L6: Surgical TTT of Peptic Ulcer Flashcards
(141 cards)
1
Q
Indications of Surgery in PU
A
2
Q
Complications of peptic ulcer disease according to onset
A
3
Q
Types of Surgeries in Relapsing (Recurrent) DU
A
- Highly Selective Vagotomy (HSV)
- total truncal abdominal vagotomy with gastrojejunostomy of mayo or pyloroplasty
- Vagotomy & Antrectomy
4
Q
Other Names for Highly Selective Vagotomy (HSV)
A
Called PCV (parietal cell vagotomy) or PGV (proximal gastric vagotomy).
5
Q
Procedure of Highly Selective Vagotomy (HSV)
A
6
Q
Advantages of Highly Selective Vagotomy (HSV)
A
7
Q
Disadvantages of Highly Selective Vagotomy (HSV)
A
8
Q
What is the most popular and most commonly done operation for peptic ulcer disease?
A
- total truncal abdominal vagotomy with gastrojejunostomy of mayo or pyloroplasty
9
Q
But indications for vagotomy and GJ are becoming less and less today.
A
…
10
Q
Procedure of total truncal abdominal vagotomy with gastrojejunostomy of mayo or pyloroplasty
A
11
Q
Vagus is …… to stomach and after vagotomy → the motility of the stomach is lost, and gastric stasis occurs.
A
- secretomotor
12
Q
…….. GJ is preferred as gravity gives a dependent drainage of the food contents.
A
Posterior
13
Q
Classically, Criteria of GJ in PU Are …….
A
“Posterior, Vertical, Retrocolic, Isoperistaltic, No loop (short loop), No tension, GJ of Mayo (PVRING)”.
14
Q
Alternatively, pyloroplasty is preferred by a few surgeons instead of GJ.
A
…
15
Q
Types of Pyloroplasty
A
- Heinecke-Mickulicz pyloroplasty
- Finney pyloroplasty
16
Q
Procedure of Heinecke-Mickulicz pyloroplasty
A
17
Q
Complications of Heinecke-Mickulicz pyloroplasty
A
18
Q
Procedure of Finney pyloroplasty
A
19
Q
Indications of Finney pyloroplasty
A
20
Q
Procedure of Vagotomy & Antrectomy
A
21
Q
Recurrence Rate in Vagotomy & Antrectomy
A
Least (1 %)
22
Q
Mortality Rate in Vagotomy & Antrectomy
A
3-4%
23
Q
Types of Surgeries for Persistent Gastric Ulcer
A
- Billroth I
- Billroth II
23
Q
Procedure of Billroth I Partial Gastrectomy
A
24
RR of **Billroth I Partial Gastrectomy**
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MR of **Billroth I Partial Gastrectomy**
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what is **Billroth II Gastrectomy** desribed as?
Described as Polya gastrectomy.
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Indication of **Billroth II Gastrectomy**
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Procedure of **Billroth II Gastrectomy**
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**HSV With Excison of the Ulcer**
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**HSV With Excison of the Ulcer** depends on ......
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Type 4 gastric ulcer
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Indication of **Pauchet procedure**
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Procedure of **Pauchet procedure**
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Which Sex is more affected by **Perforated Peptic Ulcer**?
- More common in males.
- The Ratio is 8-10 men to woman
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Site of **Perforated Peptic Ulcer**
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PPT Factors for Perforated Peptic Ulcer
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Rarely a ‘silent’ ulcer can also perforate (especially those patients treated with cortisone).
...
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Presentation of **Perforated Peptic Ulcer** with NSAIDs
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Presentation of **Perforated Peptic Ulcer** with H.Pylori
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Mortality of **Perforated Peptic Ulcer**
- Perforated peptic ulcers have a mortality rate of 5-10%.
- Perforated gastric ulcers in the elderly have 20-30% mortality rate.
41
Golden Time to operate on Perforated Peptic Ulcer
within 6 hours.
42
Onset of **Stage Of Chemical Peritonitis**
2-4 hours from the time of perforation.
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GIT Symptoms of ****Stage Of Chemical Peritonitis****
There may be an episode of coffee ground vomitus, followed by melaena later.
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Stages of duodenal ulcer perforation
- Stage Of Chemical Peritonitis
- Stage of Reaction
- Stage of Bacterial Peritonitis
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Characters of Pain in **Stage Of Chemical Peritonitis**
Severe agonizing pain.
