消化性溃疡 中山大学 内科学课件

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 MF： 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 old 95% within 2cm from the pylorus 5% 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 vagotomy 5) 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% 6cm of the pylorus Similar to DU in many ways symptoms complications,GU,Symptoms and signs Epigastric pain less relief by food or antacids tends to appear earlier after eating More common: Vomiting Anorexia厌食 Aggravation by eating,Clinical Findings,GU,Laboratory Findings GU accompanied by DU: hypersecretion BAO & MAO: low or normal Achlorhydria:酸缺乏 malignant GU (5%) DU with GU: benign ulcer,GU,X-ray Finding Ulcer on the lesser curvature Suggestions of malignanacy (in the absence of a tumor mass, just a crater) 1) deepest penetration not beyond the expected border of the gastric wall 2) prominent rim (rolled up) 3) diameter 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 pyloroplasty 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 haemorhage 2.Breakage/leakage of duodenal stump 3.Stomal fistula 4.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 r