Gastric ulcer Duodenal ulcer Pancreatitis Ileus. Barbora Konečná

Transcription

1 Gastric ulcer Duodenal ulcer Pancreatitis Ileus Barbora Konečná

2 Peptic ulcers of stomach and duodenum (PUD) Ulcers are chronic, often solitary lesions, that occur in any part of GIT that is exposed to aggresive factors of the gastric fluids Ulceration disruption of mucosa at least to the muscularis mucosae layer due to secretion of HCl and activation of pepsinogen Erosion superficial damage (mucosa)

3 Peptic ulcers of stomach and duodenum (PUD) Occur due to dysbalance of gastro-duodenal protective mechanisms and aggressive factors, while the effects are further enhanced by external or immunological factors

4 Peptic ulcers of stomach and duodenum (PUD) Protective factors normal composition and production of mucin Alk. secretion of HCO 3- intact microcirculation regeneration of gastric mucosa secretion of endogenous prostaglandins Agressive factors Helicobacter pylori drugs with ulcerogenous effects (NSAIDs) deleterious effects of duodenal fluids smoking, alcohol disruptions of microcirculation in the mucosa and submucosa

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6 PUD H. pylori infection colonization of gastric mucosa Does not enter cells, only mucosa (extracellular pathogens) Urease ammonium acid neutralization reflexive production of acid Proteases disruption of mucous layer Weak resistance of the mucosa Digestion of the mucosa by acid and pepsin Chronic ulcerations

7 PUD Other factors Zollinger Elisson syndrome (gastrinoma) Meckel s diverticulum and ectopic gastric mucous membrane

8 PUD symptomes Epigastric pain (heatburn) Pain worse at night and 1-3 hours after meal Nauseas, vomiting, loss of weight Complications: anemia, bleeding, perforation Cancer development is rare and connected to gastritis

9 PUD animal models NSAIDs Acetic acid / acetic acid + H.pylori Ethanol Histamine

10 Gastric ulcer More in men, 5 th -6 th decade Similar to duodenal ulcer but surrounded by gastritis More acid, more probability usually at the border of corpus and antrum Production of acid Normal or decreased Sometimes achlorhydria (absence of HCl) 10-20% have duodenal ulcer Damage of mucus barrier dominates Epigastric pain the most often symptom Heals but appears again on the same spot

11 Duodenal ulcer 4x more often than gastric Chronic, recurrent Oval, 1 cm, Into submucosis and muscularis propria Bottom blood or exsudate with erythrocytes and cell infiltration, inflammation Acid secretion normal to increased, sometimes increased secretion of pepsin 50% have increased pepsinogen in serum

12 Often hereditary Increased incidence HLA-B5 antigens Connected to smoking ß decreased microcirculation Bicarbonates secretion inhibition Quick emptying of gaster to duodenum Incidence Chronic kidney disease Alcoholic cirrhosis COPD % - H. pylori à bad healing Epigastric pain 90min-3 hours after food Penetration sometimes

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15 Pancreatitis Inflammation of the pancreas connected with edema, different degree of autodigestion, necrosis and haemorrhagia 5th decade Acute (reversible) vs chronic (irreversible damage)

16 Acute - etiology Gallstones Alcohol Idiopathic Diseases of duodenum Endocrine or metabolic disease Immunological facotors Hereditary factors Drugs Infections Other causes: Drugs and toxic substances hypercalciemia Renal failure Viral infections Cystic fibrosis Trauma, operations ERCP hyperlipidemia

17 Alcohol Direct toxic effect on pancreatic cells Alcohol is metabolized by pancreas and causes oxidative stress Promotes synthesis of digestive enzymes Destabilizes intracellular membranes Predisposes to autodigestion

18 necrosis Pancreatitis Autodigestion Proteolytic enzymes are activated in pancreas instead of duodenum Endotoxines, viruses, ischemia... etc. Activated proteolytic enzymes may activate other Proteolysis, edema, interstitial bleeding, vascular damage,

19 Acute - pathophysiology Abnormal activation of digestive enzymes within the pancreas (trypsinogen trypsin) Cell death apoptosis and necrosis 2 types based on predominant response to cell injury 1. Mild Inflammation and edema 2. Severe Necrosis - No capsule over pancreas spreading of inflammation and necrosis

20 Acute - symptoms Severe upper abdominal pain Nausea and vomiting Loss of appetite Fever and chills Shock Tachycardia Respiratory distress Peritonitis Hiccup

21 Acute less common signs Grey-Turner's sign (hemorrhagic discoloration of the flanks) Cullen's sign (hemorrhagic discoloration of the umbilicus) Körte's sign (pain or resistance in the zone where the head of pancreas is located) Kamenchik's sign (pain with pressure under the xiphoid process)

22 Differential diagnosis Perforated peptic ulcer Ciliary colic Acute cholecystitis Pneumonia Peuritic pain Myocardial infarction

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24 Balthazar score Balthazar grade Appearance on CT CT grade points Grade A Normal CT 0 points Grade B Grade C Focal or diffuse enlargement of the pancreas Pancreatic gland abnormalities and peripancreatic inflammation 1 point 2 points Grade D Fluid collection in a single location 3 points Grade E Two or more fluid collections and / or gas bubbles in or adjacent to pancreas 4 points Necrosis percentage No necrosis 0 points 0 to 30% necrosis 2 points 30 to 50% necrosis 4 points Over 50% necrosis 6 points Points

25 Acute - treatment Fluid replacement Pain control Bowel rest Nutritional support Antibiotics ERCP Surgery

26 Chronic - causes Alcohol Autoimmune disorders Intraductal obstruction Tumors Ischemia Calcific stones Idiopathic

27 Chronic risk factors Smoking Genetic predisposition Cystic fibrosis

28 Chronic - symptoms Upper abdominal pain increases after drinking and eating Nausea and vomiting Steatorrhea Weight loss even when eating habits and amounts are normal Type 1 diabetes

29 Animal models of Pancreatitis Caerulein ( proteolytic enzymes secretion) Lipopolysacharide + ethanol

30 Ileus intestinal distension and slower or no movement of stool in the intestinal lumen failure of peristalsis Laparotomy, metabolic/electrolytic hypokaliemia Hyponatremia, hypomagnesemia, uremia, diabetic coma, abdominal infection, retroperitoneal bleeding, intestinal ischemia, sepsa, spinal cord injuries Drugs opiates, psychotropics, anticholinergics

31 Ileus Mechanical obstruction (volvulus, gallstone, adhesion) Paralytic bowel paralysis (surgery, medications, muscle and nerve disorders, cancer, Crohn disease) Signs and symptoms: Abdominal pain that comes and goes Loss of appetite Constipation Vomiting Swelling of abdomen

32 Ileus Complications: Necrosis Peritonitis Treatment Obstruction diet, surgery Paralysis identifying the cause, surgery

33 Thank you J