STROMAL TUMOURS GIT LYMPHOMAS

Presentation: Presentation:
 Most often located in the stomach  Non-specific dyspeptic upper GIT
but may occur anywhere in the GIT. symptoms.
 Only cause symptoms when large  GI bleeding.
enough to cause compression, or
ulcerate and bleed, or become Investigations:
clinically palpable.  Endoscopy…
- May appear similar to
Mx: adenocarcinoma of the stomach.
 Small (<2cm) GISTs are of little - Biopsy essential to confirm dx.
OTHER clinical relevance.
 Larger, high-grade lesions can Mx:

GASTRIC metastasize and be fatal.

 Primary Mx is Sx resection of the part
of the stomach involved.
 Early-stage, low-grade lymphomas
may respond to H. pylori eradication
alone.

CANCERS  They are responsive to Rx w’

molecular targeted therapy Imatinib.
 Systemic therapy can be highly
 Majority of gastric lymphomas will be
aggressive & high-grade, and usually
Rx w’ chemo w’ good expectation of
effective in pts w’ large, malignant, a response.
or metastatic GISTs.  Sx has limited role in Mx.

Background: Background:
 They are sub-epithelial neoplasms.  Uncommon.
 >95% express the CD117 antigen.  Vast majority are non-Hodgkin
Lymphomas.
 Usual site of involvement is the
stomach.
 Strong association w’ H. pylori inf.
 PARA- INVESTIGATIONS MANAGEMENT
Chest & Abdo X-rays:  In asymptomatic pts, the need for
OESOPHAGEAL  A large para-oesophageal hernia may surgery can be debated.
also produce a fluid level.
HERNIA

PRESENTATION
 May be asymptomatic
 Ealy satiety
 Epigastric discomfort
 Chest pain
 Dysphagia
 Occasionally, chest & cardiac
complaints
BACKGROUND
 Less common than sliding hiatus
hernia.
 OG-junctions remains below the
Barium swallow/meal: diaphragm.
 Will show the hernia w’ gastric folds  These do not predispose to GORD
above the diaphragm. except when there is an associated
 Can also help to distinguish between sliding component.
a sliding and para-oesophageal  They do however have the potential
hernia. (rarely) to cause complications such
as…
Paraesophageal hernia - Gastric volvulus w’ obstruction
- Incarceration
- Strangulation
  Unless done to remove a foreign body  Localised perforation of the thoracic
OESOPHAGEAL or if an experienced endoscopist
intends to close the perforation w’
oesophagus without mediastinitis can
also be Rx conservatively. The

PERFORATION endoscopic clips or w’ a covered

expandable stent.
passage of a fine bore feeding tube
into the stomach or proximal jejunum
is often advised for nutritional
OESOPHAGEAL support.
MANAGEMENT  Transmural perforation of the
PRESENTATION  Rx depends on the following… thoracic oesophagus generally
 Pain - Cause requires urgent thoracotomy and
 Resp distress - Site exploration of the mediastinum.
 Dysphagia - Extent of perforation
 Fever - Ass. pathology
- Duration of perforation BACKGROUND
 General principles of Rx… Potentially life-threatening esp. if
INVESTIGATIONS - IV fluids, NPO thoracic segment is involved, as these
Chest X-ray: - Broad spec Abx result in mediastinitis.
 Useful for early diagnosis. - Maintaining an adequate airway
 Free air in the retro-oesophageal - Meticulous debridement & Causes:
space in the neck and posterior drainage of the contaminated  Instrumental…
mediastinum is diagnostic. space - Endoscopy
 Pleural effusion is common and is  Oesophageal stents may be helpful in - Oesophageal dilatation
seen mostly on the left w’ distal selected pts. - Intubations of stents for
perforation.  Most pts will need long-term malignant obstruction
nutritional support. - Injection of sclerotherapy for
Gastrografin Swallow:  Perforations at the cervical varices
 Indicated to locate the site of the oesophagus usually respond to  Non-instrumental…
leak. conservative Rx. But the formation of - Post emetic (e.g., Mallory-Weiss)
 High false negative rate. an abscess or signs of spread into the - Submucosal haematoma
mediastinum requires urgent - Free rupture
Endoscopy: drainage. - Foreign body; penetrating injury
 CONTRA-INDICATED. - Anastomotic leak
 INVESTIGATIONS MANAGEMENT
GASTRIC Endoscopy:
 Primary investigation of choice.
 Clinical staging directs approach to
Rx.

