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STOMACH. James Taclin C. Banez, MD, FPSGS, FPCS. Anatomy. Arterial blood supply Lymphatic drainage Nerve supply. PHYSIOLOGY. Function: Digestion of food, reduce the size of food Acts as reservoir Absorption of Vit. 12, iron and calcium Stimulant of Gastric secretion:

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stomach

STOMACH

James Taclin C. Banez, MD, FPSGS, FPCS

anatomy
Anatomy
  • Arterial blood supply
  • Lymphatic drainage
  • Nerve supply
physiology
PHYSIOLOGY

Function:

  • Digestion of food, reduce the size of food
  • Acts as reservoir
  • Absorption of Vit. 12, iron and calcium

Stimulant of Gastric secretion:

  • Gastrin -----> (+) parietal cell
  • Acetylcholine (vagus) ---> (+) gastric cells
  • Histamine (mast cells) ---> parietal & chief cells
physiology4
PHYSIOLOGY

BAO: 2 – 5 meq of acid/hr. (vagal tone and basal histamine secretion)

MAO:

  • Cephalic (vagus) ---> (+) parietal & G cell
    • 10 meq acid/hr.
  • Gastric: ---> (+) vagus & G cell
    • 15 – 25 meq of acid/hr pH = < 2.0
  • Intestinal:
    • Chyme enters the duodenum
    • (-) gastric release
    • Secretin, gastric inhibitory peptide, peptide YY
  • ACID condition sterilized the area, except for HELICOBACTER PYLORI
gastric diseases
GASTRIC DISEASES:
  • Acid peptic Disease
  • Neoplasm
acid peptic disease
Acid peptic Disease:
  • Due to imbalance in the normal interplay between acid-pepsin and mucosal defense mechanism
  • Types:
    • Acute Gastritis (erosive):
      • Inflammation confined in the mucosa
    • True Ulcers:
      • Extends through the mucosa
peptic ulcer
Peptic ulcer
  • Duodenal Ulcer
  • Gastric Ulcer

Duodenal ulcer > gastric ulcer

Female > Male

Duodenal ulcer is younger by 10 yrs

Location:

    • Duodenal:
        • duodenal bulb
        • Hyper-secretion of acid
peptic ulcer8
Peptic ulcer

Location:

  • Gastric

Type I - proximal antrum and body

(disturbance in mucosal defense)

Type II - arises secondary to duodenal

ulcer w/ pyloric stenosis

Type III - Prepyloric and pyloric channel

- (hyper-secretion of acid)

peptic ulcer9
Peptic ulcer

Pathogenesis:

  • For both Duodenal & Gastric Ulcers:
    • Infection w/ H. pylori:
      • Decreases resistance of mucus layer from acid permeation (hydrophobicity)
      • Increase acid secretion
      • Slow duodenal emptying
      • Reduced both duodenal and gastric bicarbonate secretion
peptic ulcer10
Peptic ulcer

Pathogenesis:

  • Effects of NSAIDs
    • Decreases Prostagladin

Prostaglandin – inhibits acid secretion, stimulates mucus and HCO3 secretion and mucosal blood flow

  • Zollinger-Ellison Syndrome(1%):
    • Massive secretion of HCL due to ectopic gastrin production from non-beta islet cell tumor (gastrinoma)
    • Associated w/ type I (MEN) PPP
    • 20% multiple, 2/3 malignant, w/ slow growing
    • Parietal cell mass is increased
    • > gastrin 3-6 x the normal
peptic ulcer11
Peptic ulcer
  • For Duodenal
    • Acid Hypersecretion:
      • More parietal and chief cells
        • Genetic
        • Due to release of tophic factors - gastrin
      • Increase capacity of individual cell to secret
    • Gastric Motility abnormality
    • Impaired duodenal acid disposal
      • Reduced basal and peak duodenal bicarbonate secretion and defect in mucus
peptic ulcer12
Peptic ulcer
  • For Gastric Ulcer:
    • Reflux of Duodenal contents (pancreas and biliary)
      • Gastritis -----> Ulceration
      • Pyloric sphincter dysfunction
      • Cigarette smoking:
        • Increases duodeno-gastric reflux
        • Decrease prostaglandin synthesis
        • Decreases duodenal, gastric and pancreatic bicarbonate secretion
      • Bile acids, lysolecithin and pancreatic secretions – disturb surface mucus layer
clinical manifestation
Clinical Manifestation
  • Abdominal pain:
    • Due to irritation of afferent nerves w/in the ulcer by the acid or due to peristaltic waves passing through the ulcer
      • Duodenal: colicky or burning pain relieved w/ food intake
      • Gastric: gnawing or burning usually during or after eating.
  • N/V
  • Weight loss
  • Epigastric tenderness
diagnosis
Diagnosis:
  • UGIS (double contrast)
  • Endoscopy
treatment
Treatment:
  • Medical:

