View Full Version : PEPTIC ULCER (Aetiology-Pathology-Investigations-Clinical Picture-Treatment)

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04-21-2008, 03:57 PM
It is so named because in addition to hyperacidity required to occurence of the disease pepsin is probably also required.
m Aetiology:
a) Duodenal ulcer: Gastric hypersecretion of acid due to:
1- Genetic & blood group: run in families espcially blood group 0 (3 : 1 of other blood groups, ABO gene may modify the size of parietal cell mass).
2- Gastric fators:
Increase vagal stimulation in ulcer diathesis patient (tall, thin, neurotic and worry).
Increase parietal cell mas (threshold is 109).
Hormonal over secrtion (Zollinger-Ellison Syndrome).
Infection by Helicobacter pylori: submucous spirochetal bacteria that split urea to ammonia. The high alkalinity of ammonia stimulate G cells to secrete gastrin through the feedback mechanism. Removal of the organism by metronidazol (Flagyl) or bism
uth salts (Denol) reduce the recurrent ulcer rate. It is now considered as the most important factor for the occurrence of the disease.
3- Extragastric factors:
Hyperparathyroidism increase Ca increase HCl.
b) Gastric ulcer: Devitalization of the mucosa due to :
1- Trauma.
2- Local ischaemia by:
a) thrombosis b) low capillary perfusion
3- Chronic gastritis.
4- Vitamin A deficiency. 5- Local infection.
m Pathology:
1- Incidence: male more than female.
Doudenal : Gastric 4 : 1 Abroad & 20 : 1 in Egypt.
2- Site: a) Lesser curvature
b) First part of duodenum
Which are called ulcer bearing areas. Why these sites? as they are the most sites exposed to trauma of food and acidity of evacuating stomach.
FN.B. Any ulcer outside the ulcer bearing area malignancy should be suspected.
Prepyloric ulcers and pyloric ulcers are similar to duodenal ulcer in the aetiology but it is difficult to treat and liable to malignant change.
Other sites of benign peptic ulceration:
l Lower end of oesophagus due to reflux aesophagitis.
l Jejunum after gastrojejunostomy due to persistant acidity.
l Meckel's diverticulum due to ectopic gastric glands.

3- Size: Less than 1 inch if more ® susp. of malignancy.
4- Shape: Usually oval or rounded.
5- Single or multiple: Usually single but ulcer on anterior wall of the duodenum may be faced by another one on the posterior wall which called "Kissig Ulcer".
6- Special criteria:
a) Margin: inflammed = activity.
b) Edge: Slopping in benign ulcers & everted in malignancy.
c) Floor: covered with granulation tissue.
d) Base: The ulcer resting on serosa after damage of mucosa, muscularis mucosa, musculosa.
7- Criteria of peptic ulcer from outside stomach during exploration:
a) Inspection: loss of luster, fibrosis ® whitish area at the base of ulcer puckering of the wall.
b) Palpation: induration, tip of finger enter in the ulcer nich and when rubbing the serosa over the suspected area by piece of gauze ® subserosal peticheal hge. due to rupture of the congested capillaries (Stippling sign).
If no criteria detected with +ve history and investigation. A gastrotomy may be needed.

m Investigations:
I- Barium Meal:
A- The dye is barium sulphate from 30% (thin barium) to (70 : 80)% (barium paste).
B- The patient firstly given 1 spoon of barium paste to delineate the gastric wall [gastric relief film].
C- The patient is then put under screen to detect.
l Sites of tenderness.
l Gastric motility and rate of evacuation.
D- Serial films are then taken after giving the patient the rest of barium 50%. We may find.

1- Delayed evacuation due to pylorospasm or fibrosis.
2- Deformed duodenal cap. Some- times it gives trifoliate appearance (serial films is needed)
3- If fibrosis is marked ® obstruction ® hugely dilated stomach ® soap plate appearance.
1- Rapid evacuation due to gastric irritation.
2- Ulcer niche in lesser curve (creater) ulcer noch in greater curve due to spasm of related muscles.
3- If fibrosis®Hour glass stomach or tea pot appearance.

