of gastroduodenal anastomosis
Jaboulay pyloroplasty
- Side to side gastroduodenostomy
- Pylorus not incised
- Separate incisions: at prepyloric antrum and D1
- Greater curvature of prepyloric antrum attached to medial wall of adjacent duodenum
Johnson classification
1) Type 1
2) Type 2
3) Type 3
4) Type 4
5) Type 5
Gastric ulcer at
1) lesser curve/incisura
2) combined gastric and duodenal
3) prepyloric
4) juxtaesophageal
5) drug related
