surgical management of APD, sor adv med students

2. Acid Peptic disease,
Surgical complications And
Management
DR. NADIR MEHMOOD
Prof of Surgery
RMU

3. LEARNING OBJECTIVES
• At the end of this discussion, a student shall be able to;
• Define APD, and its types
• Enumerate its complications
• Recognize clinical features of complications, describe
clinical features and assessment of patient with peritonitis
• Enumerate investigative findings of such conditions
• Enumerat the management principles of such patients
• Describe operative options in such patients
• Enlist the postoperative care in such patients

4. Acid Peptic Disease
• Many conditions, result of damage from acid n peptic
activity in gastric secretion.
• Acid and mucosal barriers mechanism disturb, leads to
erosion of mucosa and wall to variable extent, along with
healing and fibrosis, leads to complications.
• Affect esophagus, stomach, duodenum, gastrojejunostomy
site and Meckel’s diverticulum.
• Smoking, alcohol, NSAIDs, foods, caffeine, steroids and
H.pyori.

5. Complications of Acid Peptic
Disease
Perforation
Bleeding
Penetration
Gastric outlet obstruction
Malignant transformation

6. Perforated peptic ulcer
• Epidemiology
• Overall and despite the widespread use of gastric antisecretory agents
and eradication therapy,
• The incidence of perforated peptic ulcer has changed little.
• Previously, most patients were middle aged, with a ratio of 2:1 of
male:female.
• An increase in the numbers of females
• Perforations most commonly occur in elderly female patients.
• NSAIDs appear to be responsible for most of these perforations
• Fasting in the month of Ramazan, after 10th day is common.

7. Clinical features
• The classical presentation of perforated duodenal ulcer is instantly recognizable
• History of peptic ulceration, develops sudden onset severe generalized abdominal
pain due to the irritant effect of gastric acid on the peritoneum.
• Although the contents of an acid-producing stomach are relatively low in bacterial
load, bacterial peritonitis supervenes over a few hours
• Initially, the patient may be shocked with a tachycardia but a pyrexia is not usually
observed until some hours after the event.
• The abdomen exhibits a board-like rigidity
• The patient is disinclined to move because of the pain.
• The abdomen does not move with respiration.
• Patients with this form of presentation need early operation without which the
patient will deteriorate with a septic peritonitis

8. Clinical features (cont.)
• This classical presentation of the perforated peptic ulcer is observed less
commonly than in the past.
• Elderly patient who is taking NSAIDs will have a less dramatic presentation,
• The board-like rigidity seen in the abdomen of younger patients
• May present only with pain in the epigastrium and right iliac fossa
Occasionally perforations may seal
• All of these factors may combine to make the diagnosis of perforated
peptic ulcer difficult.
• Most common site of perforation is the anterior aspect of the duodenum.
• Gastric ulcers may perforate into the lesser sac, These patients may not
have obvious peritonitis

9. Differential diagnosis:
1. Perforated duodenal ulcer
2. Complicated appendicitis
3. Mesenteric Ischemia
4. Intestinal blockage
5. Typhoid fever

10. ACUTE ABDOMEN
• General name for presence of symptoms and signs of
inflammation of peritoneum (abdominal lining)
• Determining exact cause is irrelevant in pre-hospital
care
• Important factor is recognizing acute abdomen is
present

11. 3 Major Types
• Primary Caused by the spread of an infection from the
blood & lymph nodes to the peritoneum. Very rare < 1%
• Usually occurs in people who have an accumulation of
fluid in their abdomen (ascites).
• The fluid that accumulates creates a good environment
for the growth of bacteria
• Secondary Caused by the entry of bacteria or enzymes
into the peritoneum from the gastrointestinal or biliary
tract.
•Tertiary Recurrent peritonits, post op

12. Symptoms
• An acutely ill patient tends to lie “very” still because any
movement causes excruciating pain.
• They will lie with their knees bent to decrease strain on
the tender peritoneum
• What does pain feel like?
• Steady pain - inflammatory process
• Crampy pain - obstructive process
• Was onset of pain gradual or sudden?
• Sudden = perforation, hemorrhage, infarct
• Gradual = peritoneal irrigation, hollow organ distension

13. EXAM & EVALUATION
• GPE
• Feel & press the abdomen to detect any swelling & tenderness in
the area as well as signs of fluid collected in the area.
• Listen to the bowel sounds & check for difficulty breathing, low
blood pressure & signs of dehydration.

