Peptic ulcer & upper gi bleeding

Peptic ulcer, Upper GI bleeding, esophageal varices, Portal hypertension

1. PEPTIC ULCER & UPPER GI BLEEDING By Dr. Abdul Qadeer MBBS; FCPS; FICS Assistant Professor in General Surgery King Faisal University College of Medicine Kingdom of Saudi Arabia

2. OBJECTIVES Definition of peptic ulcer Epidemiology of peptic ulcer Causes of peptic ulcer Clinical presentation Investigations Treatment Definition of upper GI bleeding Epidemiology of upper GI bleeding Causes Clinical presentation Investigations Treatment

3. 1. Definition of peptic ulcer A lesion in the lining (mucosa) of the digestive tract, typically in the stomach or duodenum, caused by the digestive action of pepsin and stomach acid.

4. 2. Epidemiology of peptic ulcer 10% of the population has ulcers Annual incidence of symptomatic peptic ulcer is about 0.3% Duodenal ulcers are 4 times as common as gastric ulcers and occur at the duodenal cap Gastric ulcers mostly occur in the lesser curvature. Usually benign. 5% are malignant May occur on the stoma following gastric surgery, esophagus & Meckel’s diverticulum having ectopic gastric tissue

5. In general, the ulcer occurs at a junction between different types of epithelia, the ulcer occurring in the epithelium least resistant to acid damage Gastric malignancy is common in Japan, Chile, Finland & Iceland due to environmental & diet factors.

6. 3. Causes of peptic ulcer Higher pepsin/gastric acid levels, though the ulcers have been seen in patients having normal levels Gastrinoma ( Zollinger -Ellison syndrome) Helicobacter pylori in 80-95% cases Consumption of NSAIDs Stress i.e. emotional, trauma, surgical Injury or death of mucus-producing cells

7. Gastrinoma triangle

8. Causes of peptic ulcer Smoking Alcohol/diet Hypercalcemia ( calcium secretion) Genetic factor: first-degree relatives Blood group O

9. 4. Clinical presentation of p. ulcer Pain: epigastric, may radiate to back, intermittent, may be relieved by eating Periodicity: the symptoms may disappear for weeks or months (due to spontaneous healing) Vomiting Alteration in weight:: Weight loss or gain Bleeding: acute (hematemesis or malena ) or chronic (anemia)

10. Clinical presentation of p. ulcer O/E: may be normal or epigastric tenderness Perforation GOO (Gastric outlet obstruction)

11. 5. Investigations in peptic ulcer Gastoduodenoscopy : investigation of choice, biopsy is taken for histopathology and tissue for culture, especially H. Pylori Radiological: Barium meal Laboratory tests: CLO (Campylobacter-like organism) test Urea breath test (UBT) H.Pylori stool antigen ( HpSA ) test

12. Clo test kit

13. Urea breath test

14. 6. Treatment of peptic ulcer Medical treatment: H2-receptor antagonists: cimetidine, ranitidine, famotidine, nizatidine PPIs: omeprazole, lansoprazole, esomeprazole, pantoprazole etc. Eradication therapy: PPIs + antibiotics Surgical treatment: Gastrectomy: Billroth I, Billroth II, Gastrojejunostomy Vagotomy : Truncal , Selective, Highly selective

15. gastrectomy

16. vagotomy

17. Sequelae of p.ulcer surgery Recurrent ulceration Small stomach syndrome Bile vomiting Early & late dumping Post- vagotomy diarrhea Malignant transformation Nutritional consequences Gallstones

18. Dumping syndrome

19. Early & late dumping syndromes

20. 7. Definition of upper Gi bleeding Where the source of bleeding is in: Esophagus Stomach Duodenum

21. 8. Epidemiology of upper gi bleeding Incidence: 100/100 000 in Western world Strongly associated with NSAIDs use 5-10% in-hospital mortality

22. 9. Causes of upper gi bleeding Ulcers: esophageal, gastric, duodenal Erosions: esophageal, gastric, duodenal Mallory-Weiss tear Esophageal varices Tumor Vascular lesions e.g. Dieulafoy’s disease Aortic-enteric fistula

23. 10. Clinical presentation of upper gi bleeding Hematemesis Malena Associated with GI perforation Shock

24. 11. Investigations of upper gi bleeding Upper GI endoscopy Contrast studies CXR erect posture: diagnostic of GI perforation

25. X-ray chest erect posture

26. Xray abdomen lateral decubitus

27. endoscopy

28. Barium meal

29. 12. Treatment of upper gi bleeding Resuscitation Treat the cause

30. Emergency management of acute non- variceal upper GIT haemorrhage I.V access with large bore cannula Basic investigations - blood count , routine biochemistry , cross match blood Hourly measurements of BP, pulse and urine output I.V colloids or crystalloids –pt with hypotension and tachycardia Transfuse with blood Endoscopy for diagnosis & Rx I.V PPI therapy for bleeding peptic ulcer

31. Emergency management of acute variceal upper GIT bleeding 0.9 % saline Vasopressor( terlipressin ) Prophylactic antibiotics Emergency endoscope Variceal band ligation Proton pump inhibitor Phosphate enema/lactulose enema

32. Management of Peptic ulcer ENDOSCOPIC THERAPY with * Bipolar electro coagulation * Heater probe * Injection therapy - Absolute alcohol - 1:10000 epinephrine * Clips High dose constant infusion of iv PPI E.g. Omeprazole – 80 mg bolus & 8 mg/ hr infusion

33. Prevention of recurrent bleeding Eradication of H.Pylori infection Discontinue NSAIDS & acids If NSAIDS have to be used, use along with PPI Use selective COX-2 inhibitors like Coxib or traditional NSAIDS + Coxib Coxib + PPI : further significant decrease in ulcers and recurrent bleeding.

34. MALLORY-WEISS TEARS Mostly bleeding stops spontaneously (Recurrence is only 0-7%) Endoscopic therapy is only for actively bleeding Mallory-Weiss tear. Angiographic therapy with embolization & operative therapy with over sewing of tear can be done

35. Esophageal varices

36. Esophageal varices Vasoconstrictors (somatostatin, octreotide , terlipressin ) i.v terlipressin infusion at 2 mg 6 hourly, generalized vasoconstriction leading to decreased blood flow to venous system. Baloon tamponade ( Sengastaken –Blakemore tube): Triple lumen or Four lumen tube with esophageal and gastric balloons. Endoscopic variceal ligation (Band ligation) Sclerotherapy Antibiotic therapy

37. Sengastaken -Blakemore tube

38. Quinolones – for patients with cirrhosis decreases the bacterial infection & mortality. Non selective Beta blockers – Propranolol , Nadolol For recurrent esophageal bleeding – continue therapy with beta blocker + endoscopic ligation

39. If not subsided with medical therapy, Go for INVASIVE THERAPY : TIPSS ( Transjugular intrahepatic portosystemic shunt) Other shunts e.g. Danver

40. gastritis Avoiding the long-term use of alcohol, NSAIDs, coffee, high-fat foods and drugs Reducing stress through relaxation techniques Antacids, H2 blockers, PPIs Triple therapy: 2 antibiotics + a PPI is commonly used to treat H. Pylori related gastritis

41. THE END