ulcerative disease of the stomach and duodenum
TRANSCRIPT
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PEPTIC ULCER
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AGGRESSIVE FACTORS
• hydrochloric acid
• pepsin
• reverse diffusion of ions of hydrogen
• products of lipid hyperoxidation
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DEFENSE FACTORS
• mucus and alkaline components of gastric juice
• property of epithelium of mucous tunic to permanent renewal
• local blood flow of mucous tunic and submucous membrane
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PATHOMORPHOLOGY
• Erosion
• acute ulcers • chronic ulcers
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CLASSIFICATION by Johnson (1965)
• I – ulcers of small curvature (for 3 cm higher from a goalkeeper);
• II– double localization of ulcers simultaneously in a stomach and duodenum;
• III – ulcers of goalkeeper part of stomach (not farther as 3 cm from a goalkeeper)
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CLINICAL MANAGEMENT
• Pain
• Vomiting
• Heartburn
• Belching
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COMPLICATIONS
• Penetration
• Stenosis
• Perforation
• Bleeding
• Malignization
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DIAGNOSIS PROGRAM• 1. Anamnesis and physical examination. • 2. Endoscopy. • 3. X-Ray examination of stomach. • 4. Examination of gastric secretion by the
method of aspiration of gastric contents. • 5. Gastric pH metry. • 6. Multiposition biopsy of edges of ulcer and
mucous tunic of stomach. • 7. Gastric Dopplerography. • 8. Sonography of abdominal cavity organs. • 9. General and biochemical blood analysis. • 10. Coagulogram.
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X-Ray examination THE DIRECT SIGNS: • symptom of “Haudek's niche” • ulcerous billow and convergence of folds of mucous
tunic.
INDIRECT SIGNS: • symptom of “forefinger” (circular spasm of muscles) • segmental hyperperistalsis, • pylorospasm, • delay of evacuation from a stomach• duodenogastric reflux • disturbance of function of cardial part
(gastroesophageal reflux).
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SYMPTOM OF
“Haudek's niche”
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STENOSIS
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GASTROSCOPY
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DEVICE FOR GASTRIC DOPPLEROGRAPHY
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Endoscopic picture of the normal stomach wall
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Endoscopic picture of the peptic ulcer
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CONSERVATIVE THERAPY
a) Omeprazole 20 mg 2 time per day or Н2- blocker histamine receptor (ranitidine) — 150 mg in the evening, famotidine — 40 mg at night, roxatidine — 150 mg in the evening
b) antiacid drugs — in accordance with the results of pH-metry;
c) reparative drugs (dalargin, solcoseryl, actovegin) — for 2 ml 1–2 times per days
d) antimicrobial drugs (clarytromicine 500 mg twice daily, de-nol, metronidazole)
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SURGICAL TREATMEN
a) at the relapse of ulcer after the course of conservative therapy;
b) in the cases when the relapses arise during supporting antiulcer therapy;
c) when an ulcer does not heal over during 1,5–2 months of intensive treatment, especially in families with “ulcerous anamnesis”;
d) ulcer with complications (perforation or bleeding);
e) at suspicion on malignization ulcers, in case of negative cytological analysis.
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Billroth I and Billroth II resection
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Billroth II resection
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Billroth I resection:
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DUODENAL ULCER
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CLASSIFICATION
I. By etiology: А. True duodenal ulcer. B. Symptomatic ulcers.
II. By passing of disease: 1. Acute (first exposed ulcer). 2. Chronic:
a) with the rare exacerbation; b) with the annual exacerbation; c) with the frequent exacerbation (2
times per a year and more frequent).
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CLASSIFICATION
III. By the stages of disease:
1. Exacerbation.
2. Scarring:
a) stage of “red” scar;
b) stage of “white” scar.
3. Remission.
IV. By localization:
1. Ulcers of bulb of duodenum.
2. Low postbulbar ulcers.
3. Combined ulcers of duodenum and stomach.
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CLASSIFICATION V. By sizes:
1. Small ulcers up to 0,5 cm. 2. Middle — up 1,5 cm. 3. Large — up to 3 cm; 4. Giant ulcers over 3 cm.
VI. By the presence of complications: 1. Bleeding. 2. Perforation. 3. Penetration. 4. Organic stenosis. 5. Periduodenitis.6. Malignization.
