STOMACH and DUODENUM DISEASE

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1 STOMACH and DUODENUM DISEASE

2 STOMACH ANATOMY In the living and upright posture, the stomach is a j-shaped. It has two surfaces, two curvatures and two openings. Esophagus Fundus cardia Pylorus B o d y duodenum Antrum

3 STOMACH ANATOMY The stomach is continuous with the esophagus at the cardia cardia Esophagus Fundus Body Pylorus duodenum Antrum

4 STOMACH ANATOMY The stomach is connected with the duodenum at the pylorus cardia Esophagus Fundus Body Pylorus duodenum Antrum

5 STOMACH ANATOMY Esophagus Fundus Cardia The lesser curvature is downward continuation of the posterior wall of the esophagus. Just before the pylorus it curves upwards to form the gastric angle. Body Pylorus angle Duodenum Antrum

6 STOMACH ANATOMY Esophagus Fundus Cardia Body Pylorus angel Duodenum Antrum If we make a vertical line at angel, the upside is body, down side is antrum.

7 STOMACH ANATOMY Cardia Esophagus Fundus If we make a level line at cardia, the upside is fundus, downside is body. Body Pylorus angel Duodenum Antrum

8 Anteriorly Liver (right part) Anterior abdominal wall (left lower part) Spleen Transverse colon and transverse mesocolon

9 Posteriorly separated by peritoneum of lesser sac, the following ( stomach-bed ) is Pancreas Left suprarenal gland Left kidney

10 STOMACH ANATOMY (Artery) the stomach is supplied mainly by three arteries. 1 Left gastric artery 2 Splenic artery 3 Commen hepatic artery

11 r Left gastric artery comes from coeliac trunk. Supply the lesser curvature and low esophagus

12 r Gives rise to posterior gastric short and left gastroepiploic artery. supply left part of greater curvature and area of the fundus

13 Comes from coeliac trunk, that makes the branches of right gastric artery, gastroduodenal artery and right gastroepiploic artery. Supply right side of lesser and greater curvature of the stomach r

14 STOMACH ANATOMY (Vein) The stomach drains either directly or indirectly into the portal vein as follows

15 Short gastric veins drain the fundus into the splenic vein Left and right gastroepiploic vein drain greater curvature to superior mesenteric vein Left and right gastric veins pass along the lesser curvature and drain it. At last, splenic vein and superior mesenteric vein flow into portal vein.

16 STOMACH ANATOMY (Lymph drainage ) All of the lymph drain into nodes along the arteries and named accordingly. The final group of nodes that receive lymph from stomach is the celiac nodes located around the celiac trunk.

17 STOMACH ANATOMY (Lymph drainage ) Right and left gastric LN. lie along the same vessels and finally to the celiac LN. Right and left gastroomental LN. lie along the same vessels, the former drain into subpyloric LN, the latter drain into splenic LN.

18 STOMACH ANATOMY (Lymph drainage ) Suprapyloric and subpyloric LN. receive lymph from pyloric part and finally to the celiac LN. Splenic LN. receive lymph from fundus and left third of stomach, and finally to the celiac LN.

19 STOMACH ANATOMY( Nerve supply ) The stomach is supplied by both the parasympathetic and sympathetic parts of the autonomic nervous system.

20 STOMACH ANATOMY( Nerve supply ) Parasympathetic innervation The anterior vagal trunk divides into anterior gastric and hepatic branches The posterior vagal trunk divides into posterior gastric and celiac branches

21 STOMACH ANATOMY ( Nerve supply ) crow s foot The anterior and posterior gastric branches descend on the anterior and posterior surfaces of the stomach as a rule about 1 to 2 cm terminal branches as far as the pyloric antrum to supply the pyloric part

22 STOMACH ANATOMY ( Nerve supply ) Sympathetic innervation Mainly from celiac ganglia Afferent and efferent fibers derives from segments (T5 -L1)

23 DUODENUM ANATOMY Long about 25 cm Between stomach and small intestine 1.superior part 2.descending part 3.horizontal part 4.ascending part

24 STOMACH PHYSIOLOGY Gastric Juice The output of gastric juice varies between 500 and 1500 ml/d. The components of gastric juice are as follows: 1 Mucus 2 Pepsinogen 3 Intrinsic factor 4 Blood Group Substances 5 Electrolytes

25 STOMACH PHYSIOLOGY Gastric Acid Secretion A. Stimulation of Acid Secretion 1 cephalic phase 2 gastric phase 3 intestinal phase

