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Complications of PU
Investigation and Management
Upper GI Bleeding
of Complications of Peptic Ulcer
Perforation
Obstruction of lumen
Malignant Change
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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
Antrum
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13 Personal history
Smoking Examination of
Alcohol drinking. Obstructive Jaundice
14 Drug history cholesterol
lowering agent, weight
reducing agent, androgens
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4 Local examination
3 General examination Inspection General contour of
Pallor, Jaundice (Depth of J ) abdomen
,Fever, Left Supraclavicular Move with respiration,
LN enlargement, Palmar visible mass in GBA
Any previous surgical scars,
erythema, clubbing and
distended vein
oedema, Scratch marks, Hernia orifices,
Cachexia Condition of umbilicus
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Causes of Obstructive
11 Mention that you would like Jaundice
to do PR examination-
Intraluminalcauses
melaena stool, clay color
stool Intramural causes
Extraluminal causes
Intraluminal causes
Intramural cause
CBD strictures
Iatrogenic
Traumatic
Periampullary carcinoma
Choledochal cyst
Cholangiocarcinoma
Sclerosing cholangitis
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Imaging Ultrasound:
Extramural causes:
causes: • shows the size of the bile ducts
• defines the level of the obstruction
Carcinoma head of pancreas
• identifies the cause (in some cases)
Chronic pancreatitis
• gives other information related to the
Malignant lymph nodes in the porta
hepatis disease (e.g. hepatic metastases, gallstones,
hepatic parenchymal change)
Others: • The echo-texture of the liver, splenomegaly,
Liver secondaries ascites, and signs of portal hypertension
Biliary atresia
Proximal obstruction
Distal obstruction may also be caused
by CBD stones/ Adult Ascaris worm/ Proximal biliary dilation usually results from
Duodenal or Periampullary lesion. obstruction at the porta hepatis (Enlarged
Metastatic Lymph nodes / Klastkin`s Tumour
Tumour))
These can be investigated by and is recognized by dilation of the
duodenoscopy and biopsied if directly intrahepatic ducts without enlargement of
seen. the distal common bile duct.
duct.
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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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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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