STOMACH AND DUODENUM

GASTRIC ANATOMY AND PHYSIOLOGY

Pic. The anatomic relationships in the upper abdomen. The stomach is bounded on its left by the spleen, posteriorly (dorsally) by the pancreas, inferiorly (caudally) by the colon, and to its right by the duodenum along the liver's edge.

Pic. 1 lig. hepatogastricum; 2 lien; 3 gaster; 4 lig. gastrocolicum; 5 duodenum; 6 lig.hepatorenale; 7 foramen epiploicum (Winslovi); 8 lig. hepatoduodenale; 9 vesica fellea; 10 hepar;11 lig. teres hepatis

Pic. 1 lien; 2 aa. et vv. gastricae breves; 3 a. et v. gastrica sinistra; 4 trun-cuscoeliacus; 5-.lienalis; 6-. he-patica communis; 7 a. et v. gastro-

epiploica sinistra; 8gaster; 9 omen tum majus; 10a. et v. gastroomentalis dextra; 11 duodenum; 12a. et v. gastricadextra; 13-, et v. gastroduodena-lis; 14 ductus choledochus; 15 v. cava inferior; 16 v. portae; 17 a. hepatica propria; 18 hepar; 19 vesicafellea

Pic. Anatomically, the stomach is divided into several segments. Functionally, the cardia and the antrum differ from the body in that they contain no acid secretory properties. The incisura is an area on the lesser curvature, which marks the antrum-body junction and is often easily seen on barium upper intestinal series.

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GASTRIC ULCER

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The gastric ulcer is the chronic disease with polycyclic passing. The main typical of peptic ulcer is the presence of ulcerous defect in a mucous

tunic. One of basic places belongs among the gastroenterology diseases to this pathology. Such phenomenon explained by not only considerable distribution of disease but also those dangerous complications which always accompany gastric ulcers.

Pic. The presence of ulcerous defect in a mucous tunic.

Etiology and pathogenesis Frequency of morbidity on the peptic ulcer among the adult population is about 4 %. More frequent age in patients with gastric ulcers is 5060 years. To development mechanism of disease is still not enough studied. From a plenty of different theories in relation to genesis of peptic ulcer no one able to explain the disease. So, each of such factors as neurogenic, mechanical, inflammatory, vascular is present in the mechanism of development of peptic ulcer. Consider for today, that disturbance between the factors of aggression and defense of mucous tunic arose peptic ulcer. To

the first factors belong: hydrochloric acid, pepsin, reverse diffusion of ions of hydrogen, products of lipid hyperoxidizing. To the second: mucus and alkaline components of gastric juice, property of epithelium of mucous tunic to permanent renewal, local blood flow of mucous tunic and submucous membrane. In the terminal stage of mechanism of origin of gastric ulcers important role has the peptic factor and disturbance of trophism of gastric wall as a result of local ischemia. It confirmed by decreasing of blood flow in the wall of stomach at patients with ulcers on 3035 % compared to the norm. It is proved, that a local and functional ischemia more frequent arises up on small curvature of stomach in the areas of ectopy of the antral mucous tunic in acid-forming. Exactly there ulcers appear. Important part in ulcerogenesis is acted by duodenogastric reflux and gastritis. Also, gastrostasis can provoke hypergastrinaemia and hypersecretion and formed gastric ulcers. Numeral scientific developments of the last years testify to the important infectious factor in the mechanism of origin of peptic ulcer conditioned, mainly, by helicobacter pylori. Pathomorphology Such stages of disease are distinguished: erosion, acute and chronic ulcers. Erosions, mainly, are plural. Their bottom as a result of formation of muriatic haematine is black, edges infiltrated by leucocytes. A defect usually does not penetrate outside muscular tissue of the mucous tunic. If necrosis gets to more deep layers of wall of stomach, a acute ulcer develops. It has a funnel-shaped form. Bottom is also black, edges is swelled. Chronic

ulcers are mainly single, sometimes arrive to the serous layer. A bottom is smooth, sometimes hilly, edges is like elevation, dense. Classification For today the most known classification of gastric ulcers by Johnson (1965). There are three types of gastric ulcers are distinguished: I ulcers of small curvature (for 3 cm higher from a goalkeeper); II double localization of ulcers simultaneously in a stomach and duodenum; III ulcers of goalkeeper part of stomach (not farther as 3 cm from a goalkeeper). In the area of small curvature of body of stomach is localized 70,9 % ulcers, on a back wall, nearer to small curvature 4,8 %, in the area of cardial part 12,9 %, in a goalkeeper part 11,4 %. The ulcers of large curvature of stomach are casuistry and meet infrequently. Clinical management The complaints of patients with the gastric ulcer always give valuable information about the disease. The detailed analysis of their anamnesis allows to pay attention to the possible reasons of origin of ulcer, time of the first complaints, to the changes of symptoms. Pain. A pain symptom in the peptic ulcer disease is very important. There are typical passing for this disease: hunger pain food intake facilitation again hunger pain food intake facilitation (so during all days). Night pain for the gastric ulcer is not typical. The such patients rarely wake up in order to take a food. For diagnostics of ulcer localization it is important to know the time of appearance of pain. Between acceptance of food and appearance of pain it is the shorter, than the higher placed gastric

ulcer. Thus, at patients with a cardial ulcer pain arises at once after the food intake, with the ulcers of small curvature in 5060 minutes, at pyloric localization approximately in two hours. However this feature it is enough relative and some patients in general do not mark dependence between food intake and pain. In other patients the pain attack is accompanied by the salivation. A epigastric region near the xiphoid process is typical localization of pain. The irradiation of pain is not usual for gastric ulcers. Irradiation occur in patients with penetration and depended from organ, in which an ulcer penetrates. At the examination of ulcerous patient it is expedient to determine the special pain points:Boas (pain at pressure on the left of the II pectoral vertebrae), Mendel (pain at percussion on the left to epigastric region). Vomiting, the sign of disturbance of motility function of stomach, is the second typical symptom of gastric ulcer. More frequent gastrostasis arises as a result of failure of stomach muscular, it atony which can be effect of organ ischemia. Vomiting could arises both on empty stomach and after food intake. Heartburn is one of early symptoms of gastric ulcer, however at the prolonged passing of disease it can be hidden or quite disappear. Often it precedes of pain arising (initial heartburn) or accompanies a pain symptom. Mostly heartburn arises after the food intake, but can appear independently. it is observed not only at hypersecretion of the hydrochloric acid, but at normal secretion, even reduced acidity of gastric juice. The belching at gastric ulcers is examined rarely, more frequent in patients with cardial and subcardial ulcers. It is necessary to bind to disturbance of function of cardial valve.

The general condition of patients with the uncomplicated gastric ulcer usually satisfactory, and in a period between the attacks even good. However for most patients lost of the body weight and pallor are typical. In a epigastric region hyperpigmental spots are examined after the prolonged application of hot-water bottle. At palpation of stomach in this area sometimes appears local painful. It is needed also to check up noise of splash, the presence of which can be the sign of possible gastrostasis. At the examination of mouth cavity a tongue has whiter-yellow incrustation. In patients with penetration ulcers and disturbances evacuations from a stomach examined dryness of tongue. Stomach, as a rule, regular rounded shape, however during the pain attack is pulled in. There is antiperistalsis arises during the pylorostenosis. The increased secretion of hydrochloric acid in patients with gastric ulcers observed rarely and, mainly, at prepyloric ulcer localizations. Mostly secretion is normal, and in some patients is even reduced. X-Ray examination. The direct signs of ulcer at X-Ray examinations are: symptom of Haudek's niche (Pic. 3.2.1), ulcerous billow and convergence of folds of mucous tunic. Indirect signs: symptom of forefinger (circular spasm of muscles), segmental hyperperistalsis, pylorospasm, delay of evacuation from a stomach, duodenogastric reflux, disturbance of function of cardial part (gastroesophageal reflux). Gastroscopy can give important information about localization, sizes, kind of ulcer, dynamics of its cicatrization, and also allow to perform biopsy with subsequent histological examination. Clinical variants and complication

The gastric ulcer passing can be acute and chronic. Acute ulcers arise as answer for the stress situations, related to the nervous overstrain, trauma, loss of blood, some infectious and somatic diseases. By a diameter ulcers has from a few millimeters to centimeter, a round or oval form with even edges. Thus in most cases clinically observed clear ulcerous clinical signs. If complications is absent (bleeding, perforation) such ulcers treated and mostly heal over. G.J. Burchynskyy (1965) such variants of clinical flow distinguished: 1. Chronic ulcer which does not heal over long time. 2. Chronic ulcer which after the conservative therapy heals over relatively easily, however inclined to the relapses after the periods of remission of a different duration. 3. Ulcers, which localization are had migrant character. Observed in people with acute ulcerous process of stomach. 4. Special form of gastric ulcer passing after the already carried disease. Passed with the expressed pain syndrome. Characterized by the presence in place of ulcerous defect of scars or deformations and absence of symptom of niche. There are such complications can develop in patients with gastric ulcer: penetration, stenosis, perforation, bleeding and malignization. Diagnosis program 1. Anamnesis 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 and mucous tunic of stomach. 7. Gastric Dopplerography. 8. Sonography of abdominal cavity organs. 9. General and biochemical blood analysis. 10. Coagulogram.

