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BY SUBRAMANIYAM SABESAN

4THYEAR

GRODNO STATE MEDICAL UNIVERSITY

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ANATOMY OF THE STOMACHy Muscular organ- food storage and digestion

y 4 parts: cardia, fundus, body, antrum

y

2 sphincters: GE (HPZ), pylorusy Nerves: vagus, greater splanhnic nerves

yArteries: RGA, LGA, RGEA, LGEA, VBA

yVeins: RGV, LGV, RGEV, LGEV- portal system, LGV

azygos vein through esoph. veins

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ANAT Y F T E ST ACH

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MICROSCOPIC ANATOMY

OF THE STOMACHy 4 layers of the wall: serosa, muscularis, muscularis

mucosae, mucosa.

y 3 divisions of the mucosa:- cardiac gland area: secretes mucus

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

- pyloroantral mucosa: G cells- gastrin

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ANATOMY-SUPRAMEZOCOLIC ORGANS

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ANATOMY OF THE DUODENUMy 4 portions: first part- 5 cm., descending-7cm,

transverse, the duodenojejunal flexure

yArteries: SPDA, IPDAyVeins: APDV, PPDV

y Posterior wall is retroperitoneal, lacks serosa

y Specialized glands Brunners gland

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GASTRO-DUODENAL DISEASE

DEFINITIONSy Erosion- superficial mucosal defect

y Ulcer- a mucosal defect extending through the

wally Chronic ulcer- infiltrated margin raised above the

surface

yAcute ulcer- sharply demarcated

y Curlings ulcer- appears in the late phase ofextensive burns

y Cushings ulcer- following op.on the CNS

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DEFINITION AND CLASSIFICATIONy Peptic ulcer is a chronic cyclic disease with

periodic ulcerating lesions affecting the upper

gastro-intestinal tract. chronic duodenal ulcer

chronic gastric ulcer

anastomotic ulcer

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AGGRESSIVE FACTORS

yhydrochloric acid

ypepsinyreverse diffusion of ions of hydrogen

yproducts of lipid hyperoxidation

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DEFENSE FACTORS

ymucus and alkaline components of

gastric juiceyproperty of epithelium ofmucous

tunic to permanent renewal

ylocal blood flow ofmucous tunic andsubmucousmembrane

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PATHOMORPHOLOGY

yErosion

yacute ulcers

ychronic ulcers

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CLASSIFICATIONby Johnson (1965)

y I ulcers of small curvature (for 3 cm higherfrom a goalkeeper);

y II double localization of ulcers simultaneouslyin a stomach and duodenum;

y III ulcers of goalkeeper part of stomach (notfarther as 3 cm from a goalkeeper)

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GASTRIC ULCER

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GASTRIC ULCER

y Commoner in men, in the elderly and in lower

socioeconomic groupsy Etiology- damage to the gastric mucosal barrier

y Risk factors: NSAID, aspirin, steroids

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GASTRIC ULCER

DIAGNOSTIC SYMPTOMS

y Burning epigastric pain

y Early after eatingy Pts. tend to fear eating

y Pts.are underweight

y Nausea and vomiting are more common than in DU

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COMPLICATIONS

y Penetration

y Stenosisy Perforation

y Bleeding

y

Malignization

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D

IAGNOSISP

ROGRAMy 1. Anamnesis and physical examination.y 2. Endoscopy.y 3. X-Ray examination of stomach.y

4. Examination of gastric secretion by themethod of aspiration of gastric contents.y 5. Gastric pH metry.y 6. Multiposition biopsy of edges of ulcer and

mucous tunic of stomach.y 7. Gastric Dopplerography.y 8. Sonography of abdominal cavity organs.y 9. General and biochemical blood analysis.y 10. Coagulogram.

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X-Ray examinationTHE DIRECTSIGNS:y symptom of Haudek's niche

y ulcerous billow and convergence of folds of mucoustunic.

INDIRECTSIGNS:

y symptom of forefinger (circular spasm of muscles)

y segmental hyperperistalsis,

y pylorospasm,

y delay of evacuation from a stomach

y duodenogastric reflux

y disturbance of function of cardial part(gastroesophageal reflux).

