1. Dr Aqeel Shakir Mahmood Consultant General and Laparoscopic Surgeon
Stomach and Duodenum
Dr Aqeel Shakir Mahmood
Assistant Professor
Consultant General and Laparoscopic Surgeon
FICMS General Surgery
CABS General Surgery
FICMS-GIT Gastrointestinal Surgery (subspecialty )
MRCS –( Ireland) General Surgery
FRCS –( London) General Surgery

2. Stomach and Duodenum Anatomy Physiology Pathology Gastritis
Peptic ulcer diseases
Operative procedures
Tumors
Carcinoma of the
stomach

3. Anatomy

4. Has four regions
Cardia
Fundus
Body
Pyloric

6. Surgical importance of blood supply
Celiac trunk
1. left gastric artery
2. Splenic artery
Left gastroepiploic artery
Short gastric artery
3. Hepatic artery
Right gastric artery
Gastroduodenal artery which give right gastroepiploic artery

9. PHYSIOLOGY Function: Digestion of food, reduce the size of food
Acts as reservoir
Absorption of Vit. 12, iron and calcium

10. Types of Cells Parietal cells
most distinctive cells in stomach (HCl & intrinsic factor)
Chief cells
pepsinogen
Mucus neck cells: - HCO Mucus

11. Types of Cells G Cells: Gastrin (hormone) ---> HCl secretion
D Cells: Somatostatin (antrum)
Enterochromaffin-like cell: Histamine

13. Physiology The mucosa lining of proximal stomach contains the
parietal (acid and intrinsic factor)and chief cells(pepsinogen)
The mucosa lining the more muscular antropyloric segment secretes an alkaline mucus but contains specialized
endocrine (G) cells that release gastrin

15. Pathology Gastritis
(inflammation of the gastric mucosa) is a common GI
problem. Gastritis may be acute, lasting several hours to a few days, or chronic, resulting from repeated exposure
to irritating agents or recurring episodes of acute gastritis.
Acute gastritis is often caused by dietary indiscretion—the person eats food that is contaminated with disease-causing
microorganisms or that is irritating or too highly seasoned.

16. Gastritis
Other causes of acute gastritis include overuse of aspirin and other nonsteroidal anti-inflammatory drugs
(NSAIDs),
Excessive alcohol intake, bile reflux, and radiation
therapy.
Severe form of acute gastritis is caused by the ingestion of strong acid or alkali, which may cause the mucosa to
become gangrenous or to perforate.

17. Gastritis
Chronic gastritis and prolonged inflammation of the stomach may be caused by either benign or malignant ulcers of the
stomach or by the bacteria Helicobacter pylori.
Chronic gastritis is sometimes associated with autoimmune
diseases such as pernicious anemia; dietary factors such as
caffeine; the use of medications, especially NSAIDs; alcohol; smoking; or reflux of intestinal contents into the stomach.

18. Clinical Manifestations
The patient with acute gastritis may have
abdominal discomfort, headache, lassitude, nausea,
anorexia, vomiting, and hiccupping.
Some have no symptoms.
The patient with chronic gastritis may complain of anorexia, heartburn after eating, belching, a sour taste in the mouth, or nausea and vomiting. Patients with chronic gastritis from vitamin deficiency usually have evidence of malabsorption of vitamin B12 caused by antibodies against intrinsic factor.

19. Peptic ulcer diseases Major types ; duodenal ulcer Other types ;
gastric ulcer
stomal ulcer
Other types ;
stress ulcer
ulcers caused by gastric irritants
steroid induced ulcer

20. Pathogenesis of peptic ulcer
Lack of protection of the mucosa
Acid production

21. Peptic Ulcer Disease Pathogenesis :
Protective factors vs. hostile factors

22. Duodenal ulcer ;pathogenetic factors
Increased acid secretion
Environment ; NSAIDS, Helicobacter
Mucosal defense ; decreased bicarbonate production, decreased gastric prostaglandin production

23. Comparing Duodenal and Gastric Ulcers

24. Clinical features of peptic ulcers
Pain
The pain is epigastric, may radiate to the back. Eating may sometimes relieve the discomfort. The pain is normally intermittent rather than intractable.
Periodicity
Symptoms may disappear for weeks or months to return again. This periodicity may be related to
the spontaneous healing of the ulcer.
Vomiting
Although this occurs, it is not a notable feature unless stenosis has occurred.
Alteration in weight
Weight loss or, sometimes, weight gain may occur. Patients with gastric ulceration are often
underweight but this may precede the occurrence of the ulcer.
Bleeding
All peptic ulcers may bleed. The bleeding may be chronic and presentation with anaemia is not
uncommon. Acute presentation may be haematemesis and melaena.

25. Clinical features of peptic ulcers
Clinical examination
Examination of the patient may reveal epigastric tenderness but, except in extreme case
(for instance gastric outlet obstruction), there is unlikely to be much else to find.