CARCINOMA  For viewing & biopsy.

 All ulcers should be biopsied!
 1x biopsy – 70% sensitivity.
 Pts who appear to have loco-regional
disease are potentially curable.
 Pts w’ advanced stage IV disease are
 7x biopsies - >98% sensitivity. usually referred for palliative care.
 Adjuvant & neoadjuvant therapy
PRESENTATION CT Abdo: options are also considered.
Majority of pts are symptomatic &  To determine stage of disease.
already have advanced disease at time  Include CT chest if it’s a proximal Sx:
of presentation. gastric lesion.  Resection (incl. adjacent LNs) is the
 Dyspepsia (most common)  Include PET-CT if concerned of cornerstone Rx for pts w’ localized
 Local complications (haemorrhage; distant LN spread. disease.
obstruction; perforation)  Lesions of the distal half of the
 Loss of weight Endoscopic U/S: stomach are Mx by distal
 Anaemia  Useful to biopsy suspicious LNs or to gastrectomy & lymphadenectomy.
 Metastasis determine depth of infiltration of  If a small distal cancer is removed a
 Dysphagia (common in masses in early lesions. partial gastrectomy w’ a Billroth I
proximal stomach or OG junction) may be suitable.
 Virchow’s node Barium Meal:  Larger distal tumours will need a
 Palpable mass  To determine functional anatomy & larger resection& Roux-en-Y or
tumour involvement. Billroth II reconstruction.
Symptoms of peptic ulcer & gastric  More extensive lesions or those
carcinoma are notoriously Staging Laparoscopy: involving the proximal half of the
indistinguishable.  Useful for picking up ~30% of pts who stomach are Mx by total gastrectomy
will have small peritoneal masses not & lymphadenectomy w’
Ddx for Dyspepsia: functional; peptic visible on CT. oesophageaojunjunal anastomosis.
ulcer disease; gastritis; GORD;  Irresectable, obstructed lesions may
oesophagitis; drug s/e; biliary disease. TNM Classification used for staging. be surgically palliated.
 Classification: (Lauren)
BACKGROUND
 Common, more so in men. Intestinal Diffuse
 Frequently incurable. Ulceration Constricting
 Usual histological type is gastric Acinar formation No acini
adenocarcinoma. Site: antrum Site: fundus
 3rd commonest cause of cancer death
in men.  Some cancers have features of both
 Peak incidence in 6th & 7th decade, (mixed).
but also seen in 20s & 30s.  Intestinal subtype most common.

Predisposing Factors:
 Chronic atrophic gastritis
 H Pylori
 EBV
 Previous gastric Sx
 Previous abdo irradiation
 Blood group A
 Family history
 Hereditary diffuse gastric cancer
 Gastric polyps
 Hypertrophic gastropathy
 Gastric ulcers (association)
 Pernicious anaemia
 Endoscopy:  Avoid fatty foods
GORD  NB to assess for oesophagitis and to
exclude other ass. conditions.


