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					Introduction
               Role of surgery
• Despite advances in medical therapy to inhibit
  acid secretion and to eradicate H. pylori, surgery
  remains important in managing these patients.
  Over the last 2 decades, there has been an
  increase in emergency operations performed for
  complications of peptic ulcers while the number
  of operations for elective indications has
  decreased markedly.
• An ulcer by definition extends through the
  muscularis mucosa in contrast to an erosion,
  which is superficial to the muscularis mucosa.
     Etiologies of Duodenal ulcer
• Duodenal ulcer disease is a disease of multiple
  etiologies. The only absolute requirements are
  secretion of acid and pepsin in conjunction
  with either H. pylori infection or ingestion of
  NSAIDs.
            Etiologies of gastric ulcers
•   Most of gastric ulcers appear to
    behave more like duodenal ulcers
    and are associated with excess acid.
•   Types I and IV gastric ulcers are
    defects in mucosal protection;
•   types II and III are associated with
    acid hypersecretion and behave like
    duodenal ulcers
•   Gastric cancers ( suspicious ) may
    ulcerate and resemble gastric ulcers.
•   Furthermore, ulcers may be caused
    by nonacid or other peptic disorders
    such as Crohn’s disease, syphilis,
    Candida infection, or malignant
    diseases such as Kaposi’s sarcoma,
    lymphoma, carcinoma, or pancreatic
    carcinoma.
        Clinical Manifestations
• Young and middle-aged patients
• Pain or one of complication ( perforation ,
  bleeding , obstruction {pyloric obstruction ,
  hour glass stomach } , penetration , malignant
  transformation in gastric ulcer )
                ABDOMINAL PAIN

The most common symptom is mid-epigastric abdominal pain
  that is usually well localized. The pain is usually tolerable
  and frequently relieved by food. Moreover, the pain may be
  episodic, may be seasonal in the spring and fall, or may
  relapse during periods of emotional stress. For these
  reasons and because it is relieved, many patients do not
  seek medical attention until they have had the disease for
  many years.
When the pain becomes constant, deeper penetration of the
  ulcer, and referral of pain to the back is usually a sign of
  penetration into the pancreas.
Diffuse peritoneal irritation is usually a sign of perforation.
                     PERFORATION

• Acute Vs subacute
• Pathology : 3 Stages
• Sudden sever abdominal pain ,assosiated with neusia and vomiting
  , and variable degree of shock
• Peritonitis , frequently accompanied by fever, tachycardia,
  dehydration, and ileus .
• Abdominal examination reveals tenderness, rigidity, and rebound.
• A hallmark of perforation is the demonstration of free air
  underneath the diaphragm on an upright chest radiograph. This
  complication of duodenal ulcer disease represents a surgical
  emergency. Once the diagnosis is made, operation should be
  performed in an expeditious fashion following appropriate fluid
  resuscitation.
                   BLEEDING

• The most common cause of death in patients
  with peptic ulcer disease is bleeding in patients
  who have major medical problems or are older
  than 65 years of age.
• Because the duodenum has an abundant blood
  supply and the gastroduodenal artery lies directly
  posterior to the duodenum bulb.
• Most duodenal ulcers present with only minor
  bleeding episodes that are detected by the
  presence of Melina
                        OBSTRUCTION

• Gastric outlet obstruction manifested by delayed gastric emptying,
    anorexia, or nausea accompanied by vomiting.
• In cases of prolonged vomiting, patients may become dehydrated and
    develop a hypochloremic, hypokalemic metabolic alkalosis. Fluid
    resuscitation requires replacement of the chloride and potassium
    deficiencies in addition to nasogastric suction for relief of the obstructed
    stomach.
In addition to acute inflammation leading to functional gastric outlet
    obstruction , chronic inflammation of the duodenum may lead to
    recurrent episodes of healing followed by repair and scarring with
    ultimately fibrosis and stenosis of the duodenal lumen. In this situation,
    the obstruction is accompanied by painless vomiting of large volumes of
    gastric contents with similar metabolic abnormalities as seen in the acute
    situation. The stomach can become massively dilated in this setting, and it
    rapidly loses its muscular tone. Marked weight loss and malnutrition are
    also common in this situation.
