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Peptic Ulcers

“Deep defect in the mucosal layer, which occupies the serosal and muscular layer”

Etiology:
Etiology of acute and chronic ulceration is multivariate. It involves the aggressive factors (gastric acid and pepsin) and protective factors (bile, pancreatic and duodenal secretions). Acute ulcers may vary in the setting of extreme psychological or physical stress. If the excretion exceeds from the normal then an ulcer occurs.

Pathogenesis:
Predisposing factors:
  • Smoking
  • Aspirin abuse
  • Alcohol consumption
Bad factors:
  • Diffusion of proteins
  • Charge on the mucous layer
  • Barry Marshin and Ovan discovered bacteria called “Helicobacter Pylori”, which causes acute gastritis or duodenitis
Clinical Features:
Duodenal ulcers:
Typical pain located in epigastric and upper umbilical region, which becomes severe in autumn and spring. Pain may aggravate at nights so called “Nocturnal pain” and/or “Hunger Pain” that is relieved soon after meals.

Gastric ulcers:
Usually occurs after the meals and is striking in nature. It may occur when high secretory activity of stomach is normal, high or below the normal level (Normosecretory, hypersecretory or hyposecretory). In some cases nausea and vomiting is stated.

Signs and Symptoms:
  • Spasmolytic and vagolytic drugs (Isosorbid, buxopan in foreign and No-Spa in Georgia)
  • Severe pain in the epigastrium
  • Sign of Dellafia (hit with a knife)
  • Well defined Blumberg’s sign (reflex rebound) and defense muscularis
  • If the orifice is quite large, we can identify gas in the abdominal cavity by X-Ray or percussion just below the liver
  • Malignisation of peptic ulcers (only for duodenal ulcers, rare)
Complications:
  • Spasmodic contraction of the smooth muscles are encountered especially in the case of duodenal ulcers
  • Bleeding (Hematemesis, Melena)
  • Perforation: when the ulcer perforates through the all of stomach
  • Free perforation in the abdominal cavity, omental sac (bursa omentalis)
Modern classification by Johnson:
  1. Mediogastric ulcers
  2. Prepyloric ulcers
  3. Pyloric ulcers Pyloric ulcers (due to the gastric secretion from G-Cells, which are located in the pyloric part and are the part of APUD system)
  4. Cardiac ulcers
  5. Conjoint or simultaneous ulcers on duodenum and stomach
Differencers between peptic and duodenal ulcers
Features
Gastric Ulcers
Duodenal Ulcers
Periodicity Less marked Well marked. Symptoms occur after mental anxiety or stress
Pain Burning, spasmodic and pricking in nature. Pain radiates to back if it is deeply located Type of pain is the same as for the gastric ulcers
Pain occurs soon after meals as food and acid irritate the ulcer Pain occurs after 2-2.5 hrs after meals when acidic chyme enters the duodenum
No pain in the empty stomach as there is no secretion Pain occur in empty stomach as the raw acid is in the duodenum
Food never relieves the pain Food relieves the pain as there occurs the dilution of acid, hence called the “Hunger Pain”
No nocturnal pain Nocturnal pain occurs due to secretion in empty stomach at nights
Vomiting Common after food, vomiting relieves the pain and is often self induced Not common or typical unless it is self induced
Haemorrhage Big haemorrhage is manifested as hematemesis, if food passes down the gut then melena occurs Usually melena occurs, if pylorus opens during massive haemorrhage then hematemesis occurs
Appetite Loss of appetite as patient is afraid to take meals or later is associated with chronic gastritis Good appetite at regular intervals to avoid the pain
Weight Loss There is loss of weight and anemia Weight gain because of regular diet rich in milk etc.
Malignancy Malignancy to chronic gastric ulcers may occur Malignancy never occurs


Treatment:
Therapeutic treatment:
  • Drugs that block the high secretory activity of the stomach e.g. H2 – Histamine blockers (H1 occurs in lungs) e.g. Ranitidine, Cimetidine, Femotidine. They can be used intravenously in acute cases
  • Hydrogen Proton pump inhibitors, which block the secretory activity of the stomach e.g. Omeprazole, Demoprazole
  • Antacids e.g. Almagil (which buffers the stomach secretion) & Almagil – A (includes anesthesia and buffer)
  • Agents that protect the mucosa from the acid secretion e.g. Sucralfate
  • Little diet after every short interval (stomach should not be empty). Boiled meat also plays an important role in buffering.
Surgical Interventions:
If the therapeutic treatment fails to heal then surgical intervention is indicated.

Billroth type I, Partial Gastrectomy:
Distal 2/3rd part including the ulcer is resected, cut edges are partially closed leaving a stoma at the lower end, which matches the lumen of duodenum and produce new anastomosis with lesion because the duodenum is mobilized.

Billroth type II Gastrectomy:
After resection of the ulcerated part and partial ligation, the duodenum is closed and first part of jejunum is joined to stomach with that part, which is partially left. The bile remains in the meal through a new anastomosis.

Vagotomy:
Total Truncal Vagotomy: Here both trunks of the vagus nerve before arising from their liver and celiac branches are completely dissected. This approach may be through thorax or abdomen. Through the thoracic approach the dissection is above the diaphragm and through the abdominal approach, the dissection is under diaphragm.

Selective Vagotomy:
After arising from the celiac and hepatic branches, little branches are dissected. The secretory activity is decreased through this vagotomy.

Highly Selective Proximal Vagotomy:
The smallest branches of Lattarjet in the distal portion of stomach activate the secretory activity and proximal Lattarjet branches activate the mobility. (Vagal activity is high during nights due to hypoglycemia)

Perforation occurs during the surgical techniques. It depends upon the severity of the inflammatory process in abdominal cavity and the time of perforation. If this time is less than six hours as in acute case, we make simple resection. If this time is more than six hours then we use hazardous incision (oricoraphy), because inflammatory process is more and other complications like peritonitis may take place.

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This article has been written by Dr. M. Javed Abbas.
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21:01 21/12/2002