Anatomy of stomach

Stomach originates as a dilation in the tubular embryonic

foregut during the fifth week of gestation.
By the seventh week, it descends, rotates, and further
dilates with a disproportionate elongation of the greater
curvature into its normal anatomic shape and position.
Following birth, it is the most proximal abdominal organ of
the alimentary tract
Parts of stomach

Cardia
Fundus-contain the parietal cells
Antrum
pylorus

Blood supply of stomach

Most of the blood supply to the stomach is from the

celiac artery
The four main arteries

Others being

the left and right gastric arteries along the lesser

curvature
the left and right gastroepiploic arteries along the
greater curvature
the inferior phrenic arteries
the short gastric arteries from the spleen.

The largest artery to the stomach - left gastric artery

Lymphatic Drainage

Drains into four zones of lymph nodes

The superior gastric group drains lymph from the
upper lesser curvature into the left gastric and paracardial
nodes.
The suprapyloric group of nodes drains the antral
segment on the lesser curvature of the stomach into the
right suprapancreatic nodes.
The pancreaticolienal group of nodes drains lymph
high on the greater curvature into the left gastroepiploic
and splenic nodes.
The inferior gastric and subpyloric group of nodes
drains lymph along the right gastroepiploic vascular
pedicle.
All four zones of lymph nodes drain into the celiac group
and into the thoracic duct.

Nerve innervation
Parasympathetic by vagus
At GEjunction- LARP
Sympathetic celiac plexus
T5

to T10, traveling in the splanchnic nerve to the

celiac ganglion

Postganglionic fibers then travel with the arterial system to innervate the stomach.

The intrinsic or enteric nervous system

consists

of neurons in Auerbach's and Meissner's

autonomic plexuses.
In these locations, cholinergic, serotoninergic, and
peptidergic neurons are present

GASTRIC MORPHOLOGY

Gastric glandular organisation

CELLS
Parietal

LOCATION
Body

Mucus
Chief
Surface epithelial

Body, antrum
Body
Diffuse

Enterochromaffin-like
G
D
Gastric mucosal
interneurons
Enteric neurons

Body
Antrum
Body, antrum
Body, antrum

Endocrine

Body

Diffuse

FUNCTION
Secretion of acid and
intrinsic factor
Mucus
Pepsin
Mucus, bicarbonate,
prostaglandins (?)
Histamine
Gastrin
Somatostatin
Gastrin-releasing peptide
Calcitonin gene-related
peptide, others
Ghrelin

INTRODUCTION STOMACH
CANCER
Benign

Polyps
Hyperplastic
Fundic gland
Neoplastic
Multiple
Tumors
Leiomyomas
Lipomas
Heterotopic pancreas

Malignant

Tumors
Carcinoma
Lymphoma
Sarcoma
Carcinoid

GASTRIC POLYPS

Hyperplastic polyps

Most common type of polyp (65 90%)

Inflammatory or regenerative polyps
In reaction to chronic inflammation or regenerative hyperplasia
Often found in HP infections

Sessile and seldom pedunculated

Mostly in the antrum
Multiple in 50% of cases
Varying in size but seldom < 2cm

Rate of malignant transformation 1 3%

Usually larger than 2 cm

GASTRIC POLYPS

Fundic Gland

Small elisions in the fundus

Hyperplasia of the normal fundic glands

Accounts for 47%of all gastric polyps

Often associated with FAP

Therefore important as a marker for disease elsewhere in the GIT tract

GASTRIC POLYPS

Neoplastic polyps

Types
Tubular
Villous (often larger - > 2cm - and malignant)

Macroscopically
More often in antrum
Pedunculated with malignant potential
Solitary, large and ulcerated

Polyps .4cm may harbour malignancy in 40% of cases

Treatment
Endoscopic removal if no malignancy identified with surveillance
Excision with malignant focus or where endoscopic removal failed

GASTRIC POLYPS

Multiple gastric polyps

Rare condition
Adenomatous and hyperplastic polyps
20% incidence f adenocarcinoma

Treatment
If confined to corpus and antrum distal gastrectomy
Otherwise total gastrectomy