                Gastric Ulcer

• Like duodenal ulcers, gastric ulcers are also
  characterized by recurrent episodes of
  quiescence and relapse. They also cause pain,
  bleeding, and obstruction and can perforate.
  Hemorrhage occurs but the most frequent
  complication is perforation. Most perforations
  occur along the anterior aspect of the lesser
  curvature. Similar to duodenal ulcer, gastric
  outlet obstruction can also occur.
      Zollinger-Ellison syndrome
• Zollinger-Ellison syndrome is a clinical triad
  consisting of gastric acid hypersecretion,
  severe peptic ulcer disease, and non-beta islet
  cell tumor of the pancreas. The tumors are
  known to produce gastrin and are referred to
  as gastrinomas.
                   Diagnosis
• History and physical examination
• Upper GIT endoscopy
• A serum gastrin level should also be obtained in
  patients with
ulcers that are refractory to medical therapy or
  require surgery.
• An upright chest radiograph is usually performed
  when ruling out perforation.
• H. pylori testing should also be done in all
  patients with suspected peptic ulcer disease.
    HELICOBACTER PYLORI TESTING

• Serology is the test of choice for initial
  diagnosis when endoscopy is not required.
• If, however, endoscopy is to be performed, the
  rapid urease assay or histology are both
  excellent options.
• After treatment (only if necessary) the urea
  breath test is the method of choice
               Treatment

• Medical Management with exceptions
 Surgical Procedures for Peptic Ulcer
               Disease
• VAGOTOMY
        TRUNCAL and drainage procedures
         SELECTIVE VAGOTOMY
        HIGHLY SELECTIVE VAGOTOMY
• Gastrectomy
Types of VAGOTOMY
Heineke-Mikulicz pyloroplasty Vs gastro-jejunostomy should be
 associated with truncal vagotomy or selective vagotomy but
                not highly selective vagotomy
Hemigastrectomy with Billroth 1
 (gastroduodenal) anastomosis
Hemigastrectomy with Billroth II
   GASTROJUJINOSTOMY
   LAPAROSCOPIC PROCEDURES
• Both parietal cell vagotomy and posterior
  truncal vagotomy with anterior seromyotomy
  (Taylor procedure) can be accomplished
  laparoscopically and represent effective
  antiulcer operations.
          Surgical Indications
• It salvages patients from life-threatening
  complications associated with perforation,
  hemorrhage, and gastric outlet obstruction.
    Approach to the Patient Bleeding
       from Peptic Ulcer Disease
• Approximately 80% of upper gastrointestinal bleeds are
  self-limited.
• The initial step in management is adequate initial and on
  going resuscitation.
• Following resuscitation, endoscopy is performed to assess
  the cause and severity of the bleed.
• Mortality increases with age ,the severity of the initial
  bleed is also an adverse prognostic factor, and this might
  include the presence of shock, a high transfusion
  requirement, or bright red blood in the nasogastric tube or
  in the stool. Recurrent bleeding, concomitant disease
  increased the mortality rate. Also Visible vessel was seen
  during endoscopy
• Endoscopy remains the investigation of choice for
  patients with upper gastrointestinal bleeding from
  peptic ulcer disease.
• Not only for diagnosis but also therapy.
• When the bleeding is controlled, long-term medical
  therapy includes antisecretory agents usually in the
  form of a proton-pump inhibitor plus testing for H.
  pylori, with treatment if positive.
• If H. pylori is present, documentation of eradication
  should be performed following therapy. If the bleeding
  continues or recurs, surgery may be indicated.
    Treatment of Bleeding Duodenal
                Ulcers
• For those patients who continue to bleed or who are
  referred by the endoscopist , the duodenal bleeding is
  usually controlled by opening the duodenum and
  oversewing the ulcer with a U stitch from the vessel,
  which is usually the pancreaticoduodenal artery or
  gastroduodenal artery.
