外科-消化性潰瘍課件

DiseasesoftheStomachandDuodenumDept.ofGastrointestinalSurgeryFirstAffiliatedHospitalSunYat-senUniversitySurgicaltreatmentforpepticulcer“Ifthereisnoacid,pepticulcerationcannotoccur.”Infact,pepticulcersmayoccuranywherewherepepsinandacidoccurtogether.Theymayoccurintheesophagus,theduodenum,thestomachitself,thejejunumaftersurgicalconstructionofagastrojejunostomy,orintheMeckel’s

diverticulum.PepticUlcerDiseaseDuodenalulcer(DU)Gastriculcer(GU)Thecauses,Clinicalfeatures,andprognosisofDUandGUaredifferent.DUandGUEtiology1.gastricacid

Nervalandhumoralsecretion2.gastricmucosaldefencesmucosalbarrierpreventantidromicdiffuse3.HelicobactorPyloriinfectionimpairmucosaldefencesPUiscausedbyanimbalancebetweensecretionofacidandpepsin,andbreakdownofmucosaldefence.Anacidenvironmentandreducedmucosaldefencesprovideidealcircumstancesforpepsintocausemucosalulceration.

EtiologyandPathogenesisDU1.Overstressoroverexcitmentofvagusnerve2.Increasednumberofparietalcells3.TooquickgastricemptyingGU1.Gastricretention2.Refluxofduodenaljuice3.Abnormityofparietalcells

EtiologyandPathogenesisOver-excitementofvagusnerve--DUBreakdownofmucosaldefences--GUHelicobactorPyloriinfection---BothIncidenceMF：

Menareaffected3timesasoftenaswomen.DUGU：DUis10timesmorecommonthanGUintheyoungpts.Butintheolderagegroupsthefrequencyisaboutequal.Ingeneralterms,theulcerativeprocesscanleadto4typesofdisability:

Pain:mostcommonBleedingPerforationObstructionChiefcell-pepsinogenCardiacglandareamucoussecretingcellParietalcell-acidoxynticglandareaparietal&chiefcellpyloricglandareaGcellCrows-footLatarjetN90%afferent10%efferentDuodenalUlcerDuodenalUlcerOccurrenceAcommondisease10%oftheadultpopulationinUSAIncidence↓since1955Complicationsremainhigh

DUMen:Women=3:1

DU:GU=10:1(young)

=1:1(old)

DU

Anyagegroup

Mostcommonin20-45yearsold

95%within2cmfromthepylorus

5%post-bulbarulcerDUPhysiologicalAbnormalities↑numbersofparietalandchiefcell↑parietalcellsensitivitytogastrin↑gastrinresponsetomeal↑gastricemptying↓inhibitionofgastrinreleasetoacidDUClinicalFindingsMorningNoonAfternoonEvening2AmSymptomsEpigastricPainAchingBurningGnawingDailyCycleofPainSome:noGIcomplainsDUFood,milk,orantacid----temporaryreliefBackpainPenetratingulcerNauseaVomiting，belchingTendenesslocalized

epigastricManynotendernessDULaboratoryFindings1)Testforoccultblood2)Gastricanalysis3)SerumgastrinInterpretationoftheresultsofgastricanalysisNormalDUZESBAOmM/hr<5>5.5>15MAOmM/hr<30>40>40DUSerumGastrinPerformedifZESsuspectedReadilyavailableNormalbasallevels:50-100pg/ml

(ConventionalPU)Abnormal>200pg/ml1)ZES2)RetainedantrumafterBIIop.DUBariummeal(upperGIseries)

Directsign:Crater

Indirectsign:DuodenaldeformityX-ray:90%reliableDUDUstomachDuodenalbulbpylorusDUDuodenalbulbstomachpylorusThickenedfoldsDUUlcercrater(niche)DUGastroduodenoscopy:UsefulEssentialsofDiagnosisEpigastricpainrelievedbyfoodorantacidsEpigastrictendernessNormalorincreasedgastricacidsecretionSignsofulcerdiseaseonupperGIx-raysorendoscopySurgicalTreatmentforDUMedicaltreatment:inmostpatientsSurgicalintervention:10%DUsIndicationsforop.1)massiveorrecurrentbleeding2)perforation3)pyloricobstruction4)intractableulcerDUWithimprovingmedicalmanagement,intractabilityasanindicationforsurgicalinterventionhasmarkedlydiminishedandnowaccountsforonlylessthan5%ofpatientswhoundergoalltypesofulceroperationsIntractableulcerprolonged,severesymptomsinadequatelyrelievedbymedicinelossofsleep,workandincomepenetratingulcerCallousulcerpost-bulbarulcercombinedulcer(DU+GU)DUOperationsforDUAims:todecreaseacidwithulcerexcisionandadrainageprocedureDUOperations1)Gastrectomy(1)Partial(PG)(G.resection)(2)Subtotal(STG)(3)Total(TG)2)Vagotomy(1)Truncal(TV)(2)Selective(SV)(3)HighlySelective(HSV)3)Drainage(1)Pyloroplasty(PP)(2)Gastrojejunostomy(GJ)

