by amgad fouad professor of surgery gastroenterology center mansoura university. comllications of...
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AMGAD FOUADAMGAD FOUAD Professor Of Surgery
Gastroenterology CenterMansoura University.
COMLLICATIONS OF COMLLICATIONS OF CHRONIC PEPTIC ULCER CHRONIC PEPTIC ULCER
1.1. Perforation Perforation
- Acute - Subacute - Chronic- Acute - Subacute - Chronic
2.2. Bleeding Bleeding
- Hematemsis - Melena - Both- Hematemsis - Melena - Both
3.3. StenosisStenosis
- pyloric stenosis - Hourglass -Tea-pot- pyloric stenosis - Hourglass -Tea-pot
4.4. MalignanacyMalignanacy
ACUTE PERFORATIONACUTE PERFORATIONIncidenceIncidence
10 – 15 %10 – 15 % DU>GU 10 timesDU>GU 10 times
Etiology Etiology Ppt alcohol Ppt alcohol
Irritant foods Irritant foods nervousnessnervousness
Path Path Ant >post wallAnt >post wall
Stages : Stages : Stage of perforationStage of perforationstage of reactionstage of reactionstage of peritonitisstage of peritonitis
C/PC/P Hist : +ve in 80 %Hist : +ve in 80 % Manifestations : 3 stagesManifestations : 3 stages
1.1. STAGE OF ONSETSTAGE OF ONSET
Sudden severe agonising painSudden severe agonising pain
ShockShock
2.2. LUCID INTERVAL:LUCID INTERVAL:
3 – 6 h3 – 6 h
Patient feels & looks betterPatient feels & looks better
Tenderness & rigidity remain.Tenderness & rigidity remain.
3.3. SEPTIC PERITONITIS:SEPTIC PERITONITIS:
6 hours6 hours
Abdomen distended & silentAbdomen distended & silent
36 – 48 hours 36 – 48 hours → Toxemia→ Toxemia
INVESTIGATIONSINVESTIGATIONS Clinical Hist → DiagnosticClinical Hist → Diagnostic Doubtful CasesDoubtful Cases
Plain X ray (70 %)Plain X ray (70 %) GIT series with water-soluble contrastGIT series with water-soluble contrast
TREATMENTTREATMENT
1.1. ResuscitationResuscitation
2.2. Urgent surgical intervention (Graham patch).Urgent surgical intervention (Graham patch).
3.3. Definitive surgeryDefinitive surgery
Subacute PerforationSubacute Perforation
A small leaking ulcer allow the body to wall A small leaking ulcer allow the body to wall
off leaking material from the general cavity off leaking material from the general cavity
by omentum or by the liver with by omentum or by the liver with
development of development of Subphrenic abcessSubphrenic abcess
Chronic perforation (penetrating ulcer)Chronic perforation (penetrating ulcer)
The ulcer base penetrates a nearby organThe ulcer base penetrates a nearby organ
LiverLiver
PancreasPancreas
Transverse colonTransverse colon
BLEEDING PEPTIC ULCERBLEEDING PEPTIC ULCER
Incidence :Incidence :
65%65%
DU > GUDU > GU
Hematemsis → GUHematemsis → GU
Melena → DUMelena → DU
Pathology :Pathology :
Mild : Granulation tissue Mild : Granulation tissue
Severe: Vs at floor Severe: Vs at floor
Fatal : Penetration of large extragastric arteryFatal : Penetration of large extragastric artery
Clinical picture:Clinical picture:
Long historyLong history
Massive bleedingMassive bleeding
Hypovolemic shockHypovolemic shock
HematemsisHematemsis
MelenaMelena
Unless bleeding stops within 48 h Unless bleeding stops within 48 h →→ irreversible shock irreversible shock
Investigations:Investigations:Fiberoptic endoscopyFiberoptic endoscopy
Selective celiac angiography.Selective celiac angiography.
TREATMENTTREATMENT
Conservative:Conservative: ResuscitationResuscitation DiagnosisDiagnosis Subsequent managementSubsequent management
Surgical:Surgical: Indication:Indication:
Profuse bleedingProfuse bleedingage > 45 years.age > 45 years.Associated pathologyAssociated pathology
procedure :procedure : AimAim→→ stop bleeding stop bleeding DU DU →→ vagotomy & drainage & under – running vagotomy & drainage & under – running GU GU →→ Partial gastrectomy Partial gastrectomy
Endoscopic:Endoscopic: LaserLaser SclerotherapySclerotherapy V.C agentsV.C agents
PYLORIC STENOSIS PYLORIC STENOSIS (GASTRIC OUTLET OBSTRUCTION)(GASTRIC OUTLET OBSTRUCTION)
Pathology:Pathology:Duod bulb Duod bulb →→ Cicatrized & stenosed Cicatrized & stenosed
Stomach Stomach →→ Hypertrophied Hypertrophied →→ Dilated Dilated
Intestine Intestine →→Normal & CollapsedNormal & Collapsed
Complications:Complications:Metabolic AlkalosisMetabolic Alkalosis
Fluid & electrolyte imbalanceFluid & electrolyte imbalance
DehydrationDehydration
Antral StasisAntral Stasis
Respiratory complicationsRespiratory complications
CLINICAL PICTURECLINICAL PICTURE Long history:Long history: Symptoms:Symptoms:
DistentionDistentionPainPainVomitingVomitingLost periodicityLost periodicityProgressive constipationProgressive constipationPicture of complicationsPicture of complications
Signs:Signs: General General →→ Dehydration Dehydration
→→ TetanyTetany →→ Mental confusionMental confusion
Abdominal Abdominal →→ Epigastric fullness Epigastric fullness →→ Visible peristaltic wavesVisible peristaltic waves →→ Succussion splash Succussion splash → → Food residueFood residue
INVESTIGATIONSINVESTIGATIONS
Blood chemistryBlood chemistry
Gastric function testsGastric function tests
Ba Meal (soup dish appearance)Ba Meal (soup dish appearance)
Endoscopy.Endoscopy.
TREATMENTTREATMENT
Pre-operative preparation:Pre-operative preparation:Gastric lavageGastric lavage
IV fluidIV fluid
AbxAbx
Surgery: Surgery: The only method of cureThe only method of cure
Vagotomy & drainageVagotomy & drainage
GastrectomyGastrectomy
Thank youThank you
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