Gastric and duodenal

ulcer disease
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







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


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
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
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)


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



Zeman, M. et al., Speciln chirurgie, ISBN 80-7262-260-9, 2004
A penetration B perforation
C bleeding D - stenosis
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


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

Zeman, M. et al., Speciln chirurgie, ISBN 80-7262-260-9, 2004
Billroth I
Billroth II
Zeman, M. et al., Speciln chirurgie, ISBN 80-7262-260-9, 2004
Zeman, M. et al., Speciln chirurgie, ISBN 80-7262-260-9, 2004
Gastro-enteroanastomosis on
Roux Y crankle
Zeman, M. et al., Speciln chirurgie, ISBN 80-7262-260-9, 2004
Vagotomy
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

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
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
Incoming crankle syndrome:


stasis of the content at incoming crankle increase
intraluminal pressure

appears after BII resection

Th.: diet, change BII to BI resection
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





Haemorrhagic mediogastric ulcer


Chronic gastric ulcer





Pylorostenosis and gastrectasia
Duodenal ulcer
Stress ulcers
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
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

Stomach cancer
Stomach cancer
Etiopathogenesis:

Praecancerosis: adenomatous polypus, chronic atrofic
gastritis, foveolar hyperplasia (Mntrier 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.
Therapy:

Currative total gastrectomy, sub-total gastrectomy
Paliative gastrostomy, jejunostomy
Stomach cancer
Zeman, M. et al., Speciln chirurgie, ISBN 80-7262-260-9, 2004
Gastric cancer
Gastric stub cancer after B II
resection
Schwanoma fundi vetriculi
Than you for your attention!!!