1. Gastritis: means inflammation of the stomach (mainly involving the mucosal and sub mucosal layers). The white blood cells (inflammatory cells) move into the wall of the stomach as a response to inflammation.

2. Gastritis does not mean that there is an ulcer (not penetrating the muscular layer) or cancer. It is usually pathological diagnosis but its features like redness, congestion and erosions are seen clearly during gastroscopy. It is either acute (inflammatory cells are neutrophils) or chronic (inflammatory cells are mononuclear cells like lymphocytes and macrophages)

3. Acute gastritis

4. Aspirin and other NSAIDs like ibuprofen and indomethacine (inhibit of cyclo-oxygenase and act as anti-prostaglandin; a protective substances in the stomach). The gastritis is usually diffuse but one part of stomach may be affected more than other parts and may be erosive and haemorrhagic. The gastritis may occur even with small doses e. g. low dose aspirin used by patients with IHD. The symptoms may occur very shortly after ingestion of such drugs e. g. after a single dose, but may be delayed for considerable time after ingestion.

5. 2. Early stage of H. pylori infection (not important). H
2. Early stage of H. pylori infection (not important). H. pylori usually cause chronic gastritis which is more important. The inflammation is usually at antral part of the stomach.
3. Alcohol drinking some time is associated with acute gastritis.
4. Bile reflux e. g. after gastric surgery causing “Biliary gastritis”. The characteristic feature during endoscopy is the presence of a lot of bile in the stomach in addition to signs of inflammation.
5. Severe physiological stress e. g. after extensive burn and head injury.
6. Other rare causes like viral infection and some other medications.

6. Pathophysiology: The mechanisms of mucosal injury in gastritis involves an imbalance of aggressive factors, such as acid production or pepsin, and defensive factors, such as mucus production, bicarbonate, and blood flow.

7. Endoscopy description of four commonest types of acute gastritis:

8. Erythematous and measles like appearance acute gastritis.
Erosive gastritis: characterized by presence of multiple areas of erosions. This may appear as multiple red, oedematous elevated areas of mucosa with central superficial ulcers (polypoidal). Usually follows NSAIDs ingestion and usually the patient is symptomatic.

9. Haemorrhagic gastritis: This is the most sever and dangerous type of gastritis which may lead to sever upper GIT bleeding. The stomach appears very red and congested and usually with multiple areas of bleeding (oozing). The mucosa is very friable and bleeds on touch.
Biliary gastritis: Described above.

10. Erythematous gastritis

11. Erosive gastritis

12. Polypoid erosive gastritis

13. secondary to reflux of bile acids
Biliary Gastritis
secondary to reflux of bile acids

14. Clinical manifestations
Most cases of gastritis are asymptomatic.
Dyspepsia symptoms (upper abdomen or epigastric discomfort or pain associated with nausea, vomiting, acidity and anorexia), in some cases.
Typical peptic ulcer symptoms also may occur.
Upper GIT bleeding may occur but is rare.

15. Investigations and D. D.
1. Most cases of acute gastritis are asymptomatic and even symptomatic cases resolve spontaneously; short time after removing the causative agent like drugs, so no need for specific investigations or treatment.
2. Some time when symptoms are sever or prolonged, the patient needs some specific investigations like gastroscopy; not only to confirm the diagnosis of acute gastritis but also to

16. exclude other causes especially:
Peptic ulcer diseases
Gastric cancers like carcinoma and lymphoma.
Another D. D. of symptomatic gastritis is “Functional non-ulcer dyspepsia” which is probably a common condition.

17. Treatment of symptomatic cases consists of
1. Remove the specific cause
2. Antacids and H2 blockers like ranitidine or PPI (proton-pump inhibitor) like omeprazol in usual doses for short period of time.
3. Anti-emetics like metoclopramide also may be needed.
4. In extremely rare and severe cases surgical interference including total gastroectomy may be needed to stop severe, continuous upper GIT bleeding despite other non-surgical measures.

18. Chronic gastritis

19. The most important 3 causes for chronic specific gastritis are:
H. pylori gastritis: The commonest cause of chronic gastritis (atrophic). Usually it is asymptomatic, involving the antral region of stomach and no indication for antibiotic treatment. histopathological examination of biopsy material shows Lymphocytes and plasma cells infiltration.