DU1)Subtotalgastrectomy2)Vagotomy&drainage3)Vagotomy&antrectomy4)Parietalcellvagotomy5)GastrojejunostomyDU1.SubtotalGastrectomy1stsuccessfulgastricresection,1881

TheodorBillrothfromViennaPopularinChinaforPUDU1.SubtotalGastrectomyDU1.SubtotalGastrectomyDU1.SubtotalGastrectomyDUgastricramnantefferentloopduodenalstumpafferentloop1.SubtotalGastrectomyDUAntecolic

anastomosisretrocolic

anastomosisMechanismofgastrectomy1)removingthegastrin-secretingantrum2)removingmajorityofthebody3)excludingtheulcer-bearingarea4)resectionofulceritself(excision)5)alkalinatingeffectDU1)Subtotalgastrectomy2)Vagotomy&drainage3)Vagotomy&antrectomy4)Parietalcellvagotomy5)GastrojejunostomyDU2.VagotomyanddrainageVagotomy

1)Truncal

vagotomy2)SelectivevagotomyDrainageprocedure

1)Pyloroplasty

(USA)2)Gastrojejunostomy

(UK)DUDU2)Vagotomy

&drainageDUDUpyloroplastyHeinecke-Mikulicz

pyloroplastyFinneypyloroplastyExcisionpyloroplastyPosteriorgastroenterostomyAnteriorjuxtapyloric

gastroenterostomyPyloricdilationbygastrotomyDU1)Subtotalgastrectomy

2)Vagotomy&drainage

3)Vagotomy&antrectomy

4)Parietalcellvagotomy

5)Gastrojejunostomy

3)Vagotomy&antrectomyDU3)Vagotomy&antrectomyobjective:↓incidenceofrecurrencerateofrecurrencelowestothercomplicationmoreDU1)Subtotalgastrectomy

2)Vagotomy&drainage

3)Vagotomy&antrectomy

4)Parietalcellvagotomy

5)Gastrojejunostomy

4.Parietalcellvagotomy(PCV)Proximalgastricvagotomy(PGV)Highly-selectivevagotomy(HSV)Super-selectivevagotomy(SSV)FirstPGVbyJohston,1969Gastricemptying:notinfluencedDrainageprocedure:unnecessaryDU4.Parietalcellvagotomy(PCV)

alowincidenceofpost-op.symptomsahigherulcerrecurrencerateatime-consumingandtechnicallydifficultop.skillandexperienceofthesurgeon

DU5.Gastroenterostomy(GastrojejunostomyFirstop.forPUWidelyused:1890s-1920sGradullydiscardedsincethenDUGastricUlcerGastricUlcerPeakincidence:aged40~50years95%onthelessercurvature60%<6cmofthepylorusSimilartoDUinmanywayssymptomscomplicationsGU

SymptomsandsignsEpigastricpainlessreliefbyfoodorantacidstendstoappearearlieraftereatingMorecommon:VomitingAnorexia厭食

AggravationbyeatingClinicalFindingsGULaboratoryFindingsGUaccompaniedbyDU:

hypersecretionBAO&MAO:lowornormalAchlorhydria:酸缺乏

malignantGU(5%)DUwithGU:benignulcer

GUX-rayFindingUlceronthelessercurvatureSuggestionsofmalignanacy(intheabsenceofatumormass,justacrater)1)deepestpenetrationnotbeyondtheexpectedborderofthegastricwall2)prominentrim(rolledup)3)diameter>2cmGUGUGUGCa