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Bariummeal- normal gastric radiological

pattern

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The radiograph pattern is benign because: the ulcerprojects outside of the stomach, the ulcer is central, thereare no over-hanging edges, radiating folds reach the ulcer

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This is a barium meal which shows a large lesser curve GU

with typical radiating folds.Up to 20% of large GU willundergo malignant change

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The endoscope detecting a gastric ulcer

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This sharply punched out GU has been present for sometime as judged by the amount of puckering of the

surrounding mucosa and depth of the ulcer

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This is a shallow GU with a hyperemic edge, the edge is notrolled and the appearances suggest a benign ulcer, although

it should be biopsied to exclude malignancy and repeatendoscopy performed to ensure healing after medical

treatment

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SYMPTOM

OF

Haudek's

niche

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STENOSIS

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GASTROSCOPY

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DEVICE FOR GASTRIC

DOPPLEROGRAPHY

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Endoscopic picture of the normal

stomach wall

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Endoscopic picture of the peptic

ulcer

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CONSERVATIVE THERAPY

a) Omeprazole 20 mg 2 time per day or 2- blockerhistamine receptor (ranitidine) 150 mg in theevening, famotidine 40 mg at night, roxatidine 150 mg in the evening

b) antiacid drugs in accordance with the results ofpH-metry;

c) reparative drugs (dalargin, solcoseryl, actovegin) for 2 ml 12 times per days

d) antimicrobial drugs (clarytromicine 500 mg twicedaily, de-nol, metronidazole)

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SURGICAL TREATMENT

a) at the relapse of ulcer after the course ofconservative therapy;

b) in the cases when the relapses arise during

supporting antiulcer therapy;c) when an ulcer does not heal over during 1,52months of intensive treatment, especially in

families with ulcerous anamnesis;

d) ulcer with complications (perforation orbleeding);

e) at suspicion on malignization ulcers, in case ofnegative cytological analysis.

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y Operative procedures:

- partial gastrectomy with gastro-duodenalanastomosis,

- partial gastrectomy with gastro-jejunal anastomosis,

- vagotomy with antrectomy

- vagotomy with antrectomy and Roux en Yanastomosis

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Billroth I and Billroth II resection

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Billroth II resection

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Billroth I resection:

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Partial gastricresection, Roux

en Y anastomosis

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DUODENAL ULCERSy The major cause- increased acidity, via the vagus

nerves or gastrin stimulus

y Campilobacter pylori- disturb local defensemechanisms- disrupts mucosal integrity

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

y The Z-E syndrome- gastrin-secreting tumor of thepancreas

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DUODENAL ULCER

DIAGNOSISy DU is a chronic disease with periods of activity and

silence

y Exacerbations may be associated with periods ofstress, alcohol abuse

y It tends to have a seasonal variation

y Remissions- complete healing

y If the disease progresses- tendacy towards fibrousscarring

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CLASSIFICATION

I. By etiology:. True duodenal ulcer.

B. Symptomatic ulcers.

II. By passing of disease:

1. Acute ( first exposed ulcer).2. Chronic:

a) with the rare exacerbation;

b) with the annual exacerbation;

c) with the frequent exacerbation (2 times per ayear and more frequent).

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CLASSIFICATION

III. By the stages of disease:1. Exacerbation.

2. Scarring:

a) stage of red scar;b) stage of white scar.

3. Remission.

IV. By localization:

1. Ulcers of bulb of duodenum.

2. Low postbulbar ulcers.

3. Combined ulcers of duodenum and stomach.

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CLASSIFICATION

V. By sizes:1. Small ulcers up to 0,5 cm.2. Middle up 1,5 cm.3. Large up to 3 cm;

4. Giant ulcers over 3 cm.VI. By the presence of complications:

1. Bleeding.2. Perforation.

3. Penetration.4. Organic stenosis.5. Periduodenitis.6. Malignization.

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CLINICAL MANAGEMENT

y Pain

y Vomitingy Heartburn

y Belching

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DUODENAL ULCER

SIGNSy Diffuse epigastric tenderness

yAnemia- occult bleeding

y Succusion splash- delayed gastric emptying

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DUODENOSCOPY

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Endoscopic view- duodenal

ulcer

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Endoscopic view

Deep duodenalulcer

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Doublecontrast gastroduodenal

radiogram-posteriorwall DU

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Lateral view ofa posteriorwall

duodenalulcer

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SYMPTOMOF

Haudek's niche

STENOSIS

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DIAGNOSIS PROGRAMy 1. Anamnesis and physical examination.

y 2. Endoscopy.

y 3. X-Ray examination of stomach and duodenum.

y 4. General and biochemical blood analysis.y 5. Coagulogram.