Smoking cessation
Reduce alcohol intake
 Mandatory to exclude malignancy in  Smaller meals
cases w’ an ass. stricture.  Avoid sleeping on a full stomach
PRESENTATION  Elderly should avoid NSAIDs
Oesophageal Motility Studies:
 May be asymptomatic.  Recommended but not essential Medical Mx:
 Heartburn (burning retrosternal / except when ass. motility disorders  PPIs - Most effective. Maintenance Rx
epigastric discomfort) & acid regurg are suspected. required in pts w’ oesophagitis due to
ass. w’ meals, stooping, & lying
high relapse rates. For others, “on
down. 24h Ambulatory pH Monitoring: demand” Rx.
 Regurg may lead to aspiration,  Indications…  H2-RA – Still used for mild
contribute to asthma, and cause - To confirm GOR in cases w’ symptomatic disease but not as
hoarseness. severe reflux symptoms without effective in healing erosive
 Many pts will have an associated macroscopic evidence of oesophagitis.
sliding hiatus hernia. oesophagitis on endoscopy.
 Majority of pts w’ GORD have mild - If reflux symptoms don’t respond Sx: (Nissen Fundoplication)
symptoms without ass. oesophagitis to appropriate Rx.  NB to choose candidates well as long-
(NERD). - Atypical GOR symptoms. term complications are common.
 Possible indications for referral for
Complications of GORD: oesophagitis;
circumferential ulceration; stenosis; MANAGEMENT Sx…
- Failure of conservative Rx.
bleeding; Barrett’s; adenocarcinoma. In the presence of typical symptoms, & - Hiatus hernia w’ poor LES
the absence of danger signs (LOW, pressures & volume reflux
INVESTIGATIONS anaemia, dysphagia), a young pt may be
given empiric Rx.
(regurg) is the strongest
indication for Sx.
Barium Swallow/Meal:
- Young pt who responds well to &
 To assess for a hernia. Lifestyle Mx: requires maintenance Rx w’ PPIs
 May also show reflux but is not a  Weight loss to control symptoms and
reliable indicator of pathological  Avoid incr. abdo pressure oesophagitis are also strong
GORD.  Elevate head of ben candidates.
Approach to…
HX & EXAM RESUS
History:
UGIT BLEED
ABCs
 Hx of periodic dyspepsia related to  Large bore IV line & catheter
meals or excessive analgesic mandatory.
ingestion may implicate peptic ulcer  Fluid resus is started w’ standard
CAUSES disease. crystalloid & colloid solutions until
Most Common Causes:  Excessive alcohol intake and known blood is available.
liver disease may suggest  Pts suspected of variceal bleeds must
 Oesophagus…
- Varices oesophageal varices. not be given sodium containing
- Mallory-Weiss tear  Mallory-Weiss tear often has a Hx of crystalloid solutions. They must only
repeated vomiting following a binge. be resuscitated w’ blood & 5%
 Stomach…
- Gastric ulcers  Attempt should be made to estimate dextrose, given FFP to replenish
- Erosive haemorrhagic gastritis amount of blood loss on hx. clotting factors, & octreotide.
 Duodenum…  Blood loss must be replaced
- Duodenal ulcers Exam: adequately and promptly w’ blood &
- Erosive duodenitis  Assess haemodynamic status and blood products as needed.
Most common causes of MAJOR UPGI general state of other systems.  In stable pts w’ a low Hb, transfusion
bleeds are peptic ulcer disease &  Shocked pts are at increased risk of trigger is 7g/dL, & target is 9g/dL.
oesophageal varices. rebleeding, esp. elderly pts.  In pts w’ IHD or at risk, transfusion
 Younger pts have a greater capacity trigger is 8g/dL, & target is 10g/dL.
Other Uncommon Causes: to compensate for haemorrhage so  Unstable pts get transfused until
 Tumours clinical findings may be more subtle. there is a clinical response &
 Vascular malformations  Look for evidence of chronic liver haemodynamic stability is achieved.
 Oesophagitis disease.  Do Baseline blood investigations.
 Oesophageal ulcers  PR exam should be done to check for  NGTs not routinely used.
melaena.  All UGIT bleed pts must receive IV
 Cameron’s ulcer
 GAVE (watermelon stomach) PPIs.
 Aorto-enteric fistula
 Splenic artery aneurysm rupture
 Haemobilia
After Resus – MBS Risk Stratification: Rockall Score:  Pts at highest risk of re-bleeding…
 0-2 – D/C w’ endoscopy follow-up  Done post endoscopy for risk - >60yrs old
within 1 week. stratification. - Shocked on admission
 >2 – admit.  Allows identification of pts at risk of - Endoscopic stigmata of recent
 >10 or suspected variceal bleed – death or adverse outcome. bleeding
considered high risk; must be  Guides on decision making regarding - Large ulcers (>2cm)
admitted to high care & have which pts need more intensive - Lesser curve gastric & posterior
endoscopy within 12hrs. monitoring & interventions. duodenal bulb ulcers.

