Stomach and duodenum
Dr. Ali khairalla
November 2015
Objectives

To understand the gross anatomy and pathophysiology of stomach disease

To be able to recognize and manage peptic ulcer complications

To be able to recognize gastric cancer presentations and understand the
principles of management
Surgical anatomy
Blood supply to stomach are through
1- lt. gastric artery which is a branch of celiac axis
2- Rt. gastric artery which is a branch of hepatic artery
3 – Rt. gastro epiploic artery branch of hepatic
artery
4- lt. gastro-epiploic artery and
5- short gastric artery ,branch of splenic artery
Innervation
The vagus nerve is the main motor &sensory nerve supply to
stomach . The vagus is of two trunks Anterior &posterior, these give
branches through lesser omentum to the stomach .
Nerve of Grassia; are the branches from ant. Vagal trunk to the
stomach
The stomach also has intrinsic innervation
1- myentric plexus( Aurbach)&
2- submucosal plexus (miessners)
these give branches through lesser omentum
Peptic ulcer

Acute peptic ulcer

Chronic peptic ulcer
Peptic ulcer




These are either
Duodenal ulcer ,affecting 1st part of duodenum
Gastric ulcer , affecting stomach
These are induced by helicobacter pylori infection or NSAID ingestion
complications
1 –perforation
2-deformity
a-gastric outlet obstruction
b-hourglass deformity
c-tea-pot deformity
3-bleeding
4-malignant changes
Perforated peptic ulcer

It was affect male more than female ,now affect female more than male

Usually was middle age group, now elderly patient

Most of patient has history of dyspepsia

These patient present in two forms
Perforated Duodenal ulcer
1st ; massive perforation

These patient develop sudden, acute, sever abdominal pain start at
epigastrium then became generalized

The patient is anxious

Pale , tachycardia

Hypotension

Abdomen not moving with respiration, Bowel sound absent

Board like rigidity
2nd ; slow perforation (leaking )

These patient preset with less sever epigastric pain due to leaking small
perforation.

Then shifted to Rt. Iliac fossa

As fluid of duodenum follow the Rt. paracolic gutter

So it may simulate acute appendicitis
Investigations

Erect plain chest X-ray will show air under diaphragm

Or ,Plain X-ray of abdomen will show air under diaphragm

CT of abdomen is accurate

Serum amylase
Treatment

IV fluid replacement

Nasogastric suction

Analgesia

Operation: (laparotomy or laparoscopy ) closure of perforation (over omental
patch ) , peritoneal lavage , and peritoneal drainage

PPI

ANTIBIOTICS
Gastric outlet obstruction

The two main causes are

gastric cancer

and pyloric stenosis secondary to peptic ulceration

Gastric outlet obstruction should be considered malignant till prove otherwise
Gastric outlet obstruction ,
due to peptic ulcer

These results from long lasting, chronic gastric or duodenal ulcer with
scaring

Pyloric stenosis occur more in male than female patient

Patient feel unwell ,dehydrated ,and fullness

And repeated vomiting, non bilious , unpleasant in nature.

The vomitus contains food ingested day or two before .
On examination

May feel distended stomach

Or see peristalsis passing from left to right

Succession splash sign positive
Diagnosis

Ba. Meal will show ;
large stomach
delayed emptying of Ba.
if Ba. pass pylorus it will show deformed duodenal cup
Treatment

Preparation of patient is essential

Correct electrolyte imbalance by normal saline & potassium replacement

Naso-gastric suction &washing

Correction of anemia and hypoprotinemia

Operation ; 1-for DU with pyloric obstruction we do truncal vagotomy and
gastro-jujenostomy
2- for Gu with pyloric obstruction we do Billroth II operation
Q; A patient presented with a short history of perfuse,
projectile vomiting without bile staining . He has history of
peptic ulceration and chronic dyspepsia and has noticed
increased bloating over the preceding 9 mo. On exam there
is distention in the epigastric region and a succession splash.
The abdominal rediograph shows agrossly distended stomach
and collapsed bowel. The most likely cause is:
A.
Carcinoma of the pylorus
B.
Carcinoma of the head of pancreas
C.
Fibrotic stricture
D.
Compression by malignant nodes
E.
Chronic pancreatitis