Stomach and duodenum
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STOMACH AND DUODENUM. Begashaw m (MD). 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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Begashaw m (MD)


  • 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

Stomach Anatomy

  • Asymmetric dilation of the proximal gastro intestinal tract

  • Capacity-1.5 to 2.0 L

  • Cardia, Fundus, Body, Antrum& Pylorus

  • Pyloric sphincter- regulates gastric emptying & prevents reflux

  • Wall - Four layers Mucosa, Submucosa, Muscularis & Serosa


Types of cells & secretion


A-Food breakdown to form chyme

- mechanical digestion and

- acid and pepsin action

B-Reservoir through receptive relaxation

  • Phases of gastric secretion

    _Cephalic - Acetylcholin by the vagusnerve

    _Gastric - Gastrin(by G cells)

    _Intestinal - mainly inhibitory - Secretin


  • Surface epithelial cells alkaline mucus

  • Mucus cells_mucus, HCO3¯

  • Parietal cellsHCl, Intrinsic factor

  • Chief cellspepsinogens, lipases


imbalance in aggressive activity of acid & pepsin & defensive mechanisms


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


Erosive gastritis

Acute gastritis - after major trauma, shock, sepsis, head Injury & ingestion of aspirin & alcohol -“Stress erosion”

Chronic gastritis->Established inflammatory reaction

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


Summary of clinical features


A- Gastroduodenoscopy and biopsy

B- Barium meal

C- Blood studies ↓ hemoglobin (Hgb) shows chronic blood loss



  • 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


Surgical treatment

A - Complications

– obstruction

_ perforation

_ bleeding

B - Intractability

Complications of PUD

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

Clinical features

Sudden onset of abdominal pain

Pale, anxious

Raised pulse rate

Abdomen still, not moving with respiration tender, board like rigidity

After 6 hrs peritonitis - silent abdominal distention

Erect plain abdominal x-ray/CXR - air under diaphragm

Air under diaphragm



Antibiotic therapy

Continuous gastric aspiration

Urgent laparotomy- peritoneal toilet and closure of perforation with omentalpatch

Anti H-pylori treatment - recurrence

Omental patch

Graham patch technique

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


  • Conservative

    - IV fluid resuscitation

    - Blood transfusion if indicated

    - Naso gastric tube insertion and saline lavage

    - H2 receptor antagonist

    - Endoscopic evaluation

    - Serial hematocrit

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

- succussionsplash

- electrolyte disturbance and metabolic alkalosis

- Barium meal-large stomach full of food residue with delay in evacuation


Surgery – truncalvagotomy and bypass operation after preliminary gastric lavage with saline for 4-5 days

Correction of fluid and electrolytes using crystalloid fluids

Gastric Cancer


- Age 40-60 years

- Sex M:F 3:1

More common in Far East – Japan


Premalignant conditions

Risk factors:

Gastric polyp,pernicious anemia, post gastrectomystomach, gastritis, cigarette smoking

& genetic makeup


- Prepyloricregion is the most common site

- Microscopic - Adenocarcinoma





-blood stream

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

Dysphagiaor fullness, belching , vomiting

Other signs

- Virchow’s nodes , Krukenbergtumor

- Abdominal mass

- Ascites

Gastric ca


- Gastroscopy and biopsy

- Hgb

- Barium meal shows filling defect

- Laparotomy (diagnostic)


- Gastrectomy when possible

- Palliative bypass surgery


- Over all 5 years survival is about 10 -20%

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