Anatomy

PEPTIC ULCER DISEASE & GASTRIC CARCINOMABy:Leong Jie Xiang Loh Tian FuMuhammad Khalis Safiq Bin Sakhiri

OutlineAnatomy of stomachPhysiology of stomachPeptic ulder DiseaseDefinitionAetiology & PathogenesisCommon sitesMacroscopic & Microscopic featuresHistory in peptic ulcerFindings on PEInvestigationsTreatmentPerforated peptic ulcer disease

Anatomy of Stomach

Blood Supply

Five main ateries :Left gastricRight gastricShort gastricLeft gastroepiploicRight gastroepiploic

Nerve

Duodenum

Blood supplyArteries : upper half superior pancreaticoduodenal artery lower half inferior pancreaticoduodenal arteryVeins : SPV portal vein IPV superior mesenteric vein

Nerve : celiac and superior mesenteric plexuses

Physiology of stomach

HCl secretion

Factors affecting HCl secretion

Stimulation of HCl secretion : Ach, Histamine, Gastrin

Inhibitor of HCl secretion : Decrease pH, Somatostatin, Prostaglandin

Stomach mucosal barrier

Peptic Ulcer Disease

Definition

Ulcer a breach on the mucosa that extends through the muscularis mucosae into submucosa or deeper.

Peptic ulcer chronic, solitary lesion occur in GI tract due to aggressive action of peptic juice.

AetiologyH. pylori infectionNSAIDSZollinger-Ellison syndromeCigarette smoking

PathogenesisH.pylori 1)penetrate mucus, secrete urease, ammonia neutralize pH, survive 2)produce protease and phospholipase, damage epithelial cells

NSAIDs suppress prostaglandin, degrade mucosal barrier

Common Sites

Lesser curvature of stomach

Anterior and posterior walls of 1st portion of duodenum

Macroscopic Features :Small, sharply punched-out appearanceMargin not elevatedClean base

Microscopic Features :In chronic, open ulcer, 4 zones can b distinguished 1) Necrosis2) Inflammation3) granulation tissue4) scar

Peptic Ulcer Disease

HistoryPain

usually in the epigastrium and may radiate into either the back or the right hypochondrium described as a continuous gnawing ache episodic is related to meal, so called indigestion or dyspepsia

HistoryNausea and vomitingAlteration in weightExcessive salivation and water brush ( duodenal ulceration )HeartburnHaematemesis and melaena

Findings on Physical ExaminationIn uncomplicated peptic ulcer disease, minor tenderness in the epigastrium is often the only abnormality.

The diagnosis of peptic ulcer nowadays depends exclusively on endoscopic finding.

DiagnosisEndoscopy Enable the ulcer to be identified, biopsy material obtained to enable differentiation between a benign and malignant ulcer

DiagnosisHelicobacter pylori detection Endoscopy biopsyHistological examinationUrease Test

13C-urea breath test

Serological testing

TreatmentTreatment for a peptic ulcer disease is medical in the first instance. Two principles of treatments are to: Eradicate H. pylori Reduce and neutralize acid secretion

Surgical treatment is only indicated for Failures of medical therapy Non-compliance with medication Patients who develop complications

Medical Treatment of Peptic Ulcer 1. H.pylori eradicationA two week course of antimicrobial therapy, such as amoxycillin, metronidazole and tetracycline.A combination of 2 antibiotics is recommended due to high incidence of bacteria resistance

4. Lifestyle changesAvoidance of smoking & alcohol intake, stop taking NASIDs, and deal with underlying anxiety states

2. Acid reduction Proton pump inhibitors ( e.g. omeprazole, lanzeprazole )H2 Receptor Antagonists ( e.g. cimetidine ,ranitidine )

3. Mucosal Protective Agents Synthetis prostaglandins ( e.g. misoprostol )

Surgical Treatment of Peptic UlcerGastic ulcer Can be treated by removing the ulcer together with the gastrin-secreting zone of the antrum ( Billroth I gastrectomy )

Surgical Treatment of Peptic UlcerDuodenal ulcer can be treated by Polya ( partial ) gastrectomy with the closure of duodenum and gastrojejunostomy Duodenotomy and pyloroplasty

