Peptic ulcer disease
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Transcript of Peptic ulcer disease
Peptic ulcer disease
Nomin-Erdene. DSOM-531
Learning objectives
Stomach gross anatomy PUD
Epidemiology Pathogenesis Clinical manifestation Diagnosing Treatment Complicated ulcer disease Surgical procedures
Divisions
Stomach begins as a dilation in the tubular embryonic foregut during the fifth week of gestation.
Stomach parts & location
Blood supply
Lymphatic drainage
Four zones of LN
Celiac group node
Thoracic duct
Innervation
Peptic ulcer disease
Peptic ulcers are defined as erosions in the gastric or duodenalmucosa that extend through the muscularis mucosae.
Lifetime Prevalence = 10% of Americans develop PUD
>10% of ER patients with abdominal pain diagnosed with PUD
Prevalence decreasing over last 30yrs
Male-to-female ratio of PUD = 2:1
4000 deaths caused by PUD each year.
PathogenesisIncreased aggressive factors
HCl acid secretion
Ethanol ingestion, smoking
NSAID
H.PYLORI
Decreased defensive factors
mucosalbicarbonate secretion
mucus production
Cell renewal
blood flow
H.Pylori infection
80% to 95% of duodenal ulcers 75% of gastric ulcers are associated with H.
pylori infection.
Production of toxin (urease)
Local mucosal immune
response
Gastrin increased
Acid secretionD cell reduction
Gastric metaplasia
NSAID
NSAID absorption
COX inhibition
Prostaglandin synthesis decreased
Mucosal protection
failure
Ulcer
Duodenal ulcer Gastric ulcer
Clinical manifestation
The most common symptom is midepigastric abdominal pain.
The pain is generally tolerable Frequently relieved by food. The pain may be episodic, worse during periods of
emotional stress. Many patients do not seek medical attention. Constant pain - deeper ulcer penetration. Referral of Pain to the back - penetration into the pancreas. Diffuse peritoneal irritation - free perforation.
Diagnosis
History & PE
Laboratory test
Upper GI radiography
Flexible upper
endoscopy
H.Pylori testing
Invasive test- Urease- Culture
Noninvasive - Serology
-Urea breath test-Stool antigen
Radiography
Less expensive Require barium Most ulcer (90%)
diagnosed accurately
Double contrast > single contrast
Flexible upper endoscopy
Most reliable method Visual diagnosis Provide to sample
tissue H.pylori testing –
mucosal biopsy
Urease assay
With endoscopy From the gastric body and the antrum Sensitivity in diagnosing infection is
greater than 90%, and specificity is 95% to 100%
Sensitivity of the test is lowered in patients who are taking PPIs, H2 antagonists, or antibiotics.
Histology H.pylori
Silver stain
Noninvasive tests
Serology
Sensitivity 90% Specificity 76-
96% Check IgG
antibodies of H.pylori
Urea breath test
Sensitivity 90% Specificity 86-
92% Recommended
discontinue antibiotics for 4 weeks
PPIs for 2 weeks to ensure optimal test accuracy.
Stool antigen
H.pylori are present in stool
Sensitivity 90% Specificity 86-92% Most cost effective
method
Treatment
Targeted agianst H.pylori
To reduce acid level
Increase the mucosal barrier
Treatment
Antacids Sucralfate H2 receptor
antagonist PPI Treatment of
H.pylori infection
lifestyle changes, smoking
cessation discontinuing
NSAIDs and aspirin
avoiding coffee and alcohol
Complicated Ulcer disease
Endoscopic approach
Evaluating by Forrest classification High-risk patients - injection of a
vasoconstrictor at the site of bleeding Guidelines for endoscopic control of
bleeding 2010: use of epinephrine plus an additional method or monotherapy with either thermocoagulation or clipping,
But discourage the use of epinephrine alone.
Nonsurgical control of bleeding
Catheter-directed angiography and endovascular embolization
Perforation
Typically complain of sudden-onset, frequently severe epigastric pain
Highest mortality rate of any complication of ulcer disease
Graham patch repair is performed
If Perforation >3cm
Gastric outlet obstruction
Acute inflammation of the duodenum
Mechanical obstruction
Delayed gastric emptying, anorexia, nausea, and vomiting
Antrectomy and reconstruction along with vagotomy.
