扬州大学：《外科学》课程教学课件（PPT讲稿，Surgery）Chapter 24. Stomach and Duodenum Diseases Part II

Chapter 24.Stomach and Duodenum Diseases

Chapter 24. Stomach and Duodenum Diseases

Sections 3. Peptic Ulcer Diseases ★★★★★.3.1Duodenalulcer·3.2Gastriculcer·3.3 Hemorrhage frompeptic ulcer· 3.4 Pyloric obstruction dueto peptic ulcer·3.5Perforatedpepticulcer

Sections 3. Peptic Ulcer Diseases ★★★★★ • 3.1 Duodenal ulcer • 3.2 Gastric ulcer • 3.3 Hemorrhage from peptic ulcer • 3.4 Pyloric obstruction due to peptic ulcer • 3.5 Perforated peptic ulcer

Pathogenesis HelicobacterpyloriinfectionNational InstitutesofHealthConsensusPanelRecommendationsfor Helicobacterpylori Treatment.90%ofDUsandPatientswithactivePUDwhoareH.pylori-positiveapproximately75%ofGUsare.Use of NSAiDs shouldnot altertreatmentassociatedwithH.pyloriDocument eradication in those with complicationsinfection.Ulcer patients in remission who are H.Pylori-positive,including.Whenthisorganismispatients on maintenance Hz receptor antagonist therapyH.pylori-positivepatientswithMALTlymphomaeradicatedaspartofulcerControversial issuesinH.Pylori-positivepatients:treatment,ulcerrecurrenceis.First-degree relativesof gastriccancerpatientsextremelyrare.Immigrants from countries with high prevalence of gastriccancerIndividuals withgastric cancerprecursor lesions (intestinalmetaplasia)·Non-ulcer dyspepsia patients who insist on eradication(benefitversusrisk)Patients on long-termantisecretorytherapyforrefluxdisease

Pathogenesis_Helicobacter pylori infection • 90% of DUs and approximately 75% of GUs are associated with H. pylori infection. • When this organism is eradicated as part of ulcer treatment, ulcer recurrence is extremely rare. National Institutes of Health Consensus Panel Recommendations for Helicobacter pylori Treatment

Pathogenesis_Helicobacter pyloriinfection·Inthecaseofduodenal andgastric ulcers,Helicobacterpylorimustcolonizeand weaken the mucosa before acid is able to do the damage,andtherapydirected against thisorganismhas a moredefinitiveeffectonthedisease.PEPTICULCERHelicobacterpyloriThebacteriacolonizedamage protectivethestomachmucosamucuslayeMucusAcid passes throughlayerweakenedmucus layecausing an ulcer6o0EpithelialConnectivetissuecells

Pathogenesis_Helicobacter pylori infection • In the case of duodenal and gastric ulcers, Helicobacter pylori must colonize and weaken the mucosa before acid is able to do the damage, and therapy directed against this organism has a more definitive effect on the disease

Pathogenesis_Helicobacter pyloriinfectionFOCALHELICOBACTERPYLORIGASTRITIS.PatchyHELICOBACTERPYLORIGASTRITIS.Mildsuperficialgastritisresults in erythemaandprominenceoftheareasofinflammationintheproximalgastricbodyareareaegastricae(asseen underwater)welldemarcatedbythesurroundingatrophicmucosa

Pathogenesis_Helicobacter pylori infection HELICOBACTER PYLORI GASTRITIS. Mild superficial gastritis results in erythema and prominence of the areae gastricae (as seen underwater). FOCAL HELICOBACTER PYLORI GASTRITIS. Patchy areas of inflammation in the proximal gastric body are well demarcated by the surrounding atrophic mucosa

Location and Type of Peptic Ulcer Diseases(PUDs)LocationandTypeofUlcer·PUDscanbedivided into1. Gastric Ulcer (GU)2. Duodenal Ulcer (DU)·PUDsoccurnearmucosaljunctions.·DUusuallyoccurattheduodenalpyloricjunction,:GU tend to occur at the oxyntic-antral junction,the antral-pyloric junction,orthe esophagogastricjunction

