GIT

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By Dr. Samir Al-Saffar

By Dr. Samir Al-Saffar

By Dr. Samir Al-Saffar

Gross anatomy of stomach
By Dr. Samir Al-Saffar

NERVE SUPPLY

By Dr. Samir Al-Saffar

MICROSCOPIC ANATOMY

The gastric epithelial cells are mucus producing and turned over rapidly In the pyloric part , mucus secreting glands are found
By Dr. Samir Al-Saffar

MICROSCOPIC ANATOMY

Parietal cells;Present in the body”acid-secreting” of stomachResponsible for acid secretionChief cells:PepsinogenEndocrine cells:G cells; in the gastric antrum--- gastrinEnterochromaffin-like (ECL) cells --- HistamineD cells ----- somatostatin By Dr. Samir Al-Saffar

MICROSCOPIC ANATOMY OF DUODENUM

Lined by mucus secreting columner epitheBrunner’s glandsEndocrine cells---- cholecystokininsecretin By Dr. Samir Al-Saffar

PHYSIOLOGY

Storage “reservoir”Mechanical break up of ingested foodProduction of chyme by the actions of acid and pepsinProgrammed passage of contents into duodenum By Dr. Samir Al-Saffar


H2
GASTRIC ACID SECRETION
Parietal cell
M2
Vagal stimulation
Chief cell
Gastrin
G
Acetylcholine
ECL cell
Histamine
Higher centers
Gastric distension
HCL
Duodenum
Secretin
-ve
D cell
-ve
By Dr. Samir Al-Saffar
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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
By Dr. Samir Al-Saffar

FLEXIBLE ENDOSCOPY

Diagnostic: Visual Biopsy Endoluminal Ultrasound Therapeutic: Control of bleeding, inj. Laser, diathermy Endoscopic gastro-cystostomy Endoscopic Gastrostomy Removal of Foreign bodies
By Dr. Samir Al-Saffar


Invasive, discomfort Perforation, of pharynx, oesophagus Miss-diagnosis,early gastric cancer
By Dr. Samir Al-Saffar

CONTRAST RADIOLOGY

Less commonly asked for Of value in; Hiatus Hernia specially of the rolling type Volvulous of stomach Linitus plastica
By Dr. Samir Al-Saffar

ULTRASONOGRAPHY

Conventional US Detection of large gastric tumor Metastases to liver
By Dr. Samir Al-Saffar

ULTRASONOGRAPHY

Endoluminal US;Depth of wall invasion” T staging”Local LNLiver metastasesLaparoscopic US By Dr. Samir Al-Saffar

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
By Dr. Samir Al-Saffar

LAPAROSCOPY

Well used for assessment of patients with gastric cancer Particularly for detection of peritoneal seedlings
By Dr. Samir Al-Saffar

OTHER INVESTIGATIONS

Gastric emptying studies Angiography Measurement of gastric acid secretion Gastric motility Plasma gastrin
By Dr. Samir Al-Saffar

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
By Dr. Samir Al-Saffar

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
By Dr. Samir Al-Saffar

DIAGNOSIS

Test feed Imaging: Ultrasonography Olive mass Contrast radiology no longer necessary
By Dr. Samir Al-Saffar

DIFFERENTIAL DIAGNOSIS

Gastro-oesophageal reflux Feeding problems UTI Raised intracranial pressure
By Dr. Samir Al-Saffar

TREATMENT

Correction of dehydration and electrolyte abnormalites; by using Dextrose saline plus potassiumFollowed by Operation “ Ramstedt’s” By Dr. Samir Al-Saffar

DUODENAL ATRESIA

Occur at the point of fusion between the foregut and midgut, in the neighbourhood of the ampulla of Vater.Other defectsAntenata Dx—USThe child vomits from birth and the vomitus is bile stained By Dr. Samir Al-Saffar

DUODENAL ATRESIA

Differential DX. High intestinal obstruction Pyloric stenosis Treatment: Duodenoduodenostomy
By Dr. Samir Al-Saffar

HELICOBACTER PYLORI

Proved its importance in the aetiology of ch.gastritis, peptic ulceration,and cancerWaren and Marshal in 1980 proved casual relation between HP and GastritisHP is spiral shaped, able to hydrolyse urea to ammonia “a strong alkali”Spread Feco-oralIncidence 80 – 90 % By Dr. Samir Al-Saffar

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
By Dr. Samir Al-Saffar

DIAGNOSIS OF HP INFECTION

Brith test CLO Histological examination of biopsy Serological tests
By Dr. Samir Al-Saffar

