Peptic Ulcer Flashcards
What is peptic ulcer ?
Ulcer formation in the upper GI tract that affect lining of stomach “ gastric ulcer ”., duodenum “ duodenal ulcer “ , or lower part of esophagus.
- gastric ulcer : found inside the stomach.
Duodenal ulcer: found inside the duodenum which is the 1st part of the small intestine.
Cause of peptic ulcer disease ?
- H. pylori ( common cause ). Spirae shape helps bacteria invade the mucosa. Produce urease which break urea which produce ammonia + carbon dioxide = neutralize acid + breaks mucosa.
- spread from oral oral feco oral. - NSAID usage = decrease prostaglandin ( play role of health of stomach lining ) prostaglandin made us feel pain.
- Zollinger - Ellison Syndrome : tumor formation that over secrete gastric = increase stomach acid
- Smoking, alcohol, genetics increase susceptibility , stress or food ( it doesn’t actually cause it )
Comparison between signs and symptoms of gastric / duodenal ulcer ?
Main: Indigestion and Epigastric pain
Diagnosis?
- scope of the stomach ( EGD )
- upper GI series ( pt drinks barium that will coat upper GI
- CT scan with contrast
- H.pylori ; blood test, stool test
Urea breath test ( pt ingest urea tablet) if H.pylori present break urea into ammonia + carbon dioxide. * breath sample collected to measure CO2 levels.
Complications ?
- GI bleeding
- Erodes a hole in lining = perforation
- Bowel blockage @ pylorus from chronic ulceration
- increase risk of GI cancer
Treatment
Meds: PPI, H2 receptor blockers, Antibiotics, anti acid.
Severe cases that causing complications ( vagotemy, pylorolasty, gastric resection )
Intervention
Goal ( Assess, moniter, Educate, Administer meds )
1. Assessing : VS bowel = sounds, tenderness, stools / vomit.
2. Ask patient: onset of pain, food help ? ( to differentiate between gastric and deudnal ulcer )
Medication Hx ; med usage ( NSAIDs, Salicylate, corticosteroids, Antiocoagulant )
Family Hx of H.pylori, smoke, drink alcohol or caffeine.
Monitoring : complications of PUD and after surgery
GI bleeding : increase heart rate , decrease BP
Perforation
Peritonitis
Dumbing syndrome
Dumping syndrome
Watch after gastric resection
Stomach not able to regulate movement of food..
Happens 15 to 40 mins after eating ( Early dumping )
- Fluid shift cause small bowel distension and increase motility and heart tires to compensate for the sudden shift
S&S : bloating, nausea, diarrhea, hypotension , syncope.
- 3 hours ( Late dumping ) :
Food that entered too quickly sm. Intestine rich in carbs / sugar = cause the pancreas to release insulin = hypoglycemia
S&S : sweating, weak and dizzy .
Patient education
Medications for PUD
“ Antacid Medications Help Basic Peptic Aliments. “
MODIFIED JOHNSON CLASSIFICATION
Type I MODIFIED JOHNSON CLASSIFICATION
Lesser curvature ( 60% of gastric ulcers )
Type II MODIFIED JOHNSON CLASSIFICATION
Synchronous ulcer in gastric body and duodenum ( most common in first portion )
Type III MODIFIED JOHNSON CLASSIFICATION
Prepyrloric
Type IV MODIFIED JOHNSON CLASSIFICATION
Near gastroeshageal junction
Type V MODIFIED JOHNSON CLASSIFICATION
related to NSAIDs, can be located anywhere, but typically
greater curvature
D
B
A
Yellow : benign gastric ulcer
Red : Malignant gastric ulcer
The indication for surgery in PUD
Medically refractory disease or interactability
Urgent / emergency indication of peptic university surgury
Perforation
Obstruction
Bleeding
The second most common complication of peptic ulcer
Perforated peptic ulcer
Clinical features of perforated peptic ulcer
Acute onset of sharp Abdul pain
Approximately 1/3 of patients have a history of peptic UD
On physical exam
The patient will be lying motionless
The abdomen does not move with respiration
Abdominal rigidity ( board like rigidity )
Work up of perforated peptic ulcer ( Lab)
CBC ( leukocytosis with a left shift )
Blood chemistries decreased albumin, and elevated BUN and
creatinine.
CRP
Amylase and lipase to exclude pancreatitis
Radiography of Perforated PUD
Treatment of perforated PUD
Adequate volume resuscitation
Broad spectrum IV Abx
Adequate analgesia
Intravenous PPI
The patient is hemodynaomic instable and perforated > 24 hours and had duodenal ulcer, how would you manage him surgically?
Simple omental patch closure and abdominal lavage
The patient is hemodynaomic stable and perforated < 24 hours and had duodenal ulcer, how would you manage him surgically?
Omental patch + Highly selective vagotomy
Or
Patch + truncal vagotomy and drainage
Patient is stable with no multiple operative risk factors and on Type 2 , 3 gastric ulcers, how would manage him surgically?
Distal gastrectomy +Vagotomy
Unstable patient or high risk patient gastric ulcer , how would you manage him surgically ?
Wedge excision, vagotomy and drainage
Artery of hge in bleeding PUD
Gastriduodenal artery
Operation for bleeding peptic ulcer ( hemodynamically unstable or high operative risk )
Stable patient with low operative risk ( bleeding )
Types of obstruction
Acute obstruction:
- Caused by edema and dysmotility
• Chronic obstruction:
- Due to scar formation
Clincal presentation
Nausea • Nonbilious vomiting • Epigastric pain and distension • Weight loss
Physical examination:
• The patient appear unwell and dehydrated
Abdominal examination:
- Distended stomach and a succussion splash may be audible
• We should examine for jaundice and adenopathy
Management of acute obstruction
Rehydration with intravenous isotonic saline + potassium • NPO • Nasogastric suction • Maintain input/output charts • IV PPIs
Management of chronic obstruction
Intractable Duodenal Ulcers D.D
