Post on 14-Jan-2016
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Peptic Ulcer Disease
• 3 月前无明显诱因下出现上腹部疼痛 , 自诉针扎样痛,不剧,多饥饿时好发,进食后可缓解,无他处放射痛,持续 10 多分钟可自行缓解,伴返酸 。
• 1 月前患者上腹痛加重,为持续性,有夜间发作。未予重视未就诊。
• 半月前患者无明显诱因下出现黑便, 2 天 1 次。• 4 天前患者晚餐后出现呕吐,为胃内容物中带暗红
色血块,未见鲜红色血,有头晕乏力,胸闷气促,冒冷汗 , 解黑色大便 2 次。
• 1 天前患者再次出现呕血,色鲜红,同时解黑便,伴头晕头痛,呼吸困难,四肢厥冷,遂转我院急诊,急查血常规示血红蛋白 3.9g/dl, 予静脉补液并输红细胞 8u ,急诊内镜:“十二指肠球部前壁 0.8 X 0.8cm 溃疡伴出血( A1 期)”。
手术记录 2010-3-26
• 远端胃大部切除(毕 2 式吻合) + 十二指肠残端造瘘
• 探查:十二指肠球部至胃幽门部有质硬的瘢痕组织。十二指肠球部与周围组织粘连严重。于幽门环下约 4cm 处切断十二指肠,十二指肠残端内放置蘑菇头引流管,并丝线闭合十二指肠残端,用闭合器断胃,距 Treiz 韧带12cm 处提起空肠,于横结肠前行胃空肠端侧吻合,胃小弯对输入袢,置腹腔引流管 2根于十二指肠残端附近。
• 十二指肠溃疡术后 8 天,呕血 8 小时• 患者 8 天前因十二指肠溃疡术后在我院行急
诊远端胃大部切除(毕 II 式吻合) + 十二指肠残端造瘘术。术后无呕血不适,无腹痛腹胀,仍有黑便、低热,其余生命体征平稳,术后 7 天带腹腔引流管及十二指肠造瘘管转至省青春医院继续治疗。 8 小时前患者无明显诱因下出现大量呕血,腹腔造瘘管及引流管有血性液体流出,伴腹痛,便血。
• 2010-3-26 急诊胃镜:十二直肠球部前壁 0.8 X 0.8cm 溃疡伴出血, A1 期
手术记录 04-03
• 探查:见腹腔内淡红色积液约 500ml ,腹腔内未见明显新鲜出血,原胃空肠吻合口通畅,未见梗阻,愈合佳,打开残胃前壁,见胃腔内新鲜血液及凝血块约 800ml ,吸尽血液,检查残胃,未见明显溃疡和出血点,仔细探查见输入袢肠管有新鲜血液流出,输入袢植入胃镜,检查见十二指肠残端内后壁有明显出血点,遂打开十二指肠残端,见残端充血水肿明显,有一活动性出血点,予 prolene 线缝合止血,后再用胃镜探查整个肠袢无明显出血。冲洗腹腔,彻底止血。置冲洗引流管 4根于十二指肠残端附件,一根盆腔引流管,另在胃肠吻合下 40cm 处置一空肠营养造瘘管,残胃前壁置入蘑菇造瘘管置于输入襻内
手术记录 04-16
• 探查腹腔:腹腔内脏器粘连水肿严重,小肠及结肠内可见大量血凝块,先行粘连松解后,见空肠部分浆肌层缺损,分离暴露十二指肠残端,切开十二指肠残端,见大量鲜血及血凝块喷涌而出,吸除血液及血凝块,见十二指肠残端有一直径大小约为0 .8cm溃疡,溃疡内可见一动脉断端鲜血喷出。予 proline 线沿溃疡缝合后未见明显活动性出血,请术中胃镜,探查十二指肠残端、胃及胃肠吻合口未见明显活动性出血,遂予缝合十二指肠切口,并置入 24# 蘑菇管 1 根行十二指肠残端造瘘,切除浆肌层缺损肠段约 8cm ,行肠肠端侧吻合,十二指肠残端处放置引流管 3 根。
手术记录 05-01
• 探查腹腔:腹腔内脏器粘连水肿严重,腹腔内结构显示不清,十二指肠水肿明显,先行粘连松解后,沿造瘘管分离暴露十二指肠残端,切开十二指肠残端,见鲜血及血凝块喷涌而出,吸除血液及血凝块,见十二指肠残端后壁内侧有一动脉出血,术中病人心跳骤停,经心肺复苏,心跳恢复,压迫止血,迅速补液输血,予 proline 线缝合十二指肠出血部位后未见明显活动性出血,肠壁水肿炎症严重无法缝合,予开放,拔除十二指肠残端造瘘管,十二指肠残端处放置引流管 4根 。
Pathogenesis“ self-digestion” — Peptic ulcer
no acid, no ulcer
(no HP, no ulcer?)