TREATMENT

Eradication therapy: Combination of antibiotics,like; Metronidazol + Amoxil or Claithromycin + Amoxil With the use of proton pump inhibitor,like Omerprazol, Lansoprazol
By Dr. Samir Al-Saffar

GASTRITIS

Type A gastritis; Autoimmune Ab against parietal cell Gastric atrophy----achlorhydria Malabsorption of B12 Pernicious anaemia Sparing of antrum ---- hypergastrinaemia---- Hypertrophy of ELC Predispose to gastric cancer
By Dr. Samir Al-Saffar

Type B gastritis; Due HP infection Affect the antrum Prone to peptic ulceration

By Dr. Samir Al-Saffar


Reflux Gastritis; Enterogastric reflux Common after gastric surgery Occasionally found after cholecystectomy Treatment: Bile chelating or prokinetic agent Revisional surgery
By Dr. Samir Al-Saffar


Erosive gastritis: Caused by agents that disturb the gastric mucosal barrier; like NSAIDs and alcohol. NSAID inhibition of Cox1 PG Cox2 inhibitors type of NSAID act as antiinflammatory without affection on gastric barrier
By Dr. Samir Al-Saffar


Stress gastritis A common sequel of serious illness or injury May follow cardiopulmonary bypass Attributed to a reduction of blood supply to superficial mucosa of stomach May lead to stress ulceration that may bleed Treatment: Prevention; routine use of H2 antagonists, + - mucosal barrier agents like sucralfate
By Dr. Samir Al-Saffar

PEPTIC ULCER

Not related to pepsinAll can be healed by using proton pump inhibitorsCan occur in the; 1st part of duodenum, lesser curve of stomach stoma of gastrojejunostomy, oesophagus, Meckel’s diverticulum By Dr. Samir Al-Saffar


Aetiology;Gastric acid secretion;In DU usually above normalIn Gu normal Gastrinoma”Zollinger-Ellison syndrome”Healing can occur only in the absence of acidH.pylori infection: is the most important factorNSAIDs ingestionCigarette smoking, predispose to peptic ulcer By Dr. Samir Al-Saffar

DUODENAL ULCERATION

Incidence: Decrease in its incidence Peak incidence is now in a much older ages Less marked difference between male and female. Bleeding and perforation is seen more in the elderly.
By Dr. Samir Al-Saffar


Pathology: Most common in the 1st part of duodenum Penetrates the mucosa and into the muscle coat Healing by fibrosis deformity stenosis Healed ulcer leave a permanent scar May be more than one ulcer Anterior ulcer perforate Posterior ulcer bleed
By Dr. Samir Al-Saffar


Histopatholgy: Destruction of muscular coat Base of ulcer is covered with granulation tissue Endarteritis obliterance of surrounding arteries
By Dr. Samir Al-Saffar



GASTRIC ULCERS
Incidence: Less common than DU Sex incidence is equal Affected patients are older than DU patients More prevalent in low socioeconomic groups More common in developing world than the west
By Dr. Samir Al-Saffar

Aetiology: H.pylori infection NSAIDs Smoking

By Dr. Samir Al-Saffar


Pathology: Similar to that of DU Fibrosis Hour glass deformity Penetration Lesser curve of the stomach
By Dr. Samir Al-Saffar


Malignancy in gastric ulcers:GU may be associated with gastric malignancyBenign Gu may change into gastric cancerA malignant gastric ulcer from the startAll GU should be regarded as being malignant until proved otherwise usually by well targeted multiple biopsis “as many as10” By Dr. Samir Al-Saffar

CLINICAL FEATURES OF PEPTIC ULCERS

Pain: Epigastric, gnawing, may radiate to back, eating may relieve the discomfort, intemittent Periodicity: Intermittent, spring and autmen Vomiting: indicates stenosis Alteration in weight: Wt loss or gain may occur Wt loss more with GU
By Dr. Samir Al-Saffar



Bleeding: All may bleed; May be chronic anaemia Acute presentation with hematemesis and melaena
By Dr. Samir Al-Saffar

CLINICAL EXAMINATION

Epigastric tenderness
By Dr. Samir Al-Saffar

INVESTIGATION

Gastroduodenoscopy:Investigation of choiceHighly specific and sensitiveDiagnosis:VisualBiopsy for any abnormal lesion in the stomachAntral biopsy for H.pylori “CLO test, histology” By Dr. Samir Al-Saffar

DUDENAL ULCERATION

GASTRIC ULCER
Endoscopic view
By Dr. Samir Al-Saffar



TREATMENT OF PEPTIC ULCERATION
Medical treatment: Proton pump inhibitors; omeprazol, lansoprazol Eradication therapy; is now routinely given to patients with peptic ulceration except in patients with : NSAID induced ulcers. Stomal ulcers Zollinger- Ellison syndrome
By Dr. Samir Al-Saffar

