Complication of peptic ulcer disease..……

PEPTIC ULCER COMPLICATION MADE EASY

1. Contents Complications of Peptic ulcer Gastric outlet obstruction Clinical features Investigation Biochemical abnormalities

2. Definition A peptic ulcer is defined as disruption of the mucosal integrity of the stomach and/or duodenum leading to a local defect or excavation due to active inflammation.

3. Complications Bleeding Perforation Stenosis Malignant transformation Gastric outlet obstruction(rare)

4. Gastric outlet obstruction Causes : Gastric cancer and pyloric stenosis secondary to Peptic ulcer Clinical features Early satiety, bloating, indigestion Epigastric pain Nausea and vomiting (cardinal symptoms) Weight loss

5. Examination and Investigation On examination-visible gastric peristalsis(L-R) ,positive succussion splash, auscultoscrapping (for distended abdomen) Endoscopy Barium meal study Serum Electrolyte ECG

6. Biochemical abnormalities Dehydration and Electrolyte abnormalities 1.metabolic alkalosis 2.hypochloraemia 3.hyponatremia 4.hypokalemia 5.hypocalcimia 6.paradoxical renal aciduria ( irritability, confused state, dehydration, convulsions rapid breathing )

7. Upper Gastrointestinal Bleeding Nirmal Raj Karki

8. Introduction: Upper Gastrointestinal (UGI ) bleeding is defined as the bleeding derived form the source in the GI tract proximal to the ligament of Treitz . UGI Bleeding is a common problem with an annual incidence of approximately 80 to 150 per 100,000 population, with estimated mortality rates between 2% to 15%.  UGI bleed is 1.5 – 2 times more common than lower GI bleed.

9. Causes of UGI bleeding:

10. Causes contd … Duodenal causes: Duodenal ulcers Vascular malformation including aorto -enteric fistulae Haematobilia i.e. bleeding form the biliary tree Haemosuccus pancreaticus i.e. bleeding from the pancreatic duct Severe superior mesenteric artery syndrome Idiopathic

11. Clinical Assessment: Hematemesis: It is vomiting of blood which is red with clots when bleeding is rapid and profuse. It is black “ coffee ground “ when less severe. Melena: It is passage of black, tarry stools containing altered blood, which is difficult to flush out. Occasionally melena may also present in case of hemorrhage from right side of the colon. Hematochezia: It is the passage of fresh blood with or without stool from the anus. Usually it represents lower GI bleeding, although an UGI lesion may bleed so briskly that blood do not remain in the bowel long enough to develop melena. Syncope: It may develop from hypotension due to intravascular volume depletion. Other clinical manifestation may include dyspepsia, epigastric pain, heart burn, diffuse abdominal pain, dysphagia, jaundice, weight loss.

12. Management of Bleeding Peptic Ulcer Medical and minimally interventional treatment On medical treatment H2-antagonist or a proton pump antagonist is started. Therapeutic endoscopy can achieve haemostasis using the combination of adrenaline injection with heater probe and/or clips In patients where the source of bleeding cannot be identified or in those who rebleed after endoscopy, angiography with transcatheter embolisation may offer a valuable alternative to surgery .

13. Reference : bailey and love surgery

14. ESOPHAGEAL VARICES

15. Contents INTRODUCTION CAUSES OF PORTAL HYPERTENSION CLINICAL MANIFESTATION THE MANAGEMENT OF VARICEAL BLEEDING.

16. Introduction Oesophageal varices are dilated and tortuous veins in the oesophageal wall, secondary to increased venous pressure in the splanchnic venous bed or the superior venacava.

17. Pre-sinusoidal Extrahepatic: portal vein thrombosis , splenic vein thrombosis (pancreatitis, pancreatic tumor), myelofibrosis, arterioportal shunt, tropical splenomegaly Intrahepatic: schistosomiasis , congenital hepatic fibrosis and portal infiltration (sarcoidosis), drugs and toxins, venoocclusive disease Sinusoidal Cirrhosis Post-sinusoidal Hepatic vein occlusion (Budd–Chiari syndrome), venoocclusive disease, congestive cardiac failure Causes of portal hypertension

18. Clinical manifestations

19. The management of variceal bleeding.

20. Sclerotherapy Sclerosants used are: ethanolamine oleate (5%); sodium morrhuate (2-5%); Sodium tetradecyl sulphate Sclerotherapy causes intimal injury, submucosal vessel thrombosis, ulceration, submucosal fibrosis 5-6 sclerotherapies are needed to create total obliteration.

21. Endoscopic variceal banding (EVB) Multishoot banding device

22. The management of variceal bleeding.

23. Oesophageal and gastric balloon tamponade Balloon Tamponade is the bridge to the definitive treatment Minnesota tube is inserted to provide temporary haemostasias Once inserted, the gastric balloon is inflated with 300 mL of air and retracted to the gastric fundus Varices are tamponade by inflation of the oesophageal balloon to 40 mmHg. The two remaining channels allow gastric and oesophageal aspiration, and the position of the tube is confirmed radiologically.