• As most of these patients are elderly, have bled a
  significant amount, and have some degree of
  hypotension, the more time-consuming parietal cell
  vagotomy is usually not performed. Instead, a truncal
  vagotomy with pyloroplasty is performed.
        Bleeding Gastric Ulcers
• For bleeding gastric ulcers, a distal
  gastrectomy with Billroth I anastomosis is
  usually performed.
     Perforated Duodenal Ulcers
• Simple patching of a perforated duodenal
  ulcer followed by medical treatment is all that
  is necessary for patients who present with a
  perforated duodenum secondary to peptic
  ulcer disease. Patch closure of the duodenum
  can be performed by either a laparoscopic or
  open procedure.
        Perforated Gastric Ulcer
• For perforated gastric ulcers that occur in
  hemodynamically stable patients, distal
  gastrectomy with Billroth I reanastomosis is
  usually performed.
• However, simple patching of the gastric ulcer,
  testing for H. pylori, and treatment if positive can
  also be considered. However, the risk of
  malignancy needs to be ruled out; therefore,
  biopsy of the ulcer bed also needs to be
  performed.
       Gastric Outlet Obstruction
• The first principle is to categorize the patient as either
  acutely or chronically obstructed.
• If the patient is acutely obstructed, the patient should
  be treated nonoperatively with nasogastric
  decompression, intravenous fluid, nutritional support
  as needed, and acid suppressive therapy. H. pylori
  should be tested for and treated.
• if the patient has chronic gastric outlet obstruction
  operative therapy is usually indicated to open up the
  gastric outlet. In addition, an acid-reducing procedure
  is necessary.
              Preoperative :
Nasogastric decompression for several days.
Correction of fluid and electrolyte imbalances.
Antisecretory therapy.
Endoscopy with biopsies.
                 Operative
• Gastrectomy can be done if technically
  feasible.
• Alternatively, gastrojejunostomy with truncal
  vagotomy is also an option.
   Postoperative Complications for
        Peptic Ulcer surgery
• Early complication : bleeding , stomal
  obstruction , duodenal blow-out
• Postgastrectomy Syndromes Secondary to
  Gastric Resection( Dumping SYNDROME,
  METABOLIC DISTURBANCES,AFFERENT LOOP
 and EFFERENT LOOP SYNDROME)
• Postvagotomy Syndromes
    Postgastrectomy Syndromes
• DUMPING SYNDROME
• Dumping syndrome refers to a symptom complex
  that occurs following ingestion of a meal when a
  portion of the stomach has been removed or the
  normal pyloric sphincter mechanism has become
  disrupted.
• Dumping syndrome exists in either a late or an
  early form, with the early form occurring more
  frequently.
                      EARLY DUMPING

• The early form of dumping syndrome usually occurs within 20 to 30
  minutes following ingestion of a meal .
• The gastrointestinal symptoms include nausea and vomiting, a sense of
  epigastric fullness, eructations, cramping abdominal pain, and often
  explosive diarrhea.
• The cardiovascular symptoms include palpitations, tachycardia,
  diaphoresis, fainting, dizziness, flushing, and occasionally blurred vision.
• This occurs because gastrectomy or interruption of the pyloric sphincteric
   mechanism prevents the stomach from preparing its contents and
  delivering them to the proximal bowel in the form of small particles in
  isotonic solution. The resultant hypertonic food bolus passes into the
  small intestine, which induces a rapid shift of extracellular fluid into the
  intestinal lumen to achieve isotonicity.
• Following this shift of extracellular fluid, luminal distention occurs and
  induces the autonomic responses listed earlier.
• Dietary measures are usually sufficient to manage these patients.
                    LATE DUMPING
• Appears 2 to 3 hours after a meal.
• The basic defect in this disorder is also rapid gastric emptying.
