16/08/2010

Complications of PU
Investigation and Management
 Upper GI Bleeding
of Complications of Peptic Ulcer
 Perforation

 Obstruction of lumen

 Malignant Change

History of haematemesis •Asking features of liver disease

 Onset, Frequency, Amount revealed, Colour, Odour /
taste, Associated with fainting
•Alcohol history
Differentiation between haematemesis from •Hepatitis ,jaundice
haemoptysis •Cirrhosis
 Associated with cough
 Froth? •Features of portal hypertension
History of melaena. •Ascites
 Onset, Frequency, Amount revealed, Associated with
fainting
Asking characteristic features of melaena
 Tarry, Sticky, Smell, Blood colour on washing

•History suggestive of peptic ulceration •History suggestive of gastric erosion

•Epigastric pain •Taking NSAID
•Hunger pain / nocturnal pain •Indigenous medicine
•Food induced pain •Alcohol ,excessive vomiting
•Aggravating and relieving factors
•History of taking antacids
•Any associated symptoms

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•History suggestive of CA stomach History of bleeding disorder

•Mass in epigastrium  Gum bleeding
•Weight loss / loss of appetite  Epistaxis
 Blood transfusion

Past medical history –bleeding D/O, VH

Past surgical history-PU
Drug history
 NSAIDs, steroids, anticoagulants, including
indigenous medicine
Family history
 I T P Haemophilia
Personal history
 Alcohol
 Smoking
GOO
 Irregular meal, hard /spicy food

C/o Vomiting and Feeling of distension Pain…..site, character,

after meal x duration periodicity, severity,
Features of GOO relieving and aggravating
1.Bloating factors.
2.Distension after meals. Change of character and
3. Vomiting  timing, relation to
loss of periodicity after
meals, character, amount and presence
or absence of undigested food. onset of GOO

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Weight loss / loss of appetite, Past history of PU

Inquire about a vague lump moving
about in the abdomen
Inquire about mass, pallor, asthenia
History of haematemesis and
melaena
History of obstructive jaundice
Personal history - alcohol, smoking
Social history-smoked food, irregular
meal.
Drug history of antacids and anti-ulcer
therapy
Prolong use of NSAIDs and steroids

MANAGEMENT Investigations
 1.Resuscitation  Oesophago-gastro-duodenoscopy
 2.History taking & physical examination to  Barium studies
know the site & cause of bleeding
 Angiography
 3.Investigations
 for detecting site & cause of bleeding  Specific investigations
 4.Definitive treatment
 arrest of haemorrhage/treatment of underlying
cause

Treatment
 Arrest of haemorrhage first …followed by
 Treatment of underlying cause of
haemorrhage

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Peptic Ulcers:
Gastric & Duodenal Ulcers

Benign Gastric Ulcer Duodenal Ulcer

Site of Biopsy for H.pylori Test

Antrum

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Liver Haemangioma CT B) Arterial phase

A) Pre-
Pre-contrast

C) Portal venous phase

D) Delayed phase

CT – we will not do delayed phase unless haemangioma suspected.

Please specify “? haemangioma” on request form.

GUD after perforation of PU Specific investigations

 Ultrasound abdomen or CT scan

 ERCP ~ to detect Peri-ampullary Ca
 Spleno-portogram
 Ba meal in Trendelenberg position ~to
detect hiatus hernia
 Liver function tests
 Biopsy of enlarged supraclavicular nodes

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Peptic Ulcer Disease Pyloroplasty

Peptic Ulcer Disease

Pyloroplasty Surgical Treatment

A. Billroth I Procedure B. Billroth II Procedure

Fig. 40-16

PG and GJ A. Billroth I Procedure

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B. Billroth II Procedure B. Billroth II Procedure

3 Chief complaint, containing, complaint +

Investigation and duration
(Pain in RHC)
Management of 4 Pain
Onset
Obstructive Jaundice Duration
Character
Severity
Radiation and referred pain
Relieving and aggravating factors
Any other associated features

5 History of upper GI upset History of jaundice

Dyspepsia Yellow colouration of skin
Nausea 6 and sclera
Vomiting High colour urine
Distension of abdomen Nature of jaundice
Colour of stool

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History of obstructive jaundice

Pale stool History of fever
7 Itchiness 8 Duration
Nature of jaundice
Type of fever
Intermittent / progressive
Chills and rigors.

11 Past medical history-bleeding

9 History of passing of
D/O, malaria, worm infestation ,
worm , bleeding similar attack
tendency
12 Past surgical history-operation
10 History of LOW, LOA & like laparotomy & bypass or
mass in RHC resection and anastomosis

13 Personal history
Smoking Examination of
Alcohol drinking. Obstructive Jaundice
14 Drug history cholesterol
lowering agent, weight
reducing agent, androgens

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3 General examination 
Pallor, Jaundice (Depth of J )
,Fever, Left Supraclavicular
LN enlargement, Palmar
erythema, clubbing and
oedema, Scratch marks,
Cachexia
5 Any localized visible mass
(describe)
6 Palpation
Light palpation & deep
palpation.
Tenderness in RHC, soft.
8 Liver enlargement &
tenderness.
Palpable gall bladder
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4 Local examination
Inspection  General contour of
abdomen
Move with respiration,
visible mass in GBA
Any previous surgical scars,
distended vein
Hernia orifices,
Condition of umbilicus
7 Mass present or not
If present description
of mass (5 S)
Consistency
Rising test.
Moves with respiration or not.
9 Feature of GOO
10 Percussion & Auscultation
Shifting dullness & any
upward enlargement of the
liver.
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11 Mention that you would like
to do PR examination-
melaena stool, clay color
stool
Causes of Obstructive
Jaundice
 Intraluminalcauses
 Intramural causes