SURGICAL TREATMENT OF UNCOMPLICATED DU ULCERATION

Peptic ulcer surgery is now of little more than historical interest
By Dr. Samir Al-Saffar

OPERATIONS FOR DUODENAL ULCER

Truncal vagotomy and drainage Highly selective vagotomy Truncal vagotomy and antrectomy Billroth II gastrectomy
By Dr. Samir Al-Saffar

PROTOCOL FOR GU

Dx of benign ulcer must be confirmed by Biopsy Give Medical treatment Endoscopic checking to ensure complete healing of the ulcer 6-8 wks later If un-healed ------Surgery

OPERATIONS FOR GASTRIC ULCER

Billroth I gastrectomy Billroth II gastrectomy Vagotomy, pyloroplasty and ulcer excision
By Dr. Samir Al-Saffar

SEQUELAE OF PEPTIC ULCER SURGERY

Recurrent ulceration Small stomach syndrome Bile vomiting Early and late dumping Post-vagotomy diarrhoea Malignant transformation Nutritional consequences Gall stones
By Dr. Samir Al-Saffar

COMPLICATIONS OF PEPTIC ULCERATION

Perforation Bleeding stenosis
By Dr. Samir Al-Saffar

PERFORATED PEPTIC ULCER

Epidemiology: Increase in the age Increase in the incidence in females
By Dr. Samir Al-Saffar

PERFORATED PEPTIC ULCER

Pathology: The ulcers that are liable for perforation are: Anterior Du Anterior or incisural gastric ulcers
By Dr. Samir Al-Saffar



PERFORATED PEPTIC ULCER
Clinical features: History of peptic ulceration Sudden onset of severe generalised abdominal pain Avoid movement May be shocked with tachycardia The abdomen dose not move with respiration Board like rigidity
By Dr. Samir Al-Saffar

PERFORATED PEPTIC ULCER

Investigations:Erect plain chest radiographAir under the diaphragm in about 50 – 70 % of casesSerum amylaseCt scan for both perforated DU and pancrititisWater soluble contrast swallow -- free peritoneal leakDiagnostic peritoneal lavage By Dr. Samir Al-Saffar


Treatment: Resuscitation Analgesia Surgery Laparotomy Laparoscopy Peritoneal toilet Closure of perforation
By Dr. Samir Al-Saffar

By Dr. Samir Al-Saffar

Is a common emergency A mortality of 5% Bleeding peptic ulcer, gastric erosions, Mallory-Weiss and oesophageal vavices. Medical treatment is ineffective Therapeutic endoscopy
By Dr. Samir Al-Saffar

CAUSES OF GIT BLEEDING

Condition % Ulcers 60Oesophageal 6Gastric 21Duodenal 33Erosions 26Oesophageal 13Gastric 9Duodenal 4Mallory-weiss tear 4 Oesophageal varices 4Tumour 0.5Vascular lesions,e.g. Dieulafoy’s disease 0.5Others 5 By Dr. Samir Al-Saffar

By Dr. Samir Al-Saffar

By Dr. Samir Al-Saffar
Epidemiology; Affect much older persons Commonly associated with NSAIDs Diagnosis: Endoscopy
Bleeding peptic ulcers

Goal of treatment: Control of bleeding Prevension of rebleeding

By Dr. Samir Al-Saffar
Bleeding peptic ulcers


1- Medical treatment H2 anatgonist Proton pump inhibitors Tranexamic acid; fibrinolysis inhibitor
Bleeding peptic ulcers
Options to control bleeding

2- Minimal invasive treatment; Therapeutic endoscopy: Injection, epinephrine Thermal , electrocoagulation Laser, APC
Bleeding peptic ulcers

3- SURGICAL TREATMENT

Criteria for surgery: Patients who continue to bleed Significat rebleeding A patient who required >6 units of blood / 24h Elderly patients Certain endoscopic features; Visible vessel in the ulcer base Spurting vessel Clot cover the ulcer
By Dr. Samir Al-Saffar
Bleeding peptic ulcers

By: Minimal surgery Definite acid lowering surgery is not required

By Dr. Samir Al-Saffar
Surgical treatment
Its Aim is to Stop bleeding

Longitudenal tear below the gastro-oesophageal junctionInduced by repetitive and strenuous vomitingDiagnosis by OGD –difficulty and easily missedSurgery may be needed to stop the bleeding By Dr. Samir Al-Saffar
Mallory-Weiss tear


