消化性溃疡中山大学内科学.ppt

1、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

2、 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,Eti

3、ology 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

4、 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 p

5、arietal 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 frequenc

6、y 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,Laparot

7、omy 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

8、,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 (gast

9、rectomy 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

10、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

11、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,

12、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，consti

13、pation 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+ Se

14、rum 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

15、 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 Gastrojejunos

16、tomy (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 pat

17、ients 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

18、Recurrent bleeding during medical therapy Repeated hospitalization for bleeding Elder patients with arteriosclerosis Accompanied with perforation and obstruction,Complications of Gastrectomy for PU Early complications1. Postoperative haemorhage2.Breakage/leakage of duodenal stump3.Stomal fistula4.Po

19、stoperative 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 ble

20、eding 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 P

21、ostoperative 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

22、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,

23、 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 duodenu

24、m,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 lesio