Avoid the following:

      • Smoking
      • Aspirin / NSAIDs
      • Coffee (acid secretion)
      • Alcohol (damage the mucosa)

Mechanism of Pharmacologic Therapy:

    • Neutralize gastric secretion (HCL): ANTACID
    • Inhibits Secretion of Acid:
      • H2 receptor antagonist – CIMETIDINE,

RANITIDINE, FAMOTIDINE

treatment16
Treatment:

Mechanism of Pharmacologic Therapy:

  • Inhibits Secretion of Acid:
    • Anticholinergic:
      • Inhibits acetylcholine

Pirenzepine HCL

    • H+ / K+ - ATPase inhibitor proton pump
      • Benzimidazole selectively inhibits parietal cells

Omeprazole, Lanzoprazole, Pantoprazole

  • Protection of Gastric Mucosa:
    • Prostaglandin:

Methylated E2 analog inhibits gastric secretion, increases mucosal bld flow & HCO3 & mucosa secretion

treatment17
Treatment:

Mechanism of Pharmacologic Therapy:

  • Protection of Gastric Mucosa:
    • Sulfated disaccharide (sucralfate)
      • Binds to protein in the ulcer as protective coat
      • It can inhibits peptic activity
    • Colloid bismuth
      • Binds w/ protein & against H. pylori
treatment18
Treatment:

Mechanism of Pharmacologic Therapy:

  • For eradication of H. pylori:
    • Bismuth based triple therapy
      • Bismuth + Tetracycline + Metronidazole
    • Proton pump inhibitor
      • Omeprazole + Amoxicillin/Clarithromycin

+ metronidazole

treatment19
Treatment:

Surgical Treatment:

Indication:

  • Intractability:
    • Highly selective vagotomy
      • Low septic complication, (-) dumping and diarrhea
    • For gastric ulcer:
      • Total or subtotal gastrectomy w/ or w/o vagotomy
treatment20
Treatment:

Surgical Treatment:

Indication:

  • Hemorrhage: s/sx
    • Critically ill
    • Endoscopy
    • Surgery: a. continue bleeding for more than 6 units

b. recurrent bleeding after endoscopically controlled

- pyloroduodenostomy + HSV

- pyloroduodenostomy + vagotomy + pyloroplasty

treatment21
Treatment:

Surgical Treatment:

Indication:

  • Perforation: S/Sx
    • Graham omental patch only for shock, perforation > 48 hrs or other medical problem
    • Vagotomy + pyloroplasty; HSV
    • Vagotomy + Gastrojejunostomy
  • Obstruction: S/Sx; Saline loading test
    • Vagotomy + Antrectomy
    • Vagotomy + Gastroenterostomy
acute gastritis erosive
Acute Gastritis (erosive)
  • Stress erosions are usually multiple, small punctuate lesion in the proximal acid secreting portion of the stomach

Clinical Settings:

  • Severe illness, trauma, burns (Cushing ulcer) or sepsis
    • Due to (-) mucosal defense (ischemia)
  • Drug and Chemical ingestion
    • Aspirin / NSAIDs
  • CNS trauma:
    • Increase gastrin ---> elevated acid secretion
    • Curling ulcer
acute gastritis
Acute Gastritis

Pathogenesis:

  • Aspirin, bile salts (backflow), alcohol
  • Mucosal ischemia

Clinical manifestations:

  • Gastrointestinal bleeding
  • Abdominal pain

Diagnosis:

  • Endoscopy / radionuclide scanning / visceral angiography
acute gastritis24
Acute Gastritis

Treatment:

  • NPO
  • NGT / Saline lavage
  • Antacids / omeprazole / sucralfate
  • Intra-arterial infusion of vasopressin
  • Surgery --> if 6-8 units over 24 hrs
    • Mortality ---> 40%
    • Near total gastrectomy
    • Vagotomy + pyloroplasty + over sewing of bleeder
    • Partial gastrectomy + vagotomy
zollinger ellison syndrome gastrinoma
Zollinger-Ellison Syndrome (Gastrinoma)
  • Symptoms tends to be more severe, unrelenting and less responsive to therapy.

