外科消化性溃疡课件

Diseases of the Stomach and Duodenum Dept. of Gastrointestinal Surgery First Affiliated Hospital Sun Yat-sen University Surgical treatment Surgical treatment forfor peptic ulcer 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 FEtiology F1.gastric acid F Nerval and humoral secretion F2.gastric mucosal defences F mucosal barrier prevent antidromic diffuse F3.Helicobactor Pylori infection F 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 PathogenesisEtiology 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 PathogenesisEtiology 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 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 postoperatively helpful 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: Pyloric obstruction: inaccurate term (in DU)inaccurate term (in DU) Accurate term: Accurate term: obstruction of gastric outletobstruction of gastric outlet Pathology Acute: inflammation, edema, spasm- reversible nasogastric suction, vigorous medical therapy Chronic: Acid injury-permanent scarring-irreversible Require operative intervention Pyloric obstructionPyloric obstruction Clinical findings A long history of symptomatic peptic ulcer Pain gradually aggravated over weeks or months Anorexia and vomiting Pyloric obstructionPyloric 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 obstructionPyloric 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 obstructionPyloric 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 obstructionPyloric obstruction X-ray findings (Barium meal) Dilated stomach Great amounts of food and fluid Gastroscopy Confirm mechanical obstruction Rule out malignancy Pyloric obstructionPyloric obstruction Outlet obstruction A. Preoperative management Gastric decompression and lavage Intravenous rehydration Correction of electrolytic imbalance Total parenteral nutrition Treatment Pyloric obstructionPyloric 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 obstructionPyloric obstruction Upper Gastrointestinal Hemorrhage FOccur F with erosion of the submucosal vessles FIntensity F Slow,chronic blood loss F Massive life-threatening acute hemorrhage Hemorrhage Upper gastrointestinal endoscopy FDiagnosis FIdentification of patients at risk for re-bleeding FSelected use of hemostatic measures F electrocoagulation and laser coagulation Hemorrhage Treatment FConservative for slow chronic blood loss FSurgery for massive bleeding Indications for surgery FMassive blood loss with shock FNo improvement after 600cc infusion during 6-8h FRecurrent bleeding during medical therapy FRepeated hospitalization for bleeding FElder patients with arteriosclerosis FAccompanied 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 F1.Intraperitoneal bleeding: intraperitoneal drainage F Mucosal necrosis, infection, not strict suture, F2.Gastric bleeding: nasogastric sunction F Traumatic surface bleeding, not firm ligation FSlow chronic bleeding FConservative FMassive life-threatening bleeding FEmergency hemostasis Breakage and leakage Bile and duodenal juice drainage Localized peritonitis 24-48h emergency operation 48h sufficient drainage and TPN Stomal fistula FEarly-acute peritonitis FLate-limited abscess FJudge through drainage and barium meal Postoperative vomiting Gatroparesis胃瘫 Postoperative obstruction F afferent obstruction F stomal obstruction F efferent obstruction FVomiting characteristics FNuture of vomitus FBarium 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 FSeveral months or years after B FBilious vomiting FEpigastric burning painless relief from food, antacid FWeight loss Faneamia Nutritional disturbances FWeight loss FMalabsorption FAnemia Gastric remnant carcinoma in the remnant 5 years after op for benign disease Complications of vogotomy FGastric retention FIschemia and necrosis of lesser curvature FDiarrhea Other diseases of the stomach and duodenum Carcinoma of the stomachCarcinoma of the stomach Gastrointestinal Gastrointestinal stromalstromal tumor(tumor(GISTGIST) ) LymphomaLymphoma PolypsPolyps Duodenal Duodenal diverticulumdiverticulum Smooth muscle tumorSmooth muscle tumor（StromalStromal tumor tumor） LeiomyomaLeiomyoma or or leiomyosarcomaleiomyosarcoma 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