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STOMACH AND DUODENUM

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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STOMACH AND DUODENUM

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  1. STOMACH AND DUODENUM Begashaw m (MD)

  2. 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

  3. 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

  4. Anatomy

  5. Types of cells & secretion

  6. Functions 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

  7. Histology • Surface epithelial cells alkaline mucus • Mucus cells_mucus, HCO3¯ • Parietal cellsHCl, Intrinsic factor • Chief cellspepsinogens, lipases

  8. Pathogenesis imbalance in aggressive activity of acid & pepsin & defensive mechanisms Factors 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

  9. Classification Erosive gastritis Acute gastritis - after major trauma, shock, sepsis, head Injury & ingestion of aspirin & alcohol -“Stress erosion” Chronic gastritis->Established inflammatory reaction

  10. 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

  11. Classification

  12. Summary of clinical features

  13. Investigations A- Gastroduodenoscopy and biopsy B- Barium meal C- Blood studies ↓ hemoglobin (Hgb) shows chronic blood loss D-H.pyloritest

  14. Treatment • 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 -Metronidazole

  15. Surgical treatment A - Complications – obstruction _ perforation _ bleeding B - Intractability

  16. Complications of PUD

  17. 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

  18. 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

  19. Air under diaphragm

  20. Treatment Resuscitate Antibiotic therapy Continuous gastric aspiration Urgent laparotomy- peritoneal toilet and closure of perforation with omentalpatch Anti H-pylori treatment - recurrence

  21. Omental patch

  22. Graham patch technique

  23. 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

  24. Management • Conservative - IV fluid resuscitation - Blood transfusion if indicated - Naso gastric tube insertion and saline lavage - H2 receptor antagonist - Endoscopic evaluation - Serial hematocrit

  25. 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

  26. Treatment Surgery – truncalvagotomy and bypass operation after preliminary gastric lavage with saline for 4-5 days Correction of fluid and electrolytes using crystalloid fluids

  27. Gastric Cancer Epidemiology - Age 40-60 years - Sex M:F 3:1 More common in Far East – Japan Etiology Premalignant conditions Risk factors: Gastric polyp,pernicious anemia, post gastrectomystomach, gastritis, cigarette smoking & genetic makeup

  28. Pathology - Prepyloricregion is the most common site - Microscopic - Adenocarcinoma Spread -Direct -lymphatic -transperitoneal -blood stream

  29. 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

  30. Gastric ca

  31. Investigations - Gastroscopy and biopsy - Hgb - Barium meal shows filling defect - Laparotomy (diagnostic)

  32. Treatment - Gastrectomy when possible - Palliative bypass surgery Prognosis - Over all 5 years survival is about 10 -20%

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