Types of Ulcer
• I Incisura
• II Gastric + Duodenal
• III Prepyloric
• IV High lesser curve
胃十二指肠溃疡的外科适应证• ① 内科治疗无效的十二指肠溃疡
(Refractory ulcer) ;• ② 各种情况的胃溃疡和胃溃疡恶变; • ③ 急性穿孔;• ④ 溃疡大出血;• ⑤ 痕性幽门梗阻;• ⑥ 应激性溃疡;• ⑦ 胰源性溃疡。• Giant Gastric Ulcers >3cm
Causes of Refractory or Recurrent Peptic Ulcer
Causes of Refractory or Recurrent Peptic Ulcer
Duodenal Ulcer (DU)
Clinical features :节律性、周期性饥饿痛 ( 夜间痛 )
ca. 30 in age , man> women
Acid dyspepsia: the classic ulcer symptom;
Burning epigastric pain:
Hunger pain (episodic) (2 to 3 hrs after meal) , Night pain, Food and alkali relief,
Periodicity of the pain: Autumn- early spring;
Belching , Heartburn 。
十二指肠溃疡
1 、外科手术适应证( 1 )严重并发症:急性穿孔、大出血和瘢痕性
幽门梗阻;( 2 )内科治疗无效 (Intractability) :顽固性溃疡 病理:慢性穿透性溃疡,球后溃疡。
临床:节律性消失,症状严重,不易止痛, GI :龛影较大 (Giant Gastric Ulcers >3cm ) 、球部严重变形、穿透出肠 壁外或位于球后部溃疡者。
十二指肠溃疡
2 、外科手术方法
胃大部切除术迷走神经切断术
Gastric Ulcer (GU)
• ①小弯溃疡, >50%;• ②高位溃疡;• ③后壁溃疡,多慢性穿透
深入胰腺;• ④复合溃疡• ⑤幽门前溃疡
Gastric Ulcer (GU)
• Irritable stomach: Indigestion, Dysgastria,
• Rule out malignancy, dyspepsia.• >40 years, female:male = 2:1 (sabiston)
• 胃痛节律性较不明显。 40 ~ 50 岁,男性较多
• 进餐后不能很好止痛,餐后 1 小时疼痛即可开始,持续 1 ~ 2 小时。对抗酸药物疗效不明显。较十二指溃疡容易复发,容易引起大出血、急性穿孔等严重并发症。约有 5 %胃溃疡可以发生恶变。
Dyspepsia
• Pain or Discomfort centred in the upper abdomen
Major structural causes of dyspepsia
• Chronic peptic ulcer (duodenal or gastric)
• Gastro-oesophageal reflux disease (>50% have no oesophagitis)
• Gastric or oesophageal adenocarcinoma (rare but of concern for patient and doctor)
胃溃疡治疗
• 经过 8 ~ 12 周内科治疗无效或愈合后复发;
• 年龄 >45 岁;• 经 X 线或胃镜证实为较大 (>2.5cm) 或
高位溃疡;• 不能排除或已证实有恶变者;• 合并或曾有急性穿孔、大出血或梗阻。
Surgical Procedures
一、 Subtotal gastrectommy1 . Billroth-I
2 . Billroth-II
3 . Roux-en-Y
4. Others
Surgical Procedures
1 . Billroth I
(1885)
Surgical Procedures
一、 Subtotal gastrectomy1 . Billroth-II
Surgical Procedures
一、胃大部切除术1 . Roux-en-Y
Surgical Procedures
一、 Subtotal gastrectomy1 . Billroth-I
2 . Billroth-II
3 . Roux-en-Y
4. Others
Surgical Procedures
二、 Vagotomy1. Truncal vagotomy
2 . Selective vagotomy
3 . Parietal cell vagotomy
(High selective vagotomy)
二、 Vagotomy
1. Truncal vagotomy迷走神经干切断术
2.选择性胃迷走神经切断木
3.高选择性胃迷走神经切断术
切断:食管裂孔水平左、右二支腹迷走神经干
二、 Vagotomy
2. Selective vagotomy
二、 Vagotomy
3. High Selective vagotomy
Parietal cell vagotomy
Perforation
• Free perforationSevere peritonitis,tenderness, rigidity, rebound Boardlike abdomen,Shock.
