peptic ulcer disease bernard m. jaffe, md professor of surgery emeritus
TRANSCRIPT
PEPTIC ULCER DISEASE
BERNARD M. Jaffe, MDProfessor of Surgery
Emeritus
PEPTIC ULCER DISEASE• 8% Annual Incidence in the
Population• 500,000 New Cases/Year• 4,000,000 Recurrences/Year• 130,000 Operations/Year• 9,000 Deaths/Year
PEPTIC ULCER DISEASE• Elective Admissions Declining, for
Complications Unchanging• Gastric Ulcer More Common in Elderly• Admissions for Bleeding GU Increasing• Decreasing Incidence in Males,
Increasing in Females• ? Due to Changes in Smoking
Patterns
CAUSES OF PUD• H. Pylori Infection• NSAID’s • Acid Hypersecretion• Zollinger- Ellison Syndrome• Acid Plays a Role in All Four
GASTRIC CELLS• Acid- Fundus Parietal Cells• Gastrin- Antrum G Cells• Pepsinogen- Diffuse Chief Cells• Histamine- Diffuse
Enterochromaffin-Like Cells
• Somatostatin- Diffuse D Cells
H. Pylori INFECTION• 90% Duodenal, 75% Gastric Ulcers• Nearly 100% Have Antral Gastritis• Eradication Prevents Recurrence• Strong Association with MALT
Lymphoma• Microaerophilic, Urease Producing• Can Live in Gastric Epithelium
GASTROINTESTINAL INJURY• Production of Toxic Products• Ammonia, Cytokines, Mucinases,
Phospholipases, Platelet Activating Factor
• Induction in Local Mucosal Immune Responses• Increases Gastrin → Increasing Acid
Secretion
H. Pylori INFECTION• World-Wide Pandemic• Usually Acquired in Childhood• Inverse Relationship Between Infection
Rates and Socio Economic Status• Transmission Mouth-to-Mouth• Higher Rate in Developing Countries-
Sanitation is a Real Issue
NSAID’S• Second Most Common Cause of PUD• Increased Use in Women >50 Years Old• Risk of Ulcers/Bleeding Parallels Drug
Use• 10% of Patients Taking NSAID’s
Develop Acute Ulcer• 2-4% Develop GI Complications/Year
ACID- INCREASED• Nocturnal Acid 70%Daytime Acid
50%• Duodenal Acid Load Maximal Acid
65% 40%• Gastrin Sensitivity Basal Gastrin• 35% 35%• Gastric Emptying 30% Parietal Cells 30%
GASTRIC ULCERS• Type I- Lesser Curvature Near Incisura• 60%• Low Levels of Acid• Type II- Combination Type I Plus DU• 15%• Excess Acid Secretion
GASTRIC ULCERS (2)• Type III- Pre-Pyloric• 20%• Behave Like DU’s • Excess Acid Secretion• Type IV- High on Lesser Curvature• <10%• Low Acid Secretion• <5% Greater Curvature
GASTRIC ULCER• Rare Before Age 40, Common 55-65
Years• Caused By NSAID’s• Acid, Pepsin Abnormalities• Co-Existing DU• Delayed Gastric Emptying• Duodenal-Gastric Reflux• Gastritis• H. Pylori Infection
DU PREDISPOSITION• Chronic Alcohol Intake• Smoking• Long-Term Steroid Use• Infection
SYMPTOMS• Mid-Epigastric Pain• Relieved By Pain• Spring > Fall• Relapses with Stress• Constant Pain- Deeper Penetration• Back Pain- Penetration Into Pancreas
COMPLICATIONS• Perforation• Bleeding• Obstruction• Chronicity
PERFORATION• Sudden Abdominal Pain, Fever• Tachycardia, Ileus, Dehydration• Exquisite Abdominal Tenderness,
Rebound, Rigidity• Free Air Under the Diaphragm, Can
Verify by Gastrograffin Swallow• Surgical Emergency
PERFORATION• Treat with Gramm Patch Omental Closure• Simultaneous Definitive Procedure IF• PUD with NO Symptoms • Failure to Respond to Medical Therapy• Best Definitive Procedure for Perforation-
Parietal Cell Vagotomy• Non-Operative Therapy Reserved for Late
Presentation with No Acute Abdomen
BLEEDING• Most Common Cause of PUD Death• Bleeding Accounts for 25% of All Upper
GI Bleeds• Can Present with Melena,
Hematemesis, or Bright Red Rectal Bleeding• Gastroduodenal Artery Lies Posterior
to Duodenal Bulb- “Visible Vessel”
OBSTRUCTION• Chronic Scarring Can Occlude Pylorus• Acute Inflammation Also Causes
Obstruction• Anorexia, Nausea, Vomiting• Hypochloremic, Hypokalemic Metabolic
Alkalosis, Dehydration, Malnutrition• Stomach Becomes Massivel Dilated and
Loses Muscular Tone
GASTRIC ULCER• Must Distinguish Benign From Malignant• Causes Same Complications as DU• 8-20% Need Operation for Complications• Bleeding Occurs in 35-40%• Perforation is Most Life-Threatening• Obstruction Occurs in Types I and II
ZOLLINGER-ELLISON SYNDROME• Triad- Gastric Acid Hypersecretion, Severe
PUD, Non-β Islet Cell Tumors• Gastrinomas in Head of Pancreas,
Duodenum • 50% Multiple, 65% Malignant, 25%
Associated with MEN Syndrome• Abdominal Pain, Diarrhea, Steatorrhea• Elevated Basal, Stimulated Gastrin Levels• Treatment Focuses on Tumor Resection
ELEVATED GASTRIN LEVELS• Z-E Syndrome• Antral G Cell Hyperplasia• Retained Gastric Antrum• Hypercalcemia• Gastric Outlet Obstruction• Anti-Secretory Drugs
ELEVATED GASTRIN LEVELS• Previous Ulcer Operation• Atrophic Gastritis• Pernicious Anemia• Chronic Renal Failure• H. Pylori Infection
PEPTIC ULCER DIAGNOSIS• EGD, Barium Swallow• H. Pylori Testing• Serology- ELISA 90% Sensitive• Urea Breath Test- Uses 14C
Specificity, Sensitivity >95%• Rapid Urease- Endoscopic Biopsy, Tissue
Placed in Urea, >90% Sensitive• Histology, Biopsy of Antrum- Best Test• Culture is Slow, Expensive
MEDICAL MANAGEMENT• Avoid Smoking, Caffeine, Alcohol, NSAID’s• Antacids- Large Frequent Doses Needed• H2 Receptor Antagonists- 70-80% Healing in
4 Weeks, 80-90% in 8 Weeks• Proton Pump Inhibitors- Most Complete
Acid Inhibition- Healing 85% in 4 Weeks, 90% in 8 Weeks
• Sucralfate- Aluminum Salt of Sulfated Sucrose- Protective Coating
OPERATIVE MANAGEMENT• Subtotal Gastrectomy- Highest
Complication Rate• Vagotomy and Antrectomy- Most
Efficacious• Vagotomy and Pyloroplasty- Major
Indication is Bleeding Gastritis• Parietal Cell Vagotomy- Most
Physiologic