Peptic ulcer presentation by UOS Students

Peptic ulcer presentation by UOS Students

1. Prepared by: Milhan, Rayan, Tanawal, Adeel, Saeed Pathophysiology of

2. Table Of Contents Introduction to peptic ulcer Types of peptic ulcer Pathogenesis of gastric ulcer Gastric ulcer – etiologies Symptoms of gastric ulcer Types of gastric ulcer Complications of ulcer Duodenal ulcer Pathogenesis of duodenal ulcer Clinical presentation Difference between gastric and duodenal ulcer Pathophysiology of peptic ulcer Morphology Investigation of peptic ulcer Treatment Surgical options References

3. Peptic Ulcer Disease “PUD” is a common cause to visit the physicians in the worldwide. It can occur in any portion of the GIT which exposed to gastric acid. Common sites:- Types: Duodenal Ulcer : almost always due to H.Pylori . Gastric Ulcer: usually due to H.Pylori , NSAID & bile reflex. Distal ⅓ of the esophagus esp ecially in patients with GERD . They may coexist together in 10- 20% of cases. 3

4. 4 Gastric Ulcer Gastric ulcers tend to be larger than duodenal ulcers Large chronic ones may erode posteriorly into the pancreas, into major vessels such as the splenic artery. Chronic gastric ulcers are much more common on the lesser curve They tend to be at the boundary between the acid-secreting and the non-acid-secreting epithelia. With atrophy of parietal cell mass, non-acid-secreting epithelium migrates up the lesser curvature

5. 5 Pathogenesis Of gastric Ulcer

6. 6 Gastric Ulcer Etiologies: H.Pylori Smoking and alcohol Drugs - NSAIDs, steroids. Physiologic stress Burns hypotension CNS trauma surgery severe medical illnesses

7. 7 Symptoms Symptoms consistent with: anemia – fatigue, dyspnea Alarm features; Bleeding/anemia Early satiety Unexplained weight loss Progressive dysphagia Recurrent vomiting Family history of GI malignancy

8. 8 Types of Gastric Ulcer

9. Bleeding : either from small B.V. erosion (causing nausea, melena , &/or anemia) or from large B.V. (causing hemorrhage & hematemesis ). 9

10. Perforation : leading to peritonitis. 10

11. Obstruction : Ulcers located in the pyloric channel or duodenum may cause gastric outlet obstruction. 11

12. 12 Ulcer occurs in the first part of duodenum, usually with in the first inch, involving the muscular layer. Eventually it shows cicatrization causing pyloric stenosis. Microscopically: ulcer with chronic inflammation with granulation tissue, gastric metaplasia of duodenal mucosa, endarteritis obliterans are visualized. An anterior ulcer perforates commonly, posterior ulcer bleeds or penetrates commonly. Duodenal Ulcer

13. Pathogenesis Of Duodenal Ulcer

14. 14 Pain is more before food, in early morning and decreases after taking food. Night pains are common. Common in males. Periodicity is more common than in chronic gastric ulcer with seasonal variation. Water-brash, heart burn, vomiting may be present. Melaena is more common, hematemesis also can occur. Good appetite and weight gain may be noted. Clinical Presentation

15. 15 Difference

16. Pathophysiology Of Peptic Ulcer Peptic ulcer disease (PUD) = mucosal defect in stomach or duodenum . Caused by imbalance : aggressive vs protective factors. Major causes: Helicobacter pylori infection NSAID use Common sites: Gastric ulcer (less common, ↑ risk of malignancy). Duodenal ulcer (more common, benign).

17. Normal Gastric Defense Mucus–bicarbonate barrier maintains protective surface. Prostaglandins (PGE2, PGI2): maintain blood flow, stimulate mucus & bicarbonate. Epithelial cells: tight junctions, rapid renewal. Good mucosal blood flow: removes H+ and toxic agents. Defense = “first line protection” against acid-pepsin attack. Pathophysiology Of Peptic Ulcer

18. Aggressive Factors Acid & Pepsin → mucosal injury if unopposed. H. pylori : urease (ammonia toxic), CagA / VacA toxins damage epithelium. NSAIDs : ↓ prostaglandins (COX-1 inhibition), direct mucosal irritation. Others : smoking, alcohol, corticosteroids, stress, bile reflux. Pathophysiology Of Peptic Ulcer

19. Gastric acid from parietal cells via H+/K+ ATPase. Stimulators: Gastrin (from G-cells). Acetylcholine (from vagus nerve). Histamine (from enterochromaffin-like cells). Inhibitors: Somatostatin. Prostaglandins (via COX pathway). Excess stimulation → hyperacidity → ↑ risk of ulcer. Acid Secretion Regulation Acid Induced Peptic Ulcer

20. H pylori Induced P eptic Ulcer

21. H pylori Induced P eptic Ulcer

22. NSAIDs Induced P eptic Ulcer

23. Morpholog y Number: Single Size: Small Shape: round to oval, sharply punched- out defect with non- elevated borders. Base: Smooth & clean. 23

24. Peptic ulcer has 4 histological zones. From the surface to the deep layers: Necrotic zone. Exudative zone. Granulation tissue zone . 4. Zone of cicatrisation (fibrosis) . 24

25. 1. Necrotic zone : lies in the floor of the ulcer and is composed of fibrinous exudate containing necrotic debris and few WBCs. 6

26. 2. Exudative zone : lies underneath the necrotic zone. The tissue shows coagulative necrosis giving with smudgy nuclear eosinophilic, appearance debris. 26

27. 3. Granulation tissue zone: It is composed of Mixed inflammatory infiltrate and many capillaries. 27

28. 4. Zone of cicatrisation (fibrosis): It is composed of dense fibrocollagenic tissue over. 28

29. These pictures show:- Necrotic debris Ulceration inflammation on the mucosal surface. 29

30. 15 Number: Single Size: Small Shape: round to oval, sharply punched- out defect with non-elevated borders. Base: Smooth & clean. Four Histological zones Necrotic zone. Exudative zone. Granulation tissue zone . Zone of cicatrisation

31. 31 Investigation In Peptic Ulcer CBC – detect anemia Urea, Electrolyte & creatinine Test Blood group and crossmatching LFTs H. pylori testing Urea breath test Stool antigen test

32. 32 Medical Treatment Treat underlying etiology a) Eradication of H.Pylori infection Tripple therapy- clarithromycin, amoxicillin, PPIs for 10 -14 days Quadruple therapy – a proton pump inhibitor (PPI), a bismuth salt, tetracycline, and metronidazole for 14 days b) Discontinue NSAIDs use c) Evaluate and treat other causes

33. 33 Surgical Options Ulcer bed management – graham patch or ligation of bleeding vessels gastric drainage – if a truncal vagotomy is performed. bypasses the pyloric sphincter mechanisms to facilitate gastric emptying and avoid stasis Pyroplasty preferred to gastrojejunostomy Definitive ulcer surgery Vagotomy – truncal vs highly selective Partial gastrectomy – antrectomy or subtotal gastrectomy

34. Robbins Basic Pathology 10 th edition. Netter's Illustrated Human Pathology, Updated Edition- L . Maximilian Buja. Harsh Mohan - Textbook of Pathology, 6th Edition. Sriram Bhat M (Ed). SRB’s Manual of Surgery, 6th Edition. Jaypee Brothers Medical Publishers, 2019. Section: Stomach and Duodenum – Peptic Ulcer Katzung BG, Trevor AJ. Basic & Clinical Pharmacology. 15th ed. McGraw-Hill; 2021 .