Gastric arterial venous malformationDifficult to diagnoseTreatment:Endoscopic----injection of sclerosantSurgery—local excision By Dr. Samir Al-Saffar
DIEULAFOY’S DISEASE

Chronic or acute Not torrential Common presentation of gastric smooth muscle tumors

By Dr. Samir Al-Saffar

The two most common causes: Pyloric stenosis Gastric cancer

By Dr. Samir Al-Saffar


In pyloric stenosis: Long history of peptic ulcer disease Unremitting pain Unpleasent vomiting that lacking bile Contain foodstaff taken several hours previously Loss of wt.
By Dr. Samir Al-Saffar

On examination: Dehydrated, loss of wt. Distended stomach, succussion splash

By Dr. Samir Al-Saffar


Metabolic effects: Hypochloraemic alkalosis Initially the urine contain low chloride and high HCO3, then dehydration---Na retention with excessive K and H ions excretion resulting in paradoxical acid urine Alkalosis-----decrease in ionized Ca---tetany
By Dr. Samir Al-Saffar

MANAGEMENT

Diagnosis: usually by Endoscopy Contrast radiology
By Dr. Samir Al-Saffar



Treatment: Correction of dehydration and metabolic abnormalities by using IV isotonic saline with K Correction of mechanical problem: Usually needs Surgery: prior to surgery; Wide bore NG tube Gastric antisecretory agents
By Dr. Samir Al-Saffar


Surgical treatment: Gastro-enterostomy Vagotomy Endoscopic treatment by balloon dilatation Disadvantages: Applicable for early cases Repeated courses perforation
By Dr. Samir Al-Saffar

GASTRIC POLYPS

Accidental finding at endoscopy May be premalignant Must be biopsied
By Dr. Samir Al-Saffar


Types of gastric polyps: Metaplastic related to H.pylori infection Inflammatory Fundic gland polyp; associated with proton pump inhibitors and familial polyposis Adenoma premalignant
By Dr. Samir Al-Saffar
Gastric polyps


Is the major cause of cancer mortality Poor prognosis Early detection The aetiology is multifactorial, but H. pylori is an important factor.
By Dr. Samir Al-Saffar



The incidence is highest in Japan and some areas of China; >70 per 100000 Men more than female Incidence increase with age Increase incidence of tumors affecting the proximal part of stomach Proximal gastric cancer dose not seem to be associated with H.pylori
By Dr. Samir Al-Saffar
Epidemiology:


Multifactorial disease H.pylori Risk factors: Pernicious anaemia and gastric atrophy Peptic ulcer surgery Cigarette smoking Diet, N-nitros compounds, excessive salt intake Alcohol Genetic
By Dr. Samir Al-Saffar
Aetiology:

CLINICAL FEATURES

By Dr. Samir Al-Saffar
Early gastric cancer Advanced gastric cancer


Early gastric cancer: Non-specfic symptoms; dyspepsia Liberal use of gastroscopy in patients with dyspepsia (Open access gastroscopy) Antisecretory agents can improve the symptoms of gastric cancer
By Dr. Samir Al-Saffar


Early satiety, bloating, distension and vomiting Bleeding, mild and chronic Obstruction, proximal---dysphagia Distal ---------gastric outlet obstruction
Advanced gastric cancer:
By Dr. Samir Al-Saffar



Non-metastatic effects:Thrombophlebitis (Trousseau’s sign)Deep vein thrombosis By Dr. Samir Al-Saffar

PATHOLOGY

Lauren classification: Intestinal gastric cancer Intestinal metaplasia Polypoid or ulcer Diffuse gastric cancer Deep infiltration no obvious mass Poorer prognosis Mixed
By Dr. Samir Al-Saffar

Early gastric cancer (90% five years survival) Cancer limited to mucosa and submucosa with or with out LN involvement ( T1,any N) Advanced gastric cancer: ( < 30% five years survival) Involve the muscularis
By Dr. Samir Al-Saffar

SPREAD OF GASTRIC CANCER

Direct spread:Penetrates the mucsularis, serosa, and ultimately adjacent organsLymphatic spreadBoth by permeation and emboliDistant nodal; supraclavicular (Troisier’s sign)Blood borne metastases:First to liver and then other organs like lung and bone By Dr. Samir Al-Saffar


Transperitoneal spread:Involve anywhere in the peritoneal cavityAscitisKrukenberg’s tumoursTumour shelfSister Joseph’s noduleLaparoscopy and cytology By Dr. Samir Al-Saffar

