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 cells-
pepsinogen, 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., descending-

7cm, transverse, the duodenojejunal flexure
• Arteries: SPDA, IPDA
• Veins: APDV, PPDV
• Posterior wall is retroperitoneal, lacks serosa
• Specialized glands Brunner’s 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
• Curling’s ulcer- appears in the late phase of
extensive burns
• Cushing’s 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 back-

penetration of the ulcer posteriorly

Vomiting may suggests the gastric outlet obstruction-

pyloric 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 gastrin-
secreting 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, gastro-
jejunal anastomosis T-L
Partial gastric resection, Roux
en Y anastomosis