Peptic ulcer

Peptic ulcer

By :
Zainab Abdullah
Qater al nada Rikan

Peptic Ulcer

are deep lesions that breech the integrity of the epithelium and pentrate through muscularis mucosa ..
the Common sites for peptic ulcers are the first part of the duodenum and the lesser curve of
e stomach, but they also occur on the stoma following gastric surgery, the oesophagus and even in a Meckel ’ s diverticulum, which contains ectopic gastric epithelium.
In general, the ulcer occurs at a junction between different types of epithelia, the ulcer
occurring in the epithelium least resistant to acid attack.

Malignancy in peptic ulcer

Chronic duodenal ulcers are not associated with malignancy and, gastric ulcers 5% regarded malignant. Multiple biopsies should always be taken
--prepyloric and pyloric ulcers may be malignant, and biopsy is essential.
--Stomal ulcers occur after a gastroenterostomy or a gastrectomy of the Billroth II type. The ulcer is usually found on the jejunal side of the stoma.


Clinical features of peptic ulcers
DU -- common -- yong -- hi social -- Devloped C -- No malig
GU -- less common -- old -- low social -- Devloping C -- <5%

Pain

The pain is epigastric, often described as gnawing and may radiate to the back. Eating may
sometimes relieve the discomfort. The pain is normally intermittent rather than
intractable.

Periodicity

One of the classical features of untreated peptic ulceration is periodicity. Symptoms may
disappear for weeks or months to return again. This periodicity may be related to the
spontaneous healing of the ulcer

Vomiting

, it is not a notable feature unless the stenosis has occurred.

# Alteration in weight

Weight loss or, sometimes, weight gain may occur. Patients with gastric ulceration are
often underweight but this may precede the occurrence of the ulcer.


# Bleeding
All peptic ulcers may bleed. The bleeding may be chronic and presentation with anaemia is
not uncommon. Acute presentation with haematemesis and melaena is discussed later

# Investigation

Gastroduodenoscopy
--.In the stomach any abnormal lesion should be multiply biopsied,
--a CLO test performed to determine the presence of H. pylori.
--A ‘ U ’ manoeuvre should be performed to exclude ulcers around the gastro-oesophageal
junction.
--if a stoma is present, for instance after gastroenterostomy or Billroth II gastrectomy, it is
important to enter both afferent and efferent loops..
-- Attention should be given to the pylorus

# Treatment of peptic ulceration

A) Medical treatment
1--modifications to the patient ’ s lifestyle, particularly the cessation of cigarette smoking.
2--H 2 - receptor antagonists
Most duodenal ulcers and gastric ulcers can be healed by a few weeks of treatment with
these drugs The problem with H 2 -receptor antagonists is that relapse once
treatment is discontinued


3--Proton pump inhibitors(PPI)
All ulcers will heal on proton pump inhibitors, such as omeprazole, lansoprazol the majority
within 2 weeks. Symptom relief rapidly, most patients being asymptomatic within a few
days. Like H 2 antagonists, omeprazole is safe and relatively devoid of serious side effects.
And relapse following cessation of therapy
4--Eradication therapy
Eradication therapy is now routinely given to patients when suggests that patient has a
peptic ulcer and H. Pylori is the principal aetiological factor (amoxicillin or clarthromycin &metronidazol with PPI ) for 2 weeks then continue other 4 w PPI

B) Surgical treatment of uncomplicated peptic ulceration

Now surgery for uncomplicated peptic ulceration has fallen markedly
Indication : doubt histology
Failure of medical Mx
Complication
5y unhealed ulcer

# Operations for GU&DU

1- Billroth I
Distal gastrectomy involve ulcer
2-Gastrojojenostomy with roux en Y
3- Vagotomy :--vagus n section with biopsy of ulcer
a-- truncal v+ drainage to avoid gastric stasis:--
1 - gastrojojenostomy
2-antrectomy
3- pyleroplasty( H-Mikulicz, Finny, Jabboli)


b--selective v + drainage(preserve caeliac br.)to avoid post op diarrhea
c --highly selective v. (proximal gastric v.) with out drainage (preserve
n of Latarjet to last 5- 7cm of pylorus)
4- Billroth II(Polya)
distal gasrectomy .,duodenum is closed with .gastrojejnostomy with roux en Y
5- Excition of ulcer + vagotomy & drainage