24. The management of variceal bleeding.

25. (Transjugular intrahepatic portosystemic stent shunts) TIPSS

26. The management of variceal bleeding.

27. Surgical shunts for portal hypertension

28. Management of bleeding oesophageal varices

29. Operations for Duodenal Ulcer and its Complication Regnantia Kashyap

30. Triple Therapy Regimen The best among all the Triple Therapy Regimen is: Omeprazole / Lansoprazole - 20 / 30 mg BD Clarithromycin - 500 mg BD Amoxycillin / Metronidazole - 1gm / 500 mg BD Given for 14 days followed by P.P.I for 4-6 weeks Short regimens for 7-10 days not very effective

31. Operations for Duodenal Ulcer Graham’s Patch Repair Truncal Vagotomy with gastrojejunostomy Vagotomy with antrectomy Selective vagotomy with pyloroplasty Highly selective vagotomy Posterior truncal vagotomy with anterior seromyotomy Posterior truncal vagotomy with Highly Selective Vagotomy without drainage procedure Linear gastrectomy

32. Graham’s Patch Repair Formation of dense adhesions between omentum and sites of perforation or inflammation thus facilitates use as patch for duodenal perforation for ulcer disease known as Graham patch. Piece of omentum is used to cover the perforation. 3 or 4 interrupted sutures are inserted through and through along the axis.

33. Truncal vagotomy Most common operation performed for duodenal ulcer disease. Pyloric relaxation is mediated by vagal stimulation, and a vagotomy without a drainage procedure can cause delayed gastric emptying. The principle of the operation is that section of the vagus nerves, which are critically involved in the secretion of gastric acid, reduces the maximal acid output by approximately 50%. The most popular drainage procedure is the Heineke-Mikulicz pyloroplasty. Gastrojejunostomy was the alternative drainage procedure to pyloroplasty. In addition to a truncal vagotomy, the antrum of the stomach is removed, thus removing the source of gastrin and the gastric remnant is joined to the duodenum. The recurrence rates after this procedure are exceedingly low.

34. Complication of Truncal vagotomy Bleeding Injury to the stomach or esophagus Staple line leak Anastomotic leak Internal hernia Delayed gastric emptying Post vagotomy diarrhea Post vagotomy hypergastrinemia Ulcer recurrence Dumping Syndrome

35. Selective Vagotomy It involves division of the vagal trunks distal to the hepatic and celiac branches, thereby preserving vagal innervation to the gallbladder and celiac plexus. Total denervation of the stomach from diaphragmatic crus to pylorus. Procedure still needs drainage, but advantage in other organs are spared, liver, gallbladder, small bowel, colon.

36. Highly Selective Vagotomy Highly selective vagotomy preserves gastric emptying and motility better then truncal vagotomy or selective vagotomy. Also called parietal cell vagotomy or proximal gastric vagotomy and it causes minimal side effects. In this operation, vagi are not divided at the trunk. Both anterior and posterior vagus are identified, isolated and preserved. Their branches, that is anterior and posterior greater gastric nerves of latarjet which run along the lesser curvature are isolated. The branches supplying parietal cell mass are divided, hence it is called parietal cell vagotomy.

37. The terminal fibers of nerve of latarjet which supply pylorus are preserved. This proved to be the most satisfactory operation for duodenal ulceration, with a low incidence of side effects and acceptable recurrence rates when performed to a high technical standard. This operation became the gold standard for operations on duodenal ulceration in the 1970s.

38. Complication of Highly Selective Vagotomy Ulcer recurrence Perfomated ulcer Bleeding duodenal ulcers Stenosis Recurrent stenosis Instead of cutting the trunk, a highly selective vagotomy cuts only the branch of the vagus nerve that triggers stomach acid. This branch connects to the parietal cells in your stomach that release gastric acid.

39. Operation for Gastric Ulcer and it’s complication

40. Contents Introduction Johnson’s classification Operative management Complication of surgery

41. Introduction Less common than duodenal ulcers 60-70% associated with H.pylori Male:Female = 2:1 Diagnosis: Endoscopy u manoeuvre during endoscopy done to evaluate fundal ulcers All the gastric ulcers should be biopsied to rule out malignancy

42. Johnson’s Classification

43. Operative Management Type I : Distal gastrectomy Type II and III : Distal gastrectomy + Vagotomy/PPI Type IV : a) Pauchet procedure = Gastrojejunostomy b) Csendes procedure = Subtotal gastrectomy + Roux- en- Y gastrojejunostomy

44. Gastric reconstruction Bilroth I reconstruction Distal gastrectomy with end to end gastroduodenal anastomosis If tension present : leak can occur

45. Bilroth II reconstruction Subtotal gastrectomy with end to side gastrojejunal anastomosis

46. Roux- en - Y gastrojejunostomy 50 cm from duodenojejunal flexure, jejunum is cut, one portion of jejunum is continuous with ileum and rest of the bowel and another 50cm is attached to duodenum Lift up the part continuous with the bowel and carry out end to side gastrojejunostomy: Roux limb Limb carrying bile and pancreatic juice is joined to roux limb: Bilio pancreatic limb

47. Vagotomy Acid reducing surgery Done in type II and III gastric ulcers But this surgery is no longer done now because PPIs are as effective as Vagotomy Types : Truncal and Highly selective Vagotomy

48. Truncal vagotomy Trunk of vagus is cut and it is most commonly performed because acid reduction, ulcer recurrence and Vagotomy complications are moderate Highly selective vagotomy Crow’s foot branches are cut and sometimes criminal nerve of Grassi can be missed out leading to recurrence of ulcers and done in chronic ulcers

49. Complications Anastomotic leak Post vagotomy diarrhea Hemorrhage Gallstone formation Duodenal stump blow out Impaired gastric emptying Dumping syndrome Nutritional complications Bilious vomiting Peptic ulcer at anastomotic site