26. Complications of Peptic Ulcer
Penetration
Stenosis
Perforation
Bleeding
Malignant transformation

27. Complications: Bleeding - chronic (minor, cause anaemia)
- acute (major, form affected vessel)
Perforation - mostly bulbus duodeni, anterior gastric wall
- acute violent pain
- bleeding can be present
Penetration - of the ulcer deeply through whole wall into
neighbor organ (pancreas, liver)
Stenosis - narrow of the lumen caused by scar, oedema or
inflammatory infiltration after healing of the ulcer
- rise only at pyloric localization
- vomiting of huge volume of gastric content

28. A – penetration B – perforation C – bleeding D - stenosis
Zeman, M. et al., Speciální chirurgie, ISBN , 2004
A – penetration B – perforation
C – bleeding D - stenosis

29. DIAGNOSIS PROGRAM 1. History and physical examination. 2. Endoscopy.
3. X-Ray examination of stomach.
4. Examination of gastric secretion by the method of
aspiration of gastric contents.
5. Gastric pH metry.
6. Multiposition biopsy of edges of ulcer of stomach.
7. Gastric Dopplerography.
8. Sonography of abdominal cavity organs.
9. General and biochemical blood analysis.

30. Investigation of the patient with suspected peptic ulcer
Gastroduodenoscopy
This is the investigation of choice in the management of suspected peptic ulceration and, is highly accurate.
In the stomach, any abnormal lesion , numerous biopsies must be
taken to exclude the presence of a malignancy.
Commonly, biopsies of the antrum will be taken to see whether
there is histological evidence of gastritis and a CLO test performe to determine the presence of H. pylori.

31. Therapy: Conservative Surgical regular lifestyle
prohibition of the smoking and alcohol
diet (proteins, milk and milky products)
pharmacology (antagonists of H2 receptors, antacids, antich-olinergics
Surgical
BI, BII resection
proximal selective vagotomy
vagotomy with pyloroplasty
suture of perforated or haemorrhagic ulcer

32. Gastric Ulcer

33. Location and Type of Ulcer:
Type 1: Primary gastric ulcer. Associated with diffuse
antral gastritis.
Type 2: Gastric ulcers with duodenal ulcers, most likely secondary to duodenal ulcers.
Type 3: Prepyloric or channel ulcer.
Type 4: Proximal stomach or gastric cardia.
Acid hyper secretion common among type 2 and 3 ulcers.
Type 1 an 4 pathophysiologycally the same.

34. Location of gastric ulcers

35. Type I gastric ulcer 60% of GU
Large volume of secretion with low or normal acid secretion

36. Type II gastric ulcer 25% of GU Usually acid hypersecretor
DU usually precedes GU

37. Type III gastric ulcer 23% of GU Prepyloric ulcer
Typically acid hypersecretor

38. Type IV gastric ulcer
Less than 10% of GU
High-lying ulcer

39. Predisposing factors ; gastric conditions
Acid and pepsin
Gastric stasis
Coexisting duodenal ulcer
Duodenogastric reflux
Gastritis
Helicobacter pylori

40. Predisposing factors ; clinical conditions
Chronic alcohol use
NSAIDS
Smoking
Long-term steroid therapy
Infection
Intraarterial chemotherapy

41. Comparing Duodenal and Gastric Ulcers
DUODENAL ULCER
Age 30–60
Male: female 2–3:1
80% of peptic ulcers are
duodenal
GASTRIC ULCER
Usually 50 and over
Male: female 1:1
15% of peptic ulcers are
gastric

42. Signs, Symptoms, and Clinical Findings
DUODENAL ULCER
Hypersecretion of stomach
acid (HCl)
May have weight gain
Pain occurs 2–3 hours after a meal; often awakened between 1–2 AM;
ingestion of food relieves
pain
Vomiting uncommon
GASTRIC ULCER
Normal—hyposecretion of
stomach acid (HCl)
Weight loss may occur
Pain occurs 1⁄2 to 1 hour after a meal; rarely occurs at night; may be relieved by vomiting;
ingestion of food does not
help, sometimes increases
pain
Vomiting common

43. Comparing Duodenal and Gastric Ulcers
DUODENAL ULCER
Hemorrhage less likely than with gastric ulcer, but if
Present, melena more
common than Hematemesis
More likely to perforate
than gastric ulcers
GASTRIC ULCER
Hemorrhage more likely to occur than with duodenal
ulcer; hematemesis more
common than melena

44. Comparing Duodenal and Gastric Ulcers
DUODENAL ULCER
Malignancy
Possibility Rare
Risk Factors
H. pylori, alcohol, smoking,
cirrhosis, stress
GASTRIC ULCER
Occasionally
H. pylori, gastritis, alcohol, smoking, use of NSAIDs, stress

45. Thank You