APD.ppt

Comprehensive ppt on APD

1. Peptic Ulcer
Professor Ravi Kant
FRCS (England), FRCS (Ireland),
FRCS(Edinburgh), FRCS(Glasgow), MS,
DNB, FAMS, FACS, FICS,
Professor of Surgery

2. Surgical Anatomy
Crow’s feet
N of Latarjet
Criminal Nerve of Grassi
Antral pump mechanism

3. Applied Anatomy : Stomach
Pressure studies
Endoscopic & Chromo-endoscopic
Contrast ( Ba meal with air)
Intra-luminal USG
Electron microscopy
USG
CT/ MR
Surgical

4. APD= Acid Peptic Disease
Peptic Ulcer
Gastric Ulcer
Duodenal Ulcer
Hyperacidity
ZE Syndrome

5. APD= Acid Peptic Disease
Acute Ulcer
Stress Ulcer
Curling’s
Cushing’s

6. APD
Incidence
Aetiology
CP
Investigations
DD
Rx

7. Peptic Ulcer
10% population affected
Gastric ulcer in elderly 5-6
th
decade
Duodenal ulcer in adults 4
th
decade
DU also in young

8. Duodenal Ulcer
Proximal duodenum
1 -2 cm of pylorus
▲acid
Distal duodenum = ZE

9. Type 1 Gastric Ulcer
most common(among gastric
Ulcers)
proximal antrum
mucosal defense
acid

10. Type II Gastric Ulcer
Secondary to DU + pyloric
stenosis

11. Type III Gastric Ulcer
Prepyloric and pyloric canal ulcer
acid ▲
common etiology with DU

12. GU: Benign Vs CA
Rugae upto margins
Small , <2cm
Sticking of barium +
Accompanying spasm
↓ Acid
Crater beyond the
normal stomach on a
barium
Rugae-short of
Small-Big
-
-
Achlorhydria
Limited to Stomach

13. APD
Incidence
Aetiology
CP
Investigations
DD
Rx

14. APD
Hurry
Worry
Curry

15. Pathogenesis
Imbalance of acid-pepsin
and mucosal defence
H. pylori infection
NSAID
ZE Syndrome
Type A personality

16. H.pylori
95% -duodenal ulcer
80% -gastric ulcer
mucosal resistance
hydrophobicity
eradication reduces ulcer
recurrence

17. NSAID
Suppress prostaglandins
prostaglandin ►
acid secretion
▲mucosal blood flow
mucus & bicarbonate secretion
10 -30% in chronic users

18. ZE= Zollinger Ellison Syndrome
Recurrent
Recalcitrant
Resistant
Unusual sites
Multiple
Malignant

19. ZE Syndrome
0.1 -1.0% of peptic ulcer
Type I and Type II
Gastrin secretion from non-beta cell
tumor of pancreas -Gastrinoma
MC in pancreas ; duodenum, antrum

20. ZE Syndrome
20% multiple
66% malignant
slow growing indolent tumor
parietal cell mass increased
genetic basis
massive hyper-secretion of acid

21. ZE Syndrome
MEN -I
–hyperparathyroidism
–islet cell tumor
–pituitary tumors

22. A/ DU
NSAIDs
Acid hypersecretion
Rapid gastric emptying
Impaired acid disposal
Smoking

23. Duodenal Ulcer
Increased secretion of acid
More rapid gastric emptying
Decreased prostaglandin
Chronic duodenitis with H.pylori
Smoking

24. Gastric Ulcer
H.pylori
NSAIDs
Duodenogastric reflux
Impaired gastric mucosal defense

25. Gastric Ulcer
Acid secretion -normal to low
Reflux of duodenal contents 
gastritis ulcer
Pylorus sphincter disorder
Smoking
Disturbed mucosa with low grade
gastritis

26. APD
Incidence
Aetiology
CP
Investigations
DD
Rx

27. CP
Duodenal Ulcer
–pain relieved by food or alkali
–pain several hours after meal
Gastric Ulcer -gnawing or
burning pain on eating