 Extraluminal causes

Intraluminal causes

 Common bile duct stones

 Ascaris lumbricoides

 Hydatid cyst of biliary tree

Intramural cause
 CBD strictures
Iatrogenic
Traumatic
 Periampullary carcinoma

 Choledochal cyst

 Cholangiocarcinoma

 Sclerosing cholangitis

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Extramural causes:
causes:
 Carcinoma head of pancreas
 Chronic pancreatitis
 Malignant lymph nodes in the porta
hepatis
 Others:
 Liver secondaries
 Biliary atresia
Imaging Ultrasound:
• The level of biliary obstruction will help
to guide further investigation if the
cause of the obstruction is not
apparent.
 Distal obstruction may also be caused
by CBD stones/ Adult Ascaris worm/
Duodenal or Periampullary lesion.
 These can be investigated by
duodenoscopy and biopsied if directly
seen.
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Imaging Ultrasound:
• shows the size of the bile ducts
• defines the level of the obstruction
• identifies the cause (in some cases)
• gives other information related to the
disease (e.g. hepatic metastases, gallstones,
hepatic parenchymal change)
• The echo-texture of the liver, splenomegaly,
ascites, and signs of portal hypertension
Distal obstruction
 Dilation of the intra-
intra- and extrahepatic bile
ducts is present; most patients will have a
gallstone in the common bile duct or
carcinoma of the head of pancreas .
 Both diagnoses may be apparent on
ultrasound, but often the distal bile duct is
poorly seen with ultrasound due to overlying
bowel gas.
Proximal obstruction
 Proximal biliary dilation usually results from
obstruction at the porta hepatis (Enlarged
Metastatic Lymph nodes / Klastkin`s Tumour
Tumour))
and is recognized by dilation of the
intrahepatic ducts without enlargement of
the distal common bile duct.
duct.
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Investigations Stones in CBD Malignancy Acute viral Ultrasound showing dilation of

hepatitis
Serum Bilirubin 50–150 Steady rise to Variable
the common bile duct
(mmol/l) >200

Urobilinogen in Urine Reduced Absent −early (+late)

Alkaline phosphatase >3× >3× <3×

Aspartate <5× <5× >10×

Aminotransferase
White cell count ↑/Normal ↑/Normal ↓(↑lymphocy
(differential) (↑polymorphs) tes)

Ultrasound Gallstones Gallstones +/_ Dilated ducts +

Dilated Bile Duct Mass

Ultrasound showing dilation of MRCP showing stone in the

the common bile duct common bile duct

MRCP
• Contrast enhanced spiral CT and MRCP has
revolutionized the management of  Noninvasive and effective with excellent imaging
obstructive jaundice. quality .
 Advantages…good for iodine containing contrast
allergic patient.
• MRCP gives exquisite assessment of the  Quality is currently below that available from ERCP
or PTC
pancreatic duct and bile ducts without  Magnetic resonance angiography (MRA)
the risks which may occur in (ERCP) -images of the hepatic artery and portal vein.
 Alternative to selective hepatic angiography for
diagnosis.
• Diagnostic ERCP virtually obsolete.  Useful in patients with chronic liver disease and a
coagulopathy in whom the patency of the portal vein
and its branches is in question.

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Same patient after percutaneous

MRCP showing ‘double duct
transhepatic cholangiography and
dilation’ with pancreatic cancer insertion of Wall stent

CT showing tumour encasement

• Contrast-
Contrast-enhanced multislice CT is the of coeliac axis branches by
radiological investigation of choice in most Pancreatic cancer (arrow).
UK centres for assessment of biliary
malignancies.

• Contrast agents (p.o

(p.o.,
., i.v
i.v.)
.) are used and
imaging done in unenhanced, venous and
arterial phases.

Management of Bile duct stones

 CBD stones management depends on:
Endoscopic ultrasound can further  physical condition

 comorbidity and medical history

evaluate relationships to vascular
 previous attempts at intervention
structures. It may help define  if the patient has had a cholecystectomy
benign lesions mimicking cancer  availability of

(e.g. sclerosing pancreatitis) equipment/theatre/anaesthetist/expertise of

Interventionist
 patient preference.

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Steps of open exploration of the

 ERCP±sphincterotomy
ERCP± common bile duct
 Laparoscopic exploration of the
 Laparotomy
common bile duct
 Choledochotomy
 Open exploration of the common
bile duct  Choledocholithotomy

 Stenting  Exploration of CBD

 Internal or External Drainage

Percutaneous transhepatic
Biliary stent cholangiography (PTC)
 PTC is indicated where endoscopic
cholangiography has failed or is impossible,
as in patients with previous Polya
gastrectomy.
 It is often required in patients with hilar bile
duct tumours where endoscopic
cholangiography fails to visualise the
intrahepatic bile ducts.
 Sometime, preoperative preparation of
obstructive jaundiced pt. to drain bile out.

Percutaneous transhepatic
Complications of stenting
cholangiography and bilobar stent
Immediate
of Klatskin tumour
 Sepsis
 Haemorrhage
 Acute pancreatitis
 Perforation and bile leak (peritonitis)
Late
 Recurrent jaundice due to:
 Displacement
 Sludging
 Overgrowth by neoplasm
 Erosion into adjacent viscus

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