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.