3Stimulant of Gastric secretion: PHYSIOLOGYFunction:Digestion of food, reduce the size of foodActs as reservoirAbsorption of Vit. 12, iron and calciumStimulant of Gastric secretion:Gastrin -----> (+) parietal cellAcetylcholine (vagus) ---> (+) gastric cellsHistamine (mast cells) ---> parietal & chief cells
4PHYSIOLOGYBAO: 2 – 5 meq of acid/hr. (vagal tone and basal histamine secretion)MAO:Cephalic (vagus) ---> (+) parietal & G cell10 meq acid/hr.Gastric: ---> (+) vagus & G cell15 – 25 meq of acid/hr pH = < 2.0Intestinal:Chyme enters the duodenum(-) gastric releaseSecretin, gastric inhibitory peptide, peptide YYACID condition sterilized the area, except for HELICOBACTER PYLORI
5Peptic Ulcer Disease Pathogenesis : Protective factors vs. hostile factors
6Peptic ulcer Pathogenesis: For both Duodenal & Gastric Ulcers: Infection w/ H. pylori:Decreases resistance of mucus layer from acid permeation (hydrophobicity)Increase acid secretionSlow duodenal emptyingReduced both duodenal and gastric bicarbonate secretion
7Clinical Manifestation Abdominal pain:Due to irritation of afferent nerves w/in the ulcer by the acid or due to peristaltic waves passing through the ulcerDuodenal: colicky or burning pain relieved w/ food intakeGastric: gnawing or burning usually during or after eating.N/VWeight lossEpigastric tenderness
8Peptic ulcer Pathogenesis: Effects of NSAIDs Decreases ProstagladinProstaglandin – inhibits acid secretion, stimulates mucus and HCO3 secretion and mucosal blood flowZollinger-Ellison Syndrome (1%):Massive secretion of HCL due to ectopic gastrin production from non-beta islet cell tumor (gastrinoma)Associated w/ type I (MEN) PPP20% multiple, 2/3 malignant, w/ slow growingParietal cell mass is increased> gastrin 3-6 x the normal
9Symptoms of gastric ulcer disease: epigastric pain after meal or during mealupper dyspeptic syndrome – loss of appetite, nauzea, vomiting, flatulencevomiting brings reliefreduced nutritionloss of weight
13Therapy: Conservative Surgical regular lifestyle prohibition of the smoking and alcoholdiet (proteins, milk and milky products)pharmacology (antagonists of H2 receptors, antacids, anticholinergicsSurgicalBI, BII resectionproximal selective vagotomyvagotomy with pyloroplasticsuture of perforated or haemorrhagic ulcer
14Stomach resections:Billroth I (BI) – gastro-duodenoanastomosis end-to-endBillroth II (BII) – gastro-jejunoanastomosis end-to-side with blind closure of duodenumProximal selective vagotomy – denervation of parietal gastric cells
15Zeman, M. et al., Speciální chirurgie, ISBN 80-7262-260-9, 2004 Billroth I
16Zeman, M. et al., Speciální chirurgie, ISBN 80-7262-260-9, 2004 Billroth II
17Gastro-enteroanastomosis on Roux Y crankle Zeman, M. et al., Speciální chirurgie, ISBN , 2004Gastro-enteroanastomosis on Roux Y crankle
19Zeman, M. et al., Speciální chirurgie, ISBN 80-7262-260-9, 2004 Vagotomy
20Treatment Primarily medical Surgical indications PPI or H2 blocker Triple combination (double antibiotic and PPI=amoxicillin, clarithromycin, pantoprazole for 7-14 days)Surgical indicationsIntractibility (after medical therapy)HemorrhageObstructionPerforationRelative: continuous requirement of steroid therapy/NSAIDsH pylori therapy fails in as many as 20% of patients
21Treatment: Mechanism of Pharmacologic Therapy: For eradication of H. pylori:Bismuth based triple therapyBismuth + Tetracycline + MetronidazoleProton pump inhibitorOmeprazole + Amoxicillin/Clarithromycin+ metronidazole
22Treatment: Surgical Treatment: Indication: Intractability: Highly selective vagotomyLow septic complication, (-) dumping and diarrheaFor gastric ulcer:Total or subtotal gastrectomy w/ or w/o vagotomy
23A – penetration B – perforation C – bleeding D - stenosis Zeman, M. et al., Speciální chirurgie, ISBN , 2004A – penetration B – perforationC – bleeding D - stenosis
30Elective Surgical Therapy Rare; most uncomplicated ulcers heal within 12 weeksIf don’t, change medication, observe addition 12 weeksCheck serum gastrin (antral G-cell hyperplasia or gastrinoma)EGD: biopsy all 4 quadrants of ulcer (rule out malignant ulcer) if refractory
31Modified Johnson Classification TypeLocationAcidHypersecretionILesser curvature, incisuraNoIIBody of stomach, incisura, and duodenal ulcer (active or healed)YesIIIPrepyloricIVHigh on lesser curve, near gastroesophageal junctionVAnywhere (medication induced)
41Type 4 Ulcers Least common (5% of all gastric ulcers) Ulcers 2-5cm from cardia can be treated with distal gastrectomy, extending resection along the lesser curvature and BI (Pauchet/Shoemaker procedure)Ulcers closer to GEJ, tongue-shaped resection high onto lesser curve (Csendes’ procedure with Roux-en-Y reconstruction)Cardia
42CSENDES RESECTION(Line of transection; Roux-en-Y anastomosis)
44Giant Gastric Ulcer Giant gastric ulcer: >3cm; 30% malignancy risk Subtotal gastrectomy with Roux-en-Y (high morbidity and mortality)Kelling-Madlener procedure: less aggressive, antrectomy, BI reconstruction, bilateral truncal vagotomy, leave ulcer, multiple biopsies, cautery of ulcer
45Complications after stomach resection: Early – dehiscence, stenosis of anastomosis, bleeding, pancreatitis, obstructive icterus, affection of neighbour tissuesLate - days, weeks- early dumping syndrome- late dumping syndrome- incoming crankle syndrome- outcoming crankle syndrome- ulcer in anastomosis or in outcoming crankle
46Early Complications (1) 1. Failure of the stomach or stomach remnant to empty occurs after any procedure. It was formerly common after vagotomy and drainage. Causes are: A. Prolonged paralysis of stomach (doubtful)B. Edema at a stomaC. Fluid and electrolyte disorder, especially hypokalaemia.Management is conservative with NG suction, fluid, electrolyte and nutritional replacement.