Surgical procedures
Truncal vagotomy
Selective vagotomy
Parietal vagotomy
Truncal vagotomy and
antrectomy
Truncal vagotomy
Most common operation performed for duodenal ulcer disease
Pyloric relaxation is mediated by vagal stimulation, and a vagotomy without a drainage procedure can cause delayed gastric emptying.
Classic truncal vagotomy, in combination with aHeineke-Mikulicz pyloroplasty
Antrectomy
Post-operative outcome
Gastric ulcer
Most ulcers are the consequence of H. pylori infection or NSAID usage.
Usually manifest on the lesser curvature Peak incidence: 55 to 65 years old More likely to occur in individuals in:
a lower socioeconomic class common in the nonwhite than white
population
Johnson classification
Quick difference
Duodenal Gastric
Incidence More common Less common
Anatomy First part of duodenum – anterior wall
Lesser curvature of stomach
Duration Acute or chronic Chronic
Malignancy Rare Benign or malignant
Food intake Relieved by food Worsened by food
Type 1 gastric ulcer
Wedge resection – pathology examinationGastrectomy w/out vagotomy
Type 2&3 gastric ulcer
Ulcer + increased gastric acidGastrectomy w/ vagotomy
Type 4 gastric ulcer
Difficult to manageGastectomy / Rouxen Y/gastroduodenostomy
Zollinger-Ellison syndrome
Gastri
c acid
hypers
ecreti
on
Severe PUD Non-β-islet
cell tumor of
pancreas
Diagnosing ZES
Secretin-stimulated gastrin levelSerum gastrin samples are measured
before and after IV secretin (2 U/kg) administration at 5-minute intervals for 30 minutes.
An increase in the serum gastrin level of greater than 200 pg/mL is specific for gastrinoma.
Diagnosing Localize the gastrinoma is either CT or MRI of
the abdomen. However, these imaging modalities have a
relatively low sensitivity in detecting tumors that are less than 1 cm in diameter as well as small liver metastases.
Somatostatin receptor scintigraphy uses radionucleotide labeled octreotide, which binds to the ZES tumor cells and can detect hepatic metastases in 85% to 95% of patients
Treatment
Resection of tumor Patients with tumor recurrence or
metastatic disease are treated with chemotherapy (streptozotocin with 5-fluorouracil or doxorubicin or both).
THANK YOU
Because I already told you what I know only if you had listened
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REVIEW QUESTIONS
Question #1
The consistently largest artery to the stomach is the
A. Right gastric B. Left gastric C. Right gastroepiploic D. Left gastroepiploic
Answer
Answer: B The consistently largest artery to the
stomach is the left gastric artery, which usually arises directly rom the celiac trunk and divides into an ascending and descending branch along the lesser gastric curvature
Question #2
Which of the following inhibits gastrin secretion?
A. Histamine B. Acetylcholine C. Amino acids D. Acid
Answer: D Luminal peptides and amino acids are
the most potent stimulants o gastrin release, and luminal acid is the most potent inhibitor of gastrin secretion.
Question #3
Helicobacter pylori infection primarily mediates duodenal ulcer pathogenesis via
A. Antral alkalinization leading to inhibition of somatostatin release
B. Direct stimulation of gastrin release C. Local infammation with autoimmune
response D. Upregulation of parietal cell acid
production
Answer: A Helicobacter pylori possess the
enzyme urease, which converts urea into ammonia and bicarbonate, thus creating an environment around the bacteria that buffers the acid secreted by the stomach. H. pylori infection is associated with decreased levels of somatostatin,
Production of toxin (urease)
Local mucosal immune response
Gastrin increasedAcid secretion
D cell reductionGastric metaplasia
Question #4
Which of the following is the preoperative imaging study of choice for gastrinoma? A. CT scan B. Magnetic resonance imaging (MRI) C. Endoscopic ultrasound (EUS) D. Angiographic localization E. Somatostatin receptor scintigraphy
Answer: E Currently, the preoperative imaging
study of choice for gastrinoma is somatostatin-receptor scintigraphy (the octreotide scan). When the pretest probability of gastrinoma is high, the sensitivity and specificity o this modality approach 100%