Clinical Manifestation:

    • Pain
    • Diarrhea
    • Steatorrhea

Diagnosis:

    • Acid secreting studies (50meq/hr)
    • UGIS
    • Radio-immuno assay for serum Gastrin level
      • Diff: a) Pernicious anemia

b) Renal insufficiency

c) Antral gastrin hyperplasia or hyperfunction

    • CT scan and angiography to localize gastrinoma
    • Venous sampling
gastric neoplasm
Gastric Neoplasm:
  • 90% malignant
      • 95% adenocarcinoma
      • 4% lymphoma
      • 1% leiomyosarcoma (GIST-malignant gastrointestinal stromal tumors)
      • Rare – carcinoid, angiosarcoma, squamous cell CA.
      • As metastatic lesion of -->

- colon/pancreas

- melanoma/breast

  • Malaysia, Chile, Iceland and JAPAN
  • Male:Female (2:1); more common twice in

black than white

  • 6 -7 decade of life: if it occurs in young(30-40y/o) becomes more aggressive (linitis plastica or signet ring histology)
  • Low socioeconomic
adenocarcinoma
Adenocarcinoma:

Etiology:

  • Diet - high in nitrates----->nitrites (bacteria & bile salts)

- pickled, salted or smoked food

- fresh fruit & vegetable and vit C & E ---> lowers

  • H. pylori infection
    • 3 fold increase risk
  • Ebstein Barr virus
  • Genetic factor:
    • Suppression of p53 (tumor suppression gene);
    • over expression of COX-2
adenocarcinoma28
Adenocarcinoma:

Etiology:

  • Cigarette smoking (alcohol (-) effect)
  • Gastric polyp: (epithelial, inflammatory, hamatomatous, heterotopic, hyperplastic & adenoma) – adenoma & hyperplastic polyps can lead to CA.
  • Chronic atrophic gastritis (CAG):
    • Most common precursor of CA (intestinal type)
    • H. pylori causes CAG
adenocarcinoma29
Adenocarcinoma:

Etiology:

  • Intestinal metaplasia: (H. pylori)
  • Benign gastric ulcer:
    • It is now generally recognized that all gastric ulcers are cancer until proven otherwise
  • Previous Gastric resection:
    • 10 yrs later near the stoma
  • Others: - Radiation exposure - Family hx

- Pernicious anemia - Bld type A

(1.2 risk)

gastric neoplasm30
Pathology:

Gastric dysplasia ---> precursor of gastric CA

Early gastric cancer:

Limited to the mucosa and submucosa, regardless of LN status

70% are well differentiated

Cure rate is 90%

Gastric Neoplasm:
slide31
Pathology:

Macroscopic Subtypes:

  • Superficial spreading
  • Polypoid (well differentiated)
  • Fungating
  • Ulceration
  • Scirrhous (linitis plastica): infiltrates the entire thickness of the wall
    • Leather bottle stomach
    • Poor prognosis
    • Usually undifferentiated

Location of primary tumor:

  • 40% distal / 30% middle / 30% distal
histology
WHO Classification:

Adenocarcinoma:

Papillary adenocarcinoma

Tubular adenocarcinoma

Mucinous adenocarcinoma

Signet-ring cell carcinoma

Adenosquamous carcinoma

Squamous cell CA

Small cell CA

Undifferentiated CA

Others

Lauren Classification:

Intestinal type (53%)

Diffuse type (33%)

Unclassified (14%)

Ming Classification:

Expanding type (67%)

Infiltrative type (33%)

HISTOLOGY:
slide34
Microscopic Subtypes:
  • Intestinal Type
  • Diffuse Type:
slide35
Histologic type:
  • Papillary
  • Tubular
  • Mucinous
  • Signet ring

