peptic ulcer at aglance

Can occur:
o       In esophagus.
o       In jejunum in Zollinger-Ellison syndrome (↑ Gastrin à HCl).
o       After gastroenterostomy.
o       In Meckel’s diverticulum (contains ectopic gastric mucosa).


   
Epidemiology
·        Duodenal ulcer  (DU) > Gastric ulcer (GU).
·        DU in  ♂ >  ♀.
·        Incidence:  ↑ with age.
   
Etiology
1.    H. pylori.
2.    Genetic susceptibility.
3.    NSAIDs (mainly for Gastric ulcer).
4.    Hyperthyroidism (Ca+2 à acid secretion).
5.    Zollinger-Ellison syndrome (hyperacidity state).
   
Pathology
·        Gastric ulcer may occur in any part of stomach, but is most commonly in lesser curve.
·        Most duodenal ulcers occur in duodenal cap.
   
Clinical  Features
 
Symptoms:
  1.         Epigastric pain:  characteristic, pt points directly to epigastrium.
  2.         Indigestion.
  3.         Nausea, heartburn (due to acid regurgitation).
  4.         Anorexia & weight loss (esp. in gastric ulcer).
 
N.B.  Patients can present for the 1st time with major complications: e.g. hematemesis / malena / perforation.
 
N.B. In gastric ulcer, pain is aggravated by food.
 
Signs:
Epigastric tenderness:  But it does not necessarily imply disease & is usually found in non-ulcer dyspepsia.
 
N.B. Physical exam is of little help in establishing diagnosis of uncomplicated peptic ulcer diseases.
   
Investigations
 
1.     Endoscopy:  1st  Investigation with biopsy of all gastric ulcers.
2.     Barium meal (double-contrast technique).
 
 
Treatment
1.     Eradication of H. pylori.
2.     Omeprazole.
3.     H2 receptor antagonists.
4.     Stop smoking & NSAIDs.
5.     Surgery.
   
Surgical Mx
 
·        Currently surgery is reserved for complications. In the past, 2 types of operation were performed:
 
1.     Partial gastrectomy:  to remove antral area that secretes gastrin.
a.   Billroth I partial gastrectomy  à best for GU
b.   Billroth II (Polya gastrectomy)          à GU / DU.
 
2.     Vagotomy:
a.      Truncal vagotomy + gastroenterostomy / pyloroplasty.
b.     Selective vagotomy + gastroenterostomy / pyloroplasty.
c.    Highly selective vagotomy
o       Proximal gastric vagotomy.
o       Nerves supplying parietal cells are transected.
   
Long-term   Complications  of  surgery
 
   1.     Recurrence of ulcer with same symptoms.
   2.     Dumping:
o       Nausea, distension associated with sweating, faintness, palpitations.
o       Occurs in patients following gastrectomy / gastroenterostomy.
o       Due to dumping of food into jejunum à rapid fluid dilution of the high osmotic load.
o       Not a clinical problem.
 
      3.     Diarrhea:  seen after vagotomy.
      4.     Vomiting (Afferent loop syndrome / bilious vomiting).
§        Because food gets trapped owing to altered anatomy.
 
      5.     Nutritional complications:  Most commonly Fe+ def anemia caused by poor absorption.
   
Complications
 
H. pylori eradication is imperative.
   
1.      Hemorrhage.
 
2.      Penetration.
 
3.      Perforation.
·        More in duodenal ulcers (usually in peritoneal cavity).
·        May occur in lesser sac.
·        Diagnosis:  air under diaphragm.
 
4.      Fibrosis:
 
a.   Hourglass stomach.
 
b.   Teapot stomach.
 
c.    Pyloric stenosis / obstruction:
·        Gastric outflow obstruction.
·        Occur in prepyloric / duodenum.
·        Occurs because:
1.     Of active ulcer with surrounding edema.
2.     Healing has been followed by scaring.
3.     Gastric malignancy.
4.     External compression from a pancreatic cancer.
·        Main symptom:  projectile vomiting (no bile).
·        On physical examination:  abdomen has succussion splash.
·        Diagnosis:  Barium meal (soap-plate appearance).
·        Most patients require surgery.  
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