STOMACH AND DUODENUM
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Transcript of STOMACH AND DUODENUM
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STOMACH AND DUODENUM
Begashaw m (MD)
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Introduction
PUD is a common problem Helicobacter pylori (H. pylori) - important
associated risk factor Gastric cancer -One of the top five cancers -Worst prognosis - difficulty to diagnose -High index of suspicion
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Stomach Anatomy
Asymmetric dilation of the proximal gastro intestinal tract
Capacity-1.5 to 2.0 LCardia, Fundus, Body, Antrum & PylorusPyloric sphincter- regulates gastric emptying
& prevents refluxWall - Four layers Mucosa, Submucosa,
Muscularis & Serosa
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Anatomy
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Types of cells & secretion
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Functions
A-Food breakdown to form chyme - mechanical digestion and - acid and pepsin actionB-Reservoir through receptive relaxation Phases of gastric secretion_Cephalic - Acetylcholin by the vagus nerve_Gastric - Gastrin (by G cells)_Intestinal - mainly inhibitory - Secretin
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Histology
Surface epithelial cells alkaline mucus
Mucus cells_mucus, HCO3¯
Parietal cellsHCl, Intrinsic factor
Chief cells pepsinogens, lipases
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Pathogenesis imbalance in aggressive activity of acid & pepsin & defensive
mechanisms Factors 1. Helicobacter pylori 2. NSAIDs - aspirin 3. Acid hypersecretion 4. Rapid gastric emptying 5. Impaired duodenal acid disposal 6. Impaired gastric mucosal defense 7. Duodenogastric reflux
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Classification
Erosive gastritisAcute gastritis - after major trauma, shock,
sepsis, head Injury & ingestion of aspirin & alcohol -“Stress erosion”
Chronic gastritis->Established inflammatory reaction
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Duodenal ulcer -occurs in the proximal duodenum with in 1 to 2 cm of the pylorus & there is acid hyper secretion
Gastric ulcer_ acid secretion is either normal or decreased
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Classification
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Summary of clinical features
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Investigations
A- Gastroduodenoscopy and biopsyB- Barium mealC- Blood studies ↓ hemoglobin (Hgb) shows
chronic blood lossD-H.pylori test
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Treatment Medical treatment Acid reduction - H2 – receptor antagonists– cimetidine 800 mg/night for 6 wks - Proton pump inhibitor – omeprazole 20 mg/day - Irritants_avoid Anti H. pylori treatment -Bismuth tablets -Amoxicillin for 2 – 4 weeks -Metronidazole
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Surgical treatment
A - Complications – obstruction _ perforation _ bleedingB - Intractability
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Complications of PUD
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Perforated peptic ulcer
- Sex ratio 2:1 , age 45-55 years- Anterior surface of duodenum (location)- Past history of PUD is common- Gastric contents spill over the peritoneum
and bring about peritonism which will be followed by bacterial peritonitis after 6 hours
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Clinical features
Sudden onset of abdominal painPale, anxiousRaised pulse rateAbdomen still, not moving with respiration tender,
board like rigidityAfter 6 hrs peritonitis - silent abdominal distentionErect plain abdominal x-ray/CXR - air under
diaphragm
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Air under diaphragm
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Treatment
ResuscitateAntibiotic therapyContinuous gastric aspiration Urgent laparotomy - peritoneal toilet and
closure of perforation with omental patchAnti H-pylori treatment - recurrence
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Omental patch
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Graham patch technique
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Bleeding Peptic Ulcer
- Slight bleeding -trauma from solid food- Severe hemorrhage - erosion of an artery at
the base of the ulcer located posteriorly (gastoduodenal, splenic)
- Patient presents with hematemesis and/or melena
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Management
Conservative- IV fluid resuscitation- Blood transfusion if indicated- Naso gastric tube insertion and saline lavage- H2 receptor antagonist- Endoscopic evaluation- Serial hematocrit
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Gastric Outlet Obstruction-GOO
results from cicatrisation and fibrosis due to long standing duodenal or juxtapyloric ulcer
Clinical feature - pain, fullness, vomiting of large foul smelling vomit - peristaltic wave from left to right - succussion splash - electrolyte disturbance and metabolic alkalosis - Barium meal-large stomach full of food residue with
delay in evacuation
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Treatment
Surgery – truncal vagotomy and bypass operation after preliminary gastric lavage with saline for 4-5 days
Correction of fluid and electrolytes using crystalloid fluids
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Gastric Cancer Epidemiology - Age 40-60 years - Sex M:F 3:1 More common in Far East – Japan Etiology Premalignant conditions Risk factors: Gastric polyp,pernicious anemia, post gastrectomy stomach,
gastritis, cigarette smoking & genetic makeup
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Pathology- Prepyloric region is the most common site- Microscopic - AdenocarcinomaSpread -Direct -lymphatic -transperitoneal -blood stream
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Clinical features New onset dyspepsia -above 40 yrs Anorexia ,loss of weight Anemia, tiredness, weakness, pallor Persistent pain with no response to medical treatment Gastric distention Dysphagia or fullness, belching , vomiting Other signs - Virchow’s nodes , Krukenberg tumor - Abdominal mass - Ascites
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Gastric ca
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Investigations
- Gastroscopy and biopsy- Hgb- Barium meal shows filling defect- Laparotomy (diagnostic)
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Treatment - Gastrectomy when possible - Palliative bypass surgeryPrognosis - Over all 5 years survival is about 10 -
20%