Stomach and duodenum
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Transcript Stomach and duodenum
Stomach and
duodenum
Laszlo Orosz
Blood supply
Lesser curvature:
Right and left gastric artery
Greater curvature:
Right and left epigastric artery
(Branches of the Celiac trunck)
Ulceration of the stomach and
duodenum
Aetiology of duodenal ulcer
Protective mechanisms
Soluble mucus layer
Insoluble mucus layer
Bicarbonate secretion
(duodenum pancreas)
Gastroduodenal motiliy
Mucosal blood flow
Prostaglandins
Damaging factors
Acid
Pepsin
Helicobacter pylori
Drugs
Smoking
Stress
Diet
Alcohol
Pathogenetic factors in the
development of gastroduodenal
ulceration
Duodenal ulcer
Gastric ulcer
Increased acid secretory
capacity
Increased basal acid secretion
Increased parietal cell mass
Increased parietal cell
sensitivity
Prolonged meal secretory
response
Abnormal gastric emptying
Abnormal duodenal mucosal
defenses
Abnormal pyloric function
Duodenogastric reflux
Defective gastric mucosal
defenses
Mucosal nutrient blood flood
Cellular atp production
Mucusal prostaglandin
production
Mucusal bicarbonate secretion
Mucusal gel layer protection
Duodenal ulcer
Essentials of diagnosis
Epigastric pain relieved by food or antacids
Epigastric tenderness
Normal or increased gastric acid secretion
Signs of ulcer disease on upper gastrointestinal
x-rays or endoscopy
Evidence of Helicobacter pylori infection
Nonsteroidal anti-inflammatory drugs
Gastric ulcer
Essentials of diagnosis
Epigastric pain
Ulcer demonstrated by x-ray or endoscopy
Acid present on gastric analysis
Complication of ulcers
perforation
bleeding
stenosis
Causes of gastrointestinal bleeding
upper gastrintestinal tract
Acute
Peptic ulcer
Acute erosive oesophagitis, gastritis
Duodenitis
Oesophagical/gastric varices
Mallory-Weiss tears
Angiodysplasia, Dieulafoy malformation
Oesophageal/gastric neoplasia
Adenocarcinoma
Adenoma
Leiomyoma
Leiomyosarcoma
Chronic
Oesophagitis, gastritis
Peptic ulcer
Oesophageal/gastric neoplasia
Zollinger-Ellison syndrome
(gastrinoma)
Essentials of diagnosis
Peptic ulcer disease (often severe) in 95%
Gastric hypersecretion
Elevated serum gastrin
Non-B islet cell tumor of the pancreas
Therapeutic endoscopic measures
for bleeding duodenal ulcers
Electrocoagulation
Injection of ulcer base with sclerosants (ethanol,
polidocanol, adrenalin solution)
Balloon tamponade
Haemostatic clips
Tissue glue
Laser coagulation of bleeding site
Heater probe coagulation
Therapy
Conservative th. : PPI
H.pylori eradication (Antibiotics ,PPI)
Operation (mostly because of complications)
Operative treatment
indications
Absolute indications:
perforation, massive bleeding, stenosis, malignant
transformation
Relative indications:
Ineffective adequate conservative treatment
(„giant ulcer”)
Complications of surgery for peptic ulcer
Early
Duodenal stump leakage
Gastric retention-anastomositis
Hemorrhage
Late
Recurrent ulcer(marginal, anastomotic)
Gastrojejunocolic, gastrocolic fistula
Affarent loop obstruction
Efferent loop obstruction
Retroanastomotic s. Petterson hernia
Dumping syndrome
Alcaline (reflux) gastritis
Malabsortion
Anemia
Carcinoma of the gastric remnant
Gastric cancer
Risk factors
Helicobacter pylori infection
Chronic gastritis
Older age
Being male
A diet high in salted, smoked, or poorly preserved foods and low in
fruits and vegetables.
Pernicious anemia
Smoking
Intestinal metaplasia
Familial adenomatous polyposis (FAP) or gastric polyps
Genetical disposition (A mother, father, sister, or brother who has
had stomach cancer)
Histopathology
Gastric adenocarcinoma two major types of gastric cancer (Lauren
classification): intestinal type and diffuse type.
Intestinal type adenocarcinoma: tumor cells describe irregular tubular
structures, harboring pluristratification, multiple lumens, reduced
stroma ("back to back" aspect). Often, it associates intestinal
metaplasia in neighboring mucosa.
Diffuse type adenocarcinoma (mucinous, colloid): Tumor cells are discohesive
and secrete mucus which is delivered in the interstitium producing
large pools of mucus/colloid (optically "empty" spaces). It is poorly
differentiated. If the mucus remains inside the tumor cell, it pushes the
nucleus at the periphery - "signet-ring cell
Gastric polyp
Gastric polyp + carcinoma
Gastric carcinoma
Patterns of Spread of Gastric Cancer
Direct extension
Lesser and greater omentum
Liver and greater omentum
Pancreas
Spleen
Biliary tract
Transverse colon
Nodal metastases
Local
Distant
Wirchow’s node
Left axillary (Irish’s) node
Umbilical node
Vascular metastases
Liver
Pulmonary system
Bone
Brain
Peritoneal metastases
Disseminated
Pelvic
Krukenburg tumor – ovary
Symptoms
Early
Indigestion or a burning sensation (heartburn)
Loss of appetite, especially for meat
Late
Abdominal pain or discomfort int he upper abdomen
Nausea and vomiting
Diarrhea or constipation
Bloating of the stomach after meals
Weight loss
Weakness and fatigue
Bleeding (vomiting blood or having blood int he stool), which
can lead to anemia
The following tests and procedures
may be used:
Physical exam
Blood chemistry studies:
Complete blood count (CBC):
Upper endoscopy:
Fecal occult blood test:
Barium swallow:
Biopsy:
CT scan (CAT scan):
Staging
I. st. =
II. st. =
III. st. =
IV. St. =
TNM
mucosa, submucosa
mucosa, submucosa, muscularis mucosae
mucosa, submucosa, muscularis mucosae +
lymphoglandula
serosa involvment + lymhpo.gland metastasis +
distant metastasis
or
TNM (1978 óta)
T (tumor)
N (lymph node)
M (metastasis)
= is - 0 - 1- 2 - 3 - 4 - x
=0-1-2-3-x
=0-1-x
Staging
CT scan, (ultrasound examination)
Tumor markers
Carcinoembryonic antigen (CEA)
CA 72,4
1.
2.
Treatment
Surgery
subtotal or partial gastrectomy
total gastrectomy (Roux ‘n’ Y loop)
D2 lymphadenectomy
Prognosis
5 year survival rate =
12% (USA)
( was 5% in 1905-ben)
Early (in situ) 5 year survival
Stage I
Stage II
Stage III
Stage IV
= 90%
= 70%
= 30%
= 10%
= 0%
The prognosis and treatment options
depend on
The stage and extent of the cancer
spreading to lymph nodes
The patient’s general health.