stomach & duodenum
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Stomach Duodenum
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Stomach: anatomy
Cardia: located at thegastroesophageal jungtion
Fundus: lies cephalad to the junction;
Corpus: central part.
Pylorus: boundary between thestomach and duodenum;
Cardiac gland area: mucussecreting cells;
Parietal (Oxyntic) gland area:
Pyloric gland area: distal 30%of the stomach, contains Gcells manufacturing gastrin;
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Stomach: anatomy, blood supply
Left gastric artery: suppliesthe lesser curvature andconnects with right gastricartery (branch of commonhepatic artery);
Posterior gastric artery (60%of persons): arises from themiddle third of splenic artery;
Right gastroepiploic artery: abranch of the gastroduodenalartery;
Left gastroepiploic artery: abranch of splenic artery.
Vasa brevia: branches of thesplenic and left gastroepiploicarteries, supplies the fundus;
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Duodenum: blood supply
Superior pancreato-
duodenal artery
(branch of gastro-duodenal artery);
Inferior pancreato-
duodenal artery
(branch of SMA)
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Nerve supply
Left (anterior) vagal trunk;
Right (posterior) vagal trunk;
In the region of gastro-esophageal junction, eachtrunk bifurcates;
Extragastric divisions (liver,GI tract till mid transversecolon);
Anterior and posteriornerves of Latarjet (from bothtrunks);
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Stomach: physiology
Volume of empty stomach is 50 ml;
In case of receptive relaxation it canaccommodate 1000 ml;
Output of gastric juice (fasting) 500-1500ml;
1000 ml secreted after each meal;
Components of juice:
Mucus: Protects mucosa
Pepsinogen; Intrinsic factor: secreted by
parietal cells, binds with Vit.B12.Gastrectomy creates vit b12dependency.
Blood group substances. 75% ofeo le secretes blood rou
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Stomach: physiology
Infibition of acid secretion:
1. Antral inhibition: pH below2,5 in the antrum inhibits
release of Gastrin. When pHis 1,2 gastric releae inblocked; Somatostatin ingastric antral cells serves asgastrin inhibitor;
2. Intestinal inhibition:Secretin and fat blocks acidsecretion.
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Peptic Ulcer
About 10% of population will havethe disease during their lifetime;
Men are affected 3x as often aswomen;
Duodenal ulcers are 10x morecommon than gastric ulcers inyoung patients;
Result from the corrosive actionof acid gastric juice on avulnerable epithelium;
May occur in esophagus,stomach, duodenum, jejunum(after surgical reconstruction);
In the case of duodenal andgastric ulcers, Helicobacter pylori
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Peptic Ulcer
4 type of disability:
1. Pain;
2. Bleeding
3. Penetration;
4. Perforation (if other viscerado not seal the ulcer);
5. Obstruction (inflammatory
swelling and scarring)
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Gastric Ulcer. Symptoms
Epigastric pain relieded by food or antacids;
Epigastric tenderness;
Pain appear earlier after eating (within 30 min);
Vomiting; Aggravation of pain by eating;
Achlorhydria (no acid, pH>6) after pentagastrinstimulation in incompatible with benign peptic ulcer &
suggests malignant gastric ulcer;
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Duodenal Ulcer. Essentials of
diagnosis.
Most common in the
young and middle age;
95% are located within2cm of the pylorus, in the
duodenal bulb;
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Duodenal Ulcer. Essentials of
diagnosis.
Epigastric pain relieved by foodor antacids;
Epigastric tenderness. Backpain if penetrated;
Normal or increased gastric acidsecretion;
X-ray signs (deformities, ulcerniche);
Endoscopy signs;
Evidence of Helicobacter pyloriinfection
Gastric analysis (basal andmaximal acid output);
Serum gastrin (exclude
Zollinger –Ellison syndrom)
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Gastric Ulcer
Essentials of diagnosis:
Epigastric pain; Ulcer demonstrated by X-
ray;
Acid presence on gastricanalysis.