Location and Type of Peptic Ulcer Diseases (PUDs) Location and Type of Ulcer • PUDs can be divided into 1. Gastric Ulcer (GU) 2. Duodenal Ulcer (DU). • PUDs occur near mucosal junctions. • DU usually occur at the duodenal pyloric junction, • GU tend to occur at the oxyntic-antral junction, the antral-pyloric junction, or the esophagogastric junction

Location and Type of GUsType1GUmostcommon(60%70%).Typically,locatedonthelessercurvatureatorproximaltotheincisura,nearthejunctionoftheoxynticand antral mucosa.MostareassociatedwithdiffuseantralgastritisormultifocalatrophicgastritisType2GU(~15%)occurinthesameTableGastricUlcerTypeslocationasthetype1lesionbutareassociatedwitheitheractiveorTYPEACIDLEVELLOCATIONchronicduodenalulcerdisease1LowtonormalLesser curve at incisuraType3GU(20%)aretypicallylocatedIncreased三Gastricbodywith duodenal ulcerwithin2cmofthepylorus(pyloricIIIPrepyloricIncreasedchannel ulcer).IVNormalHigh on lesser curveType4GUrare,islocated intheVAnywhereNormal,NSAID-inducedproximal stomachorinthegastriccardia

Location and Type of GUs Type 1 GU most common(60%~70%). Typically, located on the lesser curvature at or proximal to the incisura, near the junction of the oxyntic and antral mucosa. Most are associated with diffuse antral gastritis or multifocal atrophic gastritis. Type 2 GU (~15%) occur in the same location as the type 1 lesion but are associated with either active or chronic duodenal ulcer disease. Type 3 GU (20%) are typically located within 2 cm of the pylorus (pyloric channel ulcer). Type 4 GU rare, is located in the proximal stomach or in the gastric cardia

FundusFundusPylorusBodyPylorusBodyIncisuraIncisuraTypeIgastric ulcerType IIAntrumAntrum0gastric uicerFundusFundusPylorusBodyPylorusBodyIncisuraIncisuraTypeIVgastric ulcerTypeIlAntrumCgastriculcerCAntrumA,Locationoftype1gastriculcer.B,Locationoftype2gastriculcer.C,Locationoftype3gastriculcer.DLocationoftype4gastriculcer.(FromKauffman GJrConterR:Stressulcerandgastriculcer.InGreenfieldLU,MulhollandMW[eds]:Surgery:ScientificPrinciplesandPractice.Philadelphia,JBLippincott,1993.]

A, Location of type 1 gastric ulcer. B, Location of type 2 gastric ulcer. C, Location of type 3 gastric ulcer. D, Location of type 4 gastric ulcer. (From Kauffman G Jr, Conter R: Stress ulcer and gastric ulcer. In Greenfield LJ, Mulholland MW [eds]: Surgery: Scientific Principles and Practice. Philadelphia, JB Lippincott, 1993.)

Clinical Manifestations1. Abdominal painPerforatedBiliary colic2. Bleedinggastriculcer3.PerforationPerforatedAcutepancreatitisduodenalulcer4. ObstrctionMeckel'sdiverticulumAcuteintestinalobstructionAcuteperforativeAcutediverticulitisappendicitisRupturedTorsionof ovaryovariancystAcute salpingitisEctopicpregnancy

Clinical Manifestations 1. Abdominal pain 2. Bleeding 3. Perforation 4. Obstrction

3.1 DU Essentials of Diagnosis·Epigastricpain relieved byfood orantacids..Epigastrictenderness..Normalorincreasedgastricacidsecretion.. Signs of ulcer disease on upper gastrointestinal x-rays or endoscopy·EvidenceofHelicobacterpyloriinfection

3.1 DU_Essentials of Diagnosis • Epigastric pain relieved by food or antacids. • Epigastric tenderness. • Normal or increased gastric acid secretion. • Signs of ulcer disease on upper gastrointestinal x-rays or endoscopy. • Evidence of Helicobacter pylori infection