胃十二指腸疾病(雙語教學(xué))說課講解

1、胃十二指腸疾病(雙語教學(xué))AcidGastric Mucosal BarrierNonsteroidal Antiinflammatory Drugs（NSAIDs）AlcohalGastric StasisHelicobacter Pylori, HPCigarette SmokingDuodenal Ulcervagus nerveoversecretion of acidGastric UlcerDisruption of gastric mucosal barrier 2,Gastric stasishunger painnight painDiagnosisHistory Fiber

2、optic Endoscopy Radiology十二指腸球部前壁可見一圓形瘍，大小約0.6cm0.7cm潰瘍，基底覆黃厚壞死苔，周邊充血水腫 十二指腸球部前壁可見一大小約1.0cm1.2cm潰瘍，潰瘍表面覆蓋黃白色壞死苔，周邊充血水腫。 Inefficacy of medical treatment intractable ulcer, telephium （hemorrhage, perforation, cicatricial Pyloric Obstruction ）Sabiston Textbook of Surgery, 18th edNo regularity of gatric

3、 pain1/2-1h after ingestion，postprandial discomfortIngestion of food and antacids can not relieve pain ,or exacerbation on eating 男，48歲。上腹痛。幽門可見，類圓形，呈開放狀態(tài)，粘膜充血水腫，可見大小約1.0cm1.2cm潰瘍，潰瘍表面覆蓋黃白色壞死苔，周邊充血水腫，色澤紅。 胃角中央可見一1.5cm1.8cm圓形深潰瘍,內(nèi)附較厚的黃色壞死苔,周邊充血水腫；經(jīng)兩次病理活檢,確診為良性潰瘍。type 1 （60%）： have low-to-normal acid

4、output. between the fundic and antral type 2（15%）： located in the body of the stomach in combination with a duodenal ulcer. associated with excess acid secretion.Type 3 （20%）：are prepyloric ulcers and are associated with hypersecretion of gastric acid. Type 4 （10%）：occur high on the lesser urvature

5、near the GE junction. are not associated with excessive acid secretion.（ulcers on the greater curvature of the stomach, 5% ）Acute Perforation of Gastroduodenal Ulcer90% of perforated duodenal ulcers occur in the anterior duodenal bulb. 60% of gastric ulcers are located in the lesser curvature.chemic

6、al peritonitis bacterial peritonitisCLINICAL MANIFESTATION AND DIAGNOSISUlcer history 10% negtiveSevere epigastric and later generalize abdominal pain。（Nausea and vomitingToxic Symptom: fever，WBC，low blood preasure。CLINICAL MANIFESTATION AND DIAGNOSISsupination仰臥 and lies stillBoardlike rigidity of

7、the abdominal musculature，boardlike venter 板狀腹Decreased bowel sounds80% cases show free air under the diaphram，eroperitoneum氣腹癥 not clear, food residue, yellowishDifferential Diagnosis1Acute Pancreatitis1Acute Cholecystitis1Acute Appendicitis 1Perforation Of Gastric Cancer indicationMild clinical ma

8、nifestation, limited peritonitisPerforation on empty stomachRule out telephium頑固性潰瘍, hemorrhage, obstruction and cancerationHard to tolerate surgical procedureThe erotion of base vessal in ulcer.Common in lesser gastric curvature or posterior wall of duodenumClinical Manifestation And DiagnosisHaema

9、temesis and melenaBlood loss 400ml, pale, dry mouth, quick pules 800ml，shockAbdominal physical sign is not obviousDifferential DiagnosisEsophageal Varices BleedingAcute HemobiliaStress Ulceration Bleedingtherapeutic principleHemostasis Subtotal gastrectomy幽門成形術(shù)Cicatricial Pyloric ObstructionSpastici

10、tyEdematousCicatricleclinical manifestation and diagnosisClinical Manifestationsplashing soundDiagnosisDifferential Diagnosis gastrointestinal decompression胃腸減壓 gastric lavage洗胃 3-7days to correct Water-Electrolyte and acid base balance disorder subtotal gastrectomy vagotomy + antrectomy胃竇切除術(shù)胃竇切除術(shù)st

11、omach-jejunum anastomosisBillroth I Simple, to fit physiological function；reduce refluxing of bile and pancreatic juice；Insufficient gastrectomy.Hemigastrectomy with Billroth 1 (gastroduodenal) anastomosis. (From Dempsey D, Pathak A: Antrectomy. Operative Techniques in General Surgery 5:86100, 2003.

