GASTRODUODENAL GASTRODUODENAL DISEASESDISEASES

SURGICAL DISEASESSURGICAL DISEASES

ANATOMY OF THE STOMACHANATOMY OF THE STOMACH

• Muscular organ- food storage and Muscular organ- food storage and digestiondigestion

• 4 parts: cardia, fundus, body, antrum4 parts: cardia, fundus, body, antrum• 2 sphincters: GE (HPZ), pylorus2 sphincters: GE (HPZ), pylorus• Nerves: vagus, greater splanhnic nervesNerves: vagus, greater splanhnic nerves• Arteries: RGA, LGA, RGEA, LGEA, VBAArteries: RGA, LGA, RGEA, LGEA, VBA• Veins: RGV, LGV, RGEV, LGEV- portal Veins: RGV, LGV, RGEV, LGEV- portal

system, LGV – azygos vein through system, LGV – azygos vein through esoph. veins esoph. veins

MICROSCOPIC ANATOMY MICROSCOPIC ANATOMY OF THE STOMACHOF THE STOMACH

• 4 layers of the wall: serosa, muscularis, 4 layers of the wall: serosa, muscularis, muscularis mucosae, mucosa.muscularis mucosae, mucosa.

• 3 divisions of the mucosa:3 divisions of the mucosa:

- cardiac gland area: secretes mucuscardiac gland area: secretes mucus

- parietal cell area: mucous cells, chief parietal cell area: mucous cells, chief cells-pepsinogen, parietal cells- HCl, IFcells-pepsinogen, parietal cells- HCl, IF

- pyloroantral mucosa: G cells- gastrinpyloroantral mucosa: G cells- gastrin

ANATOMY OF THE STOMACHANATOMY OF THE STOMACH

ANATOMY-SUPRAMEZOCOLIC ANATOMY-SUPRAMEZOCOLIC ORGANSORGANS

ANATOMY OF THE ANATOMY OF THE DUODENUMDUODENUM• 4 portions: first part- 5 cm., 4 portions: first part- 5 cm.,

descending-7cm, transverse, the descending-7cm, transverse, the duodenojejunal flexureduodenojejunal flexure

• Arteries: SPDA, IPDAArteries: SPDA, IPDA

• Veins: APDV, PPDVVeins: APDV, PPDV

• Posterior wall is retroperitoneal, lacks Posterior wall is retroperitoneal, lacks serosaserosa

• Specialized glands Brunner’s glandSpecialized glands Brunner’s gland

Normal duodenal mucosaNormal duodenal mucosaEndoscopic viewEndoscopic view

GASTRO-DUODENAL DISEASEGASTRO-DUODENAL DISEASEINVESTIGATIONSINVESTIGATIONS

• Barium meal- small mucosal changes- Barium meal- small mucosal changes- double contrast technique, not used in GI double contrast technique, not used in GI bleedingbleeding

• Endoscopy- useful in GI bleeding,- bx in Endoscopy- useful in GI bleeding,- bx in gastric cancer,- recurrent dyspepsia after gastric cancer,- recurrent dyspepsia after gastric surgerygastric surgery

• Gastric secretory tests- gastric acid output Gastric secretory tests- gastric acid output for Zollinger-Ellison syndromefor Zollinger-Ellison syndrome

• Plasma gastrin concentration Plasma gastrin concentration

GASTRO-DUODENAL DISEASEGASTRO-DUODENAL DISEASEDEFINITIONSDEFINITIONS

• Erosion- superficial mucosal defectErosion- superficial mucosal defect• Ulcer- a mucosal defect extending through Ulcer- a mucosal defect extending through

the wallthe wall• Chronic ulcer- infiltrated margin raised Chronic ulcer- infiltrated margin raised

above the surfaceabove the surface• Acute ulcer- sharply demarcatedAcute ulcer- sharply demarcated• Curling’s ulcer- appears in the late phase Curling’s ulcer- appears in the late phase

of extensive burnsof extensive burns• Cushing’s ulcer- following op.on the CNSCushing’s ulcer- following op.on the CNS

DUODENAL ULCERSDUODENAL ULCERS

• The major cause- increased acidity, via the The major cause- increased acidity, via the vagus nerves or gastrin stimulusvagus nerves or gastrin stimulus

• Campilobacter pylori- disturb local defense Campilobacter pylori- disturb local defense mechanisms- disrupts mucosal integritymechanisms- disrupts mucosal integrity

• Risk factors: tabacco, caffeine, alcohol, Risk factors: tabacco, caffeine, alcohol, aspirin, steroids, NSAID.aspirin, steroids, NSAID.

