GASTRODUODENAL DISEASES

SURGICAL DISEASES

ANATOMY OF THE STOMACH

Muscular organ- food storage and
digestion 4 parts: cardia, fundus, body, antrum 2 sphincters: GE (HPZ), pylorus Nerves: vagus, greater splanhnic nerves Arteries: RGA, LGA, RGEA, LGEA, VBA Veins: RGV, LGV, RGEV, LGEV- portal system, LGV azygos vein through esoph. veins

MICROSCOPIC ANATOMY OF THE STOMACH

4 layers of the wall: serosa, muscularis,
muscularis mucosae, mucosa. 3 divisions of the mucosa: - cardiac gland area: secretes mucus - parietal cell area: mucous cells, chief cellspepsinogen, parietal cells- HCl, IF - pyloroantral mucosa: G cells- gastrin

ANATOMY OF THE STOMACH

ANATOMY-SUPRAMEZOCOLIC ORGANS

ANATOMY OF THE DUODENUM

4 portions: first part- 5 cm., descending7cm, transverse, the duodenojejunal flexure Arteries: SPDA, IPDA Veins: APDV, PPDV Posterior wall is retroperitoneal, lacks serosa Specialized glands Brunners gland

Normal duodenal mucosa Endoscopic view

GASTRO-DUODENAL DISEASE INVESTIGATIONS

Barium meal- small mucosal changes- double

contrast technique, not used in GI bleeding Endoscopy- useful in GI bleeding,- bx in gastric cancer,- recurrent dyspepsia after gastric surgery Gastric secretory tests- gastric acid output for Zollinger-Ellison syndrome Plasma gastrin concentration

GASTRO-DUODENAL DISEASE DEFINITIONS

Erosion- superficial mucosal defect Ulcer- a mucosal defect extending through the

wall Chronic ulcer- infiltrated margin raised above the surface Acute ulcer- sharply demarcated Curlings ulcer- appears in the late phase of extensive burns Cushings ulcer- following op.on the CNS

DUODENAL ULCERS
The major cause- increased acidity, via the

vagus nerves or gastrin stimulus Campilobacter pylori- disturb local defense mechanisms- disrupts mucosal integrity Risk factors: tabacco, caffeine, alcohol, aspirin, steroids, NSAID. The Z-E syndrome- gastrin-secreting tumor of the pancreas

DUODENAL ULCER DIAGNOSIS

DU is a chronic disease with periods of
activity and silence Exacerbations may be associated with periods of stress, alcohol abuse It tends to have a seasonal variation Remissions- complete healing If the disease progresses- tendacy towards fibrous scarring

DUODENAL ULCERS SYMPTOMS

Epigastric pain- when the stomach is empty and there is nothing to buffer the acid secretion
Relief usually follows eating Failure to produce relief, if pain is felt in the backpenetration of the ulcer posteriorly Vomiting may suggests the gastric outlet obstructionpyloric stenosis

DUODENAL ULCER SIGNS

Diffuse epigastric tenderness
Anemia- occult bleeding Succusion splash- delayed gastric
emptying

DUODENAL ULCER INVESTIGATIONS

Barium meal- the mainstay of the workup Endoscopy- direct vision of the mucosa,
- biopsy for suspected lesions Helicobacter pilory test Lab.tests - anemia, - electrolyte disturbances

Endoscopic view- duodenal ulcer

Endoscopic view Deep duodenal ulcer

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

Double contrast gastroduodenal radiogram-posterior wall DU

Lateral view of a posterior wall duodenal ulcer

Deformity of duodenum due to recurrent ulceration Single contrast view

DUODENAL ULCER TREATMENT

Medical treatment avoid risk factors, H2-receptor antagonists, H-proton pump inhibitors, Hp eradication Surgical treatment vagotomy with antrectomy, partial gastrectomy with gastro-duodenal anastomosis, gastro-jejunal anastomosis

GASTRIC ULCER CLASSIFICATION

Type I- transitional zone, between the
parietal cells of the body and the gastrinsecreting cells of the antrum Type II- GU+DU Type III- pyloric channel ulcer Type IV- near the GE junction

GASTRIC ULCER

GASTRIC ULCER
Commoner in men, in the elderly and in

lower socioeconomic groups Etiology- damage to the gastric mucosal barrier Risk factors: NSAID, aspirin, steroids

GASTRIC ULCER DIAGNOSTIC SYMPTOMS

Burning epigastric pain Early after eating Pts. tend to fear eating Pts.are underweight Nausea and vomiting are more common
than in DU

GASTRIC ULCER DIAGNOSIS

Physical examination- unremarkable Epigastric tenderness Upper GI- Rx study- can detect 70%GU Endoscopy-essential, Endoscopic biopsies- to rule out a
malignancy

Barium meal- normal gastric radiological pattern

Benign gastric ulcer

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

Benign gastric ulcer

This is a barium meal which shows a large lesser curve GU with typical radiating folds.Up to 20% of large GU will undergo malignant change

Benign gastric ulcer The ulcer is extending outside the lumen of the stomach

Benign gastric ulcer

The endoscope detecting a gastric ulcer

Benign gastric ulcer

This sharply punched out GU has been present for some time as judged by the amount of puckering of the surrounding mucosa and depth of the ulcer

GASTRIC ULCER

Benign gastric ulcer

This is a shallow GU with a hyperemic edge, the edge is not rolled and the appearances suggest a benign ulcer, although it should be biopsied to exclude malignancy and repeat endoscopy performed to ensure healing after medical treatment

Benign gastric ulcer Ulcer scarring and healing after 1 month of treatment

GASTRIC ULCER
Gastric tumors will ulcerate in 25%, therefore a

suspicious GU must be proved histologically Medical treatment: antiacid drugs, cytoprotective agents, risk factors Most GUs will heal within 12 weeks Recurrence rate of 25-60% in 5 years is associated with GU treated with short-term medical therapy

GASTRIC ULCER SURGICAL TREATMENT

Indications for surgery:
- malignancy cannot be ruled out, - the ulcer fails to heal after 12-15 weeks of medical treatment, - complications develop such as perforation and severe hemorrhage

GASTRIC ULCER
Operative procedures:
- partial gastrectomy with gastro-duodenal anastomosis, - partial gastrectomy with gastro-jejunal anastomosis, - vagotomy with antrectomy - vagotomy with antrectomy and Roux en Y anastomosis

Partial gastric resection, gastrojejunal anastomosis T-L

Partial gastric resection, Roux en Y anastomosis