GastroscopyandBiopsyPerformedroutinelyArolled-upmargin:malignantulcerAflatedge:benignulcerMultiplebiopsy,brushbiopsy(obtainedfromtheedgeofulcer)False(+):rareFalse(-):5~10%GUGUDifferentialdiagnosis1)Uncomplicatedhiatalhernia2)Atrophicgastritis3)Chroniccholecystitis4)Irritablecolonsyndrome5)Carcinomaofthestomachconfusionbynonspecificcomplaintshistoryalone:impossiblefordiagnosisdistinguishableornot:onlyafterX-rayGUEmphasesexclusionofgastriccancermisdiagnosis

betweenGUandGcasometimesGU

X-ray

GastroscopyBiopsytoruleoutmalignancy

Even1)resultsconsideredthough2)ulcerisjudgedtobebenign4%willprovetobemalignantGU

Bleeding

Obstuction

PerforationMalignantchangeComplicationsGUTreatmentdominatedbyop.Reasonsfortreatmentdominatedbyop.1)difficulttocuremedically2)recurfrequentlycausemoreseveresymptomsthanDURecurrencerate:first2years40%firstyear70%3)Iftheulcerfailstoheal,difficulttodifferentiatefromcancer.4)GastrectomycuresGUefficientlyGUSurgicalTreatment

forGU1)40~50%partialgastrectomy

BillrothIreconstruction90%satisfactoryMortality10%GU2)Vagotomypluspyloroplastyinacriticallyillbleedingulcerinelderlypts.GU3)TreatmentasoutlinedinthesectiononDU1.Thegastriculcersnearthepylorus2.Theulcersalsoassociatedwithhypersecrection3.X-raychangessimilartoDUGUComplicationsofPepticUlcerComplicationsofPepticUlcer

1.

Perforatedulcer2.

Obstruction3.

Bleeding(Heamarrhage)4.

Malignantchange

0%DU1%GULonghistoryNotmalignant?PerforatedPepticUlcerOccurrencecommonabdominalemergencyacuteappendicitisperforatedulcerintestinalobstructionacutebiliaryinfection

Perforation:10%ofallpepticulcers90%inDU90%inmalesesp.25~50ycommonsites:anteriorDUGUonthelessercurverture

gastricCa

occasionallyPathophysiologyofPerforatedPepticUlcerperforationchemicalperitonitisculture(-)

over6~8hrbacterialperitonitisSevereillnessoccurrenceofdeath(mortality)hightheinterval--importantbetweenperforation(suddenonset)andsurgicalclosureMostremembertheaccuratetimeInsomecasesperforationclosedspontaneouslyprocessself-limitedsubphrenicabscessdevelopinmanyOmentumcovertheperforationClinicalFindingsAprevioushistory,Recentexacerbation

90%(+)

forgottenbypts.inagony10%(-)PerforatedulcerSevereabdominalpain

suddenonset,extremeseverityaggravatedbymovementrigidlystill

subphrenicirritation(radiationofthepain)NauseaVomitingHaematemesis嘔血

andmelaena黑便PerforatedulcerPhysicalExamination(1)AgonizingcomplexionColdextremitiesSweatingRapidshallowrespirationIntheearlyhoursshock()

PerforatedulcerPhysicalExamination(2)Abdomen:rigid(boardlikeabdominalrigidity)TendernessReboundtendernessBowelsounds:reducedorabsentLiverdullnessdiminished(1/2)Rectalexamination:pelvictendernessParacentesis穿刺:foodparticlesPerforatedulcerInthedelayedcase(>12hours)

toxemia

hypovolemicshockPerforatedulcerAbd.X-rayexam.(withthepatienterect)85%ofpatient:

pneumoperitoneumPerforatedulcerPerforatedulcerpneumoperitoneumFreeairunderthediaphragmDifferentialdiagnosisAcuteappendicitisAcutepancreatitisAcutecholecystitisIntestinalobstructionPerforatedulcerAcuteappendicitis

AbsenceofpreviousPUhistoryPainandtendernessinRLQPneumoperitoneum(-)PerforatedulcerAcutepancreatitisMoregradualonsetHighserumamylasePneumoperitoneum(-)PerforatedulcerAcutecholecystitisMoregradualonsetPneumoperitoneum(-)painandtendenessinRUQMurphysign(+)Anenlargedtendergallbladder(30%)Mildjaundice(10%)PerforatedulcerIntestinalObstructionMoregradualonset,LessseverepainCrampypainwith

Vomiting

Obstipation(gas,feces)AbdominaldistentionX-ray:dilatedbowelloopsair-fluidlevelsinaladder-likepatternPerforatedulcerTreatmentforperforationofPUFirststep

Nasogastric

sunctionEmptythestomachtoreducefurthercontaminationBloodforlaboratorystudiesIntravenousinfusioncontainingantibioticPerforatedulcerIfoverallconditionprecarious(vitalsignsunstable)Fluidresuscitation

