ByBy

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