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Surgery M4 part 2 > treatment of peptic ulcer > Flashcards

treatment of peptic ulcer Flashcards

1
Q

How should a peptic ulcer be treated medically?

A
  • H. pylori -ive -> H2RAs (cimitidine, ranitidine, famotidine) or PPIs (omeprazole)
  • H. pylori positive -> triple or quadruple therapy
  • if symptoms persist -> empiric trial of H. pylori eradication therapy
    3 months are effective with endoscopic assessment every 4-6 weeks
  • mucosal surface protectors -> sucralfate, misoprostol
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2
Q

What are the treatment regiments for H. pylori infections?

A

BISMUTH TRIPLE THERAPY

  • Bismuth -> 2 tablets 4 times a day
  • Metronidazole -> 250mg 3 times a day
  • Tetracycline -> 500mg 4 times a day

PPI TRIPLE THERAPY

  • PPI -> twice daily
  • Amoxicillin -> 1000mg 2 times a day
  • Clarithromycin OR Metronidazole 500mg 2 times a day

QUADRUPLE THERAPY

  • PPI -> twice a day
  • Bismuth -> 2 tablets 4 times a day
  • Metronidazole -> 250mg 3 times a day
  • Tetracycline -> 500mg 4 times a day
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3
Q

When should long term maintenance be considered?

A
  • all patients admitted with complications
  • high risk patients on NSAIDs or aspirin (old or debilitated)
  • all patients with history of recurrent ulcer or bleeding
  • persistent smokers with history of peptic ulcer
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4
Q

When is surgical intervention needed in case of peptic ulcer?

A
  • intractable non-healing ulcer
  • complicated ulcer
  • gastric cancer must be suspected in gastric ulcers -> BIOPSY
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5
Q

What are the surgical procedures used?

A
  • highly selective vagotomy
  • vagotomy & drainage (pyloroplasty or gastroenterostomy)
  • vagotomy & distal gastrectomy (antrectomy)
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6
Q

What are the goals of operative therapy of duodenal ulcers?

A
  • promotion of healing
  • treatment of complications
  • reduction of recurrence
  • minimization of post-op side effects
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7
Q

What are the operative procedures preformed in case of a duodenal ulcer?

A
  • truncal vagotomy & drainage
  • truncal vagotomy & antrectomy -> gastrojuejunostomy
  • parietal cell vagotomy
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8
Q

What are the gastric effects of a truncal vagotomy?

A
  • decreased acid secretion
  • accelerated liquid emptying
  • altered emptying of solids
  • increased serum gastrin -> reflex in younger patients -> do anterectomy with vagotomy
  • gastrin cell hyperplasia -> reflex in younger patients -> do anterectomy with vagotomy
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9
Q

What are the non gastric effects of truncal vagotomy?

A
  • decreased pancreatic exocrine secretion
  • decreased postprandial bile flow
  • increased gallbladder volume
  • diminished release of vagally mediated peptide hormones
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10
Q

What is the difference between the Billroth I & Billroth II procedures?

A
  • Billroth I -> Gastroduodenostomy

- Billroth II -> Gastrojejunostomy

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11
Q

What are the consequences of duodenal ulcer operations?

A

ULCER RECURRENCE RATE

  • parietal-cell vagotomy -> 5-15%
  • truncal vagotomy & pyloroplasty -> 5-15%
  • truncal vagotomy & antrectomy -> <2%

MORTALITY

  • parietal-cell vagotomy -> 0
  • truncal vagotomy & pyloroplasty -> <1
  • truncal vagotomy & antrectomy -> 1

DUMPING

  • parietal-cell vagotomy -> <5%
  • truncal vagotomy & pyloroplasty -> 10%
  • truncal vagotomy & antrectomy -> 10-15%

DIARRHEA

  • parietal-cell vagotomy -> <5%
  • truncal vagotomy & pyloroplasty -> 25%
  • truncal vagotomy & antrectomy -> 20%
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12
Q

What are the indications for operations in duodenal ulcers?

A
  • intractability
  • perforation
  • obstruction
  • hemorrhage
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13
Q

What are the standard operations for gastric ulcers?

A
  • TYPE I -> distal gastrectomy + Billroths I
  • TYPE II & III -> distal gastrectomy + vagotomy
  • TYPE IV -> depends on the site of ulcer
    - > TV + drainage + biopsy/excision of ulcer
    - > distal gastrectomy with ulcer excision
    - > distal gastrectomy with ulcer biopsy
    - > proximal gastrectomy
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14
Q

What are the indications for elective surgery in a gastric ulcer?