Sometimes associated with Polyposis syndromes

FAP
Gardner
Peutz-Jeghers
Cowden
Cronkhite Canada

GASTRIC LEIOMYOMA

Incidence of 16% at autopsy

Pathology

Arise from smooth muscle of the GIT tract

75% benign

Difficult to distinguish from GIST

Differentiation only on mitotic index

Large protruding elisions with central ulcer

Usually presents with bleeding if at all

Treatment is local excision with 2 3cm margin

GASTRIC LIPOMA

Rare subcutaneous lesions

Asymptomatic
On routine endoscopy
Require no treatment

Pillow sign

HETEROTOPIC
PANCREAS

Ectopic pancreas

Most common found in stomach

Within 6 cm from the pylorus

Also in Meckls diverticulum

Rarely larger than 4 cm

Sessile and rubbery

Submucosal in location
Histological identical to normal pancreas

Most of the patients are asymptomatic , whereas

others present with symptoms of PUD
The presenting symptoms being
Abdominal pain (MC,45%)
Epigastric discomfort(12%)
Nausea and vomitting(10%)
Bleeding(8%)

Symtomatic patients treated with excision

MENETRIERS DISEASE

Giant gastric folds (hypertrophic gastropathy)

Differentiate from

Manifestation

Infiltrating neoplasm (Ca / lymphoma)

CMV infection
Hypo-proteinaemia due to loss from ruggae
Chronic blood loss

Treatment

Medical (PPI, atropine, H2 blockers)

Surgical for refractory cases or where Ca cant be
excluded

ADENOCARCINOMA
OF THE STOMACH

Declining incidence in western world

HP associated due to chronic atrophic gastritis

It is 14th most comman cancer in the united states
The most comman site being proximal stomach-ie
adenocarcinoma of gastric cardia
Also related to
Low dietary intake vegetables and fruit
High dietary intake of starches
More common in males ( 3 : 1 )
Seventh decade of lif
More comman in blacks

Factors associated with increased

risk of developing stomach cancer
Nutritional
Low fat or protein consumption
Salted meat or fish\
High nitrate consumption
High complex-carbohydrate consumption

Environmental
Poor food preparation (smoked, salted)
Lack of refrigeration
Poor drinking water (well water)
Smoking

Factors associated with increased

risk of developing stomach cancer

Social
Low social class
Medical
Prior gastric surgery
Helicobacter pylori infection
Gastric atrophy and gastritis
Adenomatous polyps
Male gender

Pre malignant lesions

Artopic gastritis both type A and type B
Gastric polyps hyperplastic and adenomatous
(38%)
As a part of FAP syndrome
Intestinal metaplasia and dysplasia

Conditions with decreased risk of gastric

cancer
Aspirin
Diets

high in fresh fruits, vegetables,animal fat and

protien
Vit C and E

Histological types of gastric ca

adeno-carcinoma-most comman
Squamous cell carcinoma from oesophagus
Involves fundus and cardia
Others
Adenoacanthoma
Gastric lymphoma
Carcinoid tumors
Gastric sromal tumors

ADENOCARCINOMA
OF THE STOMACH

Histological typing(browmans classification)

Ulcerated carcinoma (25%)

Deep penetrated ulcer with shallow edges
Usually through all layers of the stomach

Polipoid carcinoma (25%)

Intraluminal tumors, large in size
Late metastasis

Superficial spreading carcinomas (15%)

Confinement to mucosa and sub-mucosa
Metastasis 30% at time of diagnosis
Better prognosis stage for stage

ADENOCARCINOMA
OF THE STOMACH

Histological typing

Linitis plastica (10%)

Varity of SS but involves all layers of the stomach
Early spread with poor prognosis

Advanced carcinoma (35%)

Partly within and outside the stomach
Represents advanced stage of most of the fore mentioned carcinomas