12、)Billroth II sufficient gastrectomy, complicated more postoperative complicationBillroth II operation and some of its modifications. parietal cell or highly selective vagotomy Figure 45-12 A to E, Heineke-Mikulicz pyloroplasty. (AE, From Soreide JA, Soreide A: Pyloroplasty. Operative Techniques in G

13、eneral Surgery 5:6572, 2003.)Surgical Treatment Recommendations for Complications Related to Peptic Ulcer Disease Duodenal UlcerIntractable: parietal cell vagotomy Bleeding: truncal vagotomy with pyloroplasty and oversewing of bleeding vessel Perforation: patch closure with treatment of H. pylori wi

14、th or without parietal cell vagotomy Obstruction: rule out malignancy and parietal cell vagotomy with gastrojejunostomy Sabiston Textbook of Surgery, 18th edSurgical Treatment Recommendations for Complications Related to Peptic Ulcer DiseaseGastric Ulcer Intractable: Type I: distal gastrectomy with

15、Billroth I Type II or III: distal gastrectomy with truncal vagotomyBleeding Type I: distal gastrectomy with Billroth I Type II or III: distal gastrectomy with truncal vagotomy Perforated Type I, stable: distal gastrectomy with Billroth I Type I, unstable: biopsy, patch, and treatment for H. pylori T

16、ype II or III: patch closure with treatment of H. pylori Sabiston Textbook of Surgery, 18th edSurgical Treatment Recommendations for Complications Related to Peptic Ulcer DiseaseGastric UlcerObstruction: rule out malignancy and antrectomy with vagotomy.Type IV: depends on ulcer size, distance from t

17、he gastroesophageal junction, and degree of surrounding inflammation. Giant gastric ulcers: distal gastrectomy, with vagotomy reserved for type II and III gastric ulcers. Sabiston Textbook of Surgery, 18th edOperations for high-lying ulcers near the gastroesophageal junction (type IV) POSTOPERATIVE

18、COMPLICATIONS OF SUBTOTAL GASTRECTOMYPOSTOPERATIVE COMPLICATIONSpostoperative complicationspostoperative complications of subtotal gastrectomypostoperative complications of subtotal gastrectomypostoperative complications of subtotal gastrectomyEarly Dumping Syndrome：Late Dumping Syndrome:postoperati

19、ve complications of subtotal gastrectomyAlkaline Reflux Gastritispatients Roux-en-Y anastomosis postoperative complications of vagotomyEarly gastric cancer disease involving only the mucosa or submucosa Advanced gastric cancer invasion of the muscularis or beyondEarly gastric cancer型型 隆起型隆起型a型型隆起表淺型

20、隆起表淺型b型型平坦表淺型平坦表淺型 c型型表淺凹陷型表淺凹陷型型型 凹陷型凹陷型型型表淺型表淺型Borrmanns pathologic classification of gastric cancer based on gross appearance1，spread within the gastric wall 2，lymphatic metastasis 23 group lymph nodes supraclavicular lymph nodes左鎖骨上淋巴結(jié)3，blood spread ：hepatic metastasis4，implantation metastasis種植

21、轉(zhuǎn)移5，ovaries metastasis卵巢轉(zhuǎn)移6，gastric micrometastasis微轉(zhuǎn)移N1：16 lymph nodes metastasisN2：715 lymph nodes metastasisN3：16 lymph nodes metastasisN N0 0N N1 1N N2 2N N3 3T T1 1A AB BT T2 2B BA AT T3 3A AB BT T4 4A AH H1 1 P P1 1 CY CY1 1 M M1 1N stage of the JGCA ( Japanese Gastric Cancer Association) classification (the thirteenth edition)腫瘤部位N1N2N3L/LD3,4d,5,61,7,8a,9,11p,12a,14v4sb,8p,12b/p,13,16a2/b1LM/M/ML1,3,4sb,4d,5,67,8a,9,11p,12a2,4sa,