My Presentation , Surgery II, KFU,2011

1. Peptic Ulcer
Fatimah Abdullah
6th year MS, KFU

2. Objectives
Definition.
Pathophysiology.
Etiology.
Clinical Picture.
Management.

3. Break in the gastrointestinal mucosa
exposed to the aggressive action of acid-
peptic juices.
Common sites are the
first part of the
duodenum and the
lesser curve of the
stomach.

4. The gastroduodenal mucosal integrity is
determined by protective (defensive) &
damaging (aggressive) factors.

5. • Bicarbonate • Helicobacter pylori
• Mucus layer • NSAIDs
• Prostaglandins • Pepsins
• Mucosal blood flow • Bile acids
• Epithelial renewal • Smoking and alcohol
Defensive Aggressive
Mucosal damage  erosions & ulcerations

6. H. Pylori Infection
NSAIDs
Smoking & Alcohol
Acid Hypersecretion
Stress
Family History of PUD.

8. Duodenal Ulcer Gastric ulcer
Age Any age specially 30-40 middle age 50-60
Sex More in male More in male
Occupation Stress job eg. Manager Same
Pain Epigastric , discomfort Epi. Can radiate to
back
Onset 2-3 hours after eating & Immediately after
midnight eating
Agg.by Hunger Eating

9. Duodenal Ulcer Gastric ulcer
Relived by Eating Lying down or vomiting
Duration 1-2 months Few weeks
Vomiting Uncommon Common(to relieve the
pain)
Appetite Good Pt. afraid to eat
Diet Good , eat to relieve the pain Avoid fried food
Weight No wt. loss wt. Loss
Hematemesis 40% 60%
Melena 60% 40%

10. Stool fecal occult blood.
CBC   CBL.
Rapid Urease test, urea
breath test  H. Pylori.
Upper GI Endoscopy.
Barium meal X-Ray.

11. Any patient >50 y/o with new
onset of symptoms
In all patients with “Alarming
symptoms” endoscopy is required.
Dysphagia.
Weight loss.
Vomiting.
Anorexia.
Hematemesis or Melena.

13. Life Style Change.
Medical.
Surgical.

14. Discontinue NSAIDs
Smoking cessation.
Alcohol cessation.
Stress reduction.

15. Antacids
H2-receptor blocking
agents.
Proton pump inhibitors.
Cytoprotective and
antisecretory drugs.
Antibiotics.

16. H. pylori Eradication Therapy:
• Triple therapy:
 Proton pump inhibitor .
 2 Antibiotics:
• Metronidazole + Clarithromycin.
• Clarithromycin + Amoxicillin.
» In some regimens, H2-receptor
blockers, e.g. ranitidine, are used
instead of PPI.

17. Indications:
Failure of medical treatment.
Development of complications
High level of gastric secretion and
combined duednal and gastric ulcer.
Principle:
Reduce acid and pepsin
secretion.

18. Vagotomy:
 Truncal Vagotomy with drainage.
Highly selective Vagotomy.
Combination of vagal
denervation (vagotomy) +
anterctomy.

19. Truncal vagotomy with drainage:
Resect the major trunk of the vagus to
the stomach this will lead to:
Decrease acid and pepsin secretion.
Impair antral motility and drainage.
– Two types of drainage:
Pyloroplasty.
Gastrojejnostomy.

22. Highly selective vagotomy:
• It is a parietal cells vagotomy.
• It can be done with or without
drainage.
• It is done by cut a branch
of vagus of the body and
the fundus this will lead to
decrease HCl production.

23. Combination of vagotomy+
anterctomy:
Combination of vagal denervation &
removal of the major area of gastric
production.

24. Gastrointestinal continuity is restored by
gastroduodenal (Billroth 1) anastomosis
OR gastrojejunal (Billroth 2)
anastomosis.

25. Dehiscence.
Stenosis of
anastomosis.
Bleeding.
Injury to neighbour
tissues.
Dumping syndrome

26. Hemorrhage
Perforation peptic ulcer
Gastric outlet obstruction