Laurren classification
INTESTINAL
Environmental

DIFFUSE
Familial

Gastric atrophy, intestinal metaplasia

Blood type A

Men >women

Women >men

Increasing incidence with age

Younger age group

Gland formation

Poorly differentiated, signet ring cells

Hematogenous spread

Transmural/lymphatic spread

Microsatellite instability
APC gene mutations

Decreased E-cadherin

p53, p16 inactivation

p53, p16 inactivation

Intesttinal metaplasia
-Is defined as the replacement or the gastric mucosa with
epithelium that ressebles small bowel mucosa
Due to the diversion of the gastric specific stem cells
It is due to irritaton of the gastric mucosa mainly with
H.pylori
Classified as

Complet type 1(paneth cells, goblet cells

sialomucins)
Incomplete type 2 and type 3(coloumnar cells
,goblet cells-sialomucins,sulfamucins)

Type

3 has increased risk to develop gastric cancer

Staging of gastric carcinoma

a. TNM System
b. CT Staging
c. PHNS Staging System (Japanese)
P-factor (Peritoneal dissemination)
H-factor (The presence of hepatic

metastases)
N-factor (Lymphnodes involvement)

T stage as defined by depth of penetration into

the gastric wall

 Early

Gastric Cancer:

Defined as cancer which is confined

to the
mucosa
and
submucosa
regard- less of lymph nodes status.
Advanced

Gastric Cancer:

Defined as tumor that has involved

the
muscularis propria of the
stomach wall.

Spread of gastric cancer

The diffuse type spreads rapidly through the

submucosal and serosal lymphatic and
penetrates the gastric wall at early stage,
The intestinal variety remains localized for a
while and has less tendency to disseminate.
The spread by:
1. Direct (loco regional)
2. Lymphatic
3. Blood (Haematogenous)
4. Transcoelomic

Evaluation of Gastric cancer

History
Clinical Examination
Investigations
The clinical features of gastric cancer may
arise from local disease, its complications
or its metastases.

ADENOCARCINOMA
OF THE STOMACH

Symptoms and signs

Vague discomfort difficult to distinguish from

dyspepsia
Anorexia
Meat aversion
Pronounced weight loss

At late stage
Epigastric mass
Haematemesis (15% )usually coffee ground seldom severe
Iron deficiency anaemia 40%
Very large tumors erode transverse colon large bowel obstruction

Metastasis
Vircho

node in neck-palpable left supraclavicular node

Blumer shelf peritoneal metastasis palpable by rectal
examination
Sister mary joseph node- palpable periumbilical node
Krukenberg tumor- Palpable ovarian mass
Hepatomegaly with obstructive jaundice due to secondaries
in porta hepatis

Paraneoplastic syndromes associated with gastric

cancer are

Trousseau syndrome migratory thrombophlebitis

Acanthosis nigricans-hyperpigmentation od axilla
and groin
Peripheral neuropathy

Investigations
A.
Upper gastero intestinal endoscopy

with multiple biopsy(98% acuuracy, )

biopsy taken from around the ulcer carter
and brush cytology increases the
diagnostic accuracy

Esophagogastroduodenoscopy

for

advanced disease

Laser ablation, dilation,tumor stenting

B. Radiology:
CT Scan of the chest and abdomen
Readily detects the visceral mets and malignant ascites
Drawbacks-evaluation of early primary gastric ca
,detection of small metastasis ,5mm in liver or on
peritoneal surfaces
USS upper abdomen
Barium meal-cannot differentiate benign and malignant
lesion

C. Diagnostic laparoscopy- can detect metastasis

in 23-37% of cases judged to eligible for potentially
curative ressection by CT scan

Cytologic analysis of peritoneal fluid

More sensitive methods for detecting free intrperitoneal

gastric cancer cells

Presence of free intraperitoneal gastric cancer

cells
Presence of cancer cells indicate poor prognosis

Immunostaining
Carcinoembryonicantigen(CEA)
CA19-9,CA125

Sentinel node biopsy with Tc99m

Treatment

Surgery
Chemotherapy
Radiotherapy

Treatment for localised disease

stage 1 disease.

