1. PEPTIC ULCER DISEASE
ACID PEPTIC DISEASE

2. • Gastric ulcer
• Duodenal ulcer
• Gastritis
• GERD
• Stress ulcers
• Zollinger Ellison Syndrome

3. Peptic ulcer
Definition
A mucosal defect equal to or greater than 0.5 cm that
extent to or beyond muscularis mucosa. These ulcers are
caused by increased acid/ pepsin secretion or diminished
mucosal defense.

4. Types
• Chronic
• Acute
Location
• Duodenum
• Stomach ? (4%)
• Gastric and duodenal ulcer together. 10%
• Lower oesophagus
• Jejunum after anastomosis to stomach
• Meckels diverticulm

5. Gastric / duoedenal ulcer
Prevalance
H2 receptor inhibitors
Proton pump inhibitors
Effective treatment against H Pylori
• Overall risk , 10%
• More common in males
• Duodenal ulcer 4 times more common than gastric
ulcer
• Slight increase in GU due to wide spread use of
NSAIDs

7. D cells
ECL cells
Cholecystokinin
Secretin

11. Aetiology
1. Helicobacter pylori
• urease– urea- ammonia- hypergastrinaemia-
increased acid secretion
• H. pylori- reduces the gastric mucosal resistance
against acid and pepsin. Enzymes, cytotoxins
• Local inflammatory response due to cytotoxins
• 90% in DU
• 70% in GU

12. 2. Non steroidal anti inflammatory drugs( NSAIDs)
• 30% in GU and smaller percentage in DU
• More commonly associated with complications
• Inhibit cyclooxygenase (COX,1,2) & reduce mucosal
protective prostaglandins

13. Risk factors for NSAIDs induced ulcers
• Age > 60 years
• Past history of peptic ulcer
• Additional steroids
• Multiple NSAIDs,
• High dose
• Individual NSAIDs. Piroxicam, ibuprufen

14. 3. Heriditary
• Positive family history in DU
• Blood group O
• Increased level of serum pepsinogen 1

15. 4. Smoking
• More prone to develop gastric ulcer than DU
• Ulcer less likely to heal and prone to haemorrhage and
perforation
5. Stress
Burns,
Head injury
on ventilators

16. 6. Gastric emptying
–Increased---DU
–Decreased----GU. (stasis), DG refkux
7. low socioeconomic group/ developing world
8. Steroids- atrophy of mucosa
9. Spicy foods
10. Gastrinoma

17. Summary (aetiology)
(Acid pepsin versus mucosal barrier)
• Increased acid and pepsin secretion.
– Gastrin, Histamine, acetylcholine, cholecystokinine
• Reduced mucosal barrier
– H. Pyelori
– NSAIDs
– Smoking
– Decreased bicarbonate production
– Decreased protective prostaglandins

18. Pathology Duodenal ulcer
–First part of duodenum
–50% on anterior duodenal wall, 50% on posterior
wall
–Anterior ulcers tend to perforate while posterior
tend to bleed
–Usually single but can be more than one
–Fibrosis – pyloric stenosis
–All benign

19. Pathology
Gastric ulcer
–Usually single, 2-4 cm, smooth base perpendicular
walls
–Located on lesser curve but can occur anywhere
–Larger than duodenal ulcer
–Fibrosis can lead to Hour glass deformity.
–Can penetrate into transverse colon, pancreas.
–All stomach ulcers are not benign. (4% malignant)

21. Malignancy in gastric ulcer
• Benign ulcers becoming malignant.?
• Malignant to start with
• All stomach ulcers are considered malignant until
proved benign on biopsy & follow up
• Always, always take a biopsy of stomach ulcer
• 10 well targeted biopsies

22. Clinical features
• Pain abdomen
– Epigastrium, may radiate to back
– Relation with meals- hunger pain
• Periodicity
– Episodic- lasting for several weeks (periodicity)
• Vomiting
• Alteration in weight

23. • Bleeding
– Chronic
– Acute
• Other symptoms
– Dyspepsia, heartburn, epigastric fullness, loss of appetite
• Silent
– Anaemia
– Haemetemesis
– Perforation

24. D/D pain epigastrium
• Duodenal ulcer
• Gastric ulcer
• Gastritis
• Carcinoma
• GERD
• Pancreatitis
• Cholecystitis
• Biliary colic
• Myocardial infarction
• Pleuricy
• percarditis

25. Investigations
• Blood CP
• Stool for occult blood
• Serum amylase
• Ultrasound abdomen
• ECG
• CXR

26. • Esophagogastrduodenoscopy (EGD)
• Urea breath test
•
• Direct detection of urease activity/ H pylori in biopsy
specimen
• Biopsy of any stomach ulcer

27. Treatment
• Medical
• Surgical
Goals
– pain relief
– Eradicate of H. pylori infection
– Healing of ulcer
– Prevent recurrence

28. Medical treatment
General measures
• Cessation of smoking
• Avoidance of spicy foods
• Avoid NSAIDs if possible
• Antacids. Aluminum hydroxide, Magnesium hydroxide

29. Ulcer reducing drugs
• H2 receptors inhibitors
– cimetidin
– Famotidine
– Ranitidin
• Pproton pump inhibitors
– Omeprazole .40 mg OD
– Lansoprazole. 30 mg 12hourly
– Pantoprazole 40 mg OD

30. Eradication of H. pylori
• One of the proton pump inhibitors x 02 weeks. Duration
may vary
• Combination of two antibiotics x 02 weeks
– Amoxycillin
– Clithromycin
– Metronidazole
– Tetracycline
• Bismuth added

31. Mucosal protective
• Bismuth
• Sucralfate
• Misoprostol
• Cisapride

32. • Maintenance of treatment
– Usually not required in majority after eradication therapy
for H. Pylori
– Lowest effective dose of proton pump inhibitors for
prolonged period

33. • Surgical treatment
• Indications
• Perforation
• Haemorrhage
• Gastric outlet obstruction
• Interactable disease
– Delayed healing. Ulcer persists despite 3 months of active
treatment
– Ulcer recurrence with in one year of initial healing despite
maintenance therapy

34. Surgical treatment for uncomplicated duodenal ulcer
Aim
• Diversion of acid from the duodenum
• Reducing the acid/ pepsin secretion
• Both of the above

35. Options
• Truncal vagotomy and drainage
• Truncal vagatomy and antrectomy
• Highly selective vagotomy. First choice
• Lparoscopic
• Billroth 1 gastrectomy
• Billroth 11 gastrectomy
• Gastrojejunostomy

42. Operation for gastric ulcer
Goal
• To excise the ulcer
• To reduce the acid/ pepsin output
• To minimize the bile reflux and gastric stasis
• Options
• Billroth 1 gastrectomy. (Ulcerated part included)
• Billroth II gastrectomy (Ulcerated part included)
• T.Vagotomy, Drinage and ulcer excision
• Proximal gastrectomy

45. Complications of ulcer surgery
• Recurrent ulcerations
• Small stomach syndrome
• Bile vomiting
• Early and late dumping
• Post vagotomy diarrhoea
• Malignant transformation
• Nutritional cosequences
• Gall stones

46. • Complications of peptic ulcer
– Haemorrhage
– Perforation
– Gastric outlet obstruction