Stomach & Duodenum

8/10/2019 Stomach & Duodenum

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Stomach Duodenum









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;



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;

http://en.academic.ru/pictures/enwiki/71/Gray532.png



Duodenum: blood supply

Superior pancreato-

duodenal artery

(branch of gastro-duodenal artery);

Inferior pancreato-

duodenal artery

(branch of SMA)

http://en.wikivisual.com/index.php/Image:Celiac_a_branches.gif



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);



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





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.



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



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)



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;



Duodenal Ulcer. Essentials of

diagnosis.

Most common in the

young and middle age;

95% are located within2cm of the pylorus, in the

duodenal bulb;



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)



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;



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).





Duodenal Ulcer. Treatment

Suppression of acid

output;

Uneffected unless H.pylory infection is

eradicated;

Surgery indicated in case

of complications

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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.




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.




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.

http://www.pharmacheck.com/assets/images/boxes/lansoprazole15mg/image-1.gif



Gastric Ulcer. Differential Diagnosis

Hyatal hernia;

Atrophic gastritis;

Cholecystitis;

Irritable colon syndrome; Chronic pancreatitis

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Gastric Ulcer. Complications

Bleeding;

Obstruction;

Perforation.



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;



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.



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





Duodenal Ulcer.

Surgical Treatment

Truncal vagotomy Withoutdrainage procedure canresult delayed empting ofthe stomach;

Pyloroplasty: Heineke-

Mikulicz, Jaboulay,Finney.





Theodor

Billroth



Antrectomy and vagotomy

Entails a distral

gastrectomy of

50% of

stomach. Billroth I

resection;

gastroduodenalanastomosis;



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.



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



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.

http://www.netterimages.com/image/10180.htm




(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




(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



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





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




(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.



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;



Upper GI Hemorhage

Melena one of the nineteenmunicipalities of the Province ofHavana in Cuba

Melena – hairdresser’sterminology: long hairs

http://en.wikipedia.org/wiki/Province_of_Havana


http://en.wikipedia.org/wiki/Cuba

http://en.wikipedia.org/wiki/Cuba





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;



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.



Pancreaduodenectomy (Whipple

resection)



Thank you for your attention



References:

Current Surgical Diagnosis and

Treatment. A Lange Medical Book. 12th

edition, Edited by G. Doherty and L. Way.2006. pp:508-538.

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Stomach & Duodenum