Pic. Symptom of Haudek's niche

Pic. Peptic ulcer of the stomach (endoscopy)

Differential diagnostics Chronic gastritis, as well as at an gastric ulcer, characterized by the pain syndrome, that arises after the food intake. In such patients it is possible to observe nausea and vomiting by gastric content, heartburn and belch. However, unlike an gastric ulcer, for gastritis typical symptom of quick satiation by a food. Unsteady emptying, diarrhea also more inherent to gastritises. At gastric ulcer more frequent the delays are observed, constipation for 45 days.

The cancer of stomach, it is comparative with an gastric ulcer, has considerably more short anamnesis. The most typical clinical signs of this pathology are: absence of appetite, weight loss, rapid fatigability, depression, unsociability, apathy. In such patients X-Ray examination expose the defect of filling, related to exophytic tumor and deformation of walls of organ. A final diagnosis is set after the results of multiposition biopsy of shady areas of mucous tunic of stomach. Differential diagnostics also needs to be conducted with the so called precancerous states: gastritis with the achlorhydria; chronic, continuously recurrence ulcers, poliposis and Addison-Biermer anemia. Tactic and choice of treatment method Conservative treatment of gastric ulcer always must be complex, individually differentiated, according to the etiology, pathogeny, localization of ulcer and character of clinical signs (disturbance of functions of gastroduodenal organs, complication, accompanying diseases). Conservative therapy must include: Omeprazole 20 mg 2 time per day or 2- blocker histamine receptor (ranitidine) 150 mg in the evening, famotidine 40 mg at night, roxatidine 150 mg in the evening antiacid drugs in accordance with the results of pH-metry; reparative drugs (dalargin, solcoseryl, actovegin) for 2 ml 1 2 times per days antimicrobial drugs (clarytromicine 500 mg twice daily, de-nol, metronidazole)

Treatment of patient with a gastric ulcer must continues not less than 68 weeks. Surgical treatment must performed in cases: ) at the relapse of ulcer after the course of conservative therapy; ) in the cases when the relapses arise during supporting antiulcer therapy; ) when an ulcer does not heal over during 1,52 months of intensive treatment, especially in families with ulcerous anamnesis. ) at the relapse of ulcer in patients with complications (perforation or bleeding); ) at suspicion on malignization ulcers, in case of negative cytological analysis. The choice of method of surgical treatment of gastric ulcer depended from localization and sizes of ulcer, presence of gastro- and duodenostasis, accompanying gastritis, complications of peptic ulcer (penetration, stenosis, perforation, bleeding, malignization), age of patient, general condition and accompanying diseases. In patients with cardial localization of ulcer the operation of choice is the proximal resection of stomach, which, from one side, allows to remove an ulcer, and from other to save considerable part of organ, providing it functional ability (Pic. 3.2.2). In case with large cardial ulcers, when the vagus nerves pulled in the inflammatory infiltrate and it is impossible to save integrity even one of them, operation needs to be complemented by pyloroplasty. It will give possibility to warn pylorospasm and gastrostasis, which in an early postoperative period can be the reason of anastomosis insufficiency and other complications. At the choice of method of surgical treatment of gastric ulcers with subcardial localizationon small curvature without duodenostasis it is

better to apply the methods of stomach resection with saving of passage through a duodenum. For this purpose we are developed the method of segmental resection of stomach with addition selective proximal vagotomy. The redistribution of gastric blood flow between the functional parts of stomach as reply to medicinal vagotomy (intravenous introduction 1,0 ml 0,1 % solution of atropine of sulfate) is studied. Hyperemia of acid-forming part of stomach comes after introduction of preparation. The functional scopes of stomach parts are determined. The border between acid-forming and antral parts are the most frequent localization of gastric ulcers. During this operation middle laparotomy is performed, intravenously entered 1,0 ml 0,1 % solution of atropine, then the scopes of functional stomach parts are identified and by stitches-holders is marked a intermedial segment. Selective proximal vagotomy is performed. After mobilization of large curvature of stomach within the limits of intermedial segment it resection is performed. After that gastro-gastro anastomosis end-to-end is formed (Pic. 3.2.3). The analysis of supervisions of the patients operated by such method in postoperative period has good results. It allows to recommend this operation for clinical practice, in case of gastric ulcers of subcardial localizations, without duodenostasis, penetration, malignization or nerves Latarjet damaging. The operation of choice in patients with subcardial ulcers and duodenostasis is gastric resection by Billroth II. At the choice of method of surgical treatment of ulcers which are localized in upper and middle third of stomach, it is necessary to consider such factors, as absence of penetration in a small omentum and absence of the duodenostasis. In such patients is performed segmental resection of

stomach with ulcer removing with selective proximal vagotomy. In case of penetration ulcer in a small omentum with involvement in infiltrate Latarjet nerves, such operation is impossible because of future spasm of pylorus and gastrostasis. If duodenostasis is absence than better to apply pylorus-saving resection by Maki-Shalimov. In patients with duodenostasis better to apply gastric resection by Billroth II. At the border of gastric resection near pyloric sphincter can be spasm and gastrostasis in a postoperative period . Avoiding such complication is possible, if this border of gastric resection passes no more than 1,5 cm from a pyloric sphincter (M.M. Risaev, 1986). So, at a resection, that passes higher than 2,0 cm from a pylorus, integrity of both loops is kept. Patients with antral ulcers without the duodenostasis performed the gastric resection by Billroth I (Pic. 3.2.6), and on presence of duodenostasis Billroth II. Prepiloric ulcers is similar to the ulcers of duodenum. Such localization of gastric ulcers without malignization allow to perform selective proximal vagotomy. However, at large prepyloriculcers with penetration without duodenostasis is better to perform the gastric resection by Billroth I and on presence of duodenostasis by Billroth II. By contra-indication to operations with saving of food passing through the duodenum are also decompensated pylorostenosis , functional gastrostasis and duodenostasis. In such patients it is better to perform gastric resection by Billroth II.

Pic. Billroth I and Billroth II resection

Pic. Billroth I reconstruction

Pic. Billroth II recontruction

DUODENAL ULCER The duodenal ulcer is the chronic recurrent disease which

characterized by ulcerous defect on a mucous tunic of duodenum. Pathology often makes progress with complications development.

Etiology and pathogenesis

There are some etiologic factors of the duodenal ulcer: Helicobacter pylori, emotion tension and neuropsychic stress overstrain, heredity and genetic inclination, presence of chronic gastroduodenitis, disturbance of diet and harmful habits (alcohol, smoking). In pathogenesis of peptic ulcer a leading role is played disturbance of equilibrium between aggressive and projective properties of secret of stomach and it mucous tunic. The aggressive factors are vagus hyperfunctioning and hypergastrinemia; hyperproduction of hydrochloric acid and pepsin, and also reverse diffusion of the ions +, action of bilious acids and isoleucine, toxins and enzymes of helicobacter pylori (HP). There are factors which are contribute to ulcerogenic action: disturbance of motility of stomach and duodenum, ischemia of duodenum, and metaplasia of the epithelium. Pathomorphology Morphogenesis of duodenal ulcer fundamentally does not differ from ulcer in a stomach. Chronic ulcers are mainly single, is localized on the front or back wall of bulb (bulbar ulcer) and only in 78 % cases below it (postbulbar ulcer). The plural ulcers of duodenum are met in 25 % cases.

Classification (by A.L.Hrebenev, A.O.Sheptulin, 1989) The duodenal ulcer is divided: I. By etiology: . True duodenal ulcer. . Symptomatic ulcers.

II. By passing of disease: 1. Acute (first exposed ulcer). 2. Chronic: a) with the rare exacerbation; b) with the annual exacerbation; c) with the frequent exacerbation (2 times per a year and more frequent). III. By the stages of disease: 1. Exacerbation. 2. Scarring: a) stage of red scar; b) stage of white scar. 3. Remission. IV. By localization: 1. Ulcers of bulb of duodenum. 2. Low postbulbar ulcers. 3. Combined ulcers of duodenum and stomach. V. By sizes: 1. Small ulcers up to 0,5 cm. 2. Middle up 1,5 cm. 3. Large up to 3 cm; 4. Giant ulcers over 3 cm. VI. By the presence of complications: 1. Bleeding. 2. Perforation. 3. Penetration. 4. Organic stenosis. 5. Periduodenitis.

