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Year 3 Upper GI Surgery > Peptic ulcer disease > Flashcards

Peptic ulcer disease Flashcards

1
Q

Duodenal ulcer

A

Pain before meals and at night

Relieved by eating

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2
Q

Gastric ulcer

A

Pain is worse when eating
Weight loss
Relieved by antacids

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3
Q

Risk factors

A
  • H. pylori
  • NSAIDs, steroids
  • Smoking, EtOH
  • Stress (GU)
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4
Q

Common site of gastric ulcer

A

Lesser curvature of gastric antrum

or first part of duodenum

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5
Q

Is duodenal ulcer or gastric ulcer more common?

A

Duodenal ulcer is 4x more common

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6
Q

Complications of ulcers

A
  • Haemorrhage
  • Haematemesis or melaena
  • Fe deficiency anaemia
  • Perforation: peritonitis
  • Gastric outflow obstruction
  • Vomiting
  • Colic
  • Distension

• Malignancy
- Increased risk with H. pylori infection

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7
Q

Which artery is most likely disrupted with a peptic ulcer perforation

A

Gastric - Splenic artery

Duodenal - Gastroduodenal

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8
Q

Investigations for peptic ulcer

A

Bloods: FBC, urea (↑ in haemorrhage)

  • H. Pylori breath test or stool antigen test or serum antibodies to H. pylori
  • OGD (stop PPIs >2wks before)
  • Biopsy all ulcers to check for malignancy

• Gastrin levels if Zollinger-Ellison suspected

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9
Q

Management of peptic ulcer disease

A

Medical:
• OTC antacids: Gaviscon

  • H. pylori eradication - amoxicillin + clarithromycin + PPI
  • Acid suppression
  • PPIs: lansoprazole
  • H2RAs: ranitidine

Surgery:

  • Vagotomy
  • Antrectomy with vagotomy
  • Subtotal gastrectomy with Roux en Y
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10
Q

H.Pylori eradication

A

PPI + Clarithromycin + amoxicillin

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11
Q

Vagotomy

A 
Truncal
- ↓ acid secretion directly and via ↓ gastrin as vagus NS not stimulated
- Prevents pyloric sphincter relaxation
- Combined with pyloroplasty (widening
of pylorus) or gastroenterostomy

• Selective
- Vagus nerve only denervated where it supplies
lower oesophagus and stomach
- Nerves of Laterjet (supply pylorus) left intact

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12
Q

Antrectomy with Vagotomy

A 
• Distal half of stomach removed
• Anastomosis:
- Billroth 1: directly to the duodenum
- Billroth 2 /Polya: to small bowel loop with
duodenal stump oversewn
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13
Q

When is subtotal gastrectomy with Roux en Y done

A

Occasionally performed for Zollinger-Ellison

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14
Q

Physical complication of peptic ulcer surgery

A 
Physical: 
• Reflux or bilious vomiting (improves with time)
• Abdominal fullness
• Stricture
• Stump leakage
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15
Q

Metabolic complications of peptic ulcer surgery

A

• Dumping syndrome

  • Abdo distension, flushing, n/v, fainting, sweating
  • Early: osmotic hypovolaemia
  • Late: reactive hypoglycaemia

• Blind loop syndrome → malabsorption, diarrhoea
- Overgrowth of bacteria in duodenal stump

• Vitamin deficiency

  • ↓ parietal cells → B12 deficiency
  • Bypassing proximal SB → Fe + folate deficiency
  • Osteoporosis

• Wt. loss: malabsorption of ↓ calories intake

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16
Q

Perforated duodenal ulcer

A
  • Most common - 1st part of the duodenum: highest acid conc.
  • Ant. perforation → air under diaphragm
  • Post. perforation can erode into gastroduodenal artery → bleed
  • ¾ of duodenum retroperitoneal so no air under diaphragm if perforated.
17
Q

Presentation of perforated ulcer

A 
• Sudden onset severe pain,
- beginning in the
epigastrium and then becoming generalised
• Vomiting
• Peritonitis
18
Q

Investigations of a perforated ulcer

A

• Bloods - FBC, U+E, amylase, CRP, G+S, clotting

• ABG: if mesenteric ischaemia suspected
• Urine dipstick
• Imaging
-  Erect CXR- erect for 15min first
- Air under the diaphragm seen in 70%
  • AXR
  • Rigler’s sign: air on both sides of bowel wall
19
Q

Management of peptic ulcer perforation

A 
Resuscitation
• NBM
• Aggressive fluid resuscitation
- Urinary Catheter ± CVP line
• Analgesia: morphine 
- ± cyclizine
• Abx: cef and met
• NGT

Surgical: Laparotomy
• DU: abdominal washout + omental patch repair
• GU: excise ulcer and repair defect
• Partial / gastrectomy may rarely be required
- Send specimen for histology: exclude Ca

20
Q

Conservative mx of perforated peptic ulcer disease

A

• May be considered if pt. isn’t peritonitic
• Careful monitoring, fluids + Abx
• Omentum may seal perforation spontaneously
preventing operation

21
Q

Presentation of peptic ulcer

A

Asymptomatic

Epigastric pain 
Retrosternal pain 
Nausea 
Bloating 
Post prandial discomfort 
Early satiety
22
Q

referral for urgent upper Oesophago-Gastro-Duodenoscopy (OGD)

A

New-onset dysphagia

Aged >55 years with weight loss and either upper abdominal pain, reflux, or dyspepsia

New onset dyspepsia not responding to PPI treatment

23
Q

Conservative mx of peptic ulcer

A
  • Lose wt.
  • Stop smoking and ↓ EtOH
  • Avoid hot drinks and spicy food
  • Stop drugs: NSAIDs, steroids
  • OTC antacids
24
Q

H. Pylori

A

Gram negative bacilli - spirochette

Year 3 Upper GI Surgery (8 decks)

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