Endoscopic mucosal resection

Limited surgical resection
Gastrectomy

ADENOCARCINOMA
OF THE STOMACH

Surgical resection only cure

Late presentation makes sugary often futile

It is also best way of palliative treatment
Resection at least 6 cm from the tumor mass is
necessary to ensure a low rate of anastomotic
recurrence.
Tumors of the cardia and proximal stomach
35% to 50% of all gastric adenocarcinomas.
proximal tumors are more advanced at presentation than more distant tumors,
either total gastrectomy or proximal gastric resection is necessary to remove
the tumor

Distal tumors

about 35% of all gastric cancers.

recent studies have indicated no difference in 5-year
survival between patients undergoing potentially
curative subtotal versus total gastrectomy,
subtotal gastrectomy is appropriate for patients in
whom a negative margin resection can be performed.
a luminal margin of 5 to 6 cm is recommended with
frozen-section analysis when a subtotal gastric
resection is performed for adenocarcinoma.

A, Subtotal gastrectomy with a Billroth II anastomosis. B, Total gastrectomy with a Rouxen-Y anastomosis.

Role of extended lymph node

dissection

Followed by japanese . But it is contraversial

JCGC D categories are ued to define the extent of
lymph nide dissection
D1 resection removal of level 1 nodes
D2 resection removal of level 1 and 2 nodes
D3resection - D2+removal of paraaortic nodes

D2 resection involves spleenectomy and distal

pancreatectectomy
This is associated with high mortality and morbidity

Lymph node stations ib gastric cancer-18 in

number,

1-6

Second tier

Right cardiac

Left cardiac

Node along lesser curvature

Node along greater curvatur

Fisrt tier nodes 5

7-11

Third tier

12 -18

suprapyloric

subpyloric

Along left gastric artery

Along comman hepatic artery

Along celiac axix

10

At spleenic hilum

11

Along speenic artery

12

At hepatodeodenal ligament

13

Retroduodenal lymphnode

14

At root of mesentry

15

Around middle colic artery

16

paraaortic

17

Around lower oesophagus

18

supradiaphragmatic

Palliation

To palliate pain,vomitting,bleeding,
Appetite is improved by partial gastrectomy
Other palliative procedures
Gastrojejunostomy and jejunojejunostomy
Devines exclusion procedure
For proximal growth celestin tube insertion
Endoscopic stenting
Laser recanalisation
Palliative chemotherapy-FAM regime

Adjuvant therapy

Used for T3 and T4 / node positive tumors

For patients with microscopically positive margins

5-flurouracil

based regimes have followed

2 cycles 5_FU +leucovarin ared used followed Ro

resection
FAM regime is also used

Gastric

ca are radioressitant . Radiation is used for

palliation of pain and bleeding

Prognosis

overall 12% 5 year survival

90% for stage I disease

Surveillance

Should be followed systematically

As most recurrence occur in first 3years
Its includes complete history , and physical
examination
Evry 4month for 1year
Every 6month for 2year
Every year therafter

Year endoscopy to be done for patients who have

GASTRIC LYMPHOMA

<15% of all primary gastric neoplasm's

2 different types of lymphoma

Part of systemic lymphoma with gastric

involvement (32%)
Part of primary involvement of the GIT (MALT
Tumors)
10 20% of all lymphomas occur in the abdomen
50% of those are gastric in nature

Risk factors

HP due to chronic stimulation of the MALT

In early stages of disease Rx of HP leads to
regression of the disease

GASTRIC LYMPHOMA
Primary MALT

Stomach is the most comman site of lymhoma in GIT

Early stages also referred to as pseudo-lymphoma

Indolent for long periods

Low incidence of
Spread to lymph nodes
Involvement of bone marrow,speen liver

Therefore much better prognosis

Mostly involves the antrum

Most comman type is diffuse large Bcell type
5 different types according to appearance

Infiltrative
Nodular

- Ulcerative
- Polypoid

GASTRIC LYMPHOMA
Primary MALT

At time of presentation

Pattern of metastasis similar to gastric carcinoma

Signs and symptoms

Larger than 10 cm (50%)

More than 1 focus (25%)
Ulcerated (30 50%)

Occur late and are vague

Relieved by anti-secretory drugs
Diagnosis based on histology

Sixth and seventh decade

Men more comman

ANN
ARBOR[*
]