• Contained perforation Penetrating ulcer
胃十二指肠溃疡急性穿孔Differential diagnosis
1 . Hallmark of free perforation
2 . Acute pancreatitis
3 . Acute appentitis
Perforation
Medical therapy:
• > 24h,
• Close surveillance.
溃疡病急性穿孔治疗
1 .非手术治疗适应证:症状轻、一般情况好的单纯性空腹 较小穿孔。方法:胃肠减压、输液和抗生素等。治疗 6~ 8 小时后,症状、体征加重者,改手术治疗。
溃疡病急性穿孔治疗
• 2 .手术治疗
• 手术适应证:饱食后穿孔、顽性溃疡穿孔和伴有幽门梗阻、大出血、恶变等并发症者。
Perforation
Operative approach:
• Emergency closure (Oversewing)单纯穿孔缝合术 ,
• Definitive ulcer
operation 。
Perforation
• Operative approach: Emergency closure (Oversewing),
Definitive operations.
.
溃疡病急性穿孔治疗
• 3 .手术方法• 单纯穿孔缝合术:操作简便,危险
性较少• 彻底性手术。
溃疡病急性穿孔治疗• 3 . 手术方法• 单纯穿孔缝合术 ;
• 彻底性手术。
Gastric Outlet Obstruction
• Surgery:
reliefe of obstruction,
antiulcer operation.
Gastric Outlet Obstruction
• Fibrosis, scarring, deformity, (spasm,edema).
• Gastric atony, gastric retention : bloating, anorexia, nausea, vomiting.
• Endoscopic balloon dilatation+stent.
• Surgery: absolute indication.
Peptic Ulcer HemorrhageBleeding Peptic Ulcer
• 40 %- 60 % of all upper GI Hemorrhage• 6 %- 15% in DU , 2%- 5% in GU• Conservative therapy, Endoscopy 80%• Surgical indication: Severe,
persistent or recurrentbleeding; age, general health condition, other ulcercomplications.
• Surgery is required in ca. 10% of patients
• Self-limited: 80%
• Mortality: 8% to 10%
• resuscitation
• endoscopy
Peptic Ulcer Hemorrhage
手术治疗• 单纯缝合术 ;
• 彻底性手术。
Postgastrectomy Syndromes
• Postoperative Complications for Peptic Ulcer Disease
DUMPING SYNDROME
• Dumping syndrome refers to a symptom complex that occurs following ingestion of a meal when a portion of the stomach has been removed or the normal pyloric sphincter mechanism has become disrupted.
DUMPING SYNDROME
• Early Dumping syndrome :usually occurs within 20 to 30 minutes following ingestion of a meal;
• Late Dumping syndrome:appears 2 to 3 hours after a meal
METABOLIC DISTURBANCES
• Iron deficiency anemia
• impairment in vitamin B12 metabolism:Megaloblastic anemia
AFFERENT LOOP SYNDROME
EFFERENT LOOP OBSTRUCTION
• The most common cause of efferent loop obstruction is herniation of the limb
ALKALINE REFLUX GASTRITIS
RETAINED-ANTRUM SYNDROME
• retained antrum
• recurrent ulcer following previous gastrectomy
Postvagotomy Syndromes
• POSTVAGOTOMY DIARRHEA
• vagotomy is also associated with alterations in stool frequency
• Most patients with postvagotomy diarrhea have their symptoms resolve over time
Postvagotomy Syndromes
• POSTVAGOTOMY GASTRIC ATONY
• persistent gastric stasis that results in retention of food within the stomach for several hours
Postvagotomy Syndromes
• INCOMPLETE VAGAL TRANSECTION
• possible development of recurrent ulcer formation
Minimally invasive surgery
Natural orifice translumenal endoscopic surgery (NOTES)