Surgical management of Peptic Ulcer Disease.pptx

this presentation discussed the surgical approaches to management of complications of peptic ulcer diseases. this complications include bleeding, perforation, malignant transformation and intractability. the alpathophysiology of peptic ulcer disease, principles of acid secretion and gastric pH was discussed

1. Surgical management of peptic ulcer disease (PUD) Dr Olayinka Lukman Adewunmi Division of General Surgery UMTH 6 th June, 2022

2. Outline Introduction Epidemiology Surgical anatomy Aetiology/risk factor Pathophysiology of PUD Classification of PUD Surgical complications of PUD Clinical features Investigations Treatments Prognosis Conclusion/summary References 6/5/2022 adewunmi- peptic ulcer disease 2

3. Introduction Peptic ulcer is defined as defects in the mucosa of the stomach or duodenum that extend into the muscularis mucosa Peptic ulcer occur following imbalance between the mucosa defense and acid/peptic injury It may be acute or chronic ulceration 6/5/2022 adewunmi- peptic ulcer disease 3

4. Introduction Aggressive factors NSAID H. pylori infection Alcoholism Bile salts Acid pepsin Defensive factors Tight intercellular junction Mucus Bicarbonate Mucosa blood flow Cellular restitution Epithelial renewal 6/5/2022 adewunmi- peptic ulcer disease 4

5. Introduction PUD is the most common GI disorder in the US with a prevalence of 2% and life time cumulative prevalence of 10% 6/5/2022 adewunmi- peptic ulcer disease 5

6. Relevant anatomy 6/5/2022 adewunmi- peptic ulcer disease 6

7. Relevant anatomy 6/5/2022 adewunmi- peptic ulcer disease 7

8. Relevant anatomy 6/5/2022 adewunmi- peptic ulcer disease 8

9. Aetiology Helicobacter pylori infection Drugs e.g. NSAID Severe physiological stress- curling's ulcer, Cushing's ulcer Lifestyle factors/changes e.g. smoking Hyper-secretory states- ZES, G-cell hyperplasia, etc. Genetic factors 6/5/2022 adewunmi- peptic ulcer disease 9

10. Pathophysiology H. pylori is a gram negative spirochete , urease producing organism, flagellated, The urease split urea into carbon dioxide and ammonia, creating a alkaline environment around itself and protecting from acidity of the stomach This further stimulate acid production by the parietal cells and associated parietal cell hyperplasia. With increase acid secretion, more acid is released into the duodenum and duodenal mucosa undergo metaplastic change to gastric mucosa 6/5/2022 adewunmi- peptic ulcer disease 10

11. Pathophysiology H. pylori infection of the metaplastic cell leads to acid secretion by duodenal mucosa, distorting the bicarbonate producing cell of the duodenum. The bicarbonate secretion reduce significantly 6/5/2022 adewunmi- peptic ulcer disease 11

12. Pathophysiology Other pathophysiological mechanisms production of toxins- vacA and cagA local elaboration of cytokines (IL-8) by infected mucosa recruitments of inflammatory cells and release of inflammatory mediators recruitments and activation of local immune factors increased apoptosis 6/5/2022 adewunmi- peptic ulcer disease 12

13. Classification of PUD Modified Johnson classifications Type 1 - ulcer at angularis incisura Type 2 - ulcer at angularis incisura + duodenal ulcer Type 3 - prepyloric ulcer Type 4 - ulcer at the OG junction Type 5 - NSAID-induced ulcer 6/5/2022 adewunmi- peptic ulcer disease 13

14. Clinical features Gastric ulcer Epigastric pain Worse with peppery meal Relieved by vomiting or hunger Normal weight or slight weight loss Middle age to elderly Duodenal ulcer Epigastric pain relieved by eating Patient may gain weight Young and middle age Periodicity 6/5/2022 adewunmi- peptic ulcer disease 14

15. Investigations Endoscopy ulcer and location 6/5/2022 adewunmi- peptic ulcer disease 15

16. Investigations Test for Helicobacter pylori Non invasive Invasive/Biopsy Urea breath test Histology Immunologic/blood test culture fecal antigen test Urea test 6/5/2022 adewunmi- peptic ulcer disease 16

