This document discusses peptic ulcers and duodenal ulcers. It covers the aggressive and defensive factors involved, pathomorphology, classifications, clinical presentations, complications, diagnosis, and management including conservative and surgical treatments. Specifically, it discusses classifications of ulcers based on location, size, etiology and stage. It also summarizes the signs, symptoms, diagnostic tests and treatments for complications like perforation, stenosis and bleeding. Surgical procedures for treatment include vagotomy, pyloroplasty and gastrojejunostomy.

1. PEPTIC ULCER

2. AGGRESSIVE FACTORS
• hydrochloric acid
• pepsin
• reverse diffusion of ions of hydrogen
• products of lipid hyperoxidation

3. DEFENSE FACTORS
• mucus and alkaline components of
gastric juice
• property of epithelium of mucous
tunic to permanent renewal
• local blood flow of mucous tunic and
submucous membrane

4. PATHOMORPHOLOGY
• Erosion
• acute ulcers
• chronic ulcers

5. CLASSIFICATION
by Johnson (1965)
• I – ulcers of small curvature (for 3 cm
higher from a goalkeeper);
• II– double localization of ulcers
simultaneously in a stomach and
duodenum;
• III – ulcers of goalkeeper part of
stomach (not farther as 3 cm from a
goalkeeper)

6. CLINICAL MANAGEMENT
• Pain
• Vomiting
• Heartburn
• Belching

7. COMPLICATIONS
• Penetration
• Stenosis
• Perforation
• Bleeding
• Malignization

8. DIAGNOSIS PROGRAM
• 1. Anamnesis and physical examination.
• 2. Endoscopy.
• 3. X-Ray examination of stomach.
• 4. Examination of gastric secretion by the
method of aspiration of gastric contents.
• 5. Gastric pH metry.
• 6. Multiposition biopsy of edges of ulcer and
mucous tunic of stomach.
• 7. Gastric Dopplerography.
• 8. Sonography of abdominal cavity organs.
• 9. General and biochemical blood analysis.
• 10. Coagulogram.

9. X-Ray examination
THE DIRECT SIGNS:
• symptom of “Haudek's niche”
• ulcerous billow and convergence of folds of mucous
tunic.
INDIRECT SIGNS:
• symptom of “forefinger” (circular spasm of muscles)
• segmental hyperperistalsis,
• pylorospasm,
• delay of evacuation from a stomach
• duodenogastric reflux
• disturbance of function of cardial part
(gastroesophageal reflux).

10. SYMPTOM
OF
“Haudek's
niche”

11. STENOSIS

12. GASTROSCOPY

13. DEVICE FOR GASTRIC
DOPPLEROGRAPHY

14. Endoscopic picture of the
normal stomach wall

15. Endoscopic picture of the
peptic ulcer

16. CONSERVATIVE THERAPY
a) Omeprazole 20 mg 2 time per day or Н2-
blocker histamine receptor (ranitidine)
— 150 mg in the evening, famotidine —
40 mg at night, roxatidine — 150 mg in
the evening
b) antiacid drugs — in accordance with the
results of pH-metry;
c) reparative drugs (dalargin, solcoseryl,
actovegin) — for 2 ml 1–2 times per days
d) antimicrobial drugs (clarytromicine 500
mg twice daily, de-nol, metronidazole)

17. SURGICAL TREATMEN
• at the relapse of ulcer after the course of
conservative therapy;
• in the cases when the relapses arise during
supporting antiulcer therapy;
• when an ulcer does not heal over during 1,5–2
months of intensive treatment, especially in
families with “ulcerous anamnesis”;
• ulcer with complications (perforation or
bleeding);
• at suspicion on malignization ulcers, in case
of negative cytological analysis.

18. Billroth I and Billroth II resection

19. Billroth II resection

20. Billroth I resection:

21. DUODENAL ULCER

22. CLASSIFICATION
I. By etiology:
А. True duodenal ulcer.
B. Symptomatic ulcers.
II. By passing of disease:
1. Acute (first exposed ulcer).
2. Chronic:
a) with the rare exacerbation;
b) with the annual exacerbation;
c) with the frequent exacerbation (2 times
per a year and more frequent).

23. CLASSIFICATION
III. By the stages of disease:
1. Exacerbation.
2. Scarring:
a) stage of “red” scar;
b) stage of “white” scar.
3. Remission.
IV. By localization:
1. Ulcers of bulb of duodenum.
2. Low postbulbar ulcers.
3. Combined ulcers of duodenum and stomach.