DiagnosticmeasuresX-rayassoonaspossible

PerforatedulcerEmergencyOperation:Simple;radicalThesimpleSurgicalTreatmentLaparotomyandsutureclosureClosingandbutressingtheulcerperforationwithapedicleofomentumPerforatedulcerLaparotomyandsutureclosureSolvestheimmediateproblemLive-savingop.NodefinitiveeffectontheulcerdiseaseHelicobacterpylorieradicationpostoperativelyhelpfulPerforatedulcerIndications1.Majorunderlyingmedicalillness2.Perforationlastingmorethan12hours3.SevereperitonealinflammationandstomachswellingPerforatedulcerAbout3/4ofpatientscontinuetohaveclinicallysevereulcerdiseaseaftersimpleclosureAmoreaggressivetreatmentisrecommended(gastrectomyinChina)Perforatedulcer

OtheroperationsVagotomyandpyloroplastyVagotomyandantrectomyProximalgastricvagotomyPerforatedulcerNonoperative(conservative)treatmentContinuousgastricsuctionAdministrationofantibioticinhighdosesIntravenousinfusionPeritonealabscesscommonSide-effectsgreaterthanclosureEmployedonlyforcriticallyillpatientsYoungpatientsFastingSmallperforationPerforatedulcerPyloricObstructionPyloricobstruction:

inaccurateterm(inDU)Accurateterm:

obstructionofgastricoutletPathologyAcute:inflammation,edema,spasm--reversiblenasogastricsuction,vigorousmedicaltherapyChronic:

Acidinjury-permanentscarring--irreversibleRequireoperativeinterventionPyloricobstructionClinicalfindingsAlonghistoryofsymptomaticpepticulcerPaingraduallyaggravated

overweeksormonthsAnorexiaandvomitingPyloricobstructionVomiting(characteristic,clinical

importance)IntheeveningoratnightLargeamountsoffluid:pyloricobstructionFoodingestedseveralhoursoreventwodayspreviouslyFoul-smellingFreefrombileInducevomitingtorelievesymptomsPyloricobstructionCopious大量

vomiting:

lossofweight，constipationweakness(dehydrationandelectrolytedisturbance)DehydrationandmalnutritionAsuccussionsplashPeristalsisTendernessTetany手足抽搐:severealkalosisMorninggastricjuice>200mlor>1LPyloricobstructionCopiousvomiting(highgastricacidity)DehydrationfluidlossAlkalosislossofH+SerumNa+K+

Cl-decreaseBUN1.dehydration2.renalimpairment

electrolytedisturbancesPyloricobstructionX-rayfindings(Bariummeal)DilatedstomachGreatamountsoffoodandfluidGastroscopy

ConfirmmechanicalobstructionRuleoutmalignancyPyloricobstructionOutletobstructionA.PreoperativemanagementGastricdecompressionandlavageIntravenousrehydrationCorrectionofelectrolyticimbalanceTotalparenteralnutritionTreatmentPyloricobstruction

B.Surgicaltreatment(after3to7daysofpreoperativepreparation)PartialgastrectomyVagotomywithdrainageDilatation

Gastrojejunostomy(Intheverydebilitated虛弱

elderlypatient)PyloricobstructionUpperGastrointestinalHemorrhageOccur

witherosionofthesubmucosal

vesslesIntensity

Slow,chronicbloodlossMassivelife-threateningacutehemorrhageHemorrhageUppergastrointestinalendoscopyDiagnosisIdentificationofpatientsatriskforre-bleedingSelecteduseofhemostaticmeasures

electrocoagulationandlasercoagulationHemorrhageTreatmentConservativeforslowchronicbloodlossSurgeryformassivebleedingIndicationsforsurgeryMassivebloodlosswithshockNoimprovementafter600ccinfusionduring6-8hRecurrentbleedingduringmedicaltherapyRepeatedhospitalizationforbleedingElderpatientswitharteriosclerosisAccompaniedwithperforationandobstructionComplicationsofGastrectomyforPU

Earlycomplications

1.Postoperativehaemorhage

2.Breakage/leakageofduodenalstump

3.Stomalfistula

4.PostoperativeobstructionPostoperativehaemorhage1.Intraperitonealbleeding:intraperitonealdrainageMucosalnecrosis,infection,notstrictsuture,2.Gastricbleeding:

nasogastric

sunctionTraumaticsurfacebleeding,notfirmligationSlowchronicbleedingConservativeMassivelife-threateningbleedingEmergencyhemostasisBreakageandleakageBileandduodenaljuicedrainageLocalizedperitonitis24-48hemergencyoperation>48hsufficientdrainageandTPNStomalfistulaEarly---acuteperitonitisLate---limitedabscessJudgethroughdrainageandbariummealPostoperativevomitingGatroparesis胃癱Postoperativeobstruction

afferentobstruction

stomalobstructionefferentobstructionVomitingcharacteristicsNutureofvomitusBariummealLateComplications