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,Click to edit Master title style,Click to edit Master text styles,Second Level,Third Level,Fourth Level,Fifth Level,Diseases of the Stomach and Duodenum,Dept. of Gastrointestinal Surgery,First Affiliated Hospital,Sun Yat-sen University,Surgical treatment,for,peptic ulcer,“If there is no acid,peptic ulceration cannot occur.”,In fact, peptic ulcers may occur anywhere where pepsin and acid occur together .,They may occur in the esophagus, the duodenum, the stomach itself, the jejunum after surgical construction of a gastrojejunostomy, or in the Meckels diverticulum .,Peptic Ulcer Disease,Duodenal ulcer(DU),Gastric ulcer(GU),The causes, Clinical features, and prognosis of DU and GU are different.,DU and GU,Etiology,1.gastric acid,Nerval and humoral secretion,2.gastric mucosal defences,mucosal barrier prevent antidromic diffuse,3.Helicobactor Pylori infection,impair mucosal defences,PU is caused by an imbalance between secretion of acid and pepsin, and breakdown of mucosal defence.,An acid environment and reduced mucosal defences provide ideal circumstances for pepsin to cause mucosal ulceration.,Etiology and Pathogenesis,DU,1.,Overstress or overexcitment of vagus nerve,2.,Increased number of parietal cells,3.,Too quick gastric emptying,GU,1.,Gastric retention,2.,Reflux of duodenal juice,3.,Abnormity of parietal cells,Etiology and Pathogenesis,Over-excitement of vagus nerve-,DU,Breakdown of mucosal defences-,GU,Helicobactor Pylori infection-,Both,Incidence,M,F：,Men are affected 3 times as often as women.,DU,GU：,DU is 10 times more common than GU in the young pts.,But in the older age groups the frequency is about equal.,In general terms, the ulcerative process can lead to 4 types of disability:,Pain: most common,Bleeding,Perforation,Obstruction,Chief cell-pepsinogen,Cardiac gland area,mucous secreting cell,Parietal cell-acid,oxyntic gland area,parietal & chief cell,pyloric gland area,G cell,Crows-foot,Latarjet N,90% afferent,10% efferent,Duodenal Ulcer,Duodenal Ulcer,Occurrence,A common disease,10% of the adult population in USA,Incidence ,since 1955,Complications,remain high,DU,Men:Women =,3:1,DU : GU =,10 :1,(young) =,1 :1,(old),DU,Any age group,Most common in 20 -45 years old95% within 2cm from the pylorus5% post-bulbar ulcer,DU,Physiological Abnormalities,numbers of parietal and chief cell,parietal cell sensitivity to gastrin,gastrin response to meal,gastric emptying,inhibition of gastrin release to acid,DU,Clinical Findings,Morning,Noon,Afternoon,Evening,2Am,Symptoms,Epigastric Pain,Aching,Burning,Gnawing,Daily Cycle of Pain,Some : no GI complains,DU,Food, milk,or antacid - temporary relief,Back pain,Penetrating ulcer,Nausea,Vomiting，belching,Tendeness,localized,epigastric,Many,no tenderness,DU,Laboratory Findings,1) Test for occult blood,2) Gastric analysis,3) Serum gastrin,Interpretation of the results of gastric analysis,Normal,DU,ZES,BAO mM/hr 5.5 15,MAO mM/hr 40 40,DU,Serum Gastrin,Performed if ZES suspected,Readily available,Normal basal levels:,50-100 pg/ml,(Conventional PU),Abnormal 200 pg/ml,1) ZES 2) Retained antrum after BII op.,DU,Barium meal (upper GI series),Direct sign:,Crater,Indirect sign:,Duodenal deformity,X-ray:,90% reliable,DU,DU,stomach,Duodenal bulb,pylorus,DU,Duodenal bulb,stomach,pylorus,Thickened folds,DU,Ulcer crater(niche),DU,Gastroduodenoscopy:,Useful,Essentials of Diagnosis,Epigastric pain relieved by food or antacids,Epigastric tenderness,Normal