【正文】 decrease BUN impairment electrolyte disturbances Pyloric obstruction Xray findings (Barium meal) Dilated stomach Great amounts of food and fluid Gastroscopy Confirm mechanical obstruction Rule out malignancy Pyloric obstruction Outlet obstruction A. Preoperative management Gastric depression and lavage Intravenous rehydration Correction of electrolytic imbalance Total parenteral nutrition Treatment Pyloric obstruction B. Surgical treatment (after 3 to 7 days of preoperative preparation) Partial gastrectomy Vagotomy with drainage Dilatation Gastrojejunostomy (In the very debilitated 虛弱 elderly patient) Pyloric obstruction Upper Gastrointestinal Hemorrhage ?Occur ? with erosion of the submucosal vessles ?Intensity ? Slow,chronic blood loss ? Massive lifethreatening acute hemorrhage Hemorrhage Upper gastrointestinal endoscopy ?Diagnosis ?Identification of patients at risk for rebleeding ?Selected use of hemostatic measures ? electrocoagulation and laser coagulation Hemorrhage Treatment ?Conservative for slow chronic blood loss ?Surgery for massive bleeding Indications for surgery ? Massive blood loss with shock ? No improvement after 600cc infusion during 68h ? Recurrent bleeding during medical therapy ? Repeated hospitalization for bleeding ? Elder patients with arteriosclerosis ? Acpanied with perforation and obstruction Complications of Gastrectomy for PU Early plications 1. Postoperative haemorhage fistula obstruction Postoperative haemorhage ? bleeding: intraperitoneal drainage ? Mucosal necrosis, infection, not strict suture, ? bleeding: nasogastric sunction ? Traumatic surface bleeding, not firm ligation ? Slow chronic bleeding ? Conservative ? Massive lifethreatening bleeding ? Emergency hemostasis Breakage and leakage Bile and duodenal juice drainage Localized peritonitis 2448h emergency operation 48h sufficient drainage and TPN Stomal fistula ?Earlyacute peritonitis ?Latelimited abscess ?Judge through drainage and barium meal Postoperative vomiting Gatroparesis胃癱 Postoperative obstruction ? afferent obstruction ? stomal obstruction ? efferent obstruction ? Vomiting characteristics ? Nuture of vomitus ? Barium meal Late Complications syndrome reflux gastritis ulcer(reccurrent ulcer) disturbances remanant carcinoma Dumping syndrom Fainting, sweating, dizziness Early: 30m after meal Reflex by ostomic effect of food dumped Need to lie down and rest Improved by dry meals Late: 24h after meal hypoglycaemia Bile reflux gastritis ?Several months or years after B Ⅱ ?Bilious vomiting ?Epigastric burning pain— less relief from food, antacid ?Weight loss ?aneamia Nutritional disturbances ?Weight loss ?Malabsorption ?Anemia Gastric remnant carcinoma in the remnant 5 years after op for benign disease Complications of vogotomy ?Gastric retention ?Ischemia and necrosis of lesser curvature ?Diarrhea Other diseases of the stomach and duodenum Carcinoma of the stomach Gastrointestinal stromal tumor(GIST) Lymphoma Polyps Duodenal diverticulum Smooth muscle tumor（ Stromal tumor） Leiomyoma or leiomyosara Leiomyoma is the most mon benign tumor of the stomach Symptoms are those of peptic ulcer or gastric carcinoma (Due to ulceration of mucosa ) Barium meal shows space occupying lesion Endoscopy(or EUS) and biopsy to confirm diagnosis Surgical excision is required Lymphoma Symptoms are those of peptic ulcer or gastric carcinoma Endoscopy(or EUS) and biopsy to confirm diagnosis Treatment is by surgical resection followed by radiotherapy and chemotherapy Duodeneal diverticulum Most are asymptomatic Rarely bleeding and perforation may occur Symptomatic diverticulae should be excised Gastric carcinoma Clinical findings symptoms and signs Diagnosis Gastroscopy and biopsy Barium meal