47Early Complications (2) 2. Intestinal obstruction.Causes are:A. Adhesive.B. As a consequences:(a) Twisting of the loop of a gastrojejunostomy after polya gastrectomy.(b) Herniation of loops through a mesenteric defect.(c) Retrograde intussusception of the efferent loop of a gastrojejunostomy (rare).Prophylaxis: avoid causes – such as mesenteric cul de sacs or holesTreatment: operative
48Early Complications (3) 3. Fistulae. Can occur after any operation, which involves a suture line. Most usual sites are:1. After polya gastrectomyi. Duodenal stumpii. Pancreases from trying to dissect out adifficult ulcer2. Occasionally at a Pyloroplasty
49Early Complications (4) 4. Acute pancreatitis. May follow any procedure. Its etiology is unknown, but some cases are traumatic
50Late Complications (1) Anastomotic and recurrent ulceration Causes: Inadequate resection of parietal cell mass.Isolated antrum left after polya gastrectomy.Zollinger – Ellison syndrome.Incomplete vagotmy.Persistent suture in the anastomosis. More usually this is merely a suture exposed as a consequence of ulceration from another cause.Prophylaxis: adequate primary treatment.Management is related to cause and requires investigation to ascertain the level of acid secretion or the completeness of vagotomy. Recurrence after vagotomy is best managed by polya gastrectomy.
51Late Complications (1) 2. Gastrojejunocolic fistulae. Occurs when a recurrent ulcer after gastrojejual anastomosis penetrates into the colon. It should arouse the suspicion of Zollinger-Ellison syndrome.Clinical features: Severe diarrhea occurs due to enteritis caused by cronic contents passing directly into the small bowel and acidosis, dehydration, potassium loss, anaemia and cachexia will result in death if the fastula is not interrupted surgically.Treatment:1. Good risk patient. Excision of the gastric, jejunal and colonic components and the construction of a higher gastrectomy.2. Poor risk patient. A staged procedure:(a) Stage 1: Proximal colostomy which, diverts the faecal stream from the fistula and thus stops the enteritis.(b) Stage 2: Excision of fistula and its visceral components and the construction of a higher gastrectomy and colonic anastomosis.(c) Stage 3: Closure of colostomy.
52Early dumping syndrome: group of symptoms approved shortly after mealappears after BII resectionvasomotoric sy. - face redness, fall of blood pressure, dizzinessGI sy. - vomiting, diarrhoeaTh.: diet, no sugar, low quantities of food, change BII to BI resection
53Late dumping syndrome: hypoglycaemia (sugar is not enough digested)appears after BII resectionweakness, perspiration, dizziness, tremor cca 3h after mealTh.: no sugar, change BII to BI resection
54AnemiaPartial gastrectomy and polya reconstruction interferes with duodenal absorption of iron and a macrocytic anemia may resultMore rarely, sufficient stomach has been removed to cause failure of release of intrinsic factor and thus a macrocytic anemiaMalnutrition may contribute to both.
55Weight loss and its complications Particulary after partial gastrectomy when patients are unwilling to eat sufficiently, weight loss is commonSevere malnutrition is rare, but there is an increased risk of nutrition-associated diseases such as tuberculosis.
56Bilious vomitingAny operation which, destroys or bypasses the pylorus allows bile to reach the stomach.Not only does this produce atrophic gastritis but also it may be associated with bilious vomiting.This is more likely after a polya gastrectomy where characteristically a patient eats a meal and some to 10 to 20 minutes later vomits bile only.In severe cases, either normal anatomy should be restored or the bile diverted more distally into the intestine.
57DiarrheaApart from the dumping syndrome, all vagotomies except highly selective ones seem to cause diarrheaMatters are made worse if cholecystectomy has been done or is subsequently done
58Acute Gastritis (erosive) Stress erosions are usually multiple, small punctuate lesion in the proximal acid secreting portion of the stomachClinical Settings:Severe illness, trauma, burns (Cushing ulcer) or sepsisDue to (-) mucosal defense (ischemia)Drug and Chemical ingestionAspirin / NSAIDsCNS trauma:Increase gastrin ---> elevated acid secretionCurling ulcer
60Acute Gastritis Treatment: NPO NGT / Saline lavage Antacids / omeprazole / sucralfateIntra-arterial infusion of vasopressinSurgery --> if 6-8 units over 24 hrsMortality ---> 40%Near total gastrectomyVagotomy + pyloroplasty + over sewing of bleederPartial gastrectomy + vagotomy
61Zollinger-Ellison Syndrome (Gastrinoma) Symptoms tends to be more severe, unrelenting and less responsive to therapy.Clinical Manifestation:PainDiarrheaSteatorrheaDiagnosis:Acid secreting studies (50meq/hr)UGISRadio-immuno assay for serum Gastrin levelDiff: a) Pernicious anemiab) Renal insufficiencyc) Antral gastrin hyperplasia or hyperfunctionCT scan and angiography to localize gastrinomaVenous sampling