Mode of spread:

  • Direct
  • Lymphatic
  • Hematologic
  • Transcoelomic route
slide36
Clinical Manifestation:
  • Weight loss due to anorexia and early satiety is the most common symptoms
  • Abdominal pain (not severe) common
  • Nausea / vomiting
  • Chronic occult blood loss is common;

GIT bleeding (5%)

  • Dysphagia (cardia involvement)
slide37
Clinical Manifestation:
  • Paraneoplastic syndromes ( Trousseau’s syndrome – thrombophlebitis; acanthosis nigricans – hyperpigmentation of axilla and groin; peripheral neuropathy)
  • Signs of distant metastasis:
      • Hepatomegally / ascites
      • Krukenbergs tumor
      • Blummers shelf (drop metastasis)
      • Virchow’s node
      • Sister Joseph node (pathognomonic of advances dse)
slide38
Diagnosis:
  • UGIS (double contrast)
  • Endoscopy (Biopsy / Ultrasound)
    • GOLD STANDARD
    • Best pre-operative staging
    • Needle aspiration of LN w/ ultrasound guidance
    • Can even give preop neoadjuvant tx
  • CT scan (intravenous and oral contrast):
    • For pre-operative staging
  • Whole body Positron Emission Tomography scanning (PET):
    • Tumor cell preferentially accumulate positron-emitting 18F fluorodeoxyglucose.
slide39
TREATMENT:

SURGERY:

  • The only curative tx for gastric cancer
  • Except:
    • Can’t tolerate abdominal surgery
    • Overwhelming metastasis
  • Palliation is poor w/ non-resective operations
  • GOAL: resect all tumors, w/ negative margins (5cm) and adequate lymphadenectomy (need for RFS)
  • Enbloc resection of adjacent organ is done if needed.
slide40
TREATMENT:

SURGERY:

Radical subtotal gastrectomy

Standard operation for gastric cancer

Organs resected:

Distal 75% of stomach

2 cm of duodenum

Greater & lesser omentum

Ligation of R & L gastric artery and gastroepiploic vesels

Billroth II gastojejunostomy

slide41
TREATMENT:

SURGERY:

Radical subtotal gastrectomy

Standard operation for gastric cancer

If gastric remnant left is small (<20%) do Roux-en-Y reconstruction

slide42
Extent of lymphadenectomy:

N1 – 3 to 6 N2 – 1, 2, 7, 8 & 11 N3 – 9, 10 & 12

N1 nodes are w/in 3cm of the tumor

N2 along hepatic & splenic arteries

N3 more distant nodes

Agreed upon: to avoid under staging of gastric CA, a minimum of 15 nodes should be resected w/ the gastrectomy specimen.

adjuvant treatment for gastric carcinoma
Adjuvant Treatment for Gastric Carcinoma:
  • Chemotherapy:
    • 5-fluorouracil, leucovorin, cisplatin, doxorubicin and methotrexate
    • Can not prolong survival in unresectable, metastatic or recurrent diseases
  • Radiation (4500cGy):
    • Effective in palliation for pain and bleeding
  • For stages II and III adenocarcinoma
slide44
Radical subtotal gastrectomy:
  • D1 resection (standard in USA):
    • Removes tumor and N1
  • D2 resection(standard in Asia):
    • Gastrectomy and N1 and N2 removal
    • Removes the peritoneal layer over the pancreas and anterior mesocolon
    • Removes LN along hepatic & splenic
  • Splenectomy and distal pancreatectromy not routinely removed due to higher morbidity postop.
endoscopic resection of gastric carcinoma
Endoscopic Resection of Gastric Carcinoma

Criteria:

  • Tumor < 2cm in size
  • Node negative
  • Tumor confined on the mucosa

Nodes metastasis is < 1%:

  • No mucosal ulceration
  • No lymphatic invasions
  • <3cm tumor
screening of gastric cancer
Screening of Gastric Cancer
  • Patients at risk for gastric CA should undergo yearly endoscopy and biopsy:
    • Familial adenomatous polyposis
    • Hereditary nonpolyposis colorectal cancer
    • Gastric adenomas
    • Menetrier’s disease
    • Intestinal metaplasia or dysplasia
    • Remote gastrectomy or gastrojejunostomy