Diseases of the Stomach and Duodenum,Dept. of Gastrointestinal Surgery First Affiliated Hospital Sun Yat-sen University,Surgical treatment for peptic ulcer,“If there is no acid, peptic ulceration cannot occur.” In fact, peptic ulcers may occur anywhere where pepsin and acid occur together . They may occur in the esophagus, the duodenum, the stomach itself, the jejunum after surgical construction of a gastrojejunostomy, or in the Meckels diverticulum .,Peptic Ulcer Disease,Duodenal ulcer(DU) Gastric ulcer(GU),The causes, Clinical features, and prognosis of DU and GU are different.,DU and GU,Etiology 1.gastric acid Nerval and humoral secretion 2.gastric mucosal defences mucosal barrier prevent antidromic diffuse 3.Helicobactor Pylori infection impair mucosal defences,PU is caused by an imbalance between secretion of acid and pepsin, and breakdown of mucosal defence. An acid environment and reduced mucosal defences provide ideal circumstances for pepsin to cause mucosal ulceration.,Etiology and Pathogenesis,DU 1.Overstress or overexcitment of vagus nerve 2.Increased number of parietal cells 3.Too quick gastric emptying GU 1.Gastric retention 2.Reflux of duodenal juice 3.Abnormity of parietal cells,Etiology and Pathogenesis,Over-excitement of vagus nerve-DU Breakdown of mucosal defences-GU Helicobactor Pylori infection-Both,Incidence MF： Men are affected 3 times as often as women. DU GU： DU is 10 times more common than GU in the young pts. But in the older age groups the frequency is about equal.,In general terms, the ulcerative process can lead to 4 types of disability: Pain: most common Bleeding Perforation Obstruction,Chief cell-pepsinogen,Cardiac gland area mucous secreting cell,Parietal cell-acid,oxyntic gland area parietal & chief cell,pyloric gland area G cell,Crows-foot,Latarjet N,90% afferent 10% efferent,Duodenal Ulcer,Duodenal Ulcer,Occurrence,A common disease 10% of the adult population in USA Incidence since 1955 Complications remain high,DU,Men:Women = 3:1 DU : GU = 10 :1 (young) = 1 :1 (old),DU,Any age group Most common in 20 -45 years old 95% within 2cm from the pylorus 5% post-bulbar ulcer,DU,Physiological Abnormalities,numbers of parietal and chief cell parietal cell sensitivity to gastrin gastrin response to meal gastric emptying inhibition of gastrin release to acid,DU,Clinical Findings,Morning,Noon,Afternoon,Evening,2Am,Symptoms,Epigastric Pain Aching Burning Gnawing,Daily Cycle of Pain,Some : no GI complains,DU,Food, milk,or antacid - temporary relief,Back pain,Penetrating ulcer,Nausea,Vomiting，belching,Tendeness localized epigastric,Many no tenderness,DU,Laboratory Findings,1) Test for occult blood 2) Gastric analysis 3) Serum gastrin,Interpretation of the results of gastric analysis,Normal,DU,ZES,BAO mM/hr 5.5 15 MAO mM/hr 40 40,DU,Serum Gastrin,Performed if ZES suspected Readily available Normal basal levels: 50-100 pg/ml (Conventional PU) Abnormal 200 pg/ml 1) ZES 2) Retained antrum after BII op.,DU,Barium meal (upper GI series),Direct sign: Crater Indirect sign: Duodenal deformity X-ray: 90% reliable,DU,DU,stomach,Duodenal bulb,pylorus,DU,Duodenal bulb,stomach,pylorus,Thickened folds,DU,Ulcer crater(niche),DU,Gastroduodenoscopy: Useful,Essentials of Diagnosis,Epigastric pain relieved by food or antacids Epigastric tenderness Normal or increased gastric acid secretion Signs of ulcer disease on upper GI x-rays or endoscopy,Surgical Treatment for DU,Medical treatment: in most patients,Surgical intervention: 10% DUs,Indications for op.,1) massive or recurrent bleeding 2) perforation 3) pyloric obstruction 4) intractable ulcer,DU,With improving medical management, intractability as an indication for surgical intervention has markedly diminished and now accounts for only less than 5% of patients who undergo all types of ulcer operations,Intractable ulcer,prolonged, severe symptoms,inadequately relieved by medicine,loss of sleep, work and income,penetrating ulcer Callous ulcer post-bulbar ulcer combined ulcer(DU+GU),DU,Operations for DU,Aims:,to decrease acid with ulcer excision and a drainage procedure,DU,Operations,1) Gastrectomy (1) Partial (PG) (G. resection) (2) Subtotal (STG) (3) Total (TG) 2) Vagotomy (1) Truncal (TV) (2) Selective (SV) (3) Highly Selective (HSV) 3) Drainage (1) Pyloroplasty (PP) (2) Gastrojejunostomy (GJ),DU,1) Subtotal gastrectomy 2) Vagotomy & drainage 3) Vagotomy & antrectomy 4) Parietal cell vagotomy 5) Gastrojejunostomy,DU,1. Subtotal Gastrectomy,1st successful gastric resection , 1881,Theodor Billroth from Vienna,Popular in China for PU,DU,1. Subtotal Gastrectomy,DU,1. Subtotal Gastrectomy,DU,1. Subtotal Gastrectomy,DU,gastric ramnant,efferent loop,duodenal stump,afferent loop,1. Subtotal Gastrectomy,DU,Antecolic anastomosis,retrocolic anastomosis,Mechanism of gastrectomy,1) removing the gastrin-secreting antrum 2) removing majority of the body 3) excluding the ulcer-bearing area 4) resection of ulcer itself(excision) 5) alkalinating effect,