Peptic Ulcer disease

1
Peptic Ulcer disease
2
Anatomy

• Stomach
• Regions

3
Anatomy cont.

• Stomach cont.
• Layers of walls
• Serosa
• Muscularis
• Submucosa
• Mucosa

4
Anatomy cont.

• Stomach cont.
• Glands in mucosa
• Cardiac glands
• Gastric glands
• Chief cells
• Parietal cells
• Mucous neck cells
• gastrin

5
Gastric pit
mucus neck surface cells Mucus HCO3
parietal cells (oxyntic) H secretion intrinsic
factor
Peptic cells (chief, zymogen) Pepsinogen secn
6
Functions of gastric secretions

• Digestion of proteins ( pepsinogen HCl)
• Protection of stomach ( HCO3- mucus)
• Absorption of vitamin B12 ( intrinsic factor)
• Destroy bacteria other micro-organisms
• 
  (HCl)
• 3 li per day

7
Peptic ulcer disease

• General consideration
• Peptic ulcers result from the corrosive action of
  acid gastric juice
• Ulcers may occur in oesophagus, stomach,duodenum,
  jejunum or ileum from ectopic gastric mucosa
• Can be anywhere in GI tract exposed to
  acid-pepsin gastric juice
• Other factors also contribute
• H. pylori
• Mucosal bicarbonate secretion
• Stress
• Genetics

8
GI Pathology Helicobacter pylori
9
(No Transcript)
10
Peptic ulcer disease - cont.

• Pathogenesis
• Two factors prevent stomach from digesting itself
• Gastric mucosal barrier
• First line of defense
• NSAIDS cause in changes mucosa that my facilitate
  its digestion by pepsin
• Destruction of barrier believed to be important
  factor in pathogenesis of gastric ulcers
• Results of back diffusion of H injuring
  underlying tissues
• Antrum more susceptible to back diffusion than
  fundus
• Duodenum resistant to ulceration due to Brunners
  glands which produce a highly alkaline secretion

11
Peptic ulcer disease - cont.

• Epithelial barrier
• Depends of abundant vascular supply and
  continual, rapid regeneration of epithelial cells
  (3 days)

12
Peptic ulcer disease - cont.

• Other factors
• 10-12 incidence in population
• Duodenal ulcers occur in much younger group than
  gastric 20-40 years
• Males affected 3X as often as women
• Duodenal ulcers 10X as common as gastric
• gt90 of duodenal ulcers are on anterior or
  posterior wall within 3 cm of pyloric ring
• 40-60 have family history

13
Peptic ulcer disease - cont.

• Clinical features
• Principle feature is chronic, intermittent
  epigastric pain typically relieved by food
• 25 have bleeding (more common with duodenal)
• Other signs and symptoms
• Vomiting
• Red or coffee-ground emesis
• Nausea
• Anorexia
• Weight loss
• Pain-food-relief pattern may not be typical of
  gastric ulcers food sometimes aggravates

14
Diagnostic procedures

• Barium radiologic studies
• Gastric analysis of acid secretion
• Aspirate gastric juices with nasogastric tube
• Endoscopy
• Photography
• Biopsy
• Exfoliative
• cytology

15
Differential Diagnosis

1. Gallbladder disease
2. Pancreatitis
3. Functional indegestion
4. Reflux oesphagitis

16
Peptic ulcer disease - cont.

• Medical treatment
• Primary consideration is to inhibit or buffer
  acid to relieve symptoms and promote healing
• Antacids increase pH so pepsin isnt activated
• Dietary management small frequent meals, avoid
  alcohol and caffeine
• Anticholinergics inhibit vagal stimulation
• Antimicrobial therapy
• Physical and emotional rest
• Ulcers caused by H. pylori are successfully
  treated with antimicrobial agents, bismuth salts,
  and H2 blockers
• 65-95 eradication rates

17
10 Day Regimen

1. clarithromycin 500 mg bid X 10
2. amoxicillin 1 gram bid X 10
3. omeprazole 20 mg bid X 10
4. in patients with current ulcer, continue
   omeprazole 20 mg/day for 18 days

18
kPeptic ulcer disease - cont.

• Complications
• Hemorrhage
• Most frequent complication 15-20
• Most common in ulcers of the posterior wall of
  duodenal bulb due to proximity of arteries
• Symptoms depend on severity
• Anemia
• Occult blood in stool
• Black and tarry stool
• Hematemesis
• Shock
• Mortality up to 10 - higher for patients over 50

19
Peptic ulcer disease - cont.

• Perforation
• Approximately 5 of all ulcers perforate -
  accounts for 65 of deaths from peptic ulcers
• Usually on anterior wall of duodenum or stomach
• Thought to be due to excess acid and often a
  result of NSAIDS
• Characteristic presentation
• Sudden onset of excruciating pain in upper
  abdomen chemical peritonitis
• Patient fears to move or breath
• Abdomen becomes silent to auscultation and board
  like rigidity to palpation
• Treatment immediate surgery

20
Peptic ulcer disease - cont.

• Obstruction
• Obstruction of gastric outlet in 5 of patients
• Due to inflammation and edema, pylorospasm or
  scarring
• More often with duodenal ulcers
• Symptoms
• Anorexia
• Nausea
• Bloating after eating
• Pain and vomiting when severe
• Treatment
• Restore fluids and electrolytes
• Decompress stomach with nasogastric tube
• Surgical correction - pyloroplasty

21
Peptic ulcer disease - cont.

• Intractability
• Medical therapy fails to control symptoms
  adequately, resulting in frequent, rapid
  recurrences
• Typically surgery is recommended

22
Peptic ulcer disease - cont.

• Surgical treatment for patients who do not
  respond to therapy
• For duodenal ulcers aim is to permanently reduce
  stomachs capacity to secrete acid and pepsin
• Vagotomy
• Cut vagal branches to stomach
• Eliminates cephalic phase
• Several techniques
• Antrectomy
• Removal of entire antrum
• Eliminates gastric phase
• Vagotomy plus antrectomy
• Eliminates both cephalic and gastric phases

23
Peptic ulcer disease - cont.

• Partial gastrectomy
• Removal of distal 50-75 of stomach
• Gastric remnant anastamosed to duodenum (Billroth
  I) or jejunum (Billroth II)
• For gastric ulcers
• Usually partial gastrectomy and a gastroduodenal
  anastomosis
• Normally do not do vagotomy as patients have
  normal to low acid production

24
Normal Stomach
25
Esophagus Stomach Normal
26
Gastric Ulcer
27
Peptic ulcer - Endoscopy
28
Duodenal Peptic Ulcer
29
Gastric Ulcer
30

31
GI PathologyDuodenal Peptic Ulcers, Gross
32
GI PathologyGiant gastric ulcer
33
GI Pathology Gastric Peptic Ulcer

• Gross
• Lesser curvature is the most common location in
  the stomach greatest frequency is in the first
  part of the duodenum
• Less than three centimeters in diameter
• Round to oval in shape
• Punched-out area with clean base
• Margins are usually level with surrounding mucosa
  or slightly elevated due to edema the mucosa is
  undermined at the edges

34
GI Pathology Gastric Peptic Ulcer

1. Up to 50 of those with gastric peptic ulcer have
   concurrent duodenal ulcer
2. These ulcers typically occur at mucosal junctions
   exposed to acid and pepsin (e.g., body of
   stomach/antrum)

35
GI Pathology Gastric peptic ulcer

1. Associations Chronic gastritis, Helicobacter
   pylori (50-60)
2. Peak incidence 50's
3. Location Lesser curvature, antrum

36
GI PathologyAnatomy of the stomach