20. 2.Autoimmune chronic gastritis: Involves mainly the body of the stomach with sparing of the antrum. It is due to antibody production against parietal cells. The histological features are diffuse chronic inflammation, atrophy and loss of fundic glands, intestinal metaplasia and rarely hyperplasia of enterochromoffin-like cells. The condition is a risk factor for gastric carcinoma, and also leads to pernicious anaemia due to lack of intristic factor for B12 absorption. Also may be associated with other autoimmune diseases like thyroid diseases.

21. 3.Menetrier’s disease: Is rare condition in which there is great enlargement of the gastric folds with increase in number of mucus secreting cells. Usually the disease occurs in middle aged or elderly and usually presents with symptoms of protein losing enteropathy. Treatment is with anti-secretory drugs and partial gastrectomy.

22. Atrophic gastritis
The mucosa shows signs of inflammation, at the same time the mucosal layer is thinner and appears to be more transparent.

23. GASTRIC CANCERS (gastric carcinoma, lymphoma and stromal tumor

24. Introduction: Gastric cancer is the second most common cause of cancer-related death in the world. Geographic variation exists in the incidence of this disease around the world. Many Asian countries, including Korea, China, Taiwan, and Japan, have very high rates of gastric cancer.

25. Adenocarcinoma of the stomach constitutes between 90% and 95% of all gastric malignancies. The second most common gastric malignancies are lymphomas (5%). Leiomyosarcomas (2%), carcinoids (1%), adenoacanthomas (1%), and squamous cell carcinomas (1%) are the remaining tumor histologic types.

26. Anatomical distribution of adenocarcinoma
Lower part (Antrum): %
Middle part (Body): %
Proximal part (Fundus and cardia): %
But recently the incidence of distal part carcinoma is reducing due to HP eradication, in contrast the incidence of proximal tumor (including fundus and cardia) is increasing probably due to increase incidence of Barrett’s oesophagus.

27. Regarding the gross appearance of the tumor there are different types:
Ulcerative: malignant gastric ulcer so biopsy and follow up endoscopy is indicated in gastric ulcer toexclude malignancy.
Polypoidal or Fungating tumor
Scirrhous (linitis plastic): diffuse submucosal type uncommon tumor and superficial mucosal biopsy may be negative.

28. Most cases of adenocarcinoma (distal) are due to atrophic gastritis with intestinal metaplasia.
The diffuse type which is localized at proximal stomach (fundus and cardia), and originated from normal gastric mucosa (no intestinal metaplasia and dysplasia and no role for HP infection), usually aggressive in nature and occurs in relatively young patients

29. Risk factors:
Many risk factors have been associated with the development of gastric cancer, and the pathogenesis is most likely multifactorial, but significant, genetic abnormalities are not known till now.

30. HP infection: This may lead to atrophic gastritis, achlorhydria, intestinal metaplasia, dysplasia and carcinoma.
Diet: Salted, smoked, pickled, and nitrate containing diet (Carcinogenic compounds formed). Lack of fresh vegetable and fruits from the diet and also lack of vit C and A.
Others: Like adenomatous polyp, smoking, alcohol, pernicious anaemia, familial adenomatous polyposis, partial gastrectomy for more than 15 years,…..etc. also may play a role.

31. Clinical picture

32. 1. The initial diagnosis of gastric carcinoma often is delayed because up to 80 percent of patients are asymptomatic during the early stages of stomach cancer. In Japan, a higher incidence of adenocarcinoma and regular screening processes have led to a greater number of cases of gastric cancer being detected in an early stage cancer (i.e., when limited to the mucosa and submucosa, with or without lymph node involvement).

33. 2. Late-stage gastric cancer.
Symptoms: Weight loss (most patient in advanced tumor), anaemia, abdominal pain, nausea and vomiting, early satiety, and peptic ulcer symptoms, dysphagia (proximal tumor)

34. Signs may include a palpably enlarged stomach, a primary mass (rare), an enlarged liver (secondaries), Virchow's node (i.e., left supraclavicular), Sister Mary Joseph's nodule (periumbilical), Krukenberg tumer (spread to ovary) or Blumer's shelf (metastatic tumor felt on rectal examination, with growth in the rectouterine/rectovesical space), ascites (peritoneal metastasis), thrombophlebitis (trousseau’s sign) .

