surgery of stomach and duodenum

4th stage

Surgery
Lec-
Dr.Samir alsaffar

28/2/2016

Stomach & Duodenum
Gross anatomy of stomach

Microscopic anatomy :

The gastric epithelial cells are mucus producing and turned over rapidly
In the pyloric part , mucus secreting glands are found

Parietal cells : Present in the body”acid-secreting” of stomach , Responsible for acid secretion

Chief cells : Pepsinogen

Endocrine cells :
G cells; in the gastric antrum---gastrin
Enterochromaffin-like (ECL) cells ---Histamine
D cells ---somatostatin


Microscopic anatomy of Duodenum :

Lined by mucus secreting columner epithe

Brunner’s glands
Endocrine cells----cholecystokinin secretin

Physiology :

Storage “reservoir”
Mechanical break up of ingested food
Production of chyme by the actions of acid and pepsin
Programmed passage of contents into duodenum

Gastric acid secretion :

Investigation of stomach and duodenum :

Flexible Endoscopy:
Is more sensitive than conventional radiology in the assessment of the majority of GD conditions, e.g. peptic ulceration, gastritis, and duodenitis.


Upper GIT bleeding

Early gastric cancer

Diagnostic:
Visual
Biopsy
Endoluminal Ultrasound

Therapeutic:

Control of bleeding, inj. Laser, diathermy
Endoscopic gastro-cystostomy
Endoscopic Gastrostomy
Removal of Foreign bodies

Disadvantages:

Invasive, discomfort
Perforation, of pharynx, oesophagus
Miss-diagnosis,early gastric cancer.

Contrast radiology

Less commonly asked for
Of value in;
Hiatus Hernia specially of the rolling type
Volvulous of stomach
Linitus plastica


Ultrasonography
Conventional US
Detection of large gastric tumor
Metastases to liver
Endoluminal US
Depth of wall invasion” T staging”
Local LN
Liver metastases
Laparoscopic US

CT scan and MRI

CT scan
In Gastric malignancy
Miss smaller lesions
Less accurate in T staging
Less easy to detect small liver metastases
MRI
Higher sensitivity for detection of gastric cancer liver metastases

Laparoscopy

Well used for assessment of patients with gastric cancer
Particularly for detection of peritoneal seedlings


Other investigations
Gastric emptying studies
Angiography
Measurement of gastric acid secretion
Gastric motility
Plasma gastrin
Paediatric Disorders :

Hypertrophic pyloric stenosis of infancy

Aetiology:
3:1000 births
4:1 male to female
Familial
Pathology:
Hypertrophy of musculature of pylorus and adjacent antum

Clinical features :

Commonly present at 4 wks of age
Vomiting of milk without bile---2-3 days become forcible and projectile
Immediately after vomiting, the baby is usually hungery
Wt loss---emaciation, dehydration


Diagnosis
Test feed
Imaging:
Ultrasonography Olive mass
Contrast radiology no longer necessary

Differential Diagnosis

Gastro-oesophageal reflux
Feeding problems
UTI
Raised intracranial pressure

Treatment

Correction of dehydration and electrolyte abnormalites; by using Dextrose saline plus potassium
Followed by Operation “ Ramstedt’s”

Duodenal Atresia

Occur at the point of fusion between the foregut and midgut, in the neighbourhood of the ampulla of Vater.
Other defects
Antenata Dx : US
The child vomits from birth and the vomitus is bile stained


Differential DX. : High intestinal obstruction , Pyloric stenosis

Treatment : Duodenoduodenostomy

Helicobacter Pylori
Proved its importance in the aetiology of ch.gastritis, peptic ulceration,and cancer
Waren and Marshal in 1980 proved casual relation between HP and Gastritis
HP is spiral shaped, able to hydrolyse urea to ammonia “a strong alkali”
Spread Feco-oral
Incidence 80 –90 %

Pathogensis

Antral gastritis---relase of ammonia---decrease in acidity---G cell stimulation--increase gastrin----increase in HCL
Disruption of gastric mucosa through a number of cytotoxins

Diagnosis of HP infection

Brith test
CLO
Histological examination of biopsy
Serological tests


Treatment
Eradication therapy :
Combination of antibiotics like : Metronidazol + Amoxil or Claithromycin + Amoxil
With the use of proton pump inhibitor like : Omerprazol, Lansoprazol