28. CP
Periodic chronic recurrent pain
Nausea & vomiting
Weight loss
Epigastric tenderness

29. APD
Incidence
Aetiology
CP
Investigations
DD
Rx

30. Investigations
Endoscopy
–90% sensitivity
–must in all pts. with severe pain
–excludes malignancy
–biopsy can be taken
–test for H.pylori

31. Investigations
Barium Mealdouble (air) contrast
–90% sensitivity

32. H Pylori detection:
Breath test
Blood test
Tissue test

33. APD
Incidence
Aetiology
CP
Investigations
DD
Rx

34. DD
Cholecystitis
Hiatus hernia
Pancreatitis
MI
Pneumonia
Dissecting aneurysm
Worm Infestations

35. APD
Incidence
Aetiology
CP
Investigations
DD
Rx

36. Rx -Medical
Stop smoking, NSAIDs
Stop alcohol
Antacids -acid neutralisation
H
2receptor antagonist -Ranitidine
-secretion inhibition

37. Rx-Medical
H
+
pump inhibition -H
+
/K
+
ase
inhibition -Omeprazole
Anticholinergic -secretory inhibition
Prostaglandin -Misoprostol
-mucosal protection

38. Proton Pump Blockers
Omeperazole
Eso-meperazole
Rabi-meperazole

39. Rx -Medical
Sucralfate -protective coating
Colloidal Bismuth
–eradicate H.pylori
–protective coating
Antibiotics -H.pylori
Kit for H Pylori

40. H2 Receptor Antagonists
On parietal cells
Decrease basal & stimulated acid
secretion
Pepsin output decreased
Decreased gastric blood flow
Competitive inhibitor of parietal cell

41. Rx -Duodenal Ulcer
95% control -medical Rx
Surgery-Outdated, Obsolete
Omeprazole better thanRanitidine
Ulcer heels in 80% by 6 m
recurrence in 95% by
H.pylori eradication

42. Rx -Duodenal Ulcer
Indications for surgery=Compl
–Hemorrhage
–Obstruction
–Perforation
–Intractability of pain
Intractable pain ►HSV / TV + GJ

43. Rx -DU
H2 blockers heals 75% DU in 4
weeks
H/K proton pump inhibitor better
results
ulcer may recurr in 80% cases on
stopping
treatment of H.pylori

44. Rx -DU
Indication of surgery in hemorrhage
bleeding of > than 6 units
recurrent bleed after endoscopic
control
pyloro-duodenotomy and control of
bleeding
HSV or TV + GJ

45. Rx -DU
Perforation -simple closure with
omental patch-Graham’s patch
definitive surgery
–HSV
–TV + pyloroplasty
–parietal cell vagotomy
–TV+GJ

46. Rx GU
Omeprazole, H2 receptor
antagonist -8 weeks
if pain not relieved by 2 weeks -
add one more drug
repeat endoscopy after 8 weeks
if no healing by 12 -115 weeks-
Surgery

47. Rx -GU
Type I -Distal Gastrectomy with
vagotomy + G-D or GJ
proximal ulcer-total gastrectomy
parietal cell vagotomy -high
recurrence

48. Hemorrhage
Hemorrhage -potential cause of
death
15 -20% gross bleeding
erosion of duodenal ulcer into
gastro-duodenal artery
Endoscopy –laser, sclerosant
oralcohal injection

49. Perforation
In 5-10% of cases
pneumo-peritoneum in 75% cases
peritonitis, pain, ileus
leukocytosis, hypovolumia, IIIrd
space loss
DD -acute appendicitis, enteric
perf.

50. Obstruction
Chronic ulcer disease with edema
and scarring
in 5% cases of DU
nausea, vomiting, abdominal
distension
metabolic alkalosis, paradoxical
aciduria

51. Obstruction
Endoscopy
Ba study
Scintigraphy
Rx V + G-J / G-D