14. EVALUATION
• The usual sounds made by the active intestine and heard
during examination with a stethoscope will be absent,
because the intestine usually stops functioning.
• The abdomen may be rigid and board-like
• Accumulations of fluid will be notable in primary p due to
ascites.

15. PROGNOSIS
• Untreated peritonitis, prognosis is poor, usually resulting in death.
• With Tx, prognosis is variable, dependent on the underlying causes.

16. Intra-abdominal infections result in 2
major clinical manifestations
• Early or diffuse infection results in localized or
generalized peritonitis.
• Late and localized infections produce an intra-
abdominal abscess.

17. Investigations
• BLIs
• An erect plain chest radiograph will reveal free gas under the
diaphragm in excess of 50 per cent of cases
• All patients should have serum amylase performed, the levels are
not usually as high as the levels commonly seen in acute
pancreatitis.
• Several other investigations are useful if doubt remains. A water
soluble contrast swallow will show a free peritoneal leak.
• Diagnostic peritoneal lavage will usually easily distinguish
between perforation and pancreatitis,
• CT scan will normally be diagnostic in both conditions, although
this is seldom necessary.

21. Management of Perforated Peptic ulcer
•General care of the patient;
•Specific treatment for the cause;
•Peritoneal lavage when appropriate

22. TREATMENT
GENERAL CARE OF THE PATIENT
• A fluid balance chart
• Gastrointestinal decompression
• Antibiotic therapy
• Analgesia Epidural infusion may provide excellent analgesia.
• Vital system support
SPECIFIC TREATMENT OF THE CAUSE
OPERATIVE TREATMENT WHEN APPROPRIATE
PERITONEAL LAVAGE WHEN APPROPRIATE

23. ABDOMINAL COMPLICATIONS OF
PERITONITIS
• PARALYTIC ILEUS
• PORTAL PYEMIA
• RESIDUAL OR RECURRENT ABSCESS
• INTESTINAL ADHESIONS AND OBSTRUCTION

24. SYSTEMIC COMPLICATIONS OF PERITONITIS
• BACTERIMIC/ENDOTOXIC SHOCK
• BRONCHOPNEUMONIA/RESPIRTORY FAILURE
• RENAL FAILURE
• BONE MARROW SUPPRESSION
• MULTISYSTEM FAILURE

25. Specific treatment of the cause
• Surgery: Emergency laparatomy
• Peritoneal lavage
• whole penitoneal cavity should be explored with the
sucker and mopped dry, if necessary until all
seropurulent exudate is removed.
• The use of a large volume of saline (2—3 litres)
??containing dissolved antibiotic (e.g. tetracycline)
has been shown to be very effective (Matheson).

26. Treatment
• Laparotomy is performed usually through an upper midline incision if
the diagnosis of perforated peptic ulcer can be made with confidence.
• Alternatively, laparoscopy may be employed
• Thorough peritoneal toilet to remove all of the fluid and food debris.
• If the perforation is in the duodenum it can usually be closed by
several well-placed sutures, closing the ulcer in a transverse direction
as with a pyloroplasty.
• It is common to place an omental patch (Graham's patch) over the
perforation
• Gastric ulcers should, if possible, be excised and closed,
• Occasionally a patient is seen who has a massive duodenal or gastric
perforation such that simple closure is impossible and in these
patients a Billroth II gastrectomy is a useful operation.

27. Definitive procedures
• Definitive procedures such as either truncal vagotomy
and pyloroplasty or, more recently and probably more
successfully, highly selective vagotomy during the
course of an operation for a perforation. Studies show
that in well-selected patients and in expert hands this
is a very safe strategy.
• Following operation gastric antisecretory agents
should be started immediately.

28. Minimally invasive techniques
•Perforated peptic ulcers can often be managed
by minimally invasive techniques
• The principles of operation are same;
•Thorough peritoneal toilet is performed and the
• Perforation closed by intra corporeal suturing.
• Postoperatively by nasogastric suction, and gastric
antisecretory agents commenced to promote
healing in the residual ulcer and antibiotics.

29. Laparascopic closure of Perforated DU

30. Conservative treatment
• A great deal has been written about the conservative
management of perforated ulcer.
• However, there are undoubtedly patients who are
unfit or have small leaks from perforated peptic ulcer
and relatively mild peritoneal contamination who may
be managed with intravenous fluids, nasogastric
suction and antibiotics.
• These patients are in the minority.