24. CLASSIFICATION
V. By sizes:
1. Small ulcers up to 0,5 cm.
2. Middle — up 1,5 cm.
3. Large — up to 3 cm;
4. Giant ulcers over 3 cm.
VI. By the presence of complications:
1. Bleeding.
2. Perforation.
3. Penetration.
4. Organic stenosis.
5. Periduodenitis.
6. Malignization.

25. CLINICAL MANAGEMENT
• Pain
• Vomiting
• Heartburn
• Belching

26. DUODENOSCOPY

27. SYMPTOM OF STENOSIS
“Haudek's niche”

28. DIAGNOSIS PROGRAM
• 1. Anamnesis and physical examination.
• 2. Endoscopy.
• 3. X-Ray examination of stomach and
duodenum.
• 4. General and biochemical blood
analysis.
• 5. Coagulogram.

29. CONSERVATIVE THERAPY
a) Omeprazole 20 mg 2 time per day or Н2-
blocker histamine receptor (ranitidine) — 150
mg in the evening, famotidine — 40 mg at
night, roxatidine — 150 mg in the evening
b) antiacid drugs — (almagel, maalox or
gaviscon —1 dessert-spoon in a 1 hour after
food intake);
c) reparative drugs (dalargin, solcoseryl,
actovegin) — for 2 ml 1–2 times per days
d) antimicrobial drugs (clarytromicine 500 mg
twice daily, de-nol, metronidazole)

30. INDICATIONS TO THE
ELECTIVE OPERATION
• 1. Passing of duodenal ulcer with the
frequent relapses which could not
treated conservatively.
• 2. Repeated ulcerous bleeding.
• 3. Stenosis of outcome part of stomach.
• 4. Chronic penetration ulcers with the
pain syndrome.
• 5. Suspicion for malignization ulcers.

31. METHODS OF SURGICAL
TREATMENT
• organ-saving operations;
• organ-sparing operations;
• resection.

32. TRUNK VAGOTOMY (TrV)
2 4

33. 3
SELECTIVE VAGOTOMY (SV)

34. SELECTIVE PROXIMAL
VAGOTOMY (SPV)

35. SELECTIVE PROXIMAL
VAGOTOMY (SPV)

36. Heineke-
Mikulicz
pyloroplasty

37. Heineke-Mikulicz pyloroplasty

38. GASTRODUODENOSTOMY BY
JABOULAY

39. Finney pyloroplasty

40. ULCEROUS STENOSIS
CLASSIFICATION
A
I — compensated;
II — subcompensated;
III — decompensated.
B
I — stenosis of goalkeeper;
II — stenosis of bulb of duodenum;
III — postbulbar duodenal stenosis.

41. DIAGNOSIS PROGRAM
• 1. Complaints of patient and anamnesis of
disease.
• 3. Sounding of stomach and examination of
gastric content.
• 4. Fibergastroduodenoscopy, biopsy.
• 5. Intragastric рН-metry.
• 6. Study of motility of stomach.
• 7. Roentgenologic examination of stomach and
duodenum (structural features, passage).
• 8. Sonography.

42. ULCER
STENOSIS

43. PERFORATED GASTRODUODENAL ULCERS
CLASSIFICATION
1. After etiology:
• ulcerous;
• unulcerous.
2. After localization:
• gastric (small curvature, cardial, antral,
prepyloric, pyloric) ulcer, front and back walls;
• ulcers of duodenum (front and back walls).
3. After passing:
• perforated in an abdominal cavity;
• covered perforations;
• atypical perforations.

44. DIAGNOSIS PROGRAM
• 1. Anamnesis and physical examination.
• 2. Global analysis of blood and urine, biochemical
blood test,
• coagulogram.
• 3. X-Ray examination of abdominal cavity organs
for presence of free gas (pneumoperitoneum).
• 4. Pneumogastrography, contrasting
pneumogastrography.
• 5. Fiber-gastroduodenoscopy.
• 6. Sonography of abdominal cavity organs.

45. Perforated ulcer
(pneumoperitoneum)

46. Bleeding gastroduodenal ulcers
CLASSIFICATION
• I degree is easy — observed at the loss to
20 % volume of circulatory blood (at a
patient with weight of body 70 kg it is up
to 1000 ml);
• II degree — middle weight is loss from 20
to 30 % volume of circulatory blood (1000–
1500 ml);
• The III degree is heavy — is observed at
loss of blood more than 30 % volume of
circulatory blood (1500–2500 ml).

47. DIAGNOSIS PROGRAM
• Anamnesis and physical examination.
• Finger examination of rectum.
• Gastroduodenoscopy.
• Global analysis of blood.
• Coagulogram.
• 7. Biochemical blood test.
• X-Ray examination of gastrointestinal tract.
• Electrocardiography.

48. ENDOSCOPY
stopped bleeding