6. Malignization. Clinical management Pain in the epigastric region is the most expressed symptom of duodenal ulcer, often with displacement to the right in the projection area of bulb of duodenum and gall-bladder. Also for this pathology is typical the pain, that arises in 1,52 hours after food intake, hungry and nightly pain. As a rule, it is acute, sometimes unendurable, and is halted only after the use of food or water. Such patients complains for the seasonal exacerbation, more frequent in spring and in autumn. However exacerbation can be also in winter or in summer. In the acute period of disease heartburn often increases. However heartburn is the frequent symptom of cardial insufficiency and gastroesophageal reflux. For an duodenal ulcer the acute burning feeling of acid in a esophagus, pharynx and even in the cavity of mouth is especially typical. Often are belch by air or sour content, excessive salivation. Vomiting is not a typical symptom for duodenal ulcer. More typical sign is nausea. Sometimes for facilitation patients wilfully cause vomiting. These symptoms, arises in the late periods of passing of duodenal ulcer. Intensity of pain and dyspepsia syndromes depends both on the depth of penetration and from distribution of ulcerous and periulcerous processes. Superficial ulceration within the mucous tunic, as a rule, does not cause the pain because it does not have sensible receptors. However, more deep layers of wall (muscular and especially serous) have plural sensible vegetative receptors. Therefore, on deepening and distribution of process arises visceral pain. At evident periulcerous processes and penetration of ulcers to neighboring organs and tissues, usually, a parietal peritoneum, that has spinal innervation, is pulled in. Pain becomes viscero-somatic, more intensive. A

such pain syndrome (with an irradiation in the back) is typical for low postbulbar ulcers and bulbous ulcers of back wall, which penetrates in a pancreas and hepato-duodenal ligament. Usually such patients has good appetite. Some of them limit themselves in acceptance of ordinary food, go into to the dietary feed by small portions, and some even hold back from a food, being afraid to provoke pain, and as a result of it weight is lost. Some of patients feeds more intensive and often. The psychical status of patients often are changed as a asthenoneurotic syndrome: irritates, decline of working capacity, indisposition, hypochondria, abusiveness. An inspection, as a rule, gives insignificant information. In many cases on the abdominal skin it is possible to notice hyperpigmentation after application of hot-water bottle. During the pain attack patients often occupy the forced position. At superficial palpation on the abdominal wall determined hyperesthesia in ulcer projection. In the epigastric region, during deep palpation, it is possible to define pain and muscular tension, mostly moderate intensity. There is important symptom of local percussion painful (Mendels symptom): percussion by fingers in the symmetric epigastric areas provoke pain in the ulcer, which is increased after the deep breath. The roentgenologic and endoscopic are main diagnostic methods. The symptom of ulcerous niche is a classic roentgenologic sign. It is depot of contrast agent, which is corresponded to ulcerous defect, with clear contours and light bank to which converged fold mucus. Cicatricial deformation of bulb of duodenum as a shamrock, butterfly, narrowing, tube, diverticulum and other forms is the important sign of chronic ulcerous process. A roentgenologic method is especially important for determination of configuration and sizes of stomach and duodenum, and also for estimation of motility functions. XRay examination is the main method at the peptic ulcer complicated by

stenosis, with disturbance of evacuation, duodenostasis, duodenal-gastric reflux, gastroesophageal reflux, diverticulum. But by X-Ray examination is difficult to diagnose small superficial ulcers, acute ulcers, erosions, gastritises and duodenitises. The most informing method in such cases it endoscopy. During endoscopy examination it is possible to define localization, form, sizes and depth of ulcer. During bleeding grumes, trickle or pulsating of blood are observed. By irrigation by styptic solutions, by cryocoagulation, by laser coagulation endoscopy allows to secure hemostasis. Endoscopy allows to perform the biopsy of ulcer tissues for determination of possible malignization. Clinical variants and complication In patients with low postbulbar ulcers the clinical signs are more expressed. It characterized by late (in 23 hours after food intake) and intensive hungry and nightly pain, that often irradiate to the back and to the right hypochondrium. The postbulbar ulcers are inclined to more frequent exacerbation, and also to more frequent complications, such, as penetration, stenosis and bleeding. The are more frequent ulcerous bleeding (the bulbous happen in 2025 % cases, postbulbar in 5075 %), perforations (1015 % cases). Penetration, stenosis and malignization in patients with duodenal ulcers are observed rarely. Penetration is frequent complication of low and postbulbar ulcers of duodenum, which are placed on posterior, posterior superior and posterior inferior walls. Penetrates, usually, deep chronic ulcers, by passing through all layers of duodenum in neighboring organs and tissues (head of pancreas,

hepato-duodenal ligament, small and large omentum, gall-bladder, liver). Such penetration is accompanied by development of inflammatory process in the neighboring organs and surrounding tissues and forming of cicatrical adhesions. A pain syndrome becomes more intensive, permanent and often pain irradiated in the back. Sometimes in the area of penetration it is possible to palpate painfully infiltrate. Diagnostic program 1. Anamnesis and physical examination. 2. Endoscopy. 3. X-Ray examination of stomach and duodenum. 4. General and biochemical blood analysis. 5. Coagulogram.

Pic. Duodenoscopy

Differential diagnostics The duodenal ulcer must be differentiated from acute and chroniccholecystitis, pancreatitis, gastroduodenitis. Endoscopy is help to diagnose duodenal ulcer. Tactic and choice of treatment method Conservative treatment. In most patients after conservative treatment an ulcer heals over in 46 weeks. Warning of relapses can be carried out by only supporting therapy during many years. The best therapy of duodenal ulcer is associated with a helicobacter infection, there is the use of antagonists of 2- receptors of histamine (renitidine 300 mg in the evening or 150 mg twice for days; famotidine 40 mg in the evening or 20 mg twice for days; nisatidine 300 mg in the evening or 150 mg twice for days; roxatidine 150 mg in the evening) in combination with sucralfate (venter) for 1 three times for days and antacid (almagel, maalox or gaviscon 1 dessert-spoon in a 1 hour after food intake). To this complex it is needed to add antibacterial preparations (De-nol 1 tabl. 4 times per a day during 46 weeks + oxacylline for 0,5 g 4 times per a day 10 days + Tryhopol (metronidazole) for 0,5 g 4 times per a day 15 days).

In treatment of duodenal ulcer used chinolitics and miolitics (atropine, methacin, platyphyllin), and also mesoprostol (200 mg 4 times per days) and omeprasole (20 or 40 mg on days). Such treatment of patients with the duodenal ulcer must be 46 weeks. If complications absents there is no necessity in the special diet. Because of appearance of new pharmaceutical preparations and modern therapeutic treatment, indication to the operative methods narrowed. But the number of acute complications of duodenal ulcer does not go down, especially bleeding and perforations which require the urgent surgery. Indications to the elective operation: 1. Passing of duodenal ulcer with the frequent relapses which could not treated conservatively. 2. Repeated ulcerous bleeding. 3. Stenosis of outcome part of stomach. 4. Chronic penetration ulcers with the pain syndrome. 5. Suspicion for malignization ulcers. Methods of surgical treatment. At patients with the duodenal ulcer three types of operations are distinguished: organ-saving operations; organ-sparing operations; resection. From them the better are: organ-saving operations with vagotomy, excision of ulcer and drainage operation. Types of vagotomy: trunk (TrV) (Pic.. 3.2.7), selective (SV) (Pic. 3.2.8), selective proximal (SPV) (Pic. 3.2.9). Selective proximal vagotomy is optimal in the elective surgery of duodenal ulcer. However in urgent surgery

a trunk, selective or selective proximal is often used in combination with drainage operations. Drainage Barden-Shalimov, gastroenteroanastomosis. It is necessary to mark that clean isolated SPV, performed in patients with duodenal ulcer, often (in 1520 % cases) results in the relapses. The considerably less number of relapses (810 %) is observed after SPV in combinations with drainage operations. Especially dangerous is the relapses of the ulcers placed in the projection of large duodenal papilla, after gastroduodenostomy by Jaboulay. The least number of relapses of duodenal ulcer is observed after organsaving operations, that combine SPV and ulcer excision. If ulcer localized on the anterior surface of duodenal bulb it can be performed by the method Jade (Pic. 3.2.13) with subsequent to the pyloroplasty by Heineke-Mikulich. At patients with decompensate stenosis and expressed dilatation and by the atony of stomach it is needed to apply the classic resection of stomach depending on possible damping-syndrome by Billroth -I or Billroth -II. The choice of subtotal resection of stomach needs to be done at suspicion for malignization or at histological confirmed malignization ulcers. In a duodenum this process happens very rarely. of the stomach operations are: by Heineke-Mikulicz Jaboulay, pyloroplasty, Finney pyloroplasty, submucous pyloroplasty by Divergastroduodenostomy

Pic. Trunk vagotomy (TrV)

Pic. Selective vagotomy (SV)

Pic. Selective proximal vagotomy (SPV)

Pic. Heineke-Mikulicz pyloroplasty

Pic. Gastroduodenostomy by Jaboulay

Pic. Finney pyloroplasty

ULCEROUS STENOSIS Ulcerous stenosis is complication of Peptic ulcer or duodenum, which characterized by narrowing.

Pic. Ulcer stenosis.

Etiology and pathogenesis Stenosis of outgoing part of stomach and duodenum of ulcerous origin arises as a result of scarring and common morphological changes around an ulcer. Narrowing, disturbance of the coordinated motility of goalkeeper come as a result of it and creates the obstacle to the even moving of stomach content to the duodenum.

