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The Death of an Operation

The Death of an Operation. T H E A U T O N O M I C N E R V O U S S Y S T E M. PEPTIC ULCER DISEASE. Symptoms and Signs

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The Death of an Operation

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  1. The Death of an Operation

  2. T H E A U T O N O M I C N E R V O U S S Y S T E M PEPTIC ULCER DISEASE Symptoms and Signs Symptoms depend on ulcer location and patient age; many patients, particularly the elderly, have few or even no symptoms. Pain is the most common symptom; it is often localized to the epigastrium and relieved by food or antacids. The pain is described as burning, gnawing, or hunger. The course is usually chronic and recurrent. Only about half of patients present with the characteristic pattern of symptoms.

  3. T H E A U T O N O M I C N E R V O U S S Y S T E M Vagus (CN X) From 1940’s – 1990’s highly selective vagotomy was the primary treatment for peptic ulcer disease

  4. T H E A U T O N O M I C N E R V O U S S Y S T E M normal gastric mucosa normal gastric mucosa colonized gastric mucosa H. pylori colonization H. pylori

  5. T H E A U T O N O M I C N E R V O U S S Y S T E M H. pylori is gram-negative spiral flagellated bacterium Produces urease Important in the etiology of peptic ulcers and gastric cancer Found in: 90% patients with duodenal ulceration 70% patients with gastric ulceration 60% patients with gastric cancer

  6. T H E A U T O N O M I C N E R V O U S S Y S T E M The organism can be detected by: Microscopy – silver or Giemsa staining of stomach biopsies Culture – difficult and requires special culture techniques Rapid urease test – colour changes due to change in pH 13C or 14C breath test – Ingested radioactive urea is broken down to carbon dioxide Serology – detected immunologically using an ELISA

  7. T H E A U T O N O M I C N E R V O U S S Y S T E M H2 Antagonists 65% healing at one month 85% healing at two months If stop treatment - 90% recurrence at 2 years If maintenance therapy - 20% recurrence at 5 years Proton Pump inhibitors 90 - 100% healing at 2 months Low recurrence on long term maintenance

  8. T H E A U T O N O M I C N E R V O U S S Y S T E M abnormal CXR normal CXRs

  9. T H E A U T O N O M I C N E R V O U S S Y S T E M H. Pylori eradication 80% cured with dual or triple therapy Two weeks amoxycillin, metronidazole and omeprazole Short term recurrence rates low Long term recurrence rates are at present unknown Drugs have changed the need for ulcer surgery over last 20 years Admissions for elective surgery have significantly reduced The number of complications however remain unchanged May be increasing due to increased NSAID use in elderly Bleeding and perforation still have mortality of >10%

  10. T H E A U T O N O M I C N E R V O U S S Y S T E M

  11. T H E A U T O N O M I C N E R V O U S S Y S T E M

  12. T H E A U T O N O M I C N E R V O U S S Y S T E M • Sensors: pressure sensors in the arteries of the upper body: • Respond to stretch caused by blood pressure • Higher pressure produces more nerve impulses/sec; lower blood pressure causes fewer nerve impulses/sec • Carotid sinus: sensory nerve = cranial nerve IX (glossopharyngeal) • Aortic arch: sensory nerve = cranial nerve X (vagus) • Integrating Center: medulla oblongata of the brain • Sensory nerves go to nucleus tractus solitarius • Detected blood pressure is compared with desired pressure (set point) • Centers used to correct blood pressure: • Cardiac accelerator center: increases cardiac output: uses cardiac accelerator nerve • Cardiac inhibitor center: decreases cardiac output: uses vagus nerve • Vasoconstrictor center: constricts arterioles and veins: uses spinal nerves • Constriction of blood vessels raises resistance to flow (R) • Effectors: • Heart: • SA Node: controls heart rate (HR) • Vagus nerve slows heart • Cardiac accelerator speeds up heart • Heart muscle: controls stroke volume (SV) • Cardiac accelerator nerve increases SV • No vagus fibers go to heart muscle • Arteries & veins • Results: • If pressure is low: • Reflex will increase cardiac output (CO = HR X SV) • Reflex will constrict arterioles & veins • If pressure is high: • Reflex will decrease CO • Decreased reflex activity will dilate arterioles and veins • Reflex will restore correct blood pressure • P = CO X R

  13. T H E A U T O N O M I C N E R V O U S S Y S T E M

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