The peak of incidence: 40-
60 years (10 years olderthan duodenal ulcer);
95% located on the lessercurvature. 60% within 6
cm from the pylorus;
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Gastric Ulcer. Diagnosis
Gastroscopy & biopsy.preferably 6 speciments should be obtainedfrom the edge. False-positive resultsare rare. False-negative occur in 5-10% of malignant ulcers.
Imaging studies. X-ray show ulceron the lesser curvature in the pyloricarea.
Signs of ulcer malignancy:
Ulcer greater than 2 cm;
Deepest penetration is norbeyond the expecter border ofthe gastric wall;
Meniscus sign (prominent rimcaused by edge of tumor).
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Duodenal Ulcer. Treatment
Suppression of acid
output;
Uneffected unless H.pylory infection is
eradicated;
Surgery indicated in case
of complications
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Duodenal Ulcer. Treatment
Medical treatment is aimed atdecreasing acid secretion.
Principal drugs consist of:
H2 receptor antagonists(cimetidine, ranitidine). Firstchoice. Heals ulcer in 80%within 6 weeks;
Proton pump blockers(omeprazole). Rerserved forpatientts refractory to H2antagonists or those withZollinger-Ellison syndrome.
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Duodenal Ulcer. Treatment
Antacids to be used on an“as-needed” bases to treatulcer pain;
After the ulcer has healed,discontinuation results 80%recurrence within 1 year; maybe avoided by chronicnighttime administration of
single dose of H2 antagonist +eradication of H. pylori.
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Duodenal Ulcer. Treatment
Optimal daily regimen:
Lansoprazole, 30 mg 2x
daily for 14 days; Amoxicillin, 1 g 2x daily
for 14 days;
Claritromycin, 500mg 2x
daily, 14 days
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Gastric Ulcer. Medical treatment
Same as for duodenal ulcer.
Medical treatment can bringthe condition under control.
Treatment of H. pyloriinfection can almosteliminate recurrence.
Surgery is neededprincipally for complications:
bleeding, perforation,obstruction.
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Gastric Ulcer. Differential Diagnosis
Hyatal hernia;
Atrophic gastritis;
Cholecystitis;
Irritable colon syndrome; Chronic pancreatitis
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Gastric Ulcer. Complications
Bleeding;
Obstruction;
Perforation.
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Duodenal Ulcer.
Surgical Treatment
Is now uncommon;
Procedures are aimed atreduction of acid secretion.
Just ulcer excision is notsufficient;
Vagotomy
Vagotomy & antrectomy;
Can be performedlaparoscopically;
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Four types of vagotomy
A. Truncal vagotomy produces totalabdominal vagaldenervation and
requires a drainageprocedure to preventgastric stasis.
B. Selective vagotomy spares the vagalbranches to the liverand small intestine, butproduces a total gastricvagotomy. A drainageprocedure is required.This vagotomy is rarely
performed.
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Four types of vagotomy
C. Highly selectivevagotomy (HSV) produces selectivedenervation of theparietal cell mass. Nodrainage procedure isneeded, as antralinnervation ispreserved.
D. Posterior truncal
vagotomy with anteriorseromyotomy (Tayloroperation) preservesthe anterior vagal trunk.No drainage procedure
is required
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Duodenal Ulcer.
Surgical Treatment
Truncal vagotomy Withoutdrainage procedure canresult delayed empting ofthe stomach;
Pyloroplasty: Heineke-
Mikulicz, Jaboulay,Finney.
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Theodor
Billroth
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Antrectomy and vagotomy
Entails a distral
gastrectomy of
50% of
stomach. Billroth I
resection;
gastroduodenalanastomosis;
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Antrectomy and vagotomy
Billroth II resection;Gastro-jejunalanastomosis;
In most cases
surgeon is able toremove the ulceratedportion of duodenumin the course ofresection;
Subtotalgastrectomy:resection of 2/3-3/4of distal stomach.