or increased gastric acid secretion,Signs of ulcer disease on upper GI x-rays or endoscopy,Surgical Treatment for DU,Medical treatment: in most patients,Surgical intervention: 10% DUs,Indications for op.,1) massive or recurrent,bleeding,2) perforation,3) pyloric obstruction,4) intractable ulcer,DU,With improving medical management,intractability as an indication,for surgical intervention has markedly diminished and now accounts for only,less than 5% of patients who undergo all types of ulcer operations,Intractable ulcer,prolonged, severe symptoms,inadequately relieved by medicine,loss of sleep, work and income,penetrating ulcer,Callous ulcer,post-bulbar ulcer,combined ulcer(DU+GU),DU,Operations for DU,Aims:,to decrease acid,with ulcer excision,and a drainage procedure,DU,Operations,1) Gastrectomy,(1) Partial (PG),(G. resection) (2) Subtotal (STG),(3) Total (TG),2) Vagotomy,(1) Truncal (TV),(2) Selective (SV),(3) Highly Selective (HSV),3) Drainage,(1) Pyloroplasty (PP),(2) Gastrojejunostomy (GJ),DU,1),Subtotal gastrectomy,2) Vagotomy & drainage,3) Vagotomy & antrectomy,4) Parietal cell vagotomy,5) Gastrojejunostomy,DU,1. Subtotal Gastrectomy,1st successful gastric resection , 1881,Theodor Billroth,from Vienna,Popular in China for PU,DU,1. Subtotal Gastrectomy,DU,1. Subtotal Gastrectomy,DU,1. Subtotal Gastrectomy,DU,gastric ramnant,efferent loop,duodenal stump,afferent loop,1. Subtotal Gastrectomy,DU,Antecolic anastomosis,retrocolic anastomosis,Mechanism of gastrectomy,1) removing the gastrin-secreting antrum,2) removing majority of the body,3) excluding the ulcer-bearing area,4) resection of ulcer itself(excision),5) alkalinating effect,DU,1) Subtotal gastrectomy,2) Vagotomy & drainage,3) Vagotomy & antrectomy,4) Parietal cell vagotomy,5) Gastrojejunostomy,DU,2.Vagotomy and drainage,Vagotomy,1) Truncal vagotomy,2) Selective vagotomy,Drainage procedure,1) Pyloroplasty,(USA),2) Gastrojejunostomy,(UK),DU,DU,2) Vagotomy,& drainage,DU,DU,pyloroplasty,Heinecke-Mikulicz pyloroplasty,Finney pyloroplasty,Excision pyloroplasty,Posterior gastroenterostomy,Anterior juxtapyloric gastroenterostomy,Pyloric dilation by gastrotomy,DU,1) Subtotal gastrectomy,2) Vagotomy & drainage,3) Vagotomy & antrectomy,4) Parietal cell vagotomy5) Gastrojejunostomy,3) Vagotomy & antrectomy,DU,3) Vagotomy & antrectomy,objective:,incidence of recurrence,rate of recurrence,lowest,other complication,more,DU,1) Subtotal gastrectomy,2) Vagotomy & drainage,3) Vagotomy & antrectomy,4) Parietal cell vagotomy,5) Gastrojejunostomy,4.Parietal cell vagotomy (PCV),Proximal gastric vagotomy (PGV),Highly-selective vagotomy (HSV),Super-selective vagotomy (SSV),First PGV by Johston, 1969,Gastric emptying: not influenced,Drainage procedure: unnecessary,DU,4. Parietal cell vagotomy (PCV),a low incidence of post-op.,symptoms,a higher ulcer recurrence rate,a time-consuming and technically,difficult op.,skill and experience of,the surgeon,DU,5. Gastroenterostomy,(Gastrojejunostomy,First op. for PU,Widely used :,1890s-1920s,Gradully discarded since then,DU,Gastric Ulcer,Gastric Ulcer,Peak incidence:,aged 4050 years,95%,on the lesser curvature,60%, 2cm,GU,GU,GU,GCa,Gastroscopy and Biopsy,Performed routinely,A rolled-up margin:,malignant ulcer,A flat edge:,benign ulcer,Multiple biopsy,brush biopsy,(obtained from the edge of ulcer),False (+):,rare,False (-):,510%,GU,GU,Differential diagnosis,1) Uncomplicated hiatal hernia,2) Atrophic gastritis,3) Chronic cholecystitis,4) Irritable