  When carbohydrates are delivered to the small intestine, they are
  quickly absorbed, resulting in hyperglycemia that triggers the
  release of large amounts of insulin to control the rising blood sugar.
  This results in an actual “overshooting” such that a profound
  hypoglycemia occurs in response to the insulin. This activates the
  adrenal gland to release catecholamines, which results in
  diaphoresis, tremulousness, lightheadedness, tachycardia, and
  confusion.
• The symptom complex is indistinguishable from insulin or
  hypoglycemic symptom .
• These patients should be advised to ingest frequent small meals
  and to reduce their carbohydrate intake.
      METABOLIC DISTURBANCES
• Anemia:
• Iron deficiency anemia a combination of decreased iron
  intake, impaired iron absorption, and chronic subclinical
  blood loss secondary to the hyperemic, friable gastric
  mucosa primarily involving the margins of the stoma where
  the stomach connects to the small intestine. In general, the
  addition of iron supplements to the patient’s diet corrects
  this metabolic problem.
• Megaloblastic anemia:Vitamin B12 deficiency occurs
  secondary to poor absorption ,due to lack of intrinsic factor
  secretion . The patient should be treated with
  intramuscular injections of cyanocobalamin every 3 to 4
  months indefinitely.
     METABOLIC DISTURBANCES
• Impaired absorption of fat. On occasion,
  steatorrhea may be seen after gastrectomy and
  Billroth II reconstruction as a result of inadequate
  mixing of bile salts and pancreatic lipase with
  ingested fat because of the duodenal bypass.
• Deficiency in fat-soluble vitamins may also occur.
   In the setting of steatorrhea, pancreatic
  replacement enzymes are often effective in
  decreasing fat loss.
    METABOLIC DISTURBANCES
• Both osteoporosis and osteomalacia have also
  been observed following gastric resection and
  appear to be caused by deficiencies in
  calcium.
        AFFERENT LOOP SYNDROME
•   Usually occurs when the afferent limb is
    longer than 30 to 40 cm and has been
    anastomosed to the gastric remnant in an
    antecolic fashion.
•   Following obstruction of the afferent limb,
    there is an accumulation of pancreatic and
    hepatobiliary secretion within the limb,
    resulting in its distention.
•   Pancreatic and hepatobiliary secretion occur
    in response to ingestion of food,
    accumulation of these secretions results in
    distention, which causes epigastric
    discomfort and cramping. In the setting of
    partial obstruction, the intraluminal pressure
    increases to forcefully empty its contents
    into the stomach, resulting in bilious
    vomiting that is often projectile but offers
    immediate relief of symptoms. There is no
    food contained within the vomitus.
•   If the obstruction has been present for a long
    period, it can also be aggravated by the
    development of the blind loop syndrome.
•   For both forms of afferent loop syndrome,
    acute and chronic, operation is indicated
    because it is a mechanical problem, not a
    functional problem.
  EFFERENT LOOP OBSTRUCTION
• The most common cause of efferent loop
  obstruction is herniation of the limb behind
  the anastomosis in a right-to-left fashion.
• Operative intervention is almost always
  necessary and consists of reducing the
  retroanastomotic hernia and closing the
  retroanastomotic space to prevent recurrence
  of this condition.
     POSTVAGOTOMY DIARRHEA
• Approximately 30% or more of patients suffer from
  diarrhea after gastric surgery. For most patients, it is
  not severe and usually disappears within the first 3 to 4
  months. For some patients, the diarrhea is part of the
  dumping syndrome. However, vagotomy is also
  associated with alterations in stool frequency
• Most patients with postvagotomy diarrhea have their
  symptoms resolve over time. In those patients who fail
  to resolve their symptoms, cholestyramine, an anionic
  exchange resin that absorbs bile salts and renders
  them unabsorbable and inactive, can significantly
  diminish the severity of diarrhea.
               STRESS GASTRITIS
• Stress gastritis has been referred to as stress ulcerations,
  stress erosive gastritis, and hemorrhagic gastritis.