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Peptic ulcer Surgical Complications
A. Early complications Duodenal stump leakage;
Hemorrhage
B. Late complications
Recurrent ulcer (marginal, stomal,anastomotic)
Gastrojejunocolic and gastrocolic fistula
Dumping syndrome (cardio-vascular andgastro-intestinal symptoms). Shortly aftereating palpitations, sweating, weakness,
flushing, nausea, vomiting, diarrhea etc. Alkaline gastritis
Anemia: iron deficiency anemia develops in30% within 5 years after gastrectomy;
Postvagotomy diarrhea.
Chronic gastroparesis
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Zollinger-Ellison Syndrome
(Gastrinoma)
Zollinger-Ellison
syndrome is a condition
that occurs with abnormal
production of the
hormone gastrin. A small
tumor (gastrinoma) in the
pancreas or small
intestine produces the
high levels of gastrin inthe blood.
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Zollinger-Ellison Syndrome
(Gastrinoma)
Severe peptic ulcerdisease (95%)
Gastric hypersecretion;
Elevated serum gastrin;
Non-B islet cell tumor ofthe pancreas orduodenum
Endoscopy image of multiple small ulcers in the distal duodenum in a
patient with Zollinger-Ellison syndrome
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Zollinger-Ellison Syndrome
(Gastrinoma)
APUDOMAS (gastrinproducing lesions) in thepancreas are carcinomas(60%), adenomas (25%),microadenomas (25%).
1/3 of patients have MEN1(type I multiple endocrine
metaplasia) usualygastrinomas.
Tumors may be as small as2-3 mm and often difficult tofind.
PET of a patient with elevated
gastrin levels showing a duodenal
gastrinoma not detected by other
methods.
Positron emission tomography scan
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Gastrinomas occur at least as frequently
in the duodenal wall as in the head of the
pancreas within the triangle.
Gastrinomas vary in size,ranging from 0.1 cm to morethan 20 cm in diameter. In atleast 50% of cases, these
tumors are multiple. Lesscommonly, gastrinomas maybe found in the hilum of thespleen, in the stomach, liver,or parapancreatic andmesenteric lymph nodes.
PET of a patient with elevated
gastrin levels showing a duodenal
gastrinoma not detected by other
methods.
Positron emission tomography scan
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Gastrinoma Triangle
Over 90% of gastrinomasare found within an anatomictriangle referred to as thegastrinoma triangle.[2]
The 3 points that define this
region are: (1) the confluence of the
cystic and common bile duct,(2) the junction of the secondand third portions of theduodenum, and
(3) the junction of the neckand body of the pancreas
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Zollinger-Ellison Syndrome
(Surgical treatment)
Intraoperative US ishelpful;
Most lesions will befound either in the headof the pancreas or in theduodenum;
Enucleation from thepancreas;
Longitudinalduodenotomy andpalpation of the duodenal
mucosa
EUS appearance of the suspected
gastrinoma.
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Upper GI Hemorhage
Hematemesis. Bright-red or dark bloodindicates, that the source isproximal to Treitz ligament;more common from stomach or
esophagus;denotes a more rapidly bleedinglesion, high % require surgery;
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Upper GI Hemorhage
Melena one of the nineteenmunicipalities of the Province ofHavana in Cuba
Melena – hairdresser’sterminology: long hairs
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Upper GI Hemorhage
Melena (passage of black
stools). (Greek mélaina -black),
Main possible reasons:
Peptic ulcer;
Gastritis;
Portal hypertension
Stops spontaneously in 75%.Reminder will require surgery ordie;
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Total gastrectomy with Roux-en-Y
reconstruction
If the tumor involves the upper stomach or the gastro-esophageal junction
then a total gastrectomy may be needed. In this case the esophagus is
attached to the jejunum.
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Pancreaduodenectomy (Whipple
resection)
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Thank you for your attention
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References:
Current Surgical Diagnosis and
Treatment. A Lange Medical Book. 12th
edition, Edited by G. Doherty and L. Way.2006. pp:508-538.