• The Z-E syndrome- gastrin-secreting tumor The Z-E syndrome- gastrin-secreting tumor of the pancreasof the pancreas

DUODENAL ULCERDUODENAL ULCERDIAGNOSISDIAGNOSIS• DU is a chronic disease with periods DU is a chronic disease with periods

of activity and silenceof activity and silence• Exacerbations may be associated Exacerbations may be associated

with periods of stress, alcohol abusewith periods of stress, alcohol abuse• It tends to have a seasonal variationIt tends to have a seasonal variation• Remissions- complete healingRemissions- complete healing• If the disease progresses- tendacy If the disease progresses- tendacy

towards fibrous scarringtowards fibrous scarring

DUODENAL ULCERSDUODENAL ULCERSSYMPTOMSSYMPTOMS

Epigastric pain- when the stomach is empty and Epigastric pain- when the stomach is empty and there is nothing to buffer the acid secretionthere is nothing to buffer the acid secretion

Relief usually follows eatingRelief usually follows eating

Failure to produce relief, if pain is felt in the Failure to produce relief, if pain is felt in the back- penetration of the ulcer posteriorlyback- penetration of the ulcer posteriorly

Vomiting may suggests the gastric outlet Vomiting may suggests the gastric outlet obstruction- pyloric stenosisobstruction- pyloric stenosis

DUODENAL ULCERDUODENAL ULCERSIGNSSIGNS

• Diffuse epigastric tendernessDiffuse epigastric tenderness

• Anemia- occult bleedingAnemia- occult bleeding

• Succusion splash- delayed gastric Succusion splash- delayed gastric emptyingemptying

DUODENAL ULCERDUODENAL ULCERINVESTIGATIONSINVESTIGATIONS• Barium meal- the mainstay of the workup Barium meal- the mainstay of the workup

• Endoscopy- direct vision of the mucosa,Endoscopy- direct vision of the mucosa,

- biopsy for suspected lesions- biopsy for suspected lesions

• Helicobacter pilory testHelicobacter pilory test

• Lab.testsLab.tests

- anemia,- anemia,

- electrolyte disturbances - electrolyte disturbances

Endoscopic view- duodenal Endoscopic view- duodenal ulcerulcer

Endoscopic view Endoscopic view Deep duodenal ulcerDeep duodenal ulcer

Kissing duodenal ulcers, Kissing duodenal ulcers, bleeding slowly; in the past- bleeding slowly; in the past- surgery,surgery,now- conservative treatmentnow- conservative treatment

Double contrast Double contrast gastroduodenal radiogram-gastroduodenal radiogram-posterior wall DUposterior wall DU

Lateral view of a posterior wall Lateral view of a posterior wall duodenal ulcerduodenal ulcer

Deformity of duodenum due to Deformity of duodenum due to recurrent ulcerationrecurrent ulcerationSingle contrast viewSingle contrast view

DUODENAL ULCERDUODENAL ULCERTREATMENTTREATMENT• Medical treatmentMedical treatment- avoid risk factors,avoid risk factors,- H2-receptor antagonists,H2-receptor antagonists,- H-proton pump inhibitors, H-proton pump inhibitors, - Hp eradicationHp eradication• Surgical treatmentSurgical treatment- vagotomy with antrectomy,vagotomy with antrectomy,- partial gastrectomy with gastro-duodenal partial gastrectomy with gastro-duodenal

anastomosis, gastro-jejunal anastomosisanastomosis, gastro-jejunal anastomosis

GASTRIC ULCERGASTRIC ULCERCLASSIFICATIONCLASSIFICATION

• Type I- transitional zone, between Type I- transitional zone, between the parietal cells of the body and the the parietal cells of the body and the gastrin-secreting cells of the antrumgastrin-secreting cells of the antrum

• Type II- GU+DUType II- GU+DU

• Type III- pyloric channel ulcerType III- pyloric channel ulcer

• Type IV- near the GE junctionType IV- near the GE junction

GASTRIC ULCER GASTRIC ULCER

GASTRIC ULCERGASTRIC ULCER

• Commoner in men, in the elderly and Commoner in men, in the elderly and in lower socioeconomic groupsin lower socioeconomic groups

• Etiology- damage to the gastric Etiology- damage to the gastric mucosal barriermucosal barrier

• Risk factors: NSAID, aspirin, steroidsRisk factors: NSAID, aspirin, steroids

GASTRIC ULCERGASTRIC ULCERDIAGNOSTIC SYMPTOMSDIAGNOSTIC SYMPTOMS

• Burning epigastric painBurning epigastric pain

• Early after eatingEarly after eating

• Pts. tend to fear eating Pts. tend to fear eating

• Pts.are underweightPts.are underweight

• Nausea and vomiting are more Nausea and vomiting are more common than in DUcommon than in DU

