Stomach and duodenum

Report
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
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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
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Abnormal pyloric function
Duodenogastric reflux
Defective gastric mucosal
defenses
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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
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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
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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
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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
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Conservative th. : PPI
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H.pylori eradication (Antibiotics ,PPI)
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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
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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
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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:
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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
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CT scan, (ultrasound examination)
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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.
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