Pathomorphology Such pathology in the compensation stage arises hypertrophy of the stomach walls. The pyloric ring has a 0,50,7 cm in diameter. The mucous tunic of pyloric part of stomach is thickened, with rough folds. Muscular fibers are hypertrophied and solid. Histological hyperplasia of pyloric glands is observed. During decompensation the muscular layer of stomach higher stenosis becomes thinner, tone of him goes down, and a pyloric ring narrows to a few millimetres. Microscopically present atrophy of mucous tunic and muscular fibers, vessels sclerosis. A stomach collects the form of the stretched sack which goes down to the level of small pelvis. Classification (by .. Shalimov and V.F.Saenko, 1987) Three clinical stages of stenosis are distinguished: I compensated; II subcompensated; III decompensated.

The morphological changes in the initial part of stomach and duodenum are represented by the classification offered by M.I. Kusin (1985). On the basis of clinical, roentgenologic, endoscopic, electrogastrographical and intraoperative methods the examinations distinguished three stages of stenosis: I inflammatory; II cicatricial-ulcerous; III cicatricial. In accordance with localization, by V.F.Saenko (1988) distinguished three types of stenosis: I stenosis of goalkeeper; II stenosis of bulb of duodenum; III postbulbar duodenal stenosis. First two types of stenosis are similar by functional and the organic changes. It united them by one name pyloroduodenal, or high duodenal stenosis. The second group is postbulbar duodenal stenosis. Feature of them is that a goalkeeper does not take participation in the cicatricial- ulcerous process and it function is not broken. Clinical management The first signs of stenosis can be exposed already in eight-ten years from the beginning of the peptic ulcer disease., Mainly, this is narrowing and rigidity and disturbance of retractive activity of goalkeeper, which create a barrier for transition of stomach content to the duodenum. In the stage of the compensated stenosis hypertrophy of wall of stomach develops and tone of muscular shell rises. Hereupon gastric content, slowly, but passes through the narrowed area of stomach output. In this stage

patients, usually, complained about feeling of plenitude in a epigastric area after food intake, periodic vomitings by sour gastric content. On empty a stomach by a stomach pump 200300 ml gastric content is removed. In the subcompensated stage muscular layer of stomach becomes thinner. Tone of him goes down, a peristalsis relaxes, and it looks like the stretched sack. Evacuation disorders is increased. Fermentation and rotting developed in stagnant gastric content. On this stage of disease development patients, usually, complain for the permanent feeling of weight in epigastric region and regurgitation with an unpleasant rotten smell of sulphuretted hydrogen. Vomiting becomes systematic (once or twice on a day) up to half of liter per day. On empty a stomach it possible to aspirate from it more 500 ml of content with the food used the day before. In the decompensation stage of the clinical sighn make progress quickly. There are heavy disturbances of the general condition of patient, considerable loss of weight (to 3040 %), acutely expressed dehydration of organism, hypoproteinemia, hypokalemia, azotemia and alkalosis. In case of the protracted neglected disease, as a result of progress of disturbances of metabolism, there can be a convulsive syndrome (gastric tetany). Vomiting in this stage not always can be considered by a typical sign, in fact patients often renounce to adopt a food, and a stomach acquires considerable sizes, overdistension form, it tone is violated and atrophy of wall comes. In such patients in a epigastric area it is possible to define the contours of the stretched stomach, with a slow peristalsis,. In the distance it is possible to hearken the splash. By a probe from a stomach to 1.5-2 litres of food with a putrid smell are removed. There can be gastric tetany at considerable disturbances of electrolyte metabolism.

A diagnosis is set according to a typical syndrome, results of sounding of stomach, rontgenoscopy, at which by contrasting of a barium expose stenosis of initial part of stomach or duodenum, determines it origin and estimate a degree. Roentgenologically in the compensation stage stomach in normal sizes, it peristalsis deep, increased, evacuation of content proceeds no more than 6 hours. In the stage of subcompensation a stomach is megascopic, a peristalsis is loosened, evacuation stays too long to 24 hours. During decompensation a stomach is considerably extended as a sack, deformed, the waves of antiperistalsis can take place, a contrast stays too long more than 2448 hours. The method of the double contrasting by a barium and air considerably facilitates diagnostics. Determination of stomach motility has not only diagnostic but also prognostic value for the choice of method of operation. In the stage of compensation motility of stomach is well-kept, often even increased. With the increasing the degree of stenosis the motility disturbance increased, up to gastroplegia. In the biochemical blood test is marked the decline of content of albumen to 5448 g/l; potassium to 2,92,5 mmol/l; chlorides to 8587 mmol/l. The changes of such indexes are most expressed at patients with gastrogenous tetany. The study of secretory function of stomach allows to define the degree of compensation of stenosis and importent at the choice of adequate method of operation. Gastroscopy with a biopsy is the enough informing method of examination of such patients. By this method is possible to determine a reason and degree of stenosis, and also state of mucous tunic of stomach.

Diagnosis program 1. Complaints of patient and anamnesis of disease. 3. Sounding of stomach and examination of gastric content. 4. Fibergastroduodenoscopy, biopsy. 5. Intragastric -metry. 6. Study of motility of stomach. 7. Roentgenologic examination of stomach and duodenum (structural features, passage). 8. Sonography.

Pic. X-Ray examination. Ulcer stenosis. Differential diagnostics

Stenosis of the output part of stomach and duodenum of ulcerous origin it is needed to differentiate with functional gastrostasis and narrowing of tumour and chemical genesis. Functional gastrostasis more frequent meets at women. Basic, that distinguishes it from other pathologies, there is absence of some organic changes in the area of pyloric part of stomach or in a duodenum, that can be exposed during fibergastroscopy. Differential diagnostics of stenosis of tumour genesis, as a rule, also does not cause the special difficulties. A diagnosis is finally confirmed by histological examinations of the biopsy material taken during endoscopy. Postburn stenosis of piloroantral area of stomach observed, from data of statistics, more than in 25 % cases of patients with the burn of esophagus. In anamnesis in each of such patients takes place by mistake or the intentionally taken an a swig at acid, alkali or other chemical matter. Some diagnostic difficulties can arise up at the isolated postburn stenosis of pyloric part of stomach. The however attentively collected anamnesis and professionally conducted endoscopic examination enable to set a correct diagnosis. Tactic and choice of treatment method Treatment of ulcerous stenosis of piloroantral part of stomach and duodenum must be exceptionally operative. A method depend on many factors: degree of stenosis, these secretory and motility functions of stomach, age of patient, presence of accompanying diseases and others like that. In the compensated and subcompensated stages of stenosis and at enough well-kept functions of stomach it is possible to perform of organ-saving operations (vagotomy with drainage stomach operations, economy resection of

stomach). At growth of the signs of stenosis and disturbance of basic functions of stomach, the volume of operation must be increased up resection by the Bilroths second method. At the patients and older age persons with heavy accompanying pathology is performed minimum surgery gastroenteroanastomosis. Preoperative preparation must be strictly individual. At patients with insignificant disturbances of gastric motor activity (stage of compensation, subcompensations) and with good level of metabolism indexes it is better to shorten preoperative preparation in time. Such patients, usually, operated on 34 day. Preparation before operation at patients with decompensated pilorostenosis must be directed for the correction of metabolism disturbances. Such patients must receive transfusion of liquid up to 2,53 l per day with content of the ions +, Na+, ++, amino acid and glucose; plasma, albumen. Twice on days performed decompression and washing of stomach and anti-ulcerous therapy. Effective preoperative preparation in such patients requires 57 days, sometimes more.

PERFORATED GASTRODUODENAL ULCERS The typical perforation of gastric or duodenum ulcer is strengthening of necrosis process in the area of ulcerous crater with subsequent disturbance of integrity of wall, that result to the permanent effluence of gastroduodenal content and air in a free abdominal cavity.

Etiology and pathogenesis In 50,7 % cases perforates the ulcers of duodenum, in 42,8 % are ulcers of pyloric part of stomach, in 4,8 % are ulcers of small curvature of body of stomach and in 0,7 % are cardial ulcers. Ulcers, which lie on the front wall of stomach and duodenum more frequent give the perforation with general peritonitis, while ulcers on a back wall perforation with adhesive inflammation. The reasons of ulcers perforation are: exacerbation of peptic ulcer, harmful habits, stresses, professional, athletic overexertion, faults in the feed and abuses by strong waters. Pathomorphology In pathogeny of acute perforation important: progressive necrosis processes in the area of ulcerous crater with activating of virulent infection; hyperergic type of local vaculo-stromal reaction with the thrombosis of veins of stomach and duodenum; local manifestation of autoimmune conflict with accumulation of sour mucopolysaccharides on periphery of ulcer and high coefficient of plasmatization of mucous tunic (.I. Mishkin, .. Frankfurt, 1971). Classification (by V.S. Savelev, 1986) Perforated gastroduodenal ulcers are divided: 1. After etiology: ulcerous;

 unulcerous. 2. After localization: gastric (small curvature, cardial, antral, prepyloric, pyloric) ulcer, front and back walls; ulcers of duodenum (front and back walls). 3. After passing: perforated in an abdominal cavity; covered perforations; atypical perforations.