 Endoscopic Mx…
ENDOSCOPY ANGIOGRAPHY - Diluted IV adrenalin (1:10 000)
 Dx investigation of choice!  Indicated in a small number of pts - Thermal coagulation
 Emergency endoscopy (within 12h) is who continue to bleed and when - Clipping devices
done after resus for pts w’ evidence endoscopy has failed to disclose a
of ongoing bleeding or suspected of likely bleeding site.  Angiography & Embolization…
oesophageal varices.  Bleeding from obscure & uncommon - Transcatheter arterial
 All other pts should have an sites such as the liver, pancreatic embolization is an alternative to
endoscopy within 24hrs. duct, small bowel, & colon, may be Sx in high-risk pts where
identified. endoscopic Mx has failed.
Endoscopic Stigmata of Bleeding
Peptic Ulcers (Forrest Classification):  Surgical Mx…
PEPTIC ULCER BLEEDS - Main objective is to secure the
High Risk  Start w’ IV PPI either at time of bleeding vessel.
IA Spurting blood (visible vessels) admission or once dx confirmed.
IB Ooze blood (non-visible vessel)  Oral PPI can be started once pt  Indications for Surgical Mx…
IIA Non-bleeding visible vessel stable. - Failed endoscopic Mx.
IIB Adherent clot  Risk of re-bleeding highest in first - Recurrent bleeding after 2 failed
48hrs. endoscopic Mx attempts.
Low Risk  Monitor Hb & electrolytes daily. - Associated perforation (rare).
IIC Pigmented spot  Pt must receive blood transfusion to
III Clean ulcer base maintain Hb as near to normal as
possible.
Approach to… Lumen: gallstones; bezoar; foreign
body; enterolith. HX & EXAM