colon syndrome,5) Carcinoma of the stomach,confusion by nonspecific complaints,history alone: impossible for diagnosis,distinguishable or not: only after X-ray,GU,Emphases,exclusion of gastric cancer,misdiagnosis,between GU and Gca,sometimes,GU,X-ray,Gastroscopy,Biopsy,to rule out malignancy,Even,1) results considered,though,2) ulcer is judged to be benign,4% will prove to be malignant,GU,Bleeding,Obstuction,Perforation,Malignant change,Complications,GU,Treatment,dominated by op.,Reasons for treatment dominated by op.,1) difficult to cure medically,2) recur frequently,cause more severe symptoms than DU,Recurrence rate:,first 2 years 40%,first year 70%,3) If the ulcer fails to heal,difficult to differentiate from cancer.,4) Gastrectomy cures GU efficiently,GU,Surgical Treatment,for GU,1) 4050% partial gastrectomy,Billroth I,reconstruction,90% satisfactory,Mortality 10%,GU,2) Vagotomy plus py,loroplasty,in a critically ill,bleeding ulcer,in elderly,pts.,GU,3) Treatment as outlined in the section,on DU,1. The gastric ulcers,near the pylorus,2. The ulcers also associated,with hypersecrection,3. X-ray changes similar to DU,GU,Complications of Peptic Ulcer,Complications of Peptic Ulcer,1.,Perforated ulcer,2.,Obstruction,3.,Bleeding,(,Heamarrhage),4.,Malignant change,0%,DU,1%,GU,Long history,Not malignant,?,Perforated Peptic Ulcer,Occurrence,common abdominal emergency,acute appendicitis,perforated ulcer,intestinal obstruction,acute biliary infection,Perforation:,10% of all peptic ulcers,90%,in DU,90%,in males,esp. 2550 y,common sites:,anterior DU,GU on the lesser curverture,gastric Ca,occasionally,Pathophysiology of Perforated Peptic Ulcer,perforation,chemical peritonitis,culture(-),over 68 hr,bacterial peritonitis,Severe illness,occurrence of death,(mortality) high,the interval,-important,between perforation (,sudden onset,),and surgical closure,Most remember,the accurate time,In some cases,perforation,closed spontaneously,process,self-limited,subphrenic abscess,develop in many,Omentum cover the perforation,Clinical Findings,A previous history,Recent exacerbation,90%,(+),forgotten by pts. in agony,10%,(-),Perforated ulcer,Severe abdominal pain,sudden onset, extreme severity,aggravated by movement,rigidly still,subphrenic irritation,(radiation of the pain),Nausea,Vomiting,Haematemesis,呕血,and melaena,黑便,Perforated ulcer,Physical Examination (1),Agonizing complexion,Cold extremities,Sweating,Rapid shallow respiration,In the early hours,shock (,),Perforated ulcer,Physical Examination (2),Abdomen :,rigid,(boardlike abdominal rigidity),Tenderness,Rebound tenderness,Bowel sounds:,reduced or absent,Liver dullness,diminished (1/2),Rectal examination:,pelvic tenderness,Paracentesis,穿刺,:,food particles,Perforated ulcer,In the delayed case,(, 12 hours),toxemia,hypovolemic shock,Perforated ulcer,Abd. X-ray exam.,(with the patient erect),85% of patient:,pneumoperitoneum,Perforated ulcer,Perforated ulcer,pneumoperitoneum,Free air under the diaphragm,Differential diagnosis,Acute appendicitis,Acute pancreatitis,Acute cholecystitis,Intestinal obstruction,Perforated ulcer,Acute appendicitis,Absence of previous PU history,Pain and tenderness in RLQ,Pneumoperitoneum (-),Perforated ulcer,Acute pancreatitis,More gradual onset,High serum amylase,Pneumoperitoneum (-),Perforated ulcer,Acute cholecystitis,More gradual onset,Pneumoperitoneum (-),pain and tendeness in RUQ,Murphy sign (+),An enlarged tender gallbladder (30%),Mild jaundice (10%),Perforated