A
  • failure to heal on optimal medical therapy
  • suspicion of malignancy
  • distal gastric obstruction
  • giant gastric ulcer
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15
Q

What is the recurrence rate in elective gastric ulcer operation?

A
  • gastrectomy -> 2.8%
  • Vagotomy/drainage -> 9.1%
  • highly selective vagotomy -> 8.2%
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16
Q

What are the indications for emergency surgery in a gastric ulcer?

A
  • bleeding gastric ulcer

- perforated gastric ulcer

17
Q

What are the treatment options for GASTRIC ulcer disease complications?

A

BLEEDING

  • oversew & biopsy -> in shocked patient
  • oversew + biopsy + vagotomy & drainage OR distal gastrectomy

PERFORATION

  • biopsy & patch -> in shocked patient
  • wedge excision + Vagotomy & drainage OR distal gastrectomy

OBSTRUCTION
- biopsy + HSV + gastrojejunostomy
OR
- distal gastrectomy

NONHEALING
- HSV + wedge excision
OR
- distal gastrectomy

18
Q

What are the treatment options for duodenal ulcer disease complications?

A

BLEEDING

  • oversew -> in shocked
  • oversew & vagotomy + drainage -> in old
  • vagotomy + antrectomy -> good general condition

PERFORATION

  • patch -> shock
  • patch + HSV
  • patch + vagotomy & drainage

OBSTRUCTION

  • HSV + gastrojejunostomy
  • vagotomy + drainage

NONHEALING

  • HSV
  • vagotomy + drainage
  • Vagotomy + antrectomy
19
Q

How should a perforated peptic ulcer be diagnosed?

A
  • X-ray in erect or left lateral decubitus position -> pneumoperitoneum
  • gastrografin
20
Q

How should a pyloric obstruction be diagnosed?

A
  • picture of gastric outlet obstruction + saline load test
  • hypokalemia
  • increased gastric fluid levels
  • hour-glass stomach
21
Q

What are the complications of peptic ulcer surgery?

A

EARLY

  • duodenal stump leakage
  • gastric retention
  • hemorrhage

LATE

  • recurrent ulcer
  • dumping syndrome
  • afferent loop syndrome
  • postvagotomy diarrhea
  • anemia
  • gastrojejuno-colic fistula
22
Q

how should a recurrent ulcer be treated?

A

potent antisecretory agents
H2RA (cimitidine, ranitidine, famotidine)
PPI (omeprazole)

23
Q

What is the clinical picture of a gastrojejuno-colic fistula?

A

ULCER PENETRATES TRANSVERSE COLON

  • severe diarrhea following every meal
  • foul breath & may vomit faeces
  • severe weight loss & dehydration rapid in onset
24
Q

How is a gastrojejuno-colic fistula diagnosed & treated?

A
  • barium enema

- correct dehydration & malnutrition first then reversional surgery

25
Q

When does small stomach syndrome occur?

A
  • following most ulcer operations including HSV -> loss of receptive relaxation
    EARLY SATIETY
26
Q

When does bile vomiting occur & how is it treated?

A
  • following any vagotomy with drainage or gastrectomy
  • eating precipitates abdominal pain & reflux symptoms (water-brash)
  • reversional therapy -> Roux-en-Y diversion
27
Q

What is the cause of a hypotensive picture after gastrectomy or vagotomy with drainage?

A

EARLY DUMPING

  • loss of receptive relaxation of stomach
  • signs & symptoms occur right after eating (meals rich in sucrose & fructose)

SYMPTOMS

  • bloated
  • nausea
  • vomiting
  • abdominal cramps
  • diarrhea
  • flushing
  • dizziness
  • rapid HR
28
Q

How is early dumping managed?

A
  • small, dry meals
  • avoid fluids high in carbohydrates
  • if it doesnt get better over time -> octreotide before meals
  • reversional surgery
29
Q

What is the cause of reactive hypoglycemia?

A

LATE DUMPING
- carbohydrate load in small bowel -> rise in plasma glucose -> increase insulin -> secondary hypoglycemia

OCTREOTIDE effective

30
Q

What is the cause of postvagotomy diarrhea?

A

rapid gastric emptying

  • severe & explosive diarrhea
  • like passing boiling water
  • treat with antidiarrheal preparations
31
Q

What nutritional consequences follow a gastrectomy?

A
  • weight loss
  • anemia -> iron or vit B12
  • bone disease in women
32
Q

What is the cause of gallstone development post op?

A

TRUNCAL VAGOTOMY

  • stasis in biliary tree -> stone formation
  • cholecystectomy

Surgery M4 part 2 (36 decks)

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