Peptic Ulcers Flashcards
explain the pathophysiology of peptic ulcers and how they can cause the following complications:
- pyloric stenosis
- peritonitis
- massive haemorrhage
inflammation / excessive acid secretion –> imbalance between protective and damaging factors –> mucosal barrier breached –> superficial ulceration –> spread through submucosa and muscular layers –> perfotaion/ hameorrhage
granulation tissue formation in attempted repair –> repair with scarring and distortion –> narrowing of gastric outlet –> pyloric stenosis
anterior ulceration –> peritonitis
posterior ulceration –> gastroduodenal artery damaged –> haemorrhage
what are the risk factors for developing peptic ulcers?
- H.pylori infection
- NSAIDs
- Alcohol
- Zollinger-Ellison syndrome
- head injury (Cushing’s ulcer)
what are the most common sites for peptic ulcers to develop?
stomach: gastric antrum, particularly at the lesser curve
duodenum
*can occur in the oesaphagus and is more associated with acid-pepsin reflux –> results in Barrett’s oesapahgus
what are the clinical features of peptic ulcer disease?
- often asymptomatic
- epigastric/retrosternal pain
- nausea
- bloating
- early satiety
may have symptoms of complications e.g. haemorrhage, perforation etc
what is the pattern of pain in gastric and duodenal ulcers
gastric: pain when eating
duodenal: worse 2-4 hrs after eating and is often said to get better when eating
explain what is Zollinger-Ellison syndrome?
a triad of:
- sever peptic ulcer disease
- gastric acid hypersecretion
- gastrinoma
associated with fasting gastrin level of over 1000
what investigations are undergone for suspected peptic ulcer disease?
what are the relevant findings?
non-invasive (esp in younger patients):
- Carbon-13 urea breath test
- serum Ab to H.pylori
- stool antigen test
ongoing symptoms/ older patients:
- endoscopy for visualising and biopsy
- CLO testing of biopsy
why should all ulcers be biopsied?
malignant potential of ulcers
what is the conservative management for peptic ulcers?
- lifestyle: stop smoking, NSAIDS, alcohol< spicy food
- triple therapy if relevant: (PPI, clarithromycin + amoxocillin/metronidazole for 7 days)
- PPI for 4-8 weeks to allows healing
what surgical interventions are possible in peptic ulcer disease and when are they indicated?
indications: Zollinger-Ellison syndrome, perforation, severe/relapsing disease.
these surgeries include partial gastrectomies and selective vagotomy
what are the two forms of partial gastrectomy?
gastric ulcer: Billroth I (removal of distal 2/3 od stomach and anastomose with the duodenum)
duodenal ulcer: Polya-type gastrectomy
also cutting distal 2/3 of stomach however you anastomose the cut end to the jejunum.
ulcer left in situ to heal
check the diagram in essential surgery page 305
what are the complications of partial gastrectomy?
- reduced gastric capacity
- ‘dumping’
- episodic bilious vomiting (bile reflux into stomach)
- weight loss
- Vit b12 deficiency (lack of intrinsic factor)
how do perforated peptic ulcers present?
- sudden onset pain (epigastric)
- continious pain and aggrevated by moving
- guarding (so rigid called board-like rigidity)
- tenderness
how is a perforated peptic ulcer diagnosed?
- usually a clinical diagnosis
- erect CXR - pneumoperitoneum(not always present)
- CT used to confirm free gas in the abdomen + fluid
- laproscopy may be used to identify point of perforation
why is endoscopy contra-indicated in perforations?
need to blow gas to inflate the stomach–> contents erupt into the peritoneal cavity
what is the surgical management of a perforated peptic ulcer?
- can be laparoscopic or a laparotomy
- ‘peritoneal toilet’ to clean abdomen
- suture vascularised part of greater omentum sewed on
(followed by eradication therapy)–> duodenal - gastric ulcer –> excision and simp,e closure of the stomach