LYMPHATIC DRAINAGE OF THE STOMACH

By Dr. Samir Al-Saffar

LYMPHATIC DRAINAGE OF THE STOMACH

The prognosis of operable cases of gastric carcinoma depends on whether or not there is histological evidence of regional LN involvement.
By Dr. Samir Al-Saffar

INTERNATIONAL UNION AGAINST CANCER (UICC) STAGING OF GASTRIC CANCER

T1 Tumour involves lamina propriaT2 Tumour invades muscularis or subserosaT3 Tumour involves serosaT4 Tumour invades adjacent organsN0 No lymph nodesN1 Metastasis in 1–6 regional nodesN2 Metastasis in 7–15 regional nodesN3 Metastasis in more than 15 regional nodesM0 No distant metastasisM1 Distant metastasis (this includes peritoneum and distant lymph nodes) Dr. Samir Al-Saffar


StagingIA T1 N0 M0IB T1 N1 M0T2 N0 M0II T1 N2 M0T2 N1 M0T3 N0 M0IIIA T2 N2 M0T3 N1 M0T4 N0 M0IIIB T3 N2 M0IV T4 N1–3 M0T1–3 N3 M0Any T Any N M1 Dr. Samir Al-Saffar

DIAGNOSIS

Clinical SignsInvestigations:For Dx.:-----Endoscopy, with biopsyFor extend and operability “Staging”:UltrasoundEndoluminalLaparoscopicConventional CT scan For assessment: By Dr. Samir Al-Saffar

GASTRIC TUMOR

Ulcerative
Mass
By Dr. Samir Al-Saffar

TREATMENT

Surgery: Radical Palliative Operability
By Dr. Samir Al-Saffar

Radical surgery:

By Dr. Samir Al-Saffar
Total gastrectomy
Subtotal gastrectomy


Palliative surgery: Partial gastrectomy Gastroenterostomy Gastric exclusion oesophagojejunostomy
By Dr. Samir Al-Saffar
Partial gastrectomy
Gastrojejunostomy

POSTOPERATIVE COMPLICATIONS OF GASTRECTOMY

Leakage; from oesophagojejunostomy Leakage from duodenal stump Biliary peritonitis Secndary haemorrhage
By Dr. Samir Al-Saffar

LONG TERM COMPLICATIONS

Nutritional deficiencies Dumping Diarrhoea
By Dr. Samir Al-Saffar

OTHER TREATMENT MODALITIES

Chemotherapy: Improvement in the survival of several months Combination cytotxic chemotherapy Radiotherapy: Disappointing except for bony metastases
By Dr. Samir Al-Saffar

OTHER GASTRIC TUMOURS

GASTROINTESTINAL STROMAL TUMOURS(GIST) Previously Called Gastric Leiomyoma and Leiomyosarcoma Distniction between them difficult Associated with a mutation in the tyrosine kinase c-kit oncogene. Peritoneal and liver metastases spread to lymph nodes is extremely rare.
By Dr. Samir Al-Saffar

Clinical features Non specific symptoms Bleeding Difficult to detect by endoscopy

TREATMENT wedge excision GASTRECTOMY lymphadenectomy is not required imatinib before operation


Gastric Lymphoma: Primary Part of generalized lymphoma Clinical features: Similar to gastric cancer Diagnosis is by endoscopic biopsy Ct scan for staging
By Dr. Samir Al-Saffar

Treatment: Primary lymphoma: surgery + - chemotherapy Systemic lymphoma chemotherapy

By Dr. Samir Al-Saffar

GASTRIC OPERATIONS FOR MORBID OBESITY

Obesity when the BMI of the person is more than 25BMI = (Weight in kg)/(Height in m)2Normal weight when BMI between 18 – 24.9Over weight when BMI 25 – 29.9Obesity when BMI > 30Morbid obesity when BMI >45

Bariatric Surgical procedures Laparoscopic gastric Band procedure Laparoscopic gastric bypass Laparoscopic sleeve gastrectomy

Lap Band procedure

Gastric bypass
Lap sleeve gastrectomy
Bariatric Surgical procedures

INTRAGASTRIC BALLOON

ZOLLINGER- ELLISON SYNDROME

Gastrin producing endocrine tumour Head of pancreas Duodenal loop Effects; persistant peptic ulceration Treatment: Total gastrectomy in the past Proton pump inhibitor
By Dr. Samir Al-Saffar

OTHER GASTRIC CONDITIONS

Acute gastric dilatation Trichobezoar and phytobezoar Foreign bodies in the stomach

GASTRIC VOLVULOUS

By Dr. Samir Al-Saffar

TOTAL GASTRECTOMY

By Dr. Samir Al-Saffar

By Dr. Samir Al-Saffar