GASTRIC ULCER GASTRIC ULCER DIAGNOSISDIAGNOSIS

• Physical examination- unremarkablePhysical examination- unremarkable

• Epigastric tendernessEpigastric tenderness

• Upper GI- Rx study- can detect 70%GUUpper GI- Rx study- can detect 70%GU

• Endoscopy-essential, Endoscopy-essential,

• Endoscopic biopsies- to rule out a Endoscopic biopsies- to rule out a malignancymalignancy

Barium meal- normal gastric Barium meal- normal gastric radiological patternradiological pattern

Benign gastric ulcerBenign gastric ulcerThe radiograph pattern is benign because: the The radiograph pattern is benign because: the ulcer projects outside of the stomach, the ulcer ulcer projects outside of the stomach, the ulcer

is central, there are no over-hanging edges, is central, there are no over-hanging edges, radiating folds reach the ulcerradiating folds reach the ulcer

Benign gastric ulcerBenign gastric ulcerThis is a barium meal which shows a This is a barium meal which shows a

large lesser curve GU with typical large lesser curve GU with typical radiating folds.Up to 20% of large GU will radiating folds.Up to 20% of large GU will

undergo malignant changeundergo malignant change

Benign gastric ulcerBenign gastric ulcerThe ulcer is extending outside The ulcer is extending outside the lumen of the stomachthe lumen of the stomach

Benign gastric ulcerBenign gastric ulcerThe endoscope detecting a gastric ulcerThe endoscope detecting a gastric ulcer

Benign gastric ulcerBenign gastric ulcerThis sharply punched out GU has been This sharply punched out GU has been present for some time as judged by the present for some time as judged by the amount of puckering of the surrounding amount of puckering of the surrounding

mucosa and depth of the ulcermucosa and depth of the ulcer

GASTRIC ULCERGASTRIC ULCER

Benign gastric ulcerBenign gastric ulcerThis is a shallow GU with a hyperemic This is a shallow GU with a hyperemic edge, the edge is not rolled and the edge, the edge is not rolled and the appearances suggest a benign ulcer, appearances suggest a benign ulcer,

although it should be biopsied to exclude although it should be biopsied to exclude malignancy and repeat endoscopy malignancy and repeat endoscopy performed to ensure healing after performed to ensure healing after

medical treatmentmedical treatment

Benign gastric ulcerBenign gastric ulcerUlcer scarring and healing Ulcer scarring and healing after 1 month of treatmentafter 1 month of treatment

GASTRIC ULCERGASTRIC ULCER

• Gastric tumors will ulcerate in 25%, Gastric tumors will ulcerate in 25%, therefore a suspicious GU must be proved therefore a suspicious GU must be proved histologicallyhistologically

• Medical treatment: antiacid drugs, Medical treatment: antiacid drugs, cytoprotective agents, risk factorscytoprotective agents, risk factors

• Most GUs will heal within 12 weeksMost GUs will heal within 12 weeks

• Recurrence rate of 25-60% in 5 years is Recurrence rate of 25-60% in 5 years is associated with GU treated with short-term associated with GU treated with short-term medical therapymedical therapy

GASTRIC ULCERGASTRIC ULCERSURGICAL TREATMENTSURGICAL TREATMENT

• Indications for surgery:Indications for surgery:

- malignancy cannot be ruled out,- malignancy cannot be ruled out,

- the ulcer fails to heal after 12-15 - the ulcer fails to heal after 12-15 weeks of medical treatment,weeks of medical treatment,

- complications develop such as - complications develop such as perforation and severe hemorrhageperforation and severe hemorrhage

GASTRIC ULCERGASTRIC ULCER

• Operative procedures:Operative procedures:- partial gastrectomy with gastro-- partial gastrectomy with gastro-duodenal anastomosis,duodenal anastomosis,- partial gastrectomy with gastro-- partial gastrectomy with gastro-jejunal anastomosis,jejunal anastomosis,- vagotomy with antrectomy- vagotomy with antrectomy

- vagotomy with antrectomy and - vagotomy with antrectomy and Roux en Y anastomosisRoux en Y anastomosis

Partial gastric resection, Partial gastric resection, gastro-jejunal anastomosis T-Lgastro-jejunal anastomosis T-L

Partial gastric resection, Partial gastric resection, Roux en Y anastomosisRoux en Y anastomosis