31. Recurrence of perforation
• Patients who have suffered one perforation may suffer another one.
They should therefore be managed aggressively to ensure that this
does not happen.
• In patients with Helicobacter-associated ulcers, eradication therapy is
appropriate.
• Patients on NSAIDs, who now form the majority of such patients,
should have the drug withdrawn and another analgesic substituted.
• If it is necessary to continue the NSAIDs the patient should have
concomitant treatment with a proton pump inhibitor such as
omeprazole

32. Sequelae of peptic ulcer surgery
• Recurrent ulceration,
• small stomach syndrome,
• bilious vomiting,
• early and late dumping,
• diarrhoea
• malignant transformation.
• Approximately 30 per cent of patients can expect to suffer a
degree of dysfunction following peptic ulcer surgery, and in
about 5 per cent of such patients the symptoms will be
intractable

33. Pyloric stenosis
• True pyloric stenosis is rare in adult age, It is
found mostly in children as form of congenital
hypertrophy of the pylorus or rarely adult pyloric
hypertrophy.
• Mostly it either side of the pylorus caused by
scaring due to ulcer disease in the duodenum or
ulcer scaring but more commonly malignancy in
the antrum causing obstruction.

34. Clinical Features:
Longstanding symptoms of Acid peptic disease.
 Short history indicates malignancy.
 Exacerbation of ulcer symptoms.
 Upper abdominal discomfort.
 Pain will become diffused in the upper abdomen.
 Vomiting and anorexia
Effortless and projectile vomiting, Vomits contain particles of
undigested food and absence of bile in the vomits.
 Constipation.
 Diarrhoea

35. Clinical Features( cont)
Examination
 Underweight
 Dehydration
 Anaemia
 Evidence of gastric stasis in advance cases, succussion
splash.
 Visible peristalsis passing across the upper abdomen from left
to right.
• Dilated stomach may be palpable.

37. Surgery
• surgical procedure and its choice depend upon the nature
and cause of stenosis.
• Pyeloroloplasty
• Gastrojeujenostomy
• Deuodeno deudenostomy
• Gastrectomy

38. Pyloric hypertrophy of infancy
This condition is 4 times more common in male than in female
children, May have family association.

39. Trig. 1
• A 50 years old male from wah cant shifted from Medical ward with C/o vomiting
containing coffee ground material for last 4 days and Melena for 6 days when he
was brought to Medical unit in emergency where he was admitted since 4 days.
• Patient was taking Ibuprofen and Dilofinac Na for the last three years for his
backache and has developed dyspepsia which he was managing by taking H2
blockers.
• Since last two weeks his dyspepsia was too bad and he reduced his NASID intake.
^ days back he noticed tar coloured liquid stools 2-3 times a day and developed
vomiting since last 4 days containing coffee ground material in it. He was
managed in Medical unit and vomiting stopped

40. Trig-2
• A 21 year old college boy presented in emergency early morning at 530 am with
c/o severe abdominal pain for the last -3 hours
• Vomiting and sweating for the last - 01 hour
• The patient was fine when he felt epigastric pain two weeks back treated with
antacids
• 2 pm on the morning of admission patient developed very severe pain initiating
from the epigastrium and than becoming diffused all over the abdomen. Patient
described this pain as of some one has stabbed his abdomen
• He developed sweating and vomiting after 2 hours and had severe aggravation of
pain on movement.

41. • What is your provisional Diagnosis?
• What investigations you will perform, why and when?
• What is your line of management?

42. • A 35 year old man, chronic smoker, presented in
emergency early morning at 5.30 am with c/o severe
abdominal pain for the last -3 hours
• Vomiting and sweating for the last - 01 hour
• The patient was fine when he felt epigastric pain two
weeks back, treated with antacids
• 2 pm on the morning of admission patient developed
very severe pain initiating from the epigastrium and then
becoming diffused all over the abdomen. Patient
described this pain as if some one has stabbed his
abdomen
• He developed sweating and vomiting after 2 hours and
had severe aggravation of pain on movement.

43. Question
• What is your provisional diagnosis?
• What investigations are required to confirm your diagnosis?
• What else you will do along with confirmation of your diagnosis?

44. THANK YOU