胃十二指肠疾病(双语教学)

THEDISEASEOFSTOMACHANDDUODENUM胃十二指肠疾病OutlineSURGICALTREATMENTOFPEPTICULCERCOMPLICATIONSOFPEPTICULCERSTOMACHCANCERSURGICALTREATMENTOFPEPTICULCEREtiologyAcidGastricMucosalBarrierNonsteroidalAntiinflammatoryDrugs（NSAIDs）AlcohalGastricStasisHelicobacterPylori,HPCigaretteSmokingDifferenceBetweenGastricAndDuodenalUlcerDuodenalUlcervagusnerve------oversecretionofacidGastricUlcer1,Disruptionofgastricmucosalbarrier2,GastricstasisDuodenalUlcerClinicalfeatureburning，stabbing,orgnawingepigastricpain.3－4hoursafteringestionhungerpainandnightpainIngestionoffoodandantacidsoftenrelievepainDiagnosisHistoryFiberopticEndoscopyRadiology十二指肠球部前壁可见一圆形疡，大小约0.6cm×0.7cm溃疡，基底覆黄厚坏死苔，周边充血水肿十二指肠球部前壁可见一大小约1.0cm×1.2cm溃疡，溃疡表面覆盖黄白色坏死苔，周边充血水肿。DuodenalUlcerDuodenalUlcerSurgicalindicationInefficacyofmedicaltreatment（intractableulcer,telephium顽固性溃疡）seriouscomplication（hemorrhage,perforation,cicatricialPyloricObstruction）IntractableulcerIntractabilityislooselydefinedasfailureofanulcertohealafteraninitialtrialof8to12weeksoftherapyorifpatientsrelapseaftertherapyhasbeendiscontinued.----SabistonTextbookofSurgery,18thedGastricUlcerClinicalfeatureNoregularityofgatricpain1/2-1hafteringestion，postprandialdiscomfortIngestionoffoodandantacidscannotrelievepain,orexacerbationoneating男，48岁。上腹痛。幽门可见，类圆形，呈开放状态，粘膜充血水肿，可见大小约1.0cm×1.2cm溃疡，溃疡表面覆盖黄白色坏死苔，周边充血水肿，色泽红。胃角中央可见一1.5cm×1.8cm圆形深溃疡,内附较厚的黄色坏死苔,周边充血水肿；经两次病理活检,确诊为良性溃疡。GastricUlcerTypesOfGastricUlcertype1（60%）：havelow-to-normalacidoutput.betweenthefundicandantraltype2（15%）：locatedinthebodyofthestomachincombinationwithaduodenalulcer.associatedwithexcessacidsecretion.Type3（20%）：areprepyloriculcersandareassociatedwithhypersecretionofgastricacid.Type4（10%）：occurhighonthelesserurvatureneartheGEjunction.arenotassociatedwithexcessiveacidsecretion.（ulcersonthegreatercurvatureofthestomach,5%）GastricUlcerSurgicalindicationhemorhage,perforation,obstuction,intractability,needtoruleoutthepossibilityofcarcinomaAcutePerforationofGastroduodenalUlcerpathology90%ofperforatedduodenalulcersoccurintheanteriorduodenalbulb.60%ofgastriculcersarelocatedinthelessercurvature.chemicalperitonitis6-8hbacterialperitonitisCLINICALMANIFESTATIONANDDIAGNOSISUlcerhistory10%negtiveSevereepigastricandlatergeneralizeabdominalpain。（Thepatientcantypicallyrecalltheexacttimeofonsetofabdominalpain）NauseaandvomitingToxicSymptom:fever，WBC↑，lowbloodpreasure。CLINICALMANIFESTATIONANDDIAGNOSISsupination仰卧andliesstillBoardlikerigidityoftheabdominalmusculature，boardlikeventer板状腹Decreasedbowelsounds80%casesshowfreeairunderthediaphram，eroperitoneum气腹症DIAGNOSISHistoryPhysicalexaminationX-rayDiagnosticabdominalparacentesisnotclear,foodresidue,yellowishDifferentialDiagnosisAcutePancreatitisAcuteCholecystitisAcuteAppendicitisPerforationOfGastricCancerManagementNonoperativemanagementindication：Mildclinicalmanifestation,limitedperitonitisPerforationonemptystomachRuleouttelephium顽固性溃疡,hemorrhage,obstructionandcancerationHardtotoleratesurgicalprocedurePerforationrepairPatchingtheperforatedulcerIndicationsbadgeneralcondition;12h，sinceperforate;severeinflamationinabdominalcavitySurgicaltreatmentSurgicaltreatmentRadicalSurgerysubtotalgastricresectionpatchingmethods+highlyselectivevagotomyIndicationsgoodgeneralcondition，12h,sinceperforate;mildinflamationinabdominalcavity，hadhistoryofperforation,hemorrhage,obstructionpriortothisperforationsuspectcancerationPerforationrepairPerforationrepairHemorrhageofgastroduodenalulcer-----TheleadingcauseofdeathduetopepticulcerHemorrhageofgastroduodenalulcerpathologyTheerotionofbasevessalinulcer.Commoninlessergastriccurvatureorposteriorwallofduodenum.ClinicalManifestationAndDiagnosisHaematemesisandmelenaBloodloss400ml,pale,drymouth,quickpules800ml，shockAbdominalphysicalsignisnotobviousDifferentialDiagnosisEsophagealVaricesBleeding胃底食管静脉曲张破裂出血AcuteHemobilia胆道出血GastricCancerBleedingStressUlcerationBleeding应激性溃疡出血therapeuticprincipleHemostasis止血SupplementBloodVolumePreventRecurrence.SurgicalindicationMassivehemorrhage,acutebloodlossresultinsyncope晕厥。600-800mlbloodtransfusionin6-8h，unstablebloodpresure.Haveanotherhemorrhagehistory.Duringtheperiodofantiulcerdrugtherapy.Togetherwithperforateandcicatricialpyloricobstructionpatientover60yearsoldorwitharteriosclerosis.Surgicaltreatment：SubtotalgastrectomyLigationofthebleedingvesselwithintheulcerbase＋vagotomy＋pyloroplasty幽门成形术SimpleligationofthebleedingvesselCicatricialPyloricObstructionEtiologyAndPathologySpasticity痉挛性（reflectivity反射性）Edematous水肿性（inflammation）Cicatricle瘢痕性（oraccompanywithspasticityandedematous）Oftenoccurinpatientwithduodenalulcer.Longcourseofdisease:clinicalmanifestationanddiagnosisClinicalManifestationAbdominaldistention,tovomitindigestivefoodwithoutbile.malnutritionsplashingsound振水音（+）DiagnosishistoryX-ray:bariumretention24hDifferentialDiagnosisPylorospasmandoedemacausedbyactiveulcerobstructioninducedbyGastriccancerObstructioninferiortoduodenalbulbgastroscope,X-rayTreatmentPreoperativepreparat