SBO
Hx: ask about…
 SBO, in contrast to LBO, is more  Previous Sx.
often caused by benign lesions.  Hernias that are now irreducible.
 By far the most common causes are  Malignancy or severe loss of weight.
adhesions are hernias.  Inflammatory bowel disease.
PRESENTATION  Neoplastic disease as a cause of SBO  Previous irradiation.
Presentation varies according to level is likely to be metastatic peritoneal  Prior episode of SBO.
& duration of obstruction. disease rather than a primary
 Abdo discomfort / colicky pain tumour. Exam Findings:
 Abdo distention  Primary tumours are rare but may be  Gaseous distension.
 Obstipation a lead point in intussusception.  Previous Sx scars (adhesions).
 Nausea & vomiting (bile stained)  Intussusception more common in  Early vigorous peristalsis, later
more likely w’ more proximal children. silent.
obstructions  Paeds pts may also develop SBO due  Palpable mass.
 Faeculent vomiting (in lower to a volvulus.  Signs indicating possible malignancy,
obstructions)  Haematomas may occur due to such as periumbilical mass (Sister
trauma or spontaneously in pts Mary Joseph nodule); Virchow’s
taking anticoagulants.
CAUSES  Gallstones may cause SBO by
node; hepatomegaly.
 Localized rebound tenderness &
Extrinsic: adhesions; hernias; entering through a cholecystenteric guarding suggest perforation.
neoplasms; intra-abdo sepsis/abscess; fistula.  Examine hernia site for irreducibility.
ruptured appendix/diverticulum.  Small bowel perforation may occur  Blood PR
secondary to bowel obstruction or (intussusception/infarction).
Wall: malrotation; cystic fibrosis; spontaneously in conditions such as –
Meckel’s diverticulum; Crohn’s; TB; TB; typhoid; CMV; malignancy; Features of Intussusception:
actinomycosis; haematoma; ischaemic Crohn’s; steroids; radiotherapy.  Colicky abdo pain
stricture; neoplastic; intussusception;  Pts w’ HIV may present w’
endometriosis; radiation strictures.  Palpable abdo mass
perforation but w' few clinical signs
 PR bleeding
other than generalised malaise.
  Haemoconcentration may be  The bowel must be adequately
INVESTIGATIONS present. assessed for viability before being
Plain Abdo X-Ray:  Acidosis & raised lactate are not reduced.
 Shows dilated loops of small bowel conclusive but are indicators of
(>3cm) & the absence of dilated bowel necrosis. Mx of Foreign Body:
large bowel.  Require laparotomy & enterotomy to
 Erect AXR will show multiple air-fluid remove.
levels (>2). MANAGEMENT
 May also detect foreign bodies, a Initial Mx: (ABCs)
gallstone in the small intestine, or  Aggressive early fluid resus. PATHYPHYSIOLOGY
air in biliary tree (suggesting  Appropriate electrolyte replacement. Obstruction occurs, then…
cholecystenteric fistula)  Abx if perforation suspected.  Initially increased peristalsis.
 Any free air on AXR indicates  NPO; NGT; Urine catheter.  Then peristalsis reduces.
perforation and necessitates urgent  Bowel expands.
Sx. Mx of Adhesive Bowel Obstruction:  Bowel distends w’ gas & fluid
 Conservative Mx w’ IV line & NGT proximal to obstruction due to
Oral Contrast Media: (“drip & suck”), provided there is no increased bacterial proliferation &
 Can confirm presence of total/partial suspected perforation. swallowed air.
obstruction.  Sx indicated if pt not improving or  Increased oedema of bowel wall.
deteriorates.  impaired transport of fluid &
CT:  Pt must be referred to stoma electrolytes.
 May be helpful in dx carcinoma & therapist prior to Sx.  Dehydration & hypovolaemia.
other extrinsic lesions.  Impaired venous return due to
 Sx…
 More accurately determines level of increasing intraluminal pressure.
- Adhesiolysis.
obstruction  Eventually impairs arterial blood
- Usually via open laparotomy.
 Can also detect irreversible necrotic flow.
bowel.  Gangrenous perforation may occur.
Mx of Hernias:
 Other organs compromised due to
 Usually reduced by the standard
Bloods: septic shock.
hernia incision, depending on the
 Electrolyte levels will identify extend  Distension also elevates & splints the
site.
of dehydration. diaphragm, impairing respiration.
 WCC may/may not be raised.
UPPER GI ANATOMY
ABDOMINAL WALL
INTRAPERITONEAL VS EXTRAPERITONEAL
STOMACH
DUODENUM
JEJUNUM & ILEUM
 INVESTIGATIONS MANAGEMENT
OESOPHAGEAL Endoscopy: Sx:

CANCER  For visualization & biopsy.  If early detection occurs of Barrett’s,

or even small adenocarcinomas
Bronchoscopy: limited to the mucosa, endoscopic
 If mass in upper ½ of oesophagus. mucosal resections can be done.
PRESENTATION  To rule out airway invasion. Allows for sparring of oesophagus.
 Oesophageal resection
Local Tumours Effects…
Contrast Swallow: (esophagectomy) is mainstay of Rx
 Dysphagia for oesophageal cancers infiltrating
 Mainstay of screening.
 Cough & regurg beyond the mucosa. Reserved for pts
 Odynophagia CT w’ Contrast: who are resectable & fit for Sx. Pre-
 Weight loss  Chest, abdo, & pelvis. op chemoradiation is offered to all
 Upper GI bleeding  To assess for metastasis for staging. these pts.
 Not very accurate for assessing  Trans-hiatal esophagectomy offers
Invasion of Surrounding Structures… the advantage of avoiding a chest
histologic depth of tumour (T) or
 Respiratory fistula assessing LN status. incision. After removal of the
 Hoarseness (recurrent laryngeal n.) oesophagus, continuity of the GIT is
 Hiccups (phrenic n.) PET Scan: re-established using the stomach.
 Pain (local spread)  For staging.
 Accentuates masses that are
Distant Disease… metabolically active & indicates
 Spread to lungs, liver, and CNS. faster-growing cells.
 Hypercalcaemia (paraneoplastic)  More sensitive than CT for detecting
distant mets.
Majority of pts have unresectable or
metastatic disease at the time of Oesophageal Endoscopic U/S:
presentation.  Very useful in assessing the local
depth of the tumour & LN spread.
 Also used for FNA of suspicious LNs.
Radiotherapy:  6th most common cause of cancer-
 Successful in relieving dysphagia in related death.
~50% of pts.
Predisposing Factors:
Stenting:  Sex (male)
 For pts who can’t have Sx or RT.  Age (60-70)
 For relief of dysphagia.  Smoking & alcohol
 Particularly useful when a TOF is  GORD & Barrett’s
present.  Obesity (by increasing risk of GORD)
 If the stent crosses the OG-junction,  Other factors – nutrient deficiencies;
pt must be put on reflux Rx. HPV inf; caustic strictures; achalasia;
oesophageal diverticula; Plummer-
Vinson Syndrome; diet.
STAGING Oesophageal U/S showing tumour (T) and surrounding
adenopathy (LN) in relation to the Aorta (Ao) Pathophysiology:
TNM STAGE  Oesophagus has no serosa, thus
Tis N0 M0 0 reducing its resistance against local
T1 N0 M0 I BACKGROUND spread of invasive cancer cells.
T2 N0 M0 IIA  97% are either squamous cell  Oesophagus has extensive network of
T3 N0 M0 carcinoma or adenocarcinoma. lymphatics, allowing early spread.
T1 N1 M0 IIB  Squamous cell carcinomas arise from
T2 N1 M0 cells lining the upper oesophagus. Prevention:
T3 N1 M0 III  Adenocarcinomas arise from cells at  Surveillance programs w’ Barrett’s
T4 Any N M0 the OG-junction. oesophagus.
Any T Any N M1 IV  Squamous ca is more evenly  Low grade dysplastic Barrett’s should
distributed throughout the length of be Rx locally by endoscopic
Optimal clinical staging should include the oesophagus. radiofrequency ablation.
at least a CT of the chest and  Adenocarcinoma is predominantly  Any nodularity as well as Barrett’s w’
abdomen. If available, Endoscopic U/S. found distally closer to the OG- high grade dysplasia or tumours
if appropriate, PET scan. junction. limited to the mucosa should
 8th most common cancer. undergo endoscopic mucosal
resection.
 INVESTIGATIONS MANAGEMENT
PEPTIC ULCER Endoscopy: (gastroscopy) Medical Mx:

DISEASE  Highly sensitive in confirming dx.