# Complication of peptic ulcer surgery

Early :-
1 _Hge. ,
2-paralytic ileus (truncal vagotomy )
3 -doudenal fistula due to leaking from suture lines
4-stomal obstruction due to many causes :-
Oedema ,retrograde intussusption, technical , atonic stomach ,
5-acut pancreatitis
Late :-
1) recurrence
2)G J colic fistula à diarrhea after eating &vomiting of feacal meterial
3)postgastroctomy syndrome
a-small stomach à small frequent meals
b-dumping syndrome
(early dumpingà hypotention after eating due to rapid stomach evacuation late dumping à hypoglycaemia after eating due to rapid absorption )


c- Bilios vomiting due to afferent loop obstruction
4)-postvagotomy diarrhea
5)malignent changes
6)malnutrition , Anaemia may be due to either iron or B 12 deficiency.
Bone disease may be due to calcium or Vit D
7)Intestinal Obestruction due to adhesion
8)Gallstone disease due to stasis after vagotomy

# The complications of peptic ulceration

The common complications of peptic ulcer are perforation, bleeding and stenosis. (Gastric
outlet obstruction)

(I) peptic ulce perforation

Perforations most commonly occur in elderly female patients. NSAIDs appear to be
responsible for most of these perforations. The most common site of perforation is the
anterior aspect of the duodenum. However, the anterior or incisural gastric ulcer may
perforate, gastric ulcers may perforate into the lesser sac, which can be particularly
difficult to diagnose. These patients may not have obvious peritonitis.

* Clinical features

Classic presentation is :-
The patient, have a history of peptic ulceration, develops sudden onset severe generalised
abdominal pain due to the irritant effect of gastric acid on the peritoneum.
shocked with a tachycardia but a pyrexia is not usually observed until some hours after the
event.
The abdomen exhibits a board-like rigidity and the patient is disinclined to move because of
the pain. The abdomen does not move with respiration.


* Investigations
1- erect plain chest radiograph will reveal free gas under the diaphragm in excess of 50 percent of cases with perforated peptic ulcer
2- serum amylase should performed, as distinguishing between peptic ulcer, perforatio
and pancreatitis It can be elevated following perforation of a peptic ulcer although,
fortunately, the levels are not usually as high as the levels commonly seen in acute
pancreatitis.
Several other investigations are useful if doubt remains.
3- water soluble contrast swallow will show a free peritoneal leak. .
4- Diagnostic peritoneal lavage will usually easily distinguish between perforation and
pancreatitis,
5-ultrasound &- CT scan will normally be diagnostic in both conditions, although this is
seldom necessary.

* Treatment

The initial priorities are resuscitation and analgesia (which may mask sign & symotom).
Following resuscitation and the diagnosis being established the treatment is principally
surgical. Laparotomy is performed usually through an upper midline incision.
laparoscopy may be employed.
The most important component of the operation is a thorough peritoneal toilet to remove
all of the fluid and food debris. The perforation is in the duodenum it can usually be closed
by several well-placed sutures, with entoplasty(place an omental patch over the
perforation) the sutures should not be tied so tight that they tear out.


Gastric ulcers should, if possible, be excised and closed, so that malignancy can be
excluded.
If massive duodenal or gastric perforation such that simple closure is impossible and in
these patients a Billroth II gastrectomy is a useful operation.
All patients should be treated with systemic antibiotics and there may be some advantage
in washing out the abdominal cavity with tetracycline, 1 g in 1 litre of isotonic saline.
Following operation gastric antisecretory agents should be started immediately (H2 antagonist or PPI).

(In the past many surgeons performed definitive procedures such as either truncal

vagotomy and pyloroplasty , nowadays surgery is omit the peptic ulcer treated medically )
It is important that the stomach be kept empty postoperatively by nasogastric suction, and
gastric antisecretory agents commenced to promote healing in the residual ulcer. In
patients with Helicobacter-associated ulcers, eradication therapy is appropriate. Patients
on NSAIDs should have the drug withdrawn and another analgesic substituted.

