Peptic ulcer disease

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Peptic ulcer disease Nomin-Erdene. D SOM-531

Transcript of Peptic ulcer disease

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Peptic ulcer disease

Nomin-Erdene. DSOM-531

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Learning objectives

Stomach gross anatomy PUD

Epidemiology Pathogenesis Clinical manifestation Diagnosing Treatment Complicated ulcer disease Surgical procedures

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Divisions

Stomach begins as a dilation in the tubular embryonic foregut during the fifth week of gestation.

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Stomach parts & location

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Blood supply

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Lymphatic drainage

Four zones of LN

Celiac group node

Thoracic duct

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Innervation

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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.

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PathogenesisIncreased aggressive factors

HCl acid secretion

Ethanol ingestion, smoking

NSAID

H.PYLORI

Decreased defensive factors

mucosalbicarbonate secretion

mucus production

Cell renewal

blood flow

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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

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NSAID

NSAID absorption

COX inhibition

Prostaglandin synthesis decreased

Mucosal protection

failure

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Ulcer

Duodenal ulcer Gastric ulcer

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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.

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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

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Radiography

Less expensive Require barium Most ulcer (90%)

diagnosed accurately

Double contrast > single contrast

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Flexible upper endoscopy

Most reliable method Visual diagnosis Provide to sample

tissue H.pylori testing –

mucosal biopsy

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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.

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Histology H.pylori

Silver stain

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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

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Treatment

Targeted agianst H.pylori

To reduce acid level

Increase the mucosal barrier

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Treatment

Antacids Sucralfate H2 receptor

antagonist PPI Treatment of

H.pylori infection

lifestyle changes, smoking

cessation discontinuing

NSAIDs and aspirin

avoiding coffee and alcohol

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Complicated Ulcer disease

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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.

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Nonsurgical control of bleeding

Catheter-directed angiography and endovascular embolization

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Perforation

Typically complain of sudden-onset, frequently severe epigastric pain

Highest mortality rate of any complication of ulcer disease

Graham patch repair is performed

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If Perforation >3cm

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Gastric outlet obstruction

Acute inflammation of the duodenum

Mechanical obstruction

Delayed gastric emptying, anorexia, nausea, and vomiting

Antrectomy and reconstruction along with vagotomy.

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Surgical procedures

Truncal vagotomy

Selective vagotomy

Parietal vagotomy

Truncal vagotomy and

antrectomy

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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.

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Classic truncal vagotomy, in combination with aHeineke-Mikulicz pyloroplasty

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Antrectomy

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Post-operative outcome

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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

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Johnson classification

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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

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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

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Zollinger-Ellison syndrome

Gastri

c acid

hypers

ecreti

on

Severe PUD Non-β-islet

cell tumor of

pancreas

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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.

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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

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Treatment

Resection of tumor Patients with tumor recurrence or

metastatic disease are treated with chemotherapy (streptozotocin with 5-fluorouracil or doxorubicin or both).

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THANK YOU

Because I already told you what I know only if you had listened

to me

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REVIEW QUESTIONS

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Question #1

The consistently largest artery to the stomach is the

A. Right gastric B. Left gastric C. Right gastroepiploic D. Left gastroepiploic

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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

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Question #2

Which of the following inhibits gastrin secretion?

A. Histamine B. Acetylcholine C. Amino acids D. Acid

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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.

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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

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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

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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

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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%