Stomach and duodenum Dr. Ali khairalla November 2015 Objectives
To understand the gross anatomy and pathophysiology of stomach disease
To be able to recognize and manage peptic ulcer complications
To be able to recognize gastric cancer presentations and understand the principles of management Surgical anatomy Blood supply to stomach are through
1- lt. gastric artery which is a branch of celiac axis 2- Rt. gastric artery which is a branch of hepatic artery
3 – Rt. gastro epiploic artery branch of hepatic artery 4- lt. gastro-epiploic artery and 5- short gastric artery ,branch of splenic artery
Innervation
The vagus nerve is the main motor &sensory nerve supply to stomach . The vagus is of two trunks Anterior &posterior, these give branches through lesser omentum to the stomach . Nerve of Grassia; are the branches from ant. Vagal trunk to the stomach
The stomach also has intrinsic innervation 1- myentric plexus( Aurbach)& 2- submucosal plexus (miessners) these give branches through lesser omentum
Peptic ulcer
Acute peptic ulcer
Chronic peptic ulcer Peptic ulcer
These are either
Duodenal ulcer ,affecting 1st part of duodenum
Gastric ulcer , affecting stomach
These are induced by helicobacter pylori infection or NSAID ingestion complications
1 –perforation
2-deformity a-gastric outlet obstruction b-hourglass deformity c-tea-pot deformity 3-bleeding 4-malignant changes Perforated peptic ulcer
It was affect male more than female ,now affect female more than male
Usually was middle age group, now elderly patient
Most of patient has history of dyspepsia
These patient present in two forms Perforated Duodenal ulcer
1st ; massive perforation
These patient develop sudden, acute, sever abdominal pain start at epigastrium then became generalized
The patient is anxious
Pale , tachycardia
Hypotension
Abdomen not moving with respiration, Bowel sound absent
Board like rigidity 2nd ; slow perforation (leaking )
These patient preset with less sever epigastric pain due to leaking small perforation.
Then shifted to Rt. Iliac fossa
As fluid of duodenum follow the Rt. paracolic gutter
So it may simulate acute appendicitis Investigations
Erect plain chest X-ray will show air under diaphragm
Or ,Plain X-ray of abdomen will show air under diaphragm
CT of abdomen is accurate
Serum amylase
Treatment
IV fluid replacement
Nasogastric suction
Analgesia
Operation: (laparotomy or laparoscopy ) closure of perforation (over omental patch ) , peritoneal lavage , and peritoneal drainage
PPI
ANTIBIOTICS Gastric outlet obstruction
The two main causes are
gastric cancer
and pyloric stenosis secondary to peptic ulceration
Gastric outlet obstruction should be considered malignant till prove otherwise Gastric outlet obstruction , due to peptic ulcer
These results from long lasting, chronic gastric or duodenal ulcer with scaring
Pyloric stenosis occur more in male than female patient
Patient feel unwell ,dehydrated ,and fullness
And repeated vomiting, non bilious , unpleasant in nature.
The vomitus contains food ingested day or two before .
On examination
May feel distended stomach
Or see peristalsis passing from left to right
Succession splash sign positive Diagnosis
Ba. Meal will show ; large stomach delayed emptying of Ba. if Ba. pass pylorus it will show deformed duodenal cup
Treatment
Preparation of patient is essential
Correct electrolyte imbalance by normal saline & potassium replacement
Naso-gastric suction &washing
Correction of anemia and hypoprotinemia
Operation ; 1-for DU with pyloric obstruction we do truncal vagotomy and gastro-jujenostomy 2- for Gu with pyloric obstruction we do Billroth II operation
Q; A patient presented with a short history of perfuse, projectile vomiting without bile staining . He has history of peptic ulceration and chronic dyspepsia and has noticed increased bloating over the preceding 9 mo. On exam there is distention in the epigastric region and a succession splash. The abdominal rediograph shows agrossly distended stomach and collapsed bowel. The most likely cause is:
A. Carcinoma of the pylorus
B. Carcinoma of the head of pancreas
C. Fibrotic stricture
D. Compression by malignant nodes
E. Chronic pancreatitis