(II)Haematemesis and melaena

The most common causes are-
Bleeding peptic ulcer 60%, multiple erosions 26% , Mallory—Weiss tear 4% and bleeding

oesophageal varices(portal hypertention) 4% Ca stomach 0.5%others like aortic enteric
fistula ,Whatever the cause the principles of management are identical.=è
resuscitateion IV fluid , blood , urine catheter and following this investigated urgently
OGD to determine the cause of the bleeding.


This practice is not to be encouraged, except in extremis.
In some patients bleeding is secondary to a coagulopathy. The most important current
causes of this are liver disease and inadequately controlled warfarin therapy. In these circumstances the coagulopathy should be corrected, if possible, with fresh frozen plasma.

# Bleeding peptic ulcers

Medical and minimally interventional treatments
Started on either an H 2 antagonist or a proton pump antagonist, tranexamic acid, an
inhibitor of fibrinolysis, reduces the rebleeding rate.
Octreotide, a somatostatin analogue, has not proved effective. Numerous endoscopic
devices are now available which can be used to achieve haemostasis ranging from
expensive lasers to inexpensive injection apparatus

Surgical treatment

Indication of surgery :

A patient who continues to bleed requires surgical treatment. The same applies to a significant rebleed. Patients with a visible vessel in the ulcer base, a spurting vessel or an
ulcer with a clot in the base are statistically likely to require surgical treatment to stop the bleeding.
Elderly and unfit patients are more likely to die as a result of bleeding than younger patients. Ironically, they should have early surgery. A patient who has required more than
6 units of blood in general needs surgical treatment.

(III)Gastric outlet obstruction

The two common causes of gastric outlet obstruction are gastric cancer and pyloric
stenosis secondary to peptic ulceration. gastric outlet obstruction should be considered
malignant until proven otherwise, at least in the West. Because decrease in the incidence
of peptic ulceration and the advent of potent medical treatments.


* Clinical features
There is usually a long history of peptic ulcer disease. The pain may become unremitting
and in other cases may largely disappear. The vomitus is characteristically unpleasant in
nature and is totally lacking in bile. Very often, it is possible to recognise foodstuff taken
several days previously. Losing weight, and appears unwell and dehydrated. Distended
stomach and a succussion splash may be audible on shaking the patient’s abdomen.

* Metabolic effects

The vomiting of hydrochloric acid results in hypochloraemic alkalosis.
Initially the urine has a low chloride and high bicarbonate content reflecting the primary
metabolic abnormality. This bicarbonate is excreted along with sodium, and so with time
the patient becomes progressively hyponatraemic and more profoundly dehydrated.
Because of the dehydration, a phase of sodium retention follows and potassium and hydrogen are excreted in preference. This results in the urine becoming paradoxically acidic and hypokalaemia ensues. Alkalosis leads to a lowering in the circulating ionised calcium,
and tetany can occur.

* Management

Correcting the metabolic abnormality rehydrated with intravenous isotonic saline with
potassium supplementation. Replacing the sodium chloride and water allows the kidney to
correct the acid—base abnormality.
Treat anaemic,( the haemoglobin being spuriously high on presentation.)
A large nasogastric tube The stomach should be emptied. and lavage the stomach until it is
completely emptied.


Endoscopy and contrast radiology. Biopsy of the area around the pylorus is essential to
exclude malignancy. antisecretory agent such as ranitidine, given initially intravenously to
ensure absorption.
Early cases may settle with conservative treatment, presumably as the oedema around
the ulcer diminishes as the ulcer is healed.
severe cases are treated surgically, usually with a gastroenterostomy rather than a pyloro-
plasty. The addition of a vagotomy in these circumstances may be appropriate.

Endoscopic treatment with balloon dilatation has been practised and may be most useful in early
cases. This treatment is, however, not devoid of problems. Dilating the duodenal stenosis
may result in perforation. The dilatation may have to be performed several times and
sometimes may not be successful in the long term.