26 STOMACH PHYSIOLOGY Gastric Acid Secretion B. Inhibition of Acid Secretion 1 Antral inhibition 2 intestinal inhibition

27 PEPTIC ULCER

28 Background Peptic ulcer disease remains a significant health problem in the CHINA. There are over 300,0000 cases annually with over 4 million people on some form of antiulcer therapy. They occur more commonly in men with duodenal ulcers two times more common that gastric ulcers. Frequent disease, men are affected 3-4x more than women

29 Ulcer diease What is Gastroduodenal ulcer? Ulcer is a full-thickness, round and elliptic defect that situates in gastroduodenal mucosa which interfere over lamina muscularis mucose, submucosa or penetrates across whole gastric or duodenal wall Rise of ulcer is conditioned by presence of acid gastric content

30 Pathogenesis Multifactorial Dysbalance between protective and aggressive factors Protective factors: saliva, food, alkali,duodenal fluid, mucus, fast regeneration of gastric epithelial cells, well perfused gastric mucosa Aggressive factors :HCl, pepsin, bile acids (reflux), helicobacter pylori, drugs (analgetics, aspirin, korticoids), nicotine, alcohol

31 Symptoms of gastric ulcer disease Epigastric pain after meal or during meal Upper dyspeptic syndrome loss of appetite, nausea, vomiting, flatulence Vomiting brings relief Reduced nutrition Loss of weight

32 Symptoms of duodenal ulcer disease Epigastric pain 2 hours after meal or on a empty stomach or during night Pyrosis Good nutrition Seasonal dependence (spring, autumn)

33 Endoscopy Gastric Multiple Biopsy should be obtained from the edge of the lesion Duodenal Endoscopy is useful in evaluating patients with an uncertain diagnosis

34 Laboratory finding Gastric analysis Basal acid output(bao) Maximal acid output (MAO) mean acid output(meq/h) normal duodenal ulcer Basal male female Maximal male female 20 30

35 Laboratory finding Serum gastrin Normal: pg/ml >200pg/mL always results to ulcer

36 Radiographic examination Upper gastrointestinal x-ray show an ulcer at stomach or duodenum. Gastric ulcer maybe be malignant as following: 1.The Deepest penetration of the ulcer is not beyong the expected border of the gastric wall 2.The meniscus sign is present (barium sulfate ) 3.Ulcer diameter is greater than 2cm

37 Differential diagnosis 1.Chronic cholecystitis 2.Acute and chronic pancreatitis 3.Functional indigestion 4.Reflux esophagitis 5.Gastritis

38 Essentials of diagnosis Gastric Epigastric pain not relieved by food Ulcer demonstrated by x-ray or endoscopy Acid present on gastric analysis Duodenal Epigastric pain relieved by food Epigastric tenderness Normal or increased gastric acid secretion Ulcer diagnosed by x-ray or endoscopy Evidence of Helicobacter Pylori infection

39 Complications Bleeding - chronic (minor, cause anemia) - acute (major, form affected vessel) Perforation - mostly bulbous duodenum, anterior gastric wall acute violent pain - bleeding can be present obstruction - narrow of the lumen caused by scar, oedema or inflammatory infiltration after healing of the ulcer - rise only at pyloric localization - vomiting of huge volume of gastric content

40 Complications A penetration B perforation C bleeding D - obstruction

41 Therapy Conservative regular lifestyle prohibition of the smoking and alcohol diet (proteins, milk and milky products) Four primary medicine H2-receptor antagonists Proton pump inhibitors Antacids Antibiotics

42 Therapy Surgical Indications for operation Intractability Perforation Obstruction Hemorrhage

43 Therapy Intractability (criteria) Initial healing is delayed, so that ulceration persists at 3 months despite active drug therapy Ulcers recur within 1 year of initial healing despite maintenance therapy The ulcer disease is characterized by cycles of prolonged activity with brief or absent remissions

44 Goals of elective operation Gastric Ulcer Primary goals to excise the ulcer to reduce acid/pepsin output Secondary goals to minimize bile reflux and gastric stasis

45 Goals of elective operation Duodenum Ulcer promotion of ulcer healing treatment of specific complications reduction of the possibility of recurrence minimization of postoperative side effects

