Endoscopy of upper GIT Detection of H pylori infection USG of whole abdomen Plain Xray abdomen Ba meal Xray optional CT scan of abdomen ERCP MRCP gt pancreas biliary pathology ID: 1037045
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1. Upper GIT - 2
2. Investigation Endoscopy of upper GITDetection of H. pylori infectionUSG of whole abdomenPlain X-ray abdomenBa meal X-ray ( optional )CT scan of abdomen / ERCP / MRCP > pancreas – biliary pathology.Treatment For Ch. PUControl of risk factors & life style changes –II. Medical RxAntisecretory drugs - H2 receptor antagonist, Proton pump inhibitorEradication therapy for H. pylori.Surgical Rx –For DU - Diversion of the acid away from the duodenum, reducing secretary potential of stomach or both ►
3. Billroth II gastrectomy : resection of antrum & distal body of the stomach, duodenal stump is closed off, distal end of stomach is narrowed by the closure of the lesser curve aspect & greater curve aspect is anastomosed to jejunum(retrocolic) leaving short afferent loopGastrojejunostomy Truncal vagotomy & drainage Truncal vagotomy & antrectomy ► vagotomy : i) Truncal – division of anterior & posterior vagus nerve before branching at lower end of oesophagus. ii)selective vagotomy – coeliac & hepatic nerves are preserved iii) highly selective vagotomy –nerves of Laterjet supplying the antrum are preserved but all branches of vagus to the fundus (criminal N of grassi) & body of the stomach ( supplying parietal cell mass) are divided.
4. ►Drainage procedure – as vagus nerves are motor to stomach, denervation of the antropyloloroduodenal segment results in gastric stasis following truncal vagotomy alone & so associated with drainage procedure – a) Pyloroplasty - reconstruction of pyloric ring ( ↑ size of lumen ) 1) Heineke mikulicz pyloroplasty – longitudinal section of the pyloric ring & is closed transversely. 2) Finney’s pyloroplasty – continuous inverted U shaped pyloroplasty.b) Gastrojejunostomy : opening through transverse mesocolon to the left of middle colic artery → entrance into lesser sac → most dependent part of the antrum (posterior surface ) is anastomosed with first jejunal loop in isoperistaltic manner.For GU : principal objective – diseased tissue is usually removed ( to exclude malignancy) .
5. Billroth I gastrectomy : mobilization of distal stomach including ulcer bearing area on lesser curve & resected, cut edge of remnant is partially closed from the lesser curve aspect leaving a stoma at the greater curve aspect which is anastomosed to duodenum.Truncal vagotomy, drainage & excision of ulcer.Highly selective vagotomy with excision of ulcer.Complications of peptic ulcer surgery Early : 1) Haemorrhage 2) paralytic ileus 3) stomal obstruction 4) duodenal stump blowout 5) acute pancreatitis.Remote : 1) Recurrent ulcer 2) post gastrectomy syndrome 3) post vagotomy syndrome ( gastric stasis, ↓ intestinal motility, diarrhoea, cholelithiasis ) 4) small stomach syndrome 5) retrograde jejunogastric intussusception 6) gastro jejunocolic fistula 7) Cancer in remnant( after 10 yrs) 8) pulmonary TB.
6. ►Post gastrectomy syndrome : postcibal – 1) Dumping (early hypotensive and late reactive hypoglycaemic. 2) Bilious vomiting.Nutritional syndrome – weight loss, anaemia ( iron def. & B12 def), bone disease.Rx of Ch. pancreatitis Control of risk factorsCounselling & relief of painNutritional support Control of DM ±Surgical Rx –ERCP with sphinterotomy - removal of stone, stentingPancreatico jejunostomy – lateral longitudinal ( Frey’s procedure – superficial part of head of pancreas removed )Pancreatectomy ►
7. ► Pancreaticoduodenectomy – Whipple ( Beger procedure – duodenum preserving resection of pancreatic head )Distal pancreatectomyTotal pancreatectomy ± islets autotransplantation.A patient with sudden severe upper abdominal pain –Common D/DThoracic causes / extraabdominalNon surgical causes.To reach a diagnosis or for management detailed history, physical examination & some relevent investigations are required. Treatment will depend on underlying causes.
8. Patient 1 : middle aged man, alcoholic, smoker, pain radiates through back, may gain relief by sitting & leaning forward position accompanied by nausea, repeated vomiting, retching, hiccough.O/E : Shock ± / altered vital signs, mild jaundice, swinging pyrexia, mildly distended abdomen with greyturner’s & cullen’s sign, guarding, rigidity ±, epigastric mass, ascites with shifting dullness, F/ pleural effusion.Patient 2 : middle aged male patient, pain diffuses to whole abdomen, pt is disinclined to move, may have previous h/ PUD or taking NSAID,O/E : G/E – dehydration, features of shock (±), ↓ urine output Abdomen - ● may be distended(diffusely) ● movement with respiration – restricted or absent. ● epigastric tenderness predominantly ● board like rigidity. ● obliterated upper border of liver dullness ● bowel sound : present / diminished or absent D/R/E : fullness in rectovesical /pouch of douglus.
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