17. Treatment Medical therapy PPI + clarithromycin + amoxicillin PPI + amoxicillin + metronidazole 6/5/2022 adewunmi- peptic ulcer disease 17

18. Surgical complications and management Bleeding Perforation Obstruction (Gastric Outlet Obstruction) Malignancy Refractory ulcer ( Intractability) NSAID-induced Zollinger -Ellison syndrome/ Gastrinoma ulcer at the OG junction 6/5/2022 adewunmi- peptic ulcer disease 18

19. Bleeding Clinical features hematemesis/upper GI bleeding malaena in slow/occult bleeding gastric ulcer- erosion into the left gastric aa duodenal ulcer- erosion into gastroduodenal artery medical emergency lower GI bleeding in massive upper GI bleeding (rare) rule out differentials- varices, GAVE, esophagitis, etc. 6/5/2022 adewunmi- peptic ulcer disease 19

20. Bleeding Management- Resuscitation IV access (wide bore cannula) IV fluid (crystalloids) Urethral catheter (monitor urine output) NG tube (controversial) prophylactic antibiotics IV proton-pump inhibitors- 80mg stat, then 8mg/ hr for 72hrs urgent PCV, GXM of 3-4pint, clotting profile Endoscopy 6/5/2022 adewunmi- peptic ulcer disease 20

21. Bleeding- endoscopy FORREST CLASSIFICATION Re-bleeding Type 1 Signs of a ctive bleeding 80-100% a spurting 90-100% b oozing 80-85% Type 2 Signs of recent bleeding 10-50% a Non-bleeding visible vessel 40-50% b Adherent clot on lesion 20-30% c Hematin /pigmented -covered lesion 5% Type 3 Lesion without bleeding <3% Flat spot, clean ulcer base 6/5/2022 adewunmi- peptic ulcer disease 21

22. Bleeding- endoscopy 6/5/2022 adewunmi- peptic ulcer disease 22

23. Bleeding Scoring systems Rockall scores- 0-11 Blatchford score- 0-23 AIMS65 score 6/5/2022 adewunmi- peptic ulcer disease 23

24. Bleeding- Rockall scores SCORES Variables 1 2 3 A ge <60 60-79 >80 B lood pressure Normal Pulse >100 BP > 100 Pulse >100 BP <100 C o-morbidity None CCF, IHD Renal failure, Liver failure D iagnosis on endoscopy Mallory-Weiss tear, no lesion, no SRH All other diagnosis Malignancy of the upper GI tract E ndoscopy findings None or dark spots Spurting or visible vessels, adherent clot 6/5/2022 adewunmi- peptic ulcer disease 24

25. Bleeding Endoscopic management Thermal method : contact vs non contact contact- heater probes, bipolar diathermy non contact- argon plasma coagulation, laser therapy non-thermal method mechanical clips epinephrine: 4-16mls of 1:10,000 sclerotherapy- Na tetradecyl sulphate , polidocanol , ethanolamine hemostatic sprays/powder 6/5/2022 adewunmi- peptic ulcer disease 25

26. Bleeding Re-bleeding Re-endoscopy + any above treatment Indications for surgery re-bleeding hemorrhagic shock blood transfusion of >4 pint of blood failed/absent endoscopic therapy 6/5/2022 adewunmi- peptic ulcer disease 26

27. Bleeding- Surgical option Duodenal ulcer over sew + v agotomy + drainage (V + D) vagotomy + antrectomy Gastric ulcer over sew + biopsy + V + D distal gastrectomy 6/5/2022 adewunmi- peptic ulcer disease 27

28. Surgical resection partial gastrectomy (giant ulcer >2cm) Pauchet’s proce 6/5/2022 adewunmi- peptic ulcer disease 28

29. Perforation Clinical features anterior ulcers (duodenum) and angularis incisura (gastric) chemical peritonitis (initial) bacteria peritonitis mimic appendicitis (right) or diverticulitis (left) patient usually aware of timing 6/5/2022 adewunmi- peptic ulcer disease 29

30. Perforation Management- Resuscitation IV access IV fluid Urethral catheter NG tube antibiotics- broad-spectrum IV proton-pump inhibitors (PPI)- 20-40mg stat dose urgent PCV, GXM of 1-2 pint of blood 6/5/2022 adewunmi- peptic ulcer disease 30

