Upper GIT 2 Investigation Endoscopy of upper GIT

Upper GIT - 2

Investigation Ø Endoscopy of upper GIT Ø Detection of H. pylori infection Ø USG of whole abdomen Ø Plain X-ray abdomen Ø Ba meal X-ray ( optional ) Ø CT scan of abdomen / ERCP / MRCP > pancreas – biliary pathology. Treatment For Ch. PU I. Control of risk factors & life style changes – II. Medical Rx • Antisecretory drugs - H 2 receptor antagonist, Proton pump inhibitor • Eradication therapy for H. pylori. III. Surgical Rx – For DU - Diversion of the acid away from the duodenum, reducing secretary potential of stomach or both ►

• 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 loop • Gastrojejunostomy • 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.

►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).

1. 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. 2. Truncal vagotomy, drainage & excision of ulcer. 3. 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.

► Post gastrectomy syndrome : a) postcibal – 1) Dumping (early hypotensive and late reactive hypoglycaemic. 2) Bilious vomiting. b) Nutritional syndrome – weight loss, anaemia ( iron def. & B 12 def), bone disease. Rx of Ch. pancreatitis v Control of risk factors v Counselling & relief of pain v Nutritional support v Control of DM ± v Surgical Rx – 1. ERCP with sphinterotomy - removal of stone, stenting 2. Pancreatico jejunostomy – lateral longitudinal ( Frey’s procedure – superficial part of head of pancreas removed ) 3. Pancreatectomy ►

► q Pancreaticoduodenectomy – Whipple ( Beger procedure – duodenum preserving resection of pancreatic head ) q Distal pancreatectomy q Total pancreatectomy ± islets autotransplantation. A Ø Ø Ø patient with sudden severe upper abdominal pain – Common D/D Thoracic causes / extraabdominal Non surgical causes. To reach a diagnosis or for management detailed history, physical examination & some relevent investigations are required. Treatment will depend on underlying causes.

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.