Clinical management The clinical picture of perforation is very typical and depends on distribution of inflammatory process and infection of abdominal cavity. In clinical passing of the perforations distinguish three phases: shock, imaginary prosperity and peritonitis (Mondor, 1939). For the phase of shock (to 6 hours last) typical very acute pain in epigastric region (Delafua compares it to pain from the stab with a dagger) with an irradiation in a right shoulder and collar-bone, a face is pale, with expression of strong fear, lines become (facies abdominalis) acute, a deathdamp irrigates skin covers. A pulse is at first slow (vagus pulse), later becomes frequent and less filling. Sometime observed the reflex vomiting and delay of gases. Arterial pressure is reduced. On examination stomach is pulls in, does not take part in the act of breathing. At palpation is wooden belly stomach, especially in an upper part, where, usually, there is most pain. PositiveBlumberg's sign. At percussion is disappearance of hepatic dullness (the Spizharnyy symptom). At rectal examination expose painful in the area of rectouterine or rectovesical pouch (the Kulenkampff's symptom).

The phase of shock changes by the phase of imaginary prosperity, when the reflex signs go down: the general condition of patient gets better, a pulse becomes normal, arterial pressure rises, a stomach-ache diminishes partly. However observed tension of muscles of front abdominal wall, positive Blumberg's sign. The phase of imaginary prosperity in 612 hours from the moment of perforation changes by the phase of peritonitis: a pulse is frequent, a stomach is swollen through growing flatulence, intestinal noises are not listened, a face acquires the specific kind facies Hippocratica the eyes fall back, lips turn blue, a nose becomes sharp, a tongue becomes dry and furred, breathing superficial and frequent, a temperature rises.

Variants of clinical passing and complication Covered perforation (.. Shnicler, 1912). At this pathology the perforative hole after a perforation is closed by a fibrin, by a omentum, by the fate of liver, sometimes piece of food. After that some amount of stomach content and air gets in an abdominal cavity. After the protection a stomach-ache diminishes, but proof tension of muscles of front abdominal wall, especially overhead quadrant of stomach is kept. At percussion hepatic dullness is doubtful. During x-Ray examination it is not always possible to mark gas in right hypochondrium (Pic. 3.2.14). Consequences of passing of the covered perforation: the repeated perforation with development of classic clinical signs can come; at separation of process from a free abdominal cavity a subdiaphragmatic or subhepatic abscess is formed; complete closing of defect by surrounding tissue with gradual convalescence of patient.

The atypical perforation is the perforation, at which gastric or intestinal content gets not to the abdominal cavity, but in retroperitoneal space (ulcers of back wall of duodenum), large or small omentum (ulcers of small curvature of stomach), hepato-duodenal ligament. In such patients during a perforation pain is not acutely expressed. During palpation observed insignificant rigidity of muscles of front abdominal wall. On occasion, especially on the late stages of disease, there can be hypodermic emphysema and crepitation. Diagnosis program 1. Anamnesis and physical examination. 2. Global analysis of blood and urine, biochemical blood test, coagulogram. 3. X-Ray examination of abdominal cavity organs for presence of free gas (pneumoperitoneum). 4. Pneumogastrography, contrasting pneumogastrography. 5. Fiber-gastroduodenoscopy. 6. Sonography of abdominal cavity organs. 7. Laparocentesis with the Neymark diagnostic test (to the 23 ml of abdominal cavity exudate adds 45 drops of the 10 % solution of iodine. If the admixtures of gastric content appear in exudate, then under action of iodine gastric content gets a dirtily-dark blue color). 8. Laparoscopy.

Pic. X-Ray examination of abdominal cavity organs. Presence of free gas (pneumoperitoneum).

Tactic and choice of treatment method

The diagnosed perforated gastric and duodenum ulcer is an absolute indications to operation. Preoperative preparation must include: in I phase are antishock action; in the II and III phases reanimation preparations, introductions of antibiotics for 23 hours before operation, liquidation of hypovolemia by salt blood substitutes (solution of chlorous sodium), solutions of dextran (polyhlukine, reopolihlukine, hemodes). Amount of liquid necessary for correction of hypovolemia, calculate after hematokrit by central vein pressure. Taking for the norm of hematokrit 40 %, on each 5 % higher norms need to be poured 1000,0 ml liquids. Conservative treatment (method of Tejlor, 1946) can be justified at the refusal of patient from operation or in default of conditions for its implementation. It must include: permanent nasogastral aspiration of gastric content; introduction of preparations which brake a gastric secretion (atropine, 2- blockers and others like that); introduction of antibiotics; correction of metabolism; laparocentesis with drainage and closed lavage of the abdominal cavity. In the decision of question about the choice of method of operative treatment of perforated gastroduodenal ulcers the important value has the following factors: localization of ulcer, clinico-morphological description of ulcer (perforation of acute or chronic ulcer), connected with the perforation such complications of ulcer, as bleeding, cicatricial-ulcerous stenosis, penetration, degree of risk of operation and feature of clinical situation. Operative treatments at a perforated ulcer divide into palliative and radical.

Palliative operations Palliative operations are: closure of the perforative hole of ulcer, tamponade of the perforative hole by a omentum on a leg by .. Oppel P.N.Polikarpov - ..Pidhorbunskyy (1896, 1927, 1948) (Pic. 3.2.15). Indications and terms for their implementation are: perforation of acute duodenal ulcer in youth and young age without anamnesis; perforation of acute ulcer in the IIIII phases of passing; perforation of callous gastric ulcer in the IIIII phases of passing; expressed and high degrees of risk of operation.

Radical operations The radical operations at perforated ulcers are: resection of stomach and excision of the perforative hole of ulcer in combination with pyloroplasty and StV, SV or SPV. Indications and terms for implementation of resection of stomach are: perforation of callous gastric ulcer in I phase of clinical passing; repeated perforation of ulcer; perforation of ulcer in I phase of clinical passing in combination with stenosis and bleeding of ulcer; perforation of duodenal ulcer in I phase of passing in combination with a gastric ulcer; unexpressed and moderate degree of risk of operation; sufficient qualification of surgeon and material resources of operating-anaesthetic brigade.

Indications for implementation of operation of excision of the perforative hole of ulcer with pyloroplasty, StV, SV and SPV are: perforation of ulcer of front wall of duodenum or pyloric part of stomach in the III phases of passing; perforation of ulcer of front wall of duodenum in the III phases of passing in combination with the bleeding ulcer of back wall; perforation of duodenal ulcer in the III phases of passing in combination with the compensated stenosis of outgoing part of stomach; increased gastric secretion; insignificant and moderate degree of risk of operation; sufficient qualification and technical preparedness of surgeon. video

BLEEDING GASTRODUODENAL ULCERS

Bleeding gastroduodenal ulcers are outpouring of blood in the gastrointestinal tract cavity as a result of strengthening and distribution of necrosis process in the ulcer area to vessels with the subsequent melting of their walls. Complication of peptic or duodenal ulcer by bleeding is critical situation which threatens to life of patient and requires from the surgeon of immediate and decisive actions for clarification of reasons of bleeding and choice of tactic of treatment. The ulcerous bleeding has 60 % of the acute bleeding from the upper parts of gastrointestinal tract.

Etiology and pathogenesis

The origin of the gastrointestinal bleeding at patients with a gastric or duodenal ulcer almost is always related to exacerbation of ulcerous process. The reason of bleeding is a erosive vessel, that is on the bottom of ulcer. The expressed inflammatory and sclerotic processes round the damaged vessel embarrassed its contraction, that diminishes chances on the spontaneous stop of bleeding. Gastric ulcers, compare with the ulcers of duodenum, complicated by bleeding more frequent. Bleeding at gastric ulcers are more expressed, profuse, with heavy passing. At the duodenal ulcer bleeding more frequent complicate the ulcers of back wall, which penetrates in the head of pancreas. At the men ulcer is complicated by bleeding twice more frequent, than at women. It costs to mark that 80 % patients which carried bleeding from an ulcer and treated oneself by conservative preparations, are under the permanent threat of the recurrent bleeding.

