peptic ulcer Flashcards
definition
Chronic relapsing disease with the lost of part of mucosa of epithelium cells of any portion of GIT (stomach, duodenum) exposed to aggravation action of gastric juice.
classificaiton
- Type→ 10 , 20
- Sites→ stomach (<curv, antrum, body), duodenum
- Duration→ mild(relapse <2x/year), moderate(relapse 2x/yr), severe (>2x/yr)
- Size→ small (<0.5cm), large (> 1 cm), very large : stom (<3cm), duo (> 3cm)
- Layers → superficially (< 0.5cm), deeply (> 0.5cm)
risk factors
- Genetic predisposition
a. ↑ parietal cells so ↑ HCL, pepsinogen & gastrin secretion.
b. Blood group O
c. Astenic constitution - Stress
- Male
- 1st degree relative with duodenal ulcer
- GIT disorder
- Alcohol, smoking
- drugs: aspirin & other NSAID
- dietary regime
etiology
Endogenic factor :
- hyperpepsinogenaemia, α-antitrypsin deficiency and hyperfunction of G- cells
- ZE syndrome (tumor of pancreas)
- Acute stress ulcer
- Cushing syndrome
- Arteriosclerotic vessels
- psychoemotional stress
Exogenic factor:
- diet, alcohol, smoking,
- H.pylori
- NSAID, cortocosteroids
pathogenesis
- psychoemotional theory
Stress→ ↑ SNS & PNS→ results problem in innervation of stomach →↓ prod of gastric juice→ ↑ motor activity of GIT→ spasm of vessel (with trophic damage)→ dev of PU - Infection ( Campylobacter pylori )
- camplylobacter is situated btw folds→releases uric acid→ acid present in region of neutralization & it not destroyed by gastric juice. (must give Atb)
- decrease somatostatin in duodenum, increased secretion of H - Imbalance between the defensive & aggressive factors. ( ↓ defense, ↑ aggressive )
a. Defense Factor
- production of mucous
- high regeneration
- prostaglandin production
- intensive blood flow ( mucosal )
- bicarbonate secretion
- neurohormonal reg: somatostatin, secretin, enterogastrin
b. Aggressive Factor
- campylobacter pylori
- acid & pepsin
- bile reflux
- peptic activity, impaired inhibition of acid-pepsin secretion
- duodenal reflux; exogenous: smoking, NSAIDs
Clinical symptoms acc to localization (cardia, pylorus, below duodenal)
- Cardia- when pain is in epigastric region (near xiphoid process)
- early pain syndrome
- Males > 45 years old
- Radiate to L and chest
- Not intensive
- Heartburn typical
- Associate with hiatus hernia
- Typical complication - bleeding - lesser curv- common place
- males (middle age), females (>50)
- epigastric pain
- acidity normal
- heartburn present - greater curv- rare
- males
- associate with normal & hypoacidity
- 50% in malignization - antrum- young male typical
- typical late hunger/ night pain
- dangerous for malignizatn
- typical compli- bleeding - pylorus - occur in men and occurs with decreasing of HCl secretion.
- duodenum bulb- male <40
- mainly on ant wall
- seasonal character
- night hunger late pain is typical
- typical compli – perforatn - Below duodenum: men, 40-60 years old. primary complication is bleeding due to hypersecretion of HCL and heart burn.
investigation
- Fibrogastroduodenoscopy- used in primary description of PU
- Gastroscopy with biopsy
- Secretion investigation
- X-ray with barium meal
- direct ( niche,crater)
- indirect (one mobile point, fast evacuation,finger pointing on opp side)
- determine its localization,deformation and complication.
- ―De Ker Ver‖ syndrome present in PU - Blood analysis - ↓ Hb, RBC & C.I., erythrocytosis, anemia (Iron deficiency)
- Corpological analysis - feaces on blood occult - Greger Sand Webber rxn
- Biochemical - urease activity
Role of x-ray & gastroscopy in investigation
Role of x-ray & gastroscopy in investigation
X ray: to identify the type, size, shape, localization, radiation of ulcerous process.
- To make accurate diagnosis with help of barium meal.
- To determine the severity of disease acc to layers affected (superficial, deep)
- detect cancer ( as differential diagnostic )
- present of fluid in ulcer
Gastroscopy- helps to make diagnosis & to take biopsies:
- It also can help detect cause & source of HR if present.
- to observe the mucosal surface of PU
- to perform rapid urease test, culture of biopsy, histology of gastric mucosa
treatment - antacids, h2-receptor antagonist, anticholinergic drugs, bithmus
Dietary regime- 5-6x daily in small portions.
- Exclude coffee, alcohol, smoking
- Include fish, milk production, porridge, juices
- Antacids- neutralization of HCL & peptic juice. (NaCO3, CaCO3, Aluminium OH)
- H2 receptor antagonists
- cimethidine, ranithidine, famothidine, nizathidine
- ↓ prod of HCL & ↓ night secretion - Anticholinergic drug
- Proton Pump Inhibitors
- omeprazole, lansoprazole, rabeprazole and pantoprazole
- inhibit all phases of gastric secretion - bismuth chelate eg. tripotassium dicitratobismuthate
- can binds to the ulcer crater and stimulate prostaglandin secretion, ↑ b/flow, protect mucosa
- effective against H. pylori
Complications of peptic ulcer: penetration, perforation, gastric outlet obstruction
- Penetration
- Invasion to nearest organs
- posterior wall of stomach involve pancreas, post wall of duodenum.
- Constant pain irradiatn to back, pancreas digest itself (autolysis)- gen inflammatory effect.
- May find silent puncture if omentum closes defect.
- investigation - xrays, endoscopy, laparoscopy, US, MRI, amylase.
- operation - relief pain, prevent any exocrine & endocrine insufficiency - Perforation
- Acute destruction of stomach wall.
- Young pt (19-45), more typical in DU.
- pain syndrome (knife stab)
- Peritonitis syndrome- flat abd, lose consciousness, no liver dullness-tympanic sound
- X-ray - gas below liver.
a. massive
- < 3 hours : sign of acute abdomen - rebound tenderness, high temperature, pale skin,decreased liver dullness,decreased of peristastic sound.
- 3-6 hours : decreased sign of acute abdomen as peritoneum secrete fluids and cover pain. high temperature and paralytics ileus occurs.
- 6 hours : detectable fluids amounts.
b. slow
- perforation sealed by the greater omentum.
- analgesic, infusion to treat dehydration and also shock, nasogastric tube, catherization, prophylaxis antibiotic and CVS monitoring. Operation repair of perforation and for duodenal ulcer
- Gastric Outlet obstruction
- hardness after food intake, bad appetite, foul smell from mouth, nausea, vomiting after meals
- splash sound, shifting of lower border of stomach lower than umbilicus.
- X ray after barium. compensative (<6hrs), subcompensative(6-24 hrs), decompensative(>24 hrs)
a. functional
- present during exacerbation only, due to edema & spasm
- located near antrum or sphincter.
b. Organic
- deformation & stenosis due to scar formation - necrotic
- with exacerbation & remission. sign and symptoms occurs at any time
- surgical treatment
- Malignization
- Ulcer like tumor variant.
- exam pt after & before treatment (If cancer, no effect of Tx, pain present at all times)
- Cachexia (loss mass), no appetite.