35. Gastric lymphoma (NH)
Contribute to 5% of stomach tumers. However the stomach is the comment site for extra-nodal lymphoma.
May be asymptomatic or presewnted with features just like carcinoma.
Tumer may be polypoidal or ulcerative.
Endoscopy is a diagnostic tool of choice for diagnosis.

36. 5. A rare, Low-grade, T-cell-lymphoma (MALT- oma) may follow HP infection. treatment with anti-H. pylori is needed in addition.
6. Treatment of high grade lymphoma by combination of chemotherapy, surgery and /or radiotherapy.
Prognosis: Depended on stage, histology, resectabilitry and age of the patient.

37. Other tumours
Leiomyoma (and rarely leiomyosarcoma) can occur and usually are asymptomatic but may ulcerate and cause bleeding ore may be presented with epigastric mass.
Gastric Polyps like hyperplastic polyp and adenoma.
Carcinoid-tumer: Often multiple. Occur at fundus and body originate from enterochromaffin-like (ECL). It may follow long-standing pernicious anaemia. Unlike carcinoid in othewr parts of GIt, the gastric type is usually benign, but large one should be removed.

38. Diagnosis

39. In countries where the incidence of adenocarcinoma is high, a screening tests including regular screening endoscopy are done to detect early cancer. In most of other countries the diagnosis is delayed. In general the diagnosis of carcinoma is done by the following steps:

40. 1. suspicious clinical picture: patients with dyspepsia especially in a middle aged male with “Alarm Features” which include the following:
a. weight loss
b. Anaemia
c. Hematemesis and/or
melaena
d. Dysphagia
e. Palpable abdominal mass.
The diagnosis then confirmed by next steps

41. 2. OGD (upper endoscopy): is a highly sensitive and specific diagnostic test, especially when combined with endoscopic biopsy. Multiple biopsy specimens should be obtained from any visually suspicious areas; this step involves repeated sampling at the same tissue site, so that each subsequent biopsy reaches deeper into the gastric wall.

42. 3. Good double-contrast barium swallow, a, noninvasive, and readily available study, may be used as the initial step if performed by expert radiologist. This radiographic study provides preliminary information that may help the physician determine if a gastric lesion is present and whether the lesion has benign or malignant features.

43. 4. For Staging and distal metastasis lesions: After the initial diagnosis of gastric cancer is established, further evaluation for metastases is necessary to determine treatment options.
US: of the abdomen
Computed tomographic (CT) scanning
Endoscopic ultrasonography (EUS)
Laparoscopy of abdomen also may be needed.
All important biochemical and hematological tests are also indicated

44. Pre-pyloric gastric cancer

45. Antral carcinoma

46. carcinoma of the cardia

47. Malignant gastric Ulcer

48. A huge Benign polypoid tumor
Generally all gastric polyps should be removed endoscopically

49. Endoscopic removal of gastric polyp

50. Lipoma
A very deep biopsy is necessary to obtain a histological classification.. Multiple biopsies are taken from exactly the same location (buttonhole biopsy) in order to reach deeper layers.

51. (malignant B-cell lymphoma)
MALToma
(malignant B-cell lymphoma)
The surface of the lymphoma is nodular and soft ulcerations are to be found at the periphery of the lesion.

52. gastric lymphoma

53. leiomyoma

54. TREATMENT OF GASTRIC CARCINOMA

55. Treatment of adenocarcinoma
Surgery for resectable tumors:
A. Curable resection in early carcinoma
B. Surgery as palliative treatment
In distal carcinoma: Partial gastrectomy and end to end anastomosis.
In proximal carcinoma:
Oesophageogastrectomy.
3. Pre-operative chemotherapy.
4. Radiotherapy is useless.

56. Unresectable tumors:
Chemotherapy: FAM (5 Fluro, Adriamycin, Mitomycin C).
Endoscopic Laser ablation of tumor tissue for control of dysphagia or bleeding .
Endoscopic dilatation, laser therapy, or insertion of expandable metalic stents .

57. Prognosis of adenocarcinoma
Usually is poor, except in early tumor. 5 year survival is less than 20%.