Truncal vagotomy with either pyloroplasty or gastrojejunostomy Highly selective vagotomy

Post-gastrectomy syndromeNutritional consequences Weight loss, Anaemia, Vitamin B12 Deficiency Small stomach syndromeBilious vomitingDumping SyndromeGallstones formationRecurrent ulceration

Perforated Peptic UlcerPrevious history of peptic ulcer diseasePainSudden onset of extreme severityAggravated by movementMay come with Haematemesis and Malaena

History of Perforated Peptic Ulcer

Findings on Physical ExaminationIn early stages, Stable pulse and normal blood pressure Liver dullness is diminished Rectal examination may reveal pelvic tenderness

In the delayed case ( > 12 hours ), Features of generalised peritonitis Paralytic ileus starts to manifest Features of shock

Diagnostic MethodChest X-ray In more than 70% of cases, free gas is shown on the diaphragm below.CT Scan More sensitive, andCan rule out differential diagnoses such as acute pancreatitis and perforated appendicitis when doubt exists

TreatmentImmediate procedures A nasogastric tube is passed to empty the stomach and diminish further leakage Opiate analgesia is given to relieve pain Intravenous fluid resuscitation is started Antibiotics are given to contend with the peritoneal infection An IV H2-blocker or proton pump inhibitor is commenced

Surgical TreatmentThe gastric ulcer is biopsied to exclude malignancyAn obviously malignant gastric ulcer is removed by partial gastrectomyMedical control of acid secretion together with H.pylori eradication is undertaken postoperatively.Suturing an omental plug to seal the perforation, together with lavage of peritoneal cavity

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Gastric Cancer

Outline

Anatomy of Stomach

Epidemiology

Etiology & Pathogenesis

Pathology (microscopic)

Diffuse typeIntestinal type

Pathology (macroscopic)Favored location is the less curvature of the antropyloric regionIntestinal type

Diffuse type

Spread of Gastric Cancer

History

Non-specific epigastric pain Pain radiate to the backPallorNausea & vomitingAnorexiaEarly satietyFeeling of abdominal discomfort & fullnessLOA & LOWDysphagia (oesophagogastric junction)

Examination

Examination

Investigation

Staging

Prognosis

Management

OutlineAnatomy of stomachPhysiology of stomachPeptic ulder DiseaseDefinitionAetiology & PathogenesisCommon sitesMacroscopic & Microscopic featuresHistory in peptic ulcerFindings on PEInvestigationsTreatmentPerforated peptic ulcer disease

Anatomy of Stomach

Blood Supply

Five main ateries :Left gastricRight gastricShort gastricLeft gastroepiploicRight gastroepiploic

Nerve

Duodenum

Blood supplyArteries : upper half superior pancreaticoduodenal artery lower half inferior pancreaticoduodenal arteryVeins : SPV portal vein IPV superior mesenteric vein

Nerve : celiac and superior mesenteric plexuses

Physiology of stomach

HCl secretion

Factors affecting HCl secretion

Stimulation of HCl secretion : Ach, Histamine, Gastrin

Inhibitor of HCl secretion : Decrease pH, Somatostatin, Prostaglandin

Stomach mucosal barrier

Peptic Ulcer Disease

Definition

Ulcer a breach on the mucosa that extends through the muscularis mucosae into submucosa or deeper.

Peptic ulcer chronic, solitary lesion occur in GI tract due to aggressive action of peptic juice.

AetiologyH. pylori infectionNSAIDSZollinger-Ellison syndromeCigarette smoking

PathogenesisH.pylori 1)penetrate mucus, secrete urease, ammonia neutralize pH, survive 2)produce protease and phospholipase, damage epithelial cells

NSAIDs suppress prostaglandin, degrade mucosal barrier

Common Sites

Lesser curvature of stomach

Anterior and posterior walls of 1st portion of duodenum

Macroscopic Features :Small, sharply punched-out appearanceMargin not elevatedClean base

Microscopic Features :In chronic, open ulcer, 4 zones can b distinguished 1) Necrosis2) Inflammation3) granulation tissue4) scar