Gastric and duodenal ulcer disease

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Gastric and duodenal ulcer disease
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Ulcer disease

• ulcer is a defect of gastric or duodenal mucosa
  which interfere over lamina muscularis mucosae,
  submucosa or penetrates across whole gastric or
  duodenal wall
• rise of ulcer is conditioned by presence of acid
  gastric content
• frequent disease, men are afected 3-4x more than
  women

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• Pathogenesis
• multifactorial
• dysbalance between protective and aggressive
  factors
• Protective f. saliva, food, alcalic duodenal
  fluid, mucus - mucine, fast regeneration of
  gastric epithelial cells, well perfused gastric
  mucosa
• Aggressive f. HCl, pepsin, bile acids (reflux),
  helicobacter pylori, drugs (analgetics, aspirin,
  korticoids), nicotine, alcohol

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• Classification
• Acute ulcer (ulcus acutum)
• smooth non-elevated borders and smooth base
• major bleeding into upper GIT
• Chronic ulcer (ulcus chronicum)
• rushed and elevated boders, inflammation with
  hypertrophic and fibrotic proliferation is
  present
• the most frequent form of ulcer disease
• Ulcus chronicum mediogastricum
• Ulcus chronicum ventriculi et duodeni
• Ulcus chronicum praepyloricum
• Ulcus chronicum duodeni

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• Symptoms of gastric ulcer disease
• epigastric pain after meal or during meal
• upper dyspeptic syndrome loss of appetite,
  nauzea, vomiting, flatulence
• vomiting brings relief
• reduced nutrition
• loss of weight

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• Symptoms of duodenal ulcer disease
• epigastric pain 2 hours after meal or on a empty
  stomach or during night
• pyrosis
• good nutrition
• obstipation
• seasonal dependence (spring, autumn)

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• Complications
• Bleeding - chronic (minor, cause anaemia)
• - acute (major, form affected
  vessel)
• Perforation - mostly bulbus duodeni, anterior
  gastric wall
• - acute violent pain
• - bleeding can be present
• Penetration - of the ulcer deeply through whole
  wall into
• neighbor organ (pancreas, liver)
• Stenosis - narrow of the lumen caused by scar,
  oedema or
• inflammatory infiltration after healing of
  the ulcer
• - rise only at pyloric localization
• - vomiting of huge volume of gastric
  content

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Zeman, M. et al., Speciální chirurgie, ISBN
80-7262-260-9, 2004
A penetration B perforation C bleeding D -
stenosis
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• Therapy
• Conservative
• regular lifestyle
• prohibition of the smoking and alcohol
• diet (proteins, milk and milky products)
• pharmacology (antagonists of H2 receptors,
  antacids, anticholinergics
• Surgical
• BI, BII resection
• proximal selective vagotomy
• vagotomy with pyloroplastic
• suture of perforated or haemorrhagic ulcer

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• Stomach resections
• Billroth I (BI) gastro-duodenoanastomosis
  end-to-end
• Billroth II (BII) gastro-jejunoanastomosis
  end-to-side with blind closure of duodenum
• Proximal selective vagotomy denervation of
  parietal gastric cells

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Zeman, M. et al., Speciální chirurgie, ISBN
80-7262-260-9, 2004
Billroth I
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Zeman, M. et al., Speciální chirurgie, ISBN
80-7262-260-9, 2004
Billroth II
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Zeman, M. et al., Speciální chirurgie, ISBN
80-7262-260-9, 2004
Gastro-enteroanastomosis on Roux Y crankle
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Zeman, M. et al., Speciální chirurgie, ISBN
80-7262-260-9, 2004
Vagotomy
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• Complications after stomach resection
• Early dehiscence, stenosis of anastomosis,
  bleeding, pancreatitis, obstructive icterus,
  affection of neighbour tissues
• Late - days, weeks
• - early dumping syndrome
• - late dumping syndrome
• - incoming crankle syndrome
• - outcoming crankle syndrome
• - ulcer in anastomosis or in outcoming
  crankle

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• Early dumping syndrome
• group of symptoms approved shortly after meal
• appears after BII resection
• vasomotoric sy. - face redness, fall of blood
  pressure, dizziness
• GI sy. - vomiting, diarrhoea
• Th. diet, no sugar, low quantities of food,
  change BII to BI resection

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• Late dumping syndrome
• hypoglycaemia (sugar is not enough digested)
• appears after BII resection
• weakness, perspiration, dizziness, tremor cca 3h
  after meal
• Th. no sugar, change BII to BI resection

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• Incoming crankle syndrome
• stasis of the content at incoming crankle
  increase intraluminal pressure
• appears after BII resection
• Th. diet, change BII to BI resection

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• Outcoming crankle syndrome
• chronic or acute closure of outcoming crankle
• appears after BII resection
• vomiting after meal, convulsive pain
• Th. change BII to BI resection

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Haemorrhagic mediogastric ulcer
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Chronic gastric ulcer
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Pylorostenosis and gastrectasia
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Duodenal ulcer
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Stress ulcers
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Benign stomach tumors

• rise from all layers of stomach wall
• often asymptomatic
• Polypus, Leiomyoma, Lipoma, Fibroma,
  Neurofibroma, Neurinoma, Hemangioma, Karcinoids,
  Lymfoma
• Diagnostic endoscopy, X ray
• Therapy local excision, stomach resection

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Stomach cancer

• Symptoms
• long-time asymptomatic
• feeling of full stomach, odour from mouth,
  tiredness, anaemia, occasional vomiting, loss of
  appetite, loss of weight
• Diagnosis
• gastrofibroscopy biopsy - histology
• X-ray, USG, CT - metastasis
• Wirchows nodule enlargement of left
  supraclavicular nodule

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Stomach cancer

• Etiopathogenesis
• Praecancerosis adenomatous polypus, chronic
  atrofic gastritis, foveolar hyperplasia
  (Ménétrier disease), stub of the stomach after
  BII resection
• Division
• Macroscopic exofytic polypoid form, diskyform
  ulcerous form, diffused infiltrating form
• Histopathologic adenocarcinoma, papilar,
  tubular, gelatinous cancer, round cell cancer,
  flagstone cell cancer, etc.

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Stomach cancer
Zeman, M. et al., Speciální chirurgie, ISBN
80-7262-260-9, 2004

• Therapy
• Currative total gastrectomy, sub-total
  gastrectomy
• Paliative gastrostomy, jejunostomy

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Gastric cancer
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Gastric stub cancer after B II resection
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Schwanoma fundi vetriculi
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Than you for your attention!!!