 Also allows biopsy to exclude cancer.
 PPI bd for 1 week.
 PLUS…1-week Abx course of…
 Features of benign ulcers… - Amoxicillin 1g bd
- Smooth, regular, rounded edge - Clarithromycin 500mg bd
PRESENTATION - Flat smooth base - Metronidazole 400mg bd (alt. to
- Surrounding mucosa shows clar.)
 Epigastric pain (shortly after meal if
radiating folds  Then followed by…
gastric; 2-3hrs after meal if
 Features of malignant ulcers… - Daily PPI to complete 1 month of
duodenal).
- Irregular, heaped-up or Rx.
 Food may relive the pain of duodenal
overhanging margins  Follow-up pt 6-8 wks after w’
ulcers.
- Ulcerated mass protruding into endoscopy to document healing of
 Mild epigastric tenderness. lumen ulcer & to rule out cancer.
 Nocturnal ain (common in duodenal - Nodular & irregular surrounding  Pt should also discontinue NSAID use.
ulcers). folds  If pt unable to stop NSAID (for
 Pain typically follows a daily pattern.  Biopsy of gastric antrum can be used medical reasons), maintenance PPI
 Other manifestations include to confirm presence of HP by rapid Rx is recommended.
dyspepsia, & heartburn urease test or histopathology.  Refractory ulcers (not healed by 8-12
wks of standard Rx), may continue
RED Flags (refer to exclude cancer): Breath & Serological Tests for HP: daily PPI Rx indefinitely.
 Bleeding or anaemia  Used in selected cases.  If HP is negative & NSAID use is
 Early satiety excluded, ZES should be considered.
 Unexplained weight loss
 Progressive dysphagia Sx:
 Recurrent vomiting  Reserved primarily for complications
 Family hx of gastric cancer such as bleeding, perforation, gastric
outlet obstruction, and occasionally,
Ddx: non-ulcer dyspepsia; acute for persistent penetrating ulcers.
cholecystitis; biliary colic; ACS; acute
gastritis; oesophagitis; GORD.
 CAUSES PU PERFORATION GASTRIC OUTLET
H PYLORY! Presentation: OBSTRUCTION
NSAIDS!  Acute onset epigastric pain,
Presentation:
 Other less common causes include – progressing to severe generalised
pain within 24-48h.  Dyspepsia & LOW.
lifestyle factors; severe physiologic  Anorexia, nausea & vomiting of
stress; hypersecretory states (e.g.,  Neurogenic shock.
undigested food.
gastrinoma); genetic.  Hypovolaemia.
 Dehydration.
 Corticosteroids can potentiate ulcer  Board-like rigidity.
 Upper abdo distention.
risk in pts who use NSAIDs  Absent bowel sounds.
 Visible peristalsis (left to right).
concurrently.  Gross distention (later)
 Succussion splash.
 HP & NSAIDs are synergistic in the  Hyponatraemic, hypokalaemic,
development of PUD. Investigations:
 Erect CXR & AXR (air under the metabolic alkalosis.
diaphragm in 80% of cases).
BACKGROUND  Serum amylase may be raised.
Investigations:
 AXR – dilated stomach w’ food.
 Can involve stomach or duodenum.  Contrast CT useful if in doubt or for
suspected sealed perforation.  Ba meal – hold up at the pylorus or
 3 types… duodenum w’ a dilated stomach.
- Pre-pyloric (<2cm from pylorus).  NB!!! Endoscopy CONTRAINDICATED!
 Endoscopy – for biopsy to exclude
- Combination of duodenal &
Mx: ca.
gastric ulcer.
- Ulcers >2cm from pylorus on  Initial Mx – IV fluids; analgesia; NGT;
Mx:
lesser curve. IV PPI; IV broad spec Abx.
 Rehydration.
 Ulcers occurring elsewhere in the  Sx – closure w’ omental patch,
followed by HP eradication.  Correction of potassium deficit.
stomach should raise suspicion of
analgesic abuse or gastric carcinoma.  Ulcers biopsied either during Sx or 4-  Gastric washouts w’ wide bore tube
6 wks post-op (preferred). prior to endoscopy.
 More than 95% of duodenal ulcers are
found in the 1st part of the  For larger ulcers and those where  Peptic ulcer therapy.
duodenum and are almost always cancer is suspected, a standard  Endoscopic dilatation may avoid or
benign. Billroth I gastrectomy is defer Sx in selected high-risk pts.
recommended.  Sx (pyloroplasty) is needed in most
cases.