ulcer,Intestinal Obstruction,More gradual onset, Less severe pain,Crampy pain with,Vomiting,Obstipation(gas, feces),Abdominal distention,X-ray: dilated bowel loops,air-fluid levels,in a ladder-like pattern,Perforated ulcer,Treatment for perforation of PU,First step,Nasogastric sunction,Empty the stomach,to reduce further contamination,Blood for laboratory studies,Intravenous infusion,containing antibiotic,Perforated ulcer,If overall condition,precarious (,vital signs unstable,),Fluid resuscitation,Diagnostic measures,X-ray,as soon as possible,Perforated ulcer,Emergency Operation,:,Simple; radical,The simple,Surgical,Treatment,Laparotomy and,suture closure,Closing and butressing the ulcer perforation with a pedicle of omentum,Perforated ulcer,Laparotomy and suture closure,Solves the immediate problem,Live-saving op.,No definitive effect on the ulcer disease,Helicobacter pylori eradication,postoperatively,helpful,Perforated ulcer,Indications,1.,Major underlying medical illness,2,.Perforation lasting more than 12 hours,3.,Severe peritoneal inflammation and stomach swelling,Perforated ulcer,About 3/4 of patients,continue to have clinically,severe ulcer disease,after simple closure,A more aggressive treatment,is recommended,(gastrectomy in China),Perforated ulcer,Other operations,Vagotomy and pyloroplasty,Vagotomy and antrectomy,Proximal gastric vagotomy,Perforated ulcer,Nonoperative (conservative) treatment,Continuous gastric suction,Administration of antibiotic in high doses,Intravenous infusion,Peritoneal abscess common,Side-effects greater than closure,Employed only for critically ill patients,Young patients,Fasting,Small perforation,Perforated ulcer,Pyloric Obstruction,Pyloric obstruction:,inaccurate term (in DU),Accurate term:,obstruction of gastric outlet,Pathology,Acute:,inflammation, edema, spasm-,reversible,nasogastric suction, vigorous medical therapy,Chronic:,Acid injury-permanent scarring-,irreversible,Require operative intervention,Pyloric obstruction,Clinical findings,A long history of symptomatic peptic ulcer,Pain gradually aggravated,over weeks or months,Anorexia and vomiting,Pyloric obstruction,Vomiting (,characteristic, clinical,importance,),In the evening or at night,Large amounts of fluid:,pyloric obstruction,Food ingested several hours or even,two days previously,Foul-smelling,Free from bile,Induce vomiting to relieve symptoms,Pyloric obstruction,Copious,大量,vomiting:,loss of weight，constipation,weakness (dehydration and electrolyte disturbance),Dehydration and malnutrition,A succussion splash,Peristalsis,Tenderness,Tetany,手足抽搐,: severe alkalosis,Morning gastric juice 200ml,or 1 L,Pyloric obstruction,Copious vomiting,(high gastric acidity),Dehydration,fluid loss,Alkalosis,loss of H,+,Serum,Na,+,K,+,Cl,-,decrease,BUN,1.dehydration,2.renal impairment,electrolyte disturbances,Pyloric obstruction,X-ray findings,(,Barium meal),Dilated stomach,Great amounts of food and fluid,Gastroscopy,Confirm mechanical obstruction,Rule out malignancy,Pyloric obstruction,Outlet obstruction,A. Preoperative management,Gastric decompression and lavage,Intravenous rehydration,Correction of electrolytic imbalance,Total parenteral nutrition,Treatment,Pyloric obstruction,B. Surgical treatment,(after 3 to 7 days of preoperative preparation),Partial gastrectomy,Vagotomy with drainage,Dilatation,Gastrojejunostomy,(In the very debilitated,虚弱,elderly patient),Pyloric obstruction,Upper Gastrointestinal Hemorrhage,Occur,with erosion of