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home - Stomach - Peptic Ulcer Disease - Peptic Ulcer Disease Surgery Written by Dr Sebastian Zeki
Knowledge

Knows the range of organic and non-organic causes of dyspepsia. Be
aware of current BSG and NICE guidelines for selecting patients for
investigation. Know the significance of alarm symptoms
Understands the relevance of Helicobacter pylori infection and how it
can be detected and treated.
Recognise the adverse effect of nonsteroidal anti-inflammatory drugs
Understands the physiology of gastric acid secretion, mucosal
protection and gastroduodenal motility and know how drugs can
modify these
Knows the complications of ulcer disease, the principles of surgery
that may be required and be aware of post-operative sequelae

Skills
Makes a thorough clinical assessment, perform appropriate
investigations and be familiar with how medical treatments are used.
Show awareness of how to recognise and manage complications

Behaviours
Can explain the steps taken towards making a diagnosis and
planning treatment clearly and comprehensibly

Also....

Knowledge
Knows the causes of upper gastrointestinal bleeding and its
presentation
Understands the circulatory disturbance associated with blood loss
and the pathophysiology underlying the clinical manifestations of
hypovolaemic shock
Knows the principles of assessing hypovolaemia and of restoring the
circulation. Be able to identify and correct coagulopathy
Knows the principles of using the various risk stratification tools SCE 1
Knows how endoscopic techniques are used to control bleeding CbD, DOPS, SCE 1
Understands how oesophageal and gastric varices develop and the
endoscopic and pharmacological methods that are used to control
blood loss

Skills
Can make an accurate clinical assessment, and stratify the risk. Know
the principles of fluid resuscitation and arrange endoscopy
Is aware of methods to secure haemostasis, recognise signs of rebleeding and liaise with other disciplines (such as interventional
radiology or surgery

Behaviours
Assesses and treats patients who have bleeding with appropriate
degree of urgency.

Also...
Knowledge


Understands why part or all of the patient’s stomach is removed and
the altered post-surgical anatomy

Understands the problems of a gastro-enterostomy and a Roux-en-y
anastomosis

Has awareness of dumping syndromes
Knows the various surgical operations performed for obesity (bariatric
surgery) and their complications

Skills
Can give nutritional advice and choose the appropriate method by
which an enteral feeding tube is inserted into the small bowel

Can initiate the use of pancreatic enzyme therapy
Has ability to recognise and treat early and late dumping syndrome
Behaviours
Able to help the patient carers friends and family understand how
the patient can be encouraged to gain weight

Works closely with dieticians and surgical colleagues

Peptic Ulcer Disease Surgery

Surgery For Gastric Ulcer:For Type 1 GU- Distal gastrectomy with Billroth I or II.For Type 2 GU- Vagotomy and antrectomy.For Type 3 GU- Vagotomy and antrectomy.For Type 4 GU- Subtotal gastric resection. VagotomyIt eliminates cholinergic stimulation to acid secretion.This also makes the parietal cells less responsive to histamine and gastrin and abolishes the vagal stimulus for release of antral gastrin. Pyloroplasty types: Heinecke-Mikulicz ( divides the sphincter longitudinally and closes it transversely).Finney.Jaboulay. SelectiveSelective vagotomy spares the hepatic and celiac divisions of the vagal trunks so innervation to the pancreas, small intestine, proximal colon, and hepatobiliary tree is maintainedA drainage procedure is still required since the antrum is denervatedIs ness used as no real benefit found Highly selectiveSever all branches of the vagus nerves along the lesser curvature that innervate the corpus and fundus of the stomach only (spare the antrum)Basal and stimulated acid secretion are reduced by > 75 % and 50 %, respectively.This procedure minimizes the effects of vagotomy on gastric emptying.Still some reidual gastric motility problems but solid emptying is maintained Subtotal GastrectomyIndications: Gastric ulcer and distal gastric malignancies.Physiological effect: Eliminates not only a major portion of the parietal cells, but also the antrum, removing the gastrin stimulus to acid secretion.This operation reduces basal and stimulated acid secretion by 75 % and 50 %, respectively.Side effects: The emptying of both liquids and solids is more rapid and, with removal of the pylorus, increased reflux of intestinal contents into the stomach may produce significant reflux gastritis.Aftr gastrectomy removalRoux-en-Y reconstruction is occasionally performed to divert the bile away from the remnant, although this requires an additional anastomosis.R-Y is better tolerated clinically than Bilroth II and leads to a lower incidence of Barrett's esophagus. H+ Basal and stimulated acid secretion are reduced by 80 and 50 %, respectively.Has side effect of reducing gastric motility, impairing both the receptive relaxation of the stomach and the process of antral grinding and pyloric sphincter coordination, trituration, which permits gastric emptying.Solid emptying slowed, liquid emptying sped up Truncal The distal two-thirds of the stomach, including the pylorus, is removed. Bilroth I (remnant anastomosed to the duodenum) Bilroth II-Remnant anastomosed to the jejunum distal to the ligament of Treitz Choice of procedure is based upon the degree of scarring of the duodenum and the ease with which the duodenum and gastric remnant can be brought together. Gastric resection procedures Some form of gastric emptying procedure (pyloroplasty or gastroenterostomy) must be performed. Gastroenterostomy reserved for patients with duodenal bulb scarring Principles of surgery:Sectioning the vagus (vagotomy).Eliminating hormonal stimulation from the antrum (antrectomy).Decreasing the number of parietal cells (gastric resection). Peptic Ulcer Surgery Roux en-Y Gastric bypass Proximal part of stomach Short intestinal Roux Limb Pylorus Duodenum Bypassed part of stomach Operations: Written by Dr Sebastian Zeki Gastrojejunostomy Heineke-Mikulicz Finnay Jaboulay

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