46 Therapy Surgical BI, BII resection Proximal selective vagotomy Vagotomy with pyloroplastic

47 Subtotal gastrectomy Billroth I (BI) gastro-duodenoanastomosis end-to-end Billroth II (BII) gastro-jejunoanastomosis end-to-side with blind closure of duodenum Gastro-enteroanastomosis on Roux Y crankle Proximal selective vagotomy denervation of parietal gastric cells

48 Billroth I

49 Billroth II

50 Gastro-enteroanastomosis on Roux Y crankle

51 Vagotomy

55 Complications after operation Early dehiscence, stenosis of anastomosis, bleeding, pancreatitis, obstructive icterus, affection of neighbour tissues Late - days, weeks - early dumping syndrome - late dumping syndrome - incoming crankle syndrome - outcoming crankle syndrome - ulcer in anastomosis or in outcoming crankle

56 Early dumping syndrome group of symptoms approved shortly after meal appears after BII resection vasodilator - face redness, fall of blood pressure, dizziness GI symptoms - vomiting, diarrhea Therapy: diet, no sugar, low quantities of food,change BII to BI resection

57 Late dumping syndrome hypoglycemia (sugar is not enough digested) appears after BII resection weakness, perspiration, dizziness, tremor 3h after meal Therapy: no sugar, change BII to BI resection

58 Incoming crankle syndrome stasis of the content at incoming crankle increase intraluminal pressure appears after BII resection Therapy: diet, change BII to BI resection

59 Outcoming crankle syndrome chronic or acute closure of outcoming crankle appears after BII resection vomiting after meal, convulsive pain Therapy: change BII to BI resection

60 Pyloric obstruction due to peptic ulcer Cause Inflammation and edema of pylorus Fibrosis of pylorus Clinical manifestation a long history of symptomatic peptic ulcer development of vomiting, contain food ingested several hours previously, absence of bile. dehydration and malnutrition. Diagnosis X-ray (barium) and endoscopy

61 Treatment Medical treatment A gastric tube should be passed to empty stomach. A saline load test should be performed Total parenteral nutrition should be instituted After decompression of the stomach for several days, if this indicates improvement, a gradual diet may be started.

62 Treatment Surgical treatment BI, BII resection Gastro-entero anastomosis on Roux-Y crankle

66 Perforated Duodenal Ulcer Acute perforation in 5-10%; median age 40-55y (18-90) Clinical finding Symptoms :A sudden, severe upper abdominal pain Signs :the abdominal muscles are rigid owing to severe spasm. Bowel movement sounds are reduced or absent. Plain X-ray :Plain x-rays of the abdomen reveal free subdiaphragmatic air.

67 diaphragm

68 Treatment A nasogastric tube should be passed to empty the stomach Intravenous antibiotics should be started Laparoscopy or laparotomy and suture closure of the perforation solves the immediate problem. After operation, medicine should be taked. If the ulcer be suspicious of malignant tumor, biopsy or subtotal gastrectomy should be performed.

69 Treatment If perforated gastric ulcer is considered, biopsy should be performed on operation. After closure perforation, medication should be taked routinely. Concomitant hemorrhage and perforation or perforated ulcers and obstruction can not be treated by suture closure of the perforation Definitive surgery: BI, BII resection or Gastroenteroanastomosis on Roux-Y crankle

70 Hemorrhage from peptic ulcer 1/5 patients of peptic ulcer have a bleeding experience, 2/5 of bleeding patients will die from ulcer. Endoscopic therapy indications Active bleeding at the time of endoscopy The presence of a visible vessel in the base of the ulcer

71 Hemorrhage from peptic ulcer Endoscopic therapy methods Injection into the ulcer of epinephrine epinephrine plus1% polidocanol (sclerosing agent) ethanol Nd:YAG laser

72 Operative intervention Indications Massive hemorrhage leading to shock Prolonged blood loss requiring continuing transfusion Recurrent bleeding during medical therapy or after endoscopic therapy Recurrent bleeding requiring hospitalization

73 Operative intervention Methods suture or ligation of bleeding vessel Definitive surgery: BI, BII resection or Gastroenteroanastomosis on Roux-Y crankle Truncal vagotomy and antrectomy including ulcer

The abdominal Esophagus, Stomach and the Duodenum. Prof. Oluwadiya KS

The abdominal Esophagus, Stomach and the Duodenum Prof. Oluwadiya KS www.oluwadiya.com Viscera of the abdomen Abdominal esophagus: Terminal part of the esophagus The stomach Intestines: Small and Large