the submucosal vessles,Intensity,Slow,chronic blood loss,Massive life-threatening acute hemorrhage,Hemorrhage,Upper gastrointestinal endoscopy,Diagnosis,Identification of patients at risk for re-bleeding,Selected use of hemostatic measures,electrocoagulation and laser coagulation,Hemorrhage,Treatment,Conservative for slow chronic blood loss,Surgery for massive bleeding,Indications for surgery,Massive blood loss with shock,No improvement after 600cc infusion during 6-8h,Recurrent bleeding during medical therapy,Repeated hospitalization for bleeding,Elder patients with arteriosclerosis,Accompanied with perforation and obstruction,Complications of,Gastrectomy,for PU,Early complications,1. Postoperative haemorhage2.Breakage/leakage of duodenal stump3.Stomal fistula4.Postoperative obstruction,Postoperative haemorhage,1.,Intraperitoneal bleeding: intraperitoneal drainage,Mucosal necrosis, infection, not strict suture,2.,Gastric bleeding:,nasogastric sunction,Traumatic surface bleeding, not firm ligation,Slow chronic bleeding,Conservative,Massive life-threatening bleeding,Emergency hemostasis,Breakage and leakage,Bile and duodenal juice drainage,Localized peritonitis,24-48h emergency operation,48h sufficient drainage and TPN,Stomal fistula,Early-acute peritonitis,Late-limited abscess,Judge through drainage and barium meal,Postoperative vomiting,Gatroparesis,胃瘫,Postoperative obstruction,afferent obstruction,stomal obstruction,efferent obstruction,Vomiting characteristics,Nuture of vomitus,Barium meal,Late Complications,1.Dumping syndrome,2.Bile reflux gastritis,3.Stomal ulcer(reccurrent ulcer),4.Nutritional disturbances,5.Gastric remanant carcinoma,Dumping syndrom,Fainting, sweating, dizziness,Early:,30m after meal,Reflex by ostomic effect of food dumped,Need to lie down and rest,Improved by dry meals,Late:,2-4h after meal,hypoglycaemia,Bile reflux gastritis,Several months or years after B,Bilious vomiting,Epigastric burning painless relief from food, antacid,Weight loss,aneamia,Nutritional disturbances,Weight loss,Malabsorption,Anemia,Gastric remnant carcinoma,in the remnant,5 years after op for benign disease,Complications of vogotomy,Gastric retention,Ischemia and necrosis of lesser curvature,Diarrhea,Other diseases of the stomach and duodenum,Carcinoma of the stomach,Gastrointestinal stromal tumor(,GIST,),Lymphoma,Polyps,Duodenal diverticulum,Smooth muscle tumor,（Stromal tumor）,Leiomyoma or leiomyosarcoma,Leiomyoma is the most common benign tumor of the stomach,Symptoms,are those of peptic ulcer or gastric carcinoma,(Due to ulceration of mucosa ),Barium meal,shows,space occupying lesion,Endoscopy,(or EUS) and biopsy to confirm diagnosis,Surgical excision is required,Lymphoma,Symptoms are those of peptic ulcer or gastric carcinoma,Endoscopy(or EUS) and biopsy to confirm diagnosis,Treatment is by surgical resection followed by radiotherapy and chemotherapy,Duodeneal diverticulum,Most are asymptomatic,Rarely bleeding and perforation may occur,Symptomatic diverticulae should be excised,Gastric carcinoma,Clinical findings,symptoms and signs,Diagnosis,Gastroscopy and biopsy,Barium meal,Ultrasound,CT,TNM stage,T: depth of invasion,N: lymph node metastasis,M: distant metastasis,Treatment,Surgical treatment: main,Radical resection,Palliative operation,Adjuvant therapy,chemotherapy,Radical Resection,The extent of lymphadenectomy,D1, D2, D3, D4,Resection of different lymph node station,
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