Pathomorphology Strengthening of necrosis process are leading factors in the origin of the ulcerous bleeding in the area of ulcerous crater with distribution of this process to a vessel and subsequent melting of vascular wall; activation of fibrinolysis in tissues of stomach and duodenum; ischemia of tissues of wall of stomach. Classification

Bleeding gastroduodenal ulcers after the degree of weight of loss of blood (by .. Shalimov and V.F.Saenko, 1987) are divided: I degree is easy observed at the loss to 20 % volume of circulatory blood (at a patient with weight of body 70 kg it is up to 1000 ml); II degree middle weight is loss from 20 to 30 % volume of circulatory blood (10001500 ml); The III degree is heavy is observed at loss of blood more than 30 % volume of circulatory blood (15002500 ml). Clinical management At patients with an peptic ulcer disease, bleeding pops up, mainly at night. Vomiting can be the first sign of it, mostly, at gastric localization of ulcers. Vomiting masses, as a rule, looks like coffee-grounds. Sometimes they are as a fresh red blood or its grume. The black tar-like emptying are the permanent symptom of the ulcerous bleeding, with an unpleasant smell (melena), that can take place to a few times per days. Bloody vomiting and emptying as melena is accompanied by worsening of the general condition of patient. A acute weakness, dizziness, noise in a head and darkening in eyes, sometimes loss of consciousness. A collapse with the signs of hemorrhagic shock can also develop. Exactly with a such clinical picture the such patients get to the hospital. It is needed to remember, that for diagnostics anamnesis is very important. Find out often, that at a patient an peptic ulcer was already diagnosed once. It appears sometimes, that bleeding is repeated or surgery concerning a perforated ulcer took place in the past. At some patients a gastric or duodenum ulcer is was not diagnosed before, the however attentively collected anamnesis exposed,

that at a patient had a stomach-ache. Thus it communication with acceptance of food and seasonality is typical (more frequent appears in spring and in autumn). Patients tell, that pain in overhead part of abdomen which disturbed a few days prior to bleeding suddenly disappeared after first its displays (the Bergmann's symptom). At patients with the ulcerous bleeding there are the typical changes of hemodynamic indexes: a pulse is frequent, weak filling and tension, arterial pressure is mostly reduced. These indexes need to be observed in a dynamics, as they can change during the short interval of time. There is the pallor of skin and visible mucous tunics at a examination. A stomach sometimes is moderately exaggerated, but more frequent is pulled in, soft at palpation. In overhead part it is possible to notice hyperpigmental spots tracks from the protracted application of hot-water bottle. Painful at deep palpation in the area of right hypochondrium (duodenal ulcer) or in a epigastric area (gastric ulcer) it is possible to observe at penetrated ulcers. Important symptom of Mendel also painful at percussion in the projection of piloroduodenal area. At the examination of patients with the gastrointestinal bleeding finger examination of rectum is obligatory. It needs to be performed at the first examination, because information about the presence of black excrement (melena) more frequent get according to a patient anamnesis, that can result in erroneous conclusions. Finger examination of rectum allows to expose tracks of black excrement or blood. In addition, it is sometimes possible to expose the tumour of rectum or haemorrhoidal knots which also are the source of bleeding. The deciding value in establishment of diagnosis has the endoscopic examination. Fiber-gastroduodenoscopy enables not only to deny or confirm the presence of bleeding but also, that it is especially important, to set its

reason and source. Often embarrassed the examination of stomach and duodenum present in it blood and content. In such cases it is necessary to remove blood or content, by gastric lavage, and to repeat endoscopic examination. During the examination often exposed the bleeding with fresh blood from the bottom of ulcer or ulcerous defect with one or a few erosive and thrombosed vessels (stopped bleeding). The bottom of ulcer can be covered by the package of blood. Important information about such pathology is given by haematological indexes also. Diminishment of number of red corpuscles and haemoglobin of blood, decline of haematocritis is observed in such patients. However always needed to remember, that at first time after bleeding haematological indexes can change insignificantly. Conducting of global analysis of blood in a dynamics in every a few hours is more informing. Variants of clinical passing and complication It is necessary always to remember that complication of peptic ulcer by bleeding happens considerably more frequent, than is diagnosed. Usually, to 5055 % moderate bleeding (microbleeding) have the hidden passing. The massive bleeding meet considerably rarer, however almost always run across with the brightly expressed clinical signs which often carries dramatic character. In fact profuse bleeding with the loss 5060 % to the volume of circulatory blood could stop the heart and cause the death of patient. The clinical signs and passing of disease depend on the degree of lost of blood (.. Shalimov and V.F.Saenko, 1987). For lost of blood I degree typical there is a frequent pulse to 90100, decline of arterial pressure of to 90/60 mm Hg. The excitability of patient changes by lethargy, however clear consciousness is, breathing some frequent. After the stop of bleeding and in absent of hemorrhage

compensation the expressed disturbances of circulation of blood does not observe. At patients with the II degree of hemorrhage the general condition needs to be estimated as average. Expressed pallor of skin, sticky sweat, lethargy. Pulse 120130 per min., weak filling and tension, arterial pressure 9080/50 mm Hg. At first hours the spasm of vessels (centralization of circulation of blood) comes after bleeding, that predetermines normal or increased, arterial pressure. However, as a result of the protracted bleeding compensate mechanisms of arterial pressure are exhausted and can acutely go down at any point. Without the proper compensation of hemorrhage the such patients can survive, however almost always there are considerable disturbances of blood circulation with disturbance of functions of liver and kidneys. The III degree of hemorrhage characterizes heavy clinical passing. There is a pulse in such patients 130140 per min., and arterial pressure from 60 to 0 mm Hg. Consciousness is almost always darkened, acutely expressed adynamy. Central vein pressure is low. Oliguria is observed, that can change by anuria. Without active and directed correction of hemorrhage a patient can die. But, not always weight of bleeding which is conditioned by the degree of hemorrhage correspond the general condition of patient. On occasion the considerable loss of blood during the set time is accompanied by the relatively satisfactory condition of patient. And vice versa, moderate hemorrhage can bring to the considerable worsening of general condition. It can depend both on compensate possibilities of organism and from the presence of accompanying pathology. It is needed to remember, that the ulcerous bleeding can accompanying with the perforation of ulcer. During perforation ulcers are often

accompanied by bleeding. Correct diagnostics of these two complications has the important value in tactical approach and in the choice of method of surgical treatment. In fact simple suturing of perforated and bleeding ulcer can complicated in postoperative period by the profuse bleeding and cause the necessity of the repeated operation.

Diagnosis program 1. Anamnesis and physical examination. 2. Finger examination of rectum. 3. Gastroduodenoscopy. 4. Global analysis of blood. 5. Coagulogram. 6. 7. Biochemical blood test. 7. X-Ray examination of gastrointestinal tract. 8. Electrocardiography.

Pic. Endoscopy - stopped bleeding.

Differential diagnostics At wide introduction of gastroduodenoscopy of question of differential diagnostics of bleeding lost the actuality. However much a problem arises up at impossibility to execute this examination through the heavy general condition of patient or taking into account other reasons. Differential diagnostics is conducted with bleeding of unulcerous origin, which arise up in different parts of digestive tract. For bleeding from the varicose extended veins of esophagus during portal hypertension at patients with the cirrhosis of liver the acute beginning without pain is characteristic, like during exacerbation of ulcerous disease.

These bleeding differ by the special massiveness and considerable hemorrhage. Vomiting by fresh blood, expressed tachycardia, falling of arterial pressure are observed. In such patients it is possible to find the signs of cirrhosis of liver and portal hypertension (head of jelly-fish, hypersplenism, ascites, often is icterus). Sliding hernia of the esophagus opening of diaphragm can be accompanied by formation of ulcers in the place of clench of the stomach by the legs of diaphragm and bleeding from them. However for this pathology are more typical microbleeding, that is hidden. In such patients often the present protracted anaemia which can achieve the critical values. Sometimes in them observe more expressed bleeding with classic vomiting coffeegrounds and melena. During the roentgenologic examination with barium is possible to expose the signs of sliding hernia of the esophagus opening: the obtuse cardial angle, absence or diminishment of gas bubble of stomach or ringing symptom. The cancer tumour of stomach in the destruction stage can be also complicated by bleeding. However, such bleeding are massive, and chronic character is carried mostly with gradual growth of anaemia. For this pathology there are the inherent worsenings of the general condition of patient, loss of weight of body, decline of appetite and waiver of meat food. At the roentgenologic examination the defect of filling is exposed in a stomach. The gastric bleeding can be related to the diseases of the cardiovascular system (atherosclerosis, hypertensive disease), however such happens mainly in the older years people. Clearly, that in such patients during the endoscopic examination the source of bleeding exposing is not succeeded.

Among other diseases, with which it is necessary to differentiate the ulcerous bleeding, it is needed to remember the Mallory-Weiss syndrome, benign tumours of stomach and duodenum (more frequent leiomyoma), hemorrhagic gastritis, acute (stress) erosive defeats of stomach, arteriovenous fistula of mucous tunic. Often differential diagnostics performed according to the level of localization of source of bleeding in different parts of gastrointestinal tract. For the upper parts of digestive tract (esophagus and stomach) typical there is vomiting by grume or coffee-grounds content and emptying by melena. The farther aboral placed source of bleeding, the bloody emptying changes the more so. During the bleeding from a thin bowel excrement looks as melena. In case of such pathology of colon (polypuses, tumours, unspecific ulcerous colitis) emptying have the appearance of fresh red blood, mostly as packages. Tactic and choice of treatment method The conservative therapy indicated to patients with the stopped bleeding of I degree and bleeding of the IIIII degrees at patients which have heavy accompanying pathology, because of operative risk. Conservative therapy must include: prescription of hemostatic preparations (intravenously the aminocapronic acid 5 % 200400 ml, chlorous calcium 10 % 10,0 ml, vicasol 1 % 3,0 ml); addition to the volume of circulatory blood (gelatin, poliglukine, salt blood substitutes); preparations of blood (fibrinogen 23 , cryoprecipitate);

 blood substitutes therapy (red corpuscles mass, washed red corpuscles, plasma of blood); antiulcerous preparations blocker of 2- receptor (ranitidine, roxatidine, nasatidine for 150 mg 12 times per days); antacid and adsorbents (almagel, phosphalugel, maalox for 12 dessert-spoons through 1 hour after food intake). It is expedient to apply washing of stomach by water with ice and the use 5 % solution of aminocapronic acid inward for to a 1 soupspoon in every 2030 minutes. The endoscopic methods of stop of bleeding are used also. Among them most effective is a laser and electro-coagulation. Absolute indications to surgical treatment are: 1) lasting bleeding I degree; 2) recurrent bleeding after hemorrhage I degree; 3) bleeding of the IIIII degrees; 4) stopped bleeding with hemorrhage of the IIIII degrees at the endoscopically exposed ulcerous defect with a presence onthe ulcer bottom thrombosed vessels or erosive vessels covered by the package of blood. The choice of method of surgical treatment always needs to be decided individually. On today the best tactic which gives advantage to organ-saving and organsparing methods of operations. The removing ulcer as sources of bleeding must be an obligatory condition. The methods of sewing of bleeding vessels or edging of ulcer and bandaging of vessels which feed a stomach and duodenum did not justify itself through the real threat of relapse of bleeding already in an early postoperative period (912 days). Palliative operations (cutting of ulcer, forming of roundabout anastomosis) can be justified only taking into account the general condition of patient and on a necessity as possible quick and least traumatically to make off operation.