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CLINICAL MANAGEMENT
• Pain
• Vomiting
• Heartburn
• Belching
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DUODENOSCOPY
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SYMPTOM OF “Haudek's niche”
STENOSIS
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DIAGNOSIS PROGRAM• 1. Anamnesis and physical examination.
• 2. Endoscopy.
• 3. X-Ray examination of stomach and duodenum.
• 4. General and biochemical blood analysis.
• 5. Coagulogram.
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CONSERVATIVE THERAPY
a) Omeprazole 20 mg 2 time per day or Н2- blocker histamine receptor (ranitidine) — 150 mg in the evening, famotidine — 40 mg at night, roxatidine — 150 mg in the evening
b) antiacid drugs — (almagel, maalox or gaviscon —1 dessert-spoon in a 1 hour after food intake);
c) reparative drugs (dalargin, solcoseryl, actovegin) — for 2 ml 1–2 times per days
d) antimicrobial drugs (clarytromicine 500 mg twice daily, de-nol, metronidazole)
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INDICATIONS TO THE ELECTIVE OPERATION
• 1. Passing of duodenal ulcer with the frequent relapses which could not treated conservatively.
• 2. Repeated ulcerous bleeding.
• 3. Stenosis of outcome part of stomach.
• 4. Chronic penetration ulcers with the pain syndrome.
• 5. Suspicion for malignization ulcers.
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METHODS OF SURGICAL TREATMENT
• organ-saving operations;
• organ-sparing operations;
• resection.
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TRUNK VAGOTOMY (TrV)
2 4
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3
SELECTIVE VAGOTOMY (SV)
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SELECTIVE PROXIMAL VAGOTOMY (SPV)
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SELECTIVE PROXIMAL VAGOTOMY (SPV)
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Heineke-Mikulicz
pyloroplasty
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Heineke-Mikulicz pyloroplasty
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GASTRODUODENOSTOMY BY JABOULAY
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Finney pyloroplasty
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ULCEROUS STENOSIS CLASSIFICATION
A
I — compensated;
II — subcompensated;
III — decompensated.
B
I — stenosis of goalkeeper;
II — stenosis of bulb of duodenum;
III — postbulbar duodenal stenosis.
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DIAGNOSIS PROGRAM• 1. Complaints of patient and anamnesis of
disease. • 3. Sounding of stomach and examination of
gastric content. • 4. Fibergastroduodenoscopy, biopsy. • 5. Intragastric рН-metry. • 6. Study of motility of stomach. • 7. Roentgenologic examination of stomach and
duodenum (structural features, passage). • 8. Sonography.
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ULCER STENOSIS
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PERFORATED GASTRODUODENAL ULCERS CLASSIFICATION
1. After etiology:• ulcerous;• unulcerous.2. After localization:• gastric (small curvature, cardial, antral,
prepyloric, pyloric) ulcer, front and back walls;• ulcers of duodenum (front and back walls).3. After passing:• perforated in an abdominal cavity;• covered perforations;• atypical perforations.
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DIAGNOSIS PROGRAM• 1. Anamnesis and physical examination. • 2. Global analysis of blood and urine, biochemical
blood test, • coagulogram.• 3. X-Ray examination of abdominal cavity organs
for presence of free gas (pneumoperitoneum). • 4. Pneumogastrography, contrasting
pneumogastrography.• 5. Fiber-gastroduodenoscopy. • 6. Sonography of abdominal cavity organs.
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Perforated ulcer (pneumoperitoneum)
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Bleeding gastroduodenal ulcers CLASSIFICATION
• I degree is easy — observed at the loss to 20 % volume of circulatory blood (at a patient with weight of body 70 kg it is up to 1000 ml);
• II degree — middle weight is loss from 20 to 30 % volume of circulatory blood (1000–1500 ml);
• The III degree is heavy — is observed at loss of blood more than 30 % volume of circulatory blood (1500–2500 ml).
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DIAGNOSIS PROGRAM• Anamnesis and physical examination.
• Finger examination of rectum.
• Gastroduodenoscopy.
• Global analysis of blood.
• Coagulogram.
• 7. Biochemical blood test.
• X-Ray examination of gastrointestinal tract.
• Electrocardiography.
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ENDOSCOPY stopped bleeding