Peptic Ulcer Disease

Dr. Aayush
Lamichhane
MBBS (KU)
Arterial Supply of Stomach
Veins of Stomach, Duodenum, Spleen and Pancreas
Past Questions:
1) Definition
2) Aetiology
3) Clinical Features
4) Management
5) Complications
6) Mx of Complications
 INTRODUCTION
Peptic Ulcer is defined as disruption of the
mucosal integrity of stomach and/or
duodenum leading to a local defect or
excavation due to active inflammation.
PATHOPHYSIOLOGY
H. pylori Mechanisms:
 TYPES
GASTRIC PEPTIC ULCER
DUODENAL PEPTIC ULCER
CLINICAL PRESENTATION
 DIAGNOSTIC TEST
Endoscopic procedure: most sensitive and specific
Visualizes mucosa and ulcer crater
Useful for documentation of mucosal defects
Ability to take tissue biopsy ( histology, culture, Rapid urease test )
Test for H. pylori
Upper gastrointestinal series (UGI)
Barium swallow
X-ray that visualizes structures of the upper GI tract
Urea Breath Testing: non-invasive
Used to detect H.pylori
Patient drinks a carbon-enriched urea solution
Exhaled carbon dioxide is then measured.
~ Others:
* Serology
* Stool Antigen test
In all patients with “Alarming symptoms”
endoscopy is required.

Dysphagia.
Weight loss.
Vomiting.
Anorexia.
Hematemesis or Malena or Heme positive stool (GI
bleeding)
Iron deficiency Anemia
Epigastric mass
Suspicious Barium meal
Persisting upper abdominal pain, radiating to the back
Severe, spreading, upper abdominal pain
 MANAGEMENT
LIFE STYLE MODIFICATION
Gastric acid secretion inhibitors Drug Therapy
H. pylori Eradication Therapy
SURGERY
Life Style
Modification:
Indications of H. pylori Eradication:
Peptic Ulcer
H. pylori positive dyspepsia
MALToma
Family history of Gastric Carcinoma
Long term use of NSAIDs
Indications:
Failure of medical treatment (Chronic non healing ulcer)
Recurrent ulcers
Development of complications (Perforation, hemorrhage)
Surgery for Duodenal Ulcers:
Principle:
Excluding the damaging effects of Acid from duodenum by:
Diversion of Acid away from duodenum, or
Reducing the secretory potential of stomach, or
Both

Types of Surgeries:
Billroth II Gastrectomy
Gastrojejunostomy (Gastroenterostomy)
Truncal vagotomy
Highly selective vagotomy
Trucal vagotomy and Antrectomy
 Billroth II Gastrectomy
The lower portion of the stomach is removed and the remainder is
anastomosed to the jejunum.
 GASTROENTEROSTOMY
(Gastrojejunostomy)
Creates a passage between the body of stomach to small intestines.

Allows regurgitation of alkaline duodenal contents into the stomach.

Keeps acid away from ulcerated area.
VAGOTOM Cuts vagus nerve
Y Eliminates acid secretion stimulus
 PYLOROPLASTY
– Widens the pylorus to guarantee stomach emptying even without vagus nerve stimulation
Surgery for Gastric Ulcers:
Principle:
In contrast to Duodenal ulcer surgeries,when the principle objective was
to reduce duodenal acid exposure,
In Gastric ulceration the diseased tissue is usually removed as well.
Advantage : Malignancy can be confidently excluded.
Types of Surgeries:
Billroth I Gastrectomy
 Billroth I Gastrectomy
Distal portion of the stomach is removed and the remainder is
anastomosed to the duodenum.
Sequelae of Peptic Ulcer Surgery:
Recurrent Ulceration:
Small Stomach Syndrome
Bile vomiting
Dumping Syndrome (Early and Late)
Post-vagotomy Diarrhea
Malignant Transformation
Nutritional Consequences
Gallstones
 Complications of Peptic Ulcers
Hemorrhage
Blood vessels damaged as ulcer erodes into the muscles of stomach or duodenal wall
Coffee ground vomitus or occult blood in tarry stools
Perforation
An ulcer can erode through the entire wall
Bacteria and partially digested food spill into
peritoneum=peritonitis
Narrowing and obstruction (pyloric)
Swelling and scarring can cause obstruction of food leaving stomach=repeated vomiting
Malignant transformation : rare
Pancreatitis : due to posterior penetration of ulcer
Others :
Hour glass contracture

Tea pot deformity (Hand bag stomach)