At the bleeding ulcers of duodenum it is better to apply excision of ulcer or it exteritirization after methods, developed by V.Zajtsev and Velihotskyy. Operation complemented by one of types of vagotomy, it is better by a selective proximal with piliroplastic. The resection of stomach on the second or first method of Bilroth can be realized only in the stable general condition of patient. During the resection of stomach in case of low bleeding duodenal ulcers it is better to execute mobilization of duodenum and suturing of its stump on transcholedochus drainage which formed as transcholedochus duodenotomy (Laqey, 1942). This method warns the possible intraoperative damages of choledoch, that are the possible at low duodenal ulcers. Transcholedochus duodenotomy by performing the decompression of stump of duodenum, warns insufficiency of its stitches, that can arise up in an early postoperative period. In case of bleeding gastric ulcers, the resection methods of operations are also usable. Only on occasion, when patients has the grave general condition, it is possible to assume the wedge cutting of ulcer.

video
MALIGNIZATION CANCER OF STOMACH The cancer of stomach is a malignant formation, that develops from epithelium tissue of mucus stomach. Among the tumours of organs of digestion this pathology takes first place and is the most frequent, by the reason of death from malignant formations in many countries of world. Frequency of it at the last 30 years considerably diminished in the countries

of Western Europe and North America, but yet remains high in Japan, China, countries of East Europe and South America. Etiology and pathogenesis Etiology of cancer of stomach is unknown. It is known that, as other diseases of gastrointestinal tract, a cancer damages a stomach. According to statistical information, it meets approximately in 40 % of all localizations of cancer. The factors of external environment has the substantial influencing on frequency of this pathology. Above all things, feed, smoke food, salting, freezing of products and their contamination of aflatoxin. Consider that a food factor can be: a) by a carcinogen; b) by the solvent of carcinogens; c) to grow into a carcinogen in the process of digestion; d) to be instrumental in action of carcinogens; e) not enough to neutralize carcinogens. In the USA and countries of Western Europe frequency of cancer of stomach in 2 times more large in the lower socio-economic groups of population. Some professional groups also can it (miners, farmers, works of rubber, woodworking and asbestine industry). High correlation communication is set between frequency of cancer of stomach and use of alcohol and smoking. The value of genetic factors (heredity, blood type) is not led to. The cancer of stomach arises up mainly in age 60 years and above, more frequent men are ill. Precancer. The precancer diseases of stomach are: a) chronic metaplastic disregenerator gastritis conditioned by helicobacter pylori; b) villous polypuses of stomach and chronic ulcers; c) nutritional anemia due to vitamin B12 deficiency (pernicious); d) resected stomach concerning an ulcer.

The presence of precancer changes of mucous tunic of stomach has substantial influence for frequency of stomach cancer. In those countries, where morbidity on the cancer of stomach is higher, considerably more frequent chronic gastritises are diagnosed. Lately in etiology of chronic gastritises take the important value helicbacter pylori. In Japan, where the cancer of stomach is in 40 % cases is the reason of death, chronic gastritis appears in 80 % cases of resected stomach, concerning a cancer. Connection between polypuses, chronic gastric ulcers and possible it malignization comes into question in literature during many decades. Most authors consider that polypuses could be malignant differently. There are three histological types of polypuses: hyperplastic, villous and hamartoma. There are hyperplastic polypuses, but it not malignant. Hamartoma is accumulation of cells of normal mucous tunic of stomach. They never becomes malignant. Villous polypuses are potentially malignant in 40 % cases, but it happen in 10 times less, than hyperplastic. The possibility of malignization of chronic gastric ulcers is not proved. The American scientists support a hypothesis, that the cancer of stomach can be ulcerous often, but malignization of ulcers takes place rarely (no more than 3 %). From data of the Japanese scientists, on 5070th there was higher correlation connection between chronic gastric ulcers and cancer of stomach. The frequent decline of this correlation is lately noticed (70 % on 5070th and 10 % on 80th). Frequency of cancer of stomach at patients with pernicious anaemia hesitates within the 510 %, that in 20 times higher, compare with control population. In patients with a resected stomach after peptic ulcers is multiplied the risk of origin of stomach cancer in 23 times (duration of latent period hesitates from 15 to 40 years). The reason of such dependence

is not found out, but there is a version, that this is linked with a gastric epithelium metaplasia by an intestinal type. Pathomorphology From all adenocarcinoma malignant is formations of the stomach in 95 %

observed.

Epidermoid

cancer, adeno-acanthoma

and carcinoid tumours do not exceed 1 %. Frequency of leiomyosarcoma hesitates within the limits of 13 %. Lymphoma of gastrointestinal tract is localized in a stomach. The prognosis of localization depends on the degree of invasion, histological variants of tumour. The macroscopic forms of cancer of stomach in different times were described variously. More than 60 years ago the German pathologist Bermann described 5 macroscopic forms of cancer of stomach: 1) polypoid or mushroom-like; 2) saucer-shaped or with ulcerous and expressly salient edges; 3) with ulcerous and infiltration of walls of stomach; 4) diffuse infiltrate; 5) unclassified. American pathopsychologs is selected 4 forms. The tumours of stomach with ulcerous are the most frequent macroscopic form of cancer of stomach and arise up on soil of chronic ulcer. The signs suspicious on malignization are: the sizes of ulcer more than 2 cm in a diameter, appearance of the heightened edges. The polypoid tumours of stomach observed only in 10 %. These tumours can achieve considerable sizes without an invasion and metastasis. Scirrhous carcinoma is the third macroscopic type. This category of tumours also does not exceed 10 %. The scirrhous carcinoma is the signs of infiltration by anaplastic cancer cells, diffusely developed connecting tissue

which results in the bulge and rigidity of wall of stomach. So called small cancers belong to the fourth macroscopic type. It meet comparative rarely (no more than 5 %) and is characterized by superficial accumulation of cancer cells which substitute for normal mucus in such kind: a) superficial flat layer which does not rise above the level of mucus; b) salient (bursting) formation; c) erosions. Mainly (more than 50 %) tumours arise up in a antral part or in distal (lower) third of stomach, rarer (to 15 %) in a body and in cardia (to 25 %). However, lately more often observed cardioesophageal cancers and diminishment of frequency of tumours of distal parts of stomach. In 2 % cases meet the multicentric focuses of growth, but from data of some authors, this percent could be multiplied in 10 times after carefully histological inspection of the resected stomaches. This assertion is based on the theory of the tumour field (D.I. Holovin, 1992). Especially this typically for patients which has pernicious anaemia or chronic metaplastic disregenerative gastritis. Metastasis is carried out by lymphogenic, hematogenic and implantation ways mostly. Three (from data of some authors, four) pools of lymphogenic metastasis are selected: left gastric (knots on passing of small curvature of stomach in a gastro-subgastric ligament and pericardial); splenic (mainly, suprainfrapancreatic knots); hepatic (knots in a hepato-duodenal ligament, right gastric omentum that lower pyloric groups, right gastric and suprapyloric groups, pancreatoduodenal group). However, the such way of lymphogenic metastasis is conditional and incomplete, as at presence of block lymph flow passes retrograde metastasis, so called jumping metastases which predetermine the origin of remote lymphogenic metastases in left supraclavicular lymph nodes (Virhov

metastasis) appear, in Lymph nodes of left axillar and inguinal areas, metastases in a umbilicus. Direct distribution: small and large omentum, esophagus and duodenum; liver and diaphragm; pancreas, spleen, bile ducts. Front wall of stomach: colon bowel and mesocolon; organs and tissues of retroperitoneal space. Lymphogenic metastasis: regional lymph nodes, remote lymph nodes, left supraclavicular lymph node (Virhov), lymph node of axillar area (Irish); in a umbilicus (sisters Joseph). Hematogenic metastasis: liver, lungs, bones, cerebrum. Peritoneal metastasis: peritoneum, ovarium (the Krukenberg metastasis), Duglas space (the Shnicler metastasis). Classification (by system of NM) primary tumour. 0 is a primary tumour is not determined. not enough data for estimation of primary tumour. is is invasive carcinoma: intraepithelial tumour without the invasion of own shell mucus (Carcinoma in situ). 1 is a tumour infiltrate the wall of stomach to the submucous layer. 2 is a tumour damages mucus, submucous and muscular layers. 3 is a tumour germinates in a serous shell. 4 is a tumour passes to the neighbouring structures. N are regional lymphatic nodes. N not enough information for the damage assessment of lymphatic nodes. N metastases in regional lymph nodes are not present.

