【文章內(nèi)容簡(jiǎn)介】 A flat edge: benign ulcer Multiple biopsy,brush biopsy (obtained from the edge of ulcer) False (+): rare False (): 5~10% GU GU Differential diagnosis 1) Unplicated hiatal hernia 2) Atrophic gastritis 3) Chronic cholecystitis 4) Irritable colon syndrome 5) Carcinoma of the stomach confusion by nonspecific plaints history alone: impossible for diagnosis distinguishable or not: only after Xray GU Emphases exclusion of gastric cancer misdiagnosis between GU and Gca sometimes GU Xray Gastroscopy Biopsy to rule out malignancy Even 1) results considered though 2) ulcer is judged to be benign 4% will prove to be malignant GU Bleeding Obstuction Perforation Malignant change Complications GU Treatment dominated by op. Reasons for treatment dominated by op. 1) difficult to cure medically 2) recur frequently cause more severe symptoms than DU Recurrence rate: first 2 years 40% first year 70% 3) If the ulcer fails to heal, difficult to differentiate from cancer. 4) Gastrectomy cures GU efficiently GU Surgical Treatment for GU 1) 40~50% partial gastrectomy Billroth I reconstruction 90% satisfactory Mortality 10% GU 2) Vagotomy plus pyloroplasty in a critically ill bleeding ulcer in elderly pts. GU 3) Treatment as outlined in the section on DU 1. The gastric ulcers near the pylorus 2. The ulcers also associated with hypersecrection 3. Xray changes similar to DU GU Complications of Peptic Ulcer Complications of Peptic Ulcer 1. Perforated ulcer 2. Obstruction 3. Bleeding(Heamarrhage) 4. Malignant change 0% DU 1% GU Long history Not malignant ? Perforated Peptic Ulcer Occurrence mon abdominal emergency acute appendicitis perforated ulcer intestinal obstruction acute biliary infection Perforation: 10% of all peptic ulcers 90% in DU 90% in males esp. 25~50 y mon sites: anterior DU GU on the lesser curverture gastric Ca occasionally Pathophysiology of Perforated Peptic Ulcer perforation chemical peritonitis culture() over 6~8 hr bacterial peritonitis Severe illness occurrence of death(mortality) high the interval important between perforation (sudden onset) and surgical closure Most remember the accurate time In some cases perforation closed spontaneously process selflimited subphrenic abscess develop in many Omentum cover the perforation Clinical Findings A previous history, Recent exacerbation 90% (+) fotten by pts. in agony 10% () Perforated ulcer Severe abdominal pain sudden onset, extreme severity aggravated by movement rigidly still subphrenic irritation (radiation of the pain) Nausea Vomiting Haematemesis嘔血 and melaena黑便 Perforated ulcer Physical Examination (1) Agonizing plexion Cold extremities Sweating Rapid shallow respiration In the early hours shock (?) Perforated ulcer Physical Examination (2) Abdomen : rigid (boardlike abdominal rigidity) Tenderness Rebound tenderness Bowel sounds: reduced or absent Liver dullness diminished (1/2) Rectal examination:pelvic tenderness Paracentesis穿刺 : food particles Perforated ulcer In the delayed case ( 12 hours) toxemia hypovolemic shock Perforated ulcer Abd. Xray exam. (with the patient erect) 85% of patient: pneumoperitoneum Perforated ulcer Perforated ulcer pneumoperitoneum Free air under the diaphragm Differential diagnosis