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CONSERVATIVE THERAPY

a) Omeprazole 20 mg 2 time per day or 2-blocker histamine receptor (ranitidine) 150mg in the evening, famotidine 40 mg atnight, roxatidine 150 mg in the evening

b) antiacid drugs (almagel, maalox or gaviscon1 dessert-spoon in a 1 hour after food intake);

c) reparative drugs (dalargin, solcoseryl,

actovegin) for 2 ml 12 times per daysd) antimicrobial drugs (clarytromicine 500 mg

twice daily, de-nol, metronidazole)

INDICATIONS TO THE ELECTIVE

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INDICATIONS TO THE ELECTIVE

OPERATION

y 1. Passing of duodenal ulcer with the frequentrelapses which could not treated conservatively.

y 2. Repeated ulcerous bleeding.

y 3. Stenosis of outcome part of stomach.y 4. Chronic penetration ulcers with the pain

syndrome.

y 5. Suspicion for malignization ulcers.

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METHODS OF SURGICAL

TREATMENT

y organ-saving operations;

y organ-sparing operations;

y resection.

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TRUNK VAGOTOMY (TrV)

2 4

3

SELECTIVE VAGOTOMY (SV)

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3

SELECTIVE VAGOTOMY (SV)

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SELECTIVE PROXIMAL VAGOTOMY

(SP

V)

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SELECTIVE PROXIMAL

VAGOTOMY (SPV)

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Heineke-

Mikulicz

pyloroplasty

i k ik li l l

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Heineke-Mikulicz pyloroplasty

A TR DU DEN T MY BY

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A TR DU DEN T MY BY

JABOULAY

l l

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Finney pyloroplasty

ULCEROUS STENOSIS

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ULCEROUS STENOSIS

CLASSIFICATIONA

I compensated;

II subcompensated;

III decompensated.B

I stenosis of goalkeeper;

II stenosis of bulb of duodenum;

III postbulbar duodenal stenosis.

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DIAGNOSIS PROGRAM

y 1. Complaints of patient and anamnesis of disease.

y 3. Sounding of stomach and examination of gastriccontent.

y 4. Fibergastroduodenoscopy, biopsy.y 5. Intragastric -metry.

y 6. Study of motility of stomach.

y

7. Roentgenologic examination of stomach andduodenum (structural features, passage).

y 8. Sonography.

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ULCER

STENOSIS

PERFORATED GASTRODUODENAL ULCERS

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PERFORATED GASTRODUODENAL ULCERS

CLASSIFICATION

1. After etiology:y ulcerous;y unulcerous.

2. After localization:y gastric (small curvature, cardial, antral, prepyloric,

pyloric) ulcer, front and back walls;y ulcers of duodenum (front and back walls).

3. After passing:y perforated in an abdominal cavity;y covered perforations;y atypical perforations.

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DIAGNOSIS PROGRAMy 1. Anamnesis and physical examination.

y 2. Global analysis of blood and urine, biochemicalblood test,

y coagulogram.y 3. X-Ray examination of abdominal cavity organs

for presence of free gas (pneumoperitoneum).

y 4. Pneumogastrography, contrastingpneumogastrography.

y 5. Fiber-gastroduodenoscopy.

y 6. Sonography of abdominal cavity organs.

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Perforated ulcer (pneumoperitoneum)

Bleeding gastroduodenal ulcers

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Bleeding gastroduodenal ulcers

CLASSIFICATION

y Idegree is easy observed at the loss to 20 % volumeof circulatory blood (at a patient with weight of body70 kg it is up to 1000 ml);

y II

degree middle weight is loss from 20 to 30 %volume of circulatory blood (10001500 ml);

y The IIIdegree is heavy is observed at loss of bloodmore than 30 % volume of circulatory blood (1500

2500 ml).

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FORREST CLSSIFICATIONFORREST CLASS TY

PE OF LESION RISK OF REBLEEDING

IF UNTREATED

1a Arterial spurting bleeding 100%

1b Arterial oozing bleeding /Non-spurting active

bleeding

55%

2a Visible vessel 43 %

2b Sentinel clot / Non-bleeding ulcer with anadherent clot

22%

2c Hematin covered flat spot/ Ulcer with haematin-covered base

10%

3Ulcer with clean base /

5%

No stigmata of

hemorrhage

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Spurting bleeding -1a Non-spurting active bleeding-1b

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Non-bleeding visible vessel -2a

Non-bleeding ulcer with anadherent clot -2b

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Ulcer with haematin-coveredbase -2c

Ulcer with clean base -3

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DIAGNOSIS PROGRAM

y Anamnesis and physical examination.

y Finger examination of rectum.

y Gastroduodenoscopy.

y

Global analysis of blood.y Coagulogram.

y 7. Biochemical blood test.

y X-Ray examination of gastrointestinal tract.

y Electrocardiography.

ENDOSCOPY

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ENDOSCOPY

stopped bleeding

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THANK YOU