N1 are damaged perigastral lymph nodes in the distance no more than 3 cm from a primary tumour along small or large curvature of stomach. N2 are damaged perigastral lymph nodes in the distance more than 3 cm from a primary tumour, which can be remoted during operation, including lymph nodes placed along left gastric, splenic, abdominal and general hepatic arteries. is remote metastases. not enough information for estimation of remote metastases. remote metastases are not present. 1 is presence of remote metastases. Groupment by stages Stage 0 No Mo. Stage I 1-2 No Mo. Stage II T2-3 No Mo. Stage III T1-4 N1-2 Mo. Stage IV any T, any N M1. Except for clinical classification (NM or TNM), for the most detailed study pathological classification (postsurgical, posthistological) which is signed N. G histopathological differentiation: G1 is the well differentiated tumour; G2 is the moderately differentiated tumour; G3-4 it is badly or undifferentiated tumour. Clinical management

All authors which are engaged in the study of problem of cancer of stomach underline absence or vagueness, no specificity of symptoms, especially on the early stages of disease. The displays of cancer of stomach are very various and depend on localization of tumour, character of its growth, morphological structure, distribution on contiguous organs and tissues. At localization of tumour in a cardial part patient complains firstly, as a rule, for appearance of dysphagy. At careful, purposeful collection of anamnesis it is not succeeded to expose some other, most early symptoms, which precedes to dysphagy and forces a patient to appeal to the doctor. The unpleasant feeling behind a breastbone and feeling of unpassing of hard food on a esophagus appear at the beginning of disease. After some time (as a rule, it is enough quickly, during a few weeks, sometimes even days) a hard food does not pass (it is to wash down by water or other liquid). This period can be during 13 months. Patients address a doctor exactly in this period. Other symptoms appear to this time: regurgitation, pain behind a breastbone, loss of mass of body, sometimes even exhaustion, the grey colouring of person, a skin is dry, quickly grows general weakness. Sometimes patients address a doctor, when already with large effort a spoon-meat passes only or complete stenosis came. At localization of tumour in the antral part of stomach the first complaints, as a rule, are up to appearance of feeling of weight in epigastric region after the reception of food (even in a two-bit), feeling of saturation (after the reception of glass of water), belch (at first it is simple by air, and then with a smell). Feeling of weight grows for a day, patients forced to cause vomiting. In the morning there can be vomiting by mucus with the admixtures of coffee-grounds (so called cancer water). Patients loses weight (mass of body is lost), a weakness, anaemia grows.

Tumours localized in the body of stomach show up either a pain syndrome or syndrome of so called small signs (.I. Savitskyy, 1947), which is characterized by appearance of amotivational general weakness, decline of capacity, rapid fatigueability, depression (by the loss of interest to the environment), proof decline of appetite, gastric discomfort, making progress weight lost. The carried chronic diseases of stomach, for which typical seasonality, can influence on the clinical sign of cancer of stomach. At appearance of gastric complaints out of season or in absent of effect from the got therapy concerning the exacerbation of gastritis, ulcers must guard a patient and doctor (symptom of precipice of gastric anamnesis). In case of occurring of gastric symptoms first in persons in age 50 years and older it is foremost necessary to eliminate the cancer of stomach. In parts of patients cancer of stomach shows up only the metastatic damage of other organs or complications. More than twenty so called atypical forms, which are characterized by causeless anaemia, ascites, icterus, fever, edemata, hormonal disturbances, changes of carbohydrate exchange, intestinal symptoms, are distinguished. During the examination of patients with the cancer of stomach the pallor of skin covers (at anaemia) is observed, in neglected case is frog stomach (sign of ascites). During palpation determined painful in a epigastric area, sometimes possible to palpate the tumour. During auscultation of patients with pylorostenosis it is possible to define noise of splash. Laboratory information: hypochromic anaemia, neutrophilic leukocytosis, megascopic ESR; during examination of gastric secretion: hypo- and anacidity and achlorhydria.

Gastroduodenoscopy enables to diagnose a tumour even smaller 5 mm and conduct an aiming biopsy with histological examination of the taken material. Roentgenoscopy and roentgenography examination of stomach. Basic signs: defect of filling, local absence of peristalsis, malignant relief of mucous tunic (Pic. 3.2.18). Ultrasonic examination: presence of metastases in a liver, pancreas. Computer tomography allows to estimate the basic parameters of tumour, germination in neighbouring organs and presence of metastases. It is expedient to apply laparoscopy, mainly, for the decision of question about operable of tumour (diagnostics of metastatic defeat of organs of abdominal cavity). Diagnosis program 1. Anamnesis and physical methods of examination. 2. Roentgenologic examination of stomach. 3. Endoscopic examination with a biopsy (if necessary from a few places and even repeatedly), cytologic and histological examination. 4. Sonography, computer tomography. 5. Laboratory, radioisotope methods of examination. 6. Laparoscopy. 7. Diagnostic (therapeutic) laparotomy. Differential diagnostics At an early cancer complaints depend on the previous gastric diseases. Therefore, on the basis of clinical information, suspecting a tumour is

possible only on occasion, when in patients next to clear pain symptoms an appetite goes down, appear anaemia, general weakness. In practice an early cancer is recognized at purposeful screening, and also in the process of endoscopic or roentgenologic examination of gastric patients. A differential diagnosis is conducted with an peptic ulcer, gastritis, polyposis, other gastric and ungastric diseases. For a cancer there is typical firmness of symptoms, instead of their seasonality (typical syndrome of precipice of gastric anamnesis) or tendency to their gradual progress. The row of diseases, with which the cancer of stomach is to differentiate to the doctor, depends from character of complaints of patients. Five basic clinical syndromes are selected: 1) pain; 2) gastric discomfort; 3) anaemic; 4) dysphagic; 5) disturbance of evacuation from a stomach. At patients, at what cancer of stomach shows up a pain syndrome and syndrome of gastric discomfort, a differential diagnosis is conducted with the peptic ulcer, gastritis, cancer of body of pancreas. It is oriented on features dynamics of development of pain syndrome, ingravescent of the general condition, change of character of complaints. A question about character of anaemia, source and nature of bleeding decides at an anaemic syndrome. In the process of examination attention is paid to the state of bottom of stomach, where bleeding malignant formations can be. At a dysphagic syndrome a differential diagnosis is conducted with the cicatrical narrowing, achalasia of esophagus. For malignant formations

testify short anamnesis, gradual progress of symptoms, signs of gastric discomfort, general weakness, weight lost. At disturbance of evacuation from a stomach during stenosis of pyloric part, absence of ulcerous anamnesis, declining years of patients, relatively quick (weeks, months) growth of stenosis testify for tumor. Tactic and choice of method of surgical treatment The presence of cancer of stomach is a indications for surgical treatment. However, counting on success is possible only at presence of the limited tumours (within the limits of the 0II stages). At the III stage of disease implementation of the widespread combined operations in a radical volume is possible, however most patients die during 12 years. A distal or proximal subtotal resection (Pic. 3.2.19) and total gastrectomy (Pic. 3.2.20) is performed with removing of large and small omentumes and regional areas of metastasis with obligatory histological examination of stomach on the lines of resections. During the combined operations organs which are pulled in to the pathological process are removed. In case of IV stage of disease and satisfactory state of patient palliative operations which improve quality of life of patient are performed. In case of presence of complications (mainly stenosis) and grave common condition of patient perform symptomatic operative treatments. Symptomatic is operations which will liquidate one of symptoms of cancer of stomach. In this group of operations include: 1) roundabout gastrojejunoanastomosis (Pic. 3.2.21) and jejunostoma (in case of the stenosis tumours of stomach output); 2) gastrostoma (Pic. 3.2.22) in case of the cancer of cardial part of stomach with disturbance of patency; 3) edging

of bleeding vessels in case of complication of cancer by bleeding; 4) tamponade by omentum during the perforation of tumour. The value of radial therapy and chemotherapy, as independent methods of treatment of cancer of stomach, is limited. Radial therapy is indicated for patients with cardial cancer as preoperative course or as palliative treatment. Adjuvant mono- or polychemotherapy (mainly by 5phtoruracil) is conducted in a postoperative period as combined therapy and in case of dissemination of the tumours. Prognosis. The indexes of five-year survival of patients with the cancer of stomach hesitate within the limits of 530 %, but, from data of most authors, they do not exceed 10 %.