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Site of Pain in **Stage Of Chemical Peritonitis**
In the right hypochondrium.
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Timing of Pain in **Stage Of Chemical Peritonitis**
Immediately after the perforation.
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Cause of Pain in **Stage Of Chemical Peritonitis**
- Caused by leakage of gastric and duodenal contents into the ei peritoneal cavity (mainly HCL)
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Signs of Shock in **Stage Of Chemical Peritonitis**
1. The patient is pale and anxious.
2. Pulse rate: Increased & Blood pressure: may be normal in the initial few hours.
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Abdominal Examination in **Stage Of Chemical Peritonitis**
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Another Name of **Stage of Reaction**
(also called stage of delusion OR stage of illusion)
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Duration of **Stage of Reaction**
This stage lasts for 3-6 hours.
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Mechanism of **Stage of Reaction**
- Chemical irritantion > The peritoneum reacts by secreting peritoneal fluid > HCL and bile are diluted > improvement of symptoms
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Signs of Shock in **Stage of Reaction**
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Abdominal Examination in **Stage of Reaction**
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Mechanism of **Stage of Bacterial Peritonitis**
- The peritoneal contents get contaminated with gram negative organisms (The organisms are from the intestine itself and not from the peritoneum)
resulting in bacterial peritonitis.
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CP of **Stage of Bacterial Peritonitis**
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Abdominal Examination in **Stage of Bacterial Peritonitis**
- Gross abdominal distension, guarding, rigidity, abdominal tenderness all over suggest generalized peritonitis.
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**Investigation of perforated duodenal ulcer**
- CBC
- Electrolytes
- Plain X-Ray Chest or Abdomen
- CT Scan With Contrast
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**Plain X-Ray Chest or Abdomen** in perforated duedenal ulcer
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**CT Scan With Contrast** in Perforated DU
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**Treatment of perforated duodenal ulcer**
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Treatment of perforated duodenal ulcer
- Aspiration of Stomach Contents
- With Ryle's tube.
- Aim: to reduce further contamination and to decrease biliary and pancreatic juice.
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Treatment of perforated duodenal ulcer
- Blood Grouping & Cross Matching
May be necessary for surgery
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Treatment of perforated duodenal ulcer
- Charts
Temperature, pulse, BP, respiration, urinary output (urinary bladder is catheterized using a Foley's catheter).
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Treatment of perforated duodenal ulcer
- Drugs
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Treatment of perforated duodenal ulcer
- Exploratory Laparotomy
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Treatment of perforated duodenal ulcer
- Fluids
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Postoperative follow up in perforated DU
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Surgical options in Perforated DU
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Managment of **Early Cases of Perforation**
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TTT of subacute abscess in DU
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Haemorrhage from peptic ulcer can be:
- Chronic > anemia
- Acute > massive hematemesis and melaena.
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Itis posterior duodenal ulcer that commonly bleeds because it erodes into ....... which runs posterior to the duodenum.
gastroduodenal artery
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A gastric ulcer on lesser curvature erodes into one of branches of .....
left or right gastric artery.
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PPT factors for Hemorrhagic PU
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Characteristics of individuals at an increased risk of developing acute GI bleeding
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History of a patient with Hemorrhagic PU
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CP of **Hemorrhagic PU**
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- Perforation produces ......
- Hemorrhage produces .....
- abdominal signs
- systemic signs
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Managmnet of **Hemorrhagic PU**
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Resuscitation in **Hemorrhagic PU**
Resuscitation is more important than an urgent endoscopy.
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Emergency Upper Endoscopy in Hemorrhagic PU
- is done to confirm the diagnosis.
- should be done within 12-24 hours of bleeding depending on condition of the patient
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Since elderly patients cannot tolerate shock well, decision to control bleeding surgically must be taken early.
..
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if the source cannot be detected due to large clots or massive bleeding, it can be repeated a few hours after a stomach wash and blood transfusion.
..
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Conservative TTT of ****Hemorrhagic PU****
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Non-Surgical TTT of **Hemorrhagic PU**
- Laser coagulation
- Sclerotherapy
- Haemoclip application
- Bipolar electrocoagulation
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Effect of **Laser coagulation**
It can arrest the bleeding without direct tissue contact.