• These lesions may lead to life-threatening gastric bleeding
  and by definition occur after physical trauma, shock, sepsis,
  hemorrhage, respiratory failure, or severe burns.
• They are characterized by multiple, superficial (non
  ulcerating) erosions that begin in the proximal or acid-
  secreting portion of the stomach and progress distally.
• They may also occur in the setting of central nervous
  system disease such as that seen with a Cushing ulcer or as
  a result of thermal burn injury involving more than 30% of
  the body surface area (Curling ulcer).
           Gastric Adenocarcinoma
• H pylori infection increases the risk of gastric cancer
• Morphologic types: ulcerating (15%), polypoid (25%), superficial
   spreading (15%), linitis plastica (10%), advanced (35%)
• Symptoms and signs include postprandial abdominal heaviness; early
   anorexia, with weight loss; vomiting, often with blood, if pyloric
   obstruction occurs; epigastric mass in 25%; hepatomegaly in 10%;
   stool positive for occult blood in 50% but melena in a few cases
• Signs of distant spread: metastases to the neck (Virchow node) or
   umbilicus (Sister Mary Joseph node), metastases anterior to rectum
   detectable on rectal examination (Blumer shelf), metastases to
   ovaries (Krukenberg tumors)
• Laboratory findings: carcinoembryonic antigen is elevated in 65%;
higher levels indicate extensive spread of tumor
•   Endoscopy usually identifies gastric carcinomas .
Treatment
              Haematemesis
• GI bleeding is any blood loss from the GI tract
  (from the mouth to the anus), which may
  present with haematemesis, melaena, rectal
  bleeding or anaemia.
• Haematemesis is defined as vomiting blood
  and is usually caused by upper GI disease.
• Melaena is the passage PR of a black treacle-
  like stool that contains altered blood, usually
  as a result of proximal bowel bleeding.
              Haematemesis
• Haematemesis is usually caused by lesions
   proximal to the duodenojejunal junction.
upper GI lesions can cause frank PR bleeding if
   sever
• Most tumours more commonly cause anaemia
   than frank haematemesis.
 In young adults, peptic ulcer disease (PUD)and
   varices are the common causes.
 In the elderly, tumours, PUD and angiodysplasia
   are the common causes.
                Gastric causes
• Erosive gastritis: may follow alcohol or NSAID
  intake/stress, history of dyspeptic symptoms.
• Gastric ulcer: possible herald smaller bleeds,
  accompanied by altered blood (‘coffee grounds’),
  history of PUD.
• Gastric cancer: anaemia commoner, associated
  weight loss, anorexia, dyspeptic symptoms.
• Gastric leiomyoma (rare):
• Dieulafoy’s disease (rare): younger patients, large
  bleed.
            Duodenal causes
• Duodenal ulcer: past history of duodenal ulcer,
  symptoms of back pain, hunger pains, NSAID
  use.
• Aortoduodenal fistula (rare): usually infected
  graft post AAA repair, massive haematemesis
  and PR bleed, usually fatal.
Cancer ampula of Vater
             Esophageal causes
• Bleeding varices: sudden onset, painless, large volumes,
   dark red blood, history of (alcoholic) liver disease,
   physical findings of portal hypertension.
• Reflux oesophagitis: associated with regurgitation.
• Oesophageal carcinoma (rare): scanty, blood-stained
   debris, rarely significant volume, associated with
   weight loss, anergia,dysphagia.
• Trauma during vomiting (Mallory–Weiss syndrome):
   bright red bloody vomit usually preceded by several
   normal but forceful vomiting episodes.
General (systemic causes)
                MANAGEMENT
• Resuscitation
• Minor bleed: observation, scheduled OGD ,monitor
  haemoglobin .
• Major bleed: Continued resuscitation, urgent OGD
• Varices:Endoscopic therapy, Sengstaken tube.,Surgery
• Peptic ulcer: Endoscopic therapy or surgery
• I.V. PPI treatment, correction of coagulation profile ,
  protect aganest hepatic coma if LCF is present
• Early feeding