31. Perforation Conservative management with spontaneous closure antibiotics IV Fluid analgesics PPI NG tube 6/5/2022 adewunmi- peptic ulcer disease 31

32. Perforation Surgery- Laparotomy Gastric wedge excision + closure + V+D distal gastrectomy Duodenum Graham patch, V + D 6/5/2022 adewunmi- peptic ulcer disease 32

33. Obstruction/GOO Clinical features non-bilious vomiting stale food, but sometimes recent meal dehydration malaise generalized weakness of the body epigastric mass weight loss 6/5/2022 adewunmi- peptic ulcer disease 33

34. Obstruction/GOO Management- Resuscitation IV access (wide bore cannula) IV fluid (crystalloids) Urethral catheter (monitor urine output) NG tube + lavage of the stomach prophylactic antibiotics IV proton-pump inhibitors- 20-40mg urgent PCV, GXM, EUC 6/5/2022 adewunmi- peptic ulcer disease 34

35. Obstruction/GOO Investigations PCV/CBC EUC- ↓ Na, ↓K, ↓Cl, ↓HCO3 (paradoxical aciduria) GXM Abdominopelvic USS dilated stomach pyloric/antral mass/stenosis 6/5/2022 adewunmi- peptic ulcer disease 35

36. Obstruction/GOO Upper GI Endoscopy + biopsy antral mass/ulcer biopsy for Histopathology (tumor vs fibrosis) Barium meal absence of endoscopy dilated stomach with irregular filling defects 6/5/2022 adewunmi- peptic ulcer disease 36

37. Obstruction/GOO CT abdomen characterized the gastric mass peri-gastric & para-aortic LN enlargement liver lesion/metastasis 6/5/2022 adewunmi- peptic ulcer disease 37

38. Obstruction/GOO Treatment spontaneous resolution in pyloric spasm/edema Surgery for those with cicatrizing ulcer/malignant obstruction cicatrizing PUD- vagotomy + antrectomy , vagotomy + gastro- jejunostomy antral cancer- Gastrectomy 6/5/2022 adewunmi- peptic ulcer disease 38

39. Refractory/Intractable/non-healing ulcer Possible reasons? non compliant patient failure to take prescribed medications continuous use of NSAIDs missed cancer Gastric, pancreatic, duodenal persistent H/pylori false negative test consider empirical treatment Motility disorders Zollinger -Ellison syndrome 6/5/2022 adewunmi- peptic ulcer disease 39

40. Refractory/Intractable/non-healing ulcer Lesser operation is preferable HSV ± GJ Avoid truncal vagotomy or distal gastrectomy Type IV ulcer Pauchet procedure Kelling-Madlener proc Csendes procedure 6/5/2022 adewunmi- peptic ulcer disease 40

41. Complications of surgery Anastomosis leak Anastomosis dehiscence Surgical site infection Intra-abdominal abscess Dumping syndrome T ype 1 and Type 2 Loop obstruction/syndrome Bile duct injury Benign biliary stricture Anaemia (megaloblastic anaemia) 6/5/2022 adewunmi- peptic ulcer disease 41

42. Prognosis Good in benign aetiology Poor in malignant aetiology 6/5/2022 adewunmi- peptic ulcer disease 42

43. Summary PUD can be complicated by bleeding, perforation, obstruction, malignancy and intractability Bleeding is usually due to erosion of the gastroduodenal/left gastric aa and majority resolve spontaneously or endoscopic intervention Perforation may close spontaneously but some will require laparotomy Initial conservative approach is recommended in gastric outlet obstruction for edema/spasm to resolve and those that fail to resolve will benefit from surgery 6/5/2022 adewunmi- peptic ulcer disease 43

44. THANK YOU FOR YOUR ATTENTION 6/5/2022 adewunmi- peptic ulcer disease 44

45. References Charles F. Brunicardi: Schwartz’s principles of Surgery, 10 th edition. Chapters 25, 26 & 28 Michael J Zinner and Stanley W Ashley: Maingot’s abdominal operations, 12 th edition. Chapters 21, 22, 29 & 30 O. James Garden and Simon Peterson-Brown: Oesophagogastric surgery, a companion to specialist surgical practice, 5 th edition Chapters 3, 8, 16 & 19 6/5/2022 adewunmi- peptic ulcer disease 45