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Types of Laser in Laser coagulation
- Nd YAG laser has been used more commonly because itcan penetrate tissue more Deeply compared to Argon Laser which penetrates very superficial tissues.
89
Success Rate of **Laser coagulation**
Success rate of laser coagulation is around 80%.
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Components of **Sclerotherapy**
- Epinephrine (1: 10,000) arrests bleeding by vasoconstriction.
- 2% ethanolamine, a sclerosant causes dehydration and shrinkage of surrounding tissues.
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Disadvantages of **Sclerotherapy**
It also produces inflammation and thrombosis of the bleeding vessel.
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Why is Sclerotherapy the Most Popular Method in TTT of Hemorrhagic PU?
- This is the most popular method Why? e Acheap and easy treatment.
- The success rate is around 80-90%.
92
Failure of **Bipolar electrocoagulation** in Hemorrhagic PU
Failure rate is 50%
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Surgical eradication of H. pylori prevents ......
rebleeding
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Surgical TTT of Bleeding PU
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Indications of **Bleeding PU**
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Endoscopic Prognostic Factors in Bleeding PU
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Role of Surgery in Bleeding PU
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Types of Surgery in Bleeding PU
- Surgery for Bleeding Duedonal Ulcer
- Surgery for Bleeding Gastric Ulcer
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Procedure of Surgery in Bleeding DU
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Surgery in Bleeding GU
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Haemostatic methods currently employed include:
a) Thermotherapy (heater probe, multipolar or bipolar electrocoagulation).
b) Injection of ethanol or epinephrine solutions.
102
When the bleeding iscontrolled, long-term medical therapy includes:
a) Anti secretory agents (usually proton pump inhibitor).
b) Testing for h. Pylori with treatment if positive.
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If H. pylori is present, documentation of eradication should be performed after therapy.
...
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Old Name of **Gastric outlet obstruction**
- Earlier it was called pyloric stenosis.
- However, gastric outlet obstruction is a better word.
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Site of **Gastric outlet obstruction**
Duodenal OR juxtapyloric.
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Pathogenesis of **Gastric outlet obstruction**
Chronic cicatrisation (healing by fibrosis) ----> Narrowing of pyloric antrum (which is described as pyloric stenosis).
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Presentation of **Gastric outlet obstruction**
Usually, the patient present with a long history of duodenal ulcer and a recent Hx of vomiting
108
Causes of Gastric outlet obstruction
**In General**
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Causes of Benign **GOO**
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Causes of Malignant **GOO**
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Pathophysiology of **GOO**
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Symptoms of **GOO**
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Pain in **GOO**
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Signs in **GOO**
- VGP
- Succussion Splash
- Auscultopercussion Test / Auscultoscraping Test
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Def of **Visible Gastric Peristalisis**
116
Characters of **Visible Gastric Peristalisis**
117
The presence of VGP is diagnostic of pyloric stenosis
(right to left peristalsis is seen in left sided obstructive colonic tumors).
...
118
Use of **Auscultopercussion / Auscaltoscraping Test**
To find the greater curvature of the stomach.
119
Succussion Splash in GOO
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If VGP isnot seen, itcan be made prominent by: ....
- Asking the patient to drink at least 500 1000 ml of water (It is difficult. Try and see!).
- Stimulating the abdomen by flicking movement.
121
Procedure of **Auscultopercussion / Auscaltoscraping Test**
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Investigations in **GOO**
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Gastroscopy in **GOO**
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Barium Meal in **GOO**
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Electrolytes in **GOO**
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Intro to TTT in **GOO**
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TTT of **GOO**
128
Recovery in **GOO**
129
Surgical TTT of **GOO**
130
Surgery is indicated in cases of gastric outlet obstruction in which:
1. there is significant obstruction
2. medical therapy has failed.
131
The operation usually performed is an ......
132
DDx of Pyloric Stenosis
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Compare Between **Cicatrised chronic duodenal ulcer** & **Carcinoma pyloric antrum** in terms of
- Age
- Duration
- Appetite
- Weight Loss
- Anemia
- Mass
134
The palpable mass is the deciding clinical factor (sign).
...
135
Other differences cannot truly differentiate between the two conditions.
...
136
Rarely, carcinoma of the stomach is also seen in young patients at the age of 20.
...
137
In CHPS, The mass is .....
Palpable
138
Done
...