II- Gastroduodenoscopy : "Fiber-optic":It is the most sensitive and specific investigation in the management of peptic ulceration.
1) Suspecious of malignancy in gastric ulcer or benign gastric tumours to take multiple biopsies.
2) Follow up of gastric ulcer under medical treatment to show ulcer healing.
3) For diangosis of anastomotic ulcer, the endoscope should explore the afferent and efferent loops.
4) Diangnosis of bleeding ulcers as a cause of haematemesis. Injection of the ulcer with adrenaline and other haemostatic materials can arrest bleeding.
III- Gastric Function Tests:
1) Measurement of basal acid secretion under resting conditions.
· Technique: Nasogastric tube® aspiration every 1 h.® Collection of secretion after 12 h.®Measurement of amount and free acidity.
· Normal subject < 500 cc of about 13 meq
· Duodenal ulcer pnt > 500 cc of about 65 meq
· Zollinger Ellison syndrom 2000 cc of about 200:300 meq.
2) Measurement of vagal tone effect.
· Aim: Usually to test complete section of the vagus nerve. (Hollander insulin test)
· Technique: 14 units of insulin are given I.V.® hypoglycaemia® stimulation of vagus nerve ® No effect on secretion = good vagotomy Increase Secretion = Incomplete vagotomy

FN.B. Insulin test may cause severe hypoglycemia which may result in death.
For this reason it is replaced by Chew and Spit Test . Chewing of a meal stimulate vagus instead of insulin injection.

3) Measurement of the parietal cell mass by:
a- Kay's Augmentd histamine test.
b- Pentagastrone test.[To avoid side effects of histamine]
Histamin is given I.M® direct stimulation to the parietal cell mass.
The secretion increase with the increase in the dose of histamin up to certain limit = peak of acid secretion.
FN.B. Achlorohydria, occurs when a stomach cannot produce juice with pH less than 7.0 even after maximal stimulation.

m Treatment of Gastric Ulcer
q Surgical treatment is preferred. why?
1- Medical treatment is ineffective.
2- Recurrence after medical treatment is common.
3- Possibility of malignancy cann't be excluded.
q Benefit of Medical Treatment:
1- Cure all acute gastric ulcers.
2- Releive congestion and oedema around the ulcer before operation to facilitate resction.
q Specific drugs for gastric ulcers:
Carbenoxolone sodium (derived from Liqurice ®Hasten healing of ulcer.
q The operation is " Partial Gastrectomy"
Aim of operaiton: Removal of the ulcer and diseased part.
Limits of resection:
a- Distally: 1st part of the duodenum.
b- Proximally: On lesser curve ® 1 inch below the cardia.
On greater cruve ® lower border of spleen.
FN.B. In splenomegaly resect to the level of 1st short gastric vessel.
Anastomosis: Usually by gastoduodenostomy "Billorith I" WHY?
l Healthy duodenum can be mobilized to the left (Kocher's manouver)
l Small gap between both ends.
The ulcer should be examined microscopically to detect malignancy.

m Treatment of Duodenal Ulcer
I- Medical Treatment:
1- Rest: Mental and physical.
2- Diet: Prohibit smoking, spices, alchol, caffee & tea.
3- Tranquilizer.
4- Vagal inhibitors "parasympatholytics" e.g. Atropine.
5- Antiacids: Mg trisillicate and aluminium hydroxide (the best) sodium bicarbonate not favoured Why? It cause alkalosis & effervescent nature may cause perforation.
6- Histamine 2 receptor blockers cimetidine or ranitidine inhibit histamine receptors in stomach, atrium and uterus. Medical treatment is continued for 6 m : 1 year provided that there is improvement.
7- Cytoprotective agent (Antepsin) such as sucralfate, when exposed to acid, forms viscous substance that binds to damaged mucosa.
8- Protone pump inhibitor (Omeprazole) produces marked reduction in acid secretion.
II- Surgical Treatment:
q Indications of surgical treatment:
1- Presence of complications e.g. perforation, bleeding. or obstruction.
2- Intractable ulcer not respond to medical treatment.
3- Economic reasons. "medical treatment is expensive.

q Operations for duodenal ulcer:
1- Vagotomy & drainage operation (see later).
2- Subtotal gastrectomy.
3- Vagotomy & antrectomy.
q Choice of operation:
1- If the vagus is hyperactive (Tall thin neurotic pnt) ® vagotomy Also in cases with weight loss to avoid further loss.
2- If the cell mass is great proved by histamine test ® subtotal gastrectomy.
3- If both ® vagotomy and antrectomy.
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