IE

DESCRIPTION
Tumor confined to gastrointestinal
tract

RELATIVE INCIDENCE (%)

26

IIE

Tumor with spread to regional

lymph nodes

26

IIE

Tumor with nodal involvement

beyond regional lymph nodes (paraaortic, iliac)

17

IIIEIV

Tumor with spread to other intraabdominal organs (liver, spleen) or

beyond abdomen (chest, bone
marrow)

31

GASTRIC LYMPHOMA
Primary MALT

Treatment controversial

Surgical treatment for patients without systemic

involvement
Mandatory for high grade lesions
Possible not needed for low grade lesions
Total gastrectomy and en-block for direct involvement for 1E and 2E lesions
Sparing duodenum and oesophagus

It is most effective in the treatment of

complication like

Bleeding, perforation,obstruction, fistula formation

Chemotherapy
Used for stage 3 and stage 4 disease
Adjuvant therapy for patients with high risk of recurrence
CHOP regime

Cyclophospamide,.hydrodaunorubacin,oncovin,pre
dnisone

Radiation
Contraversial
Improve survval if positive margin or gross disease
remain after surgery

GASTRIC SARCOMA

1 3 % of gastric malignancies
Arise from the mesenchymal content of the gastric wall
Mean age at diagnosis 60 years
Include a wide variety of tumors

Leiomyosarcoma
Leiomyoblastoma
GIST-mc mesenchymal tumor of GI tract, most
commanly occur in stomach (60-70%)

GIST(gastrointestinal stromal tumor)

Arise from the interstitial cells of cajal
Form the tru smooth muscle neoplasm
are defined as cellular, spindle cell, or occasionally
pleomorphic mesenchymal tumors located in the GI tract
and express the Kit (CD117, stem cell factor receptor)
protein.
They are also positive for CD34
Equal in both sexes
Comman in 50-70 age group

Classified based on tumor size and mitotic activity

Very low risk <2cm
Low risk 2-5cm
Intermediate risk -5-10cm
High risk >10cm
Mitotic activity
Benign behaviour <5/50hpf
>5/50hpf malignant
>50/50hpf high grade malignant

Ckit mutation is associated with poor prognosis

Never metastasize to local lymph nodes

Clinical features

Abdominal pain
Weight loss
GI bleed

Caraneys triad

Extraadrenal parganglioma
Pulmonary chondroma
gastric GIST

Treatment
Margin negetive resection with enbloc resection of the
adjacent organs if involved
Indices that predict recurrences are

Mitotic rate >15/50hpf

Male sex
Mixed cytomorphology

Chemotherapy

Imatinib mesylate tyrosine kinase inhibitor, has

activity against CD117

Complications of gastric surgery

Gastroparesis

Post-vagotomy diarrhea

Bile alkaline reflux

gastritis

Recurrent Ulceration

Efferent/Afferent loop
syndromes

Small-Capacity Syndrome

Postvagotomy Dysphagia

Roux limb syndrome

Dumping syndrome

Gastric Remnant
Carcinoma

Anemia, Metabolic
Disorders

Dumping syndrome

Malabsorption and metabolic disturbences

Fat malabsorption-steatorrhea
Anaemia-iron deficiency and megaloblastic anaemia

Bone disease

Early hypotension, tacycadia shock more severe

Late less severe , hpoglycemia

Deficiency of calcium and vitamin D

Gastric stasis

Due to altered gastric function or due to obstruction

Diarrhoea

Deodenal blow out

Associated with dumping syndrome

Post vagotomy
Association with fat malabsorption
Following billroth 2 on day 5
Can lead to deodenal fistula

Bile reflux gastritis

Gall stones

Weight loss
Post gastrectomy syndromes associated with
gastric reconstruction

Afferent loop syndrome

Efferent loop syndrome
Retained antrum syndrome
Roux syndrome

Thank you

GASTRIC BEZOAR

Concretions in the stomach

Tricho-bezoar (hair)

Seldom perforate but if mortality 20%

Post-gastrectomy predisposes

Phyto-bezoar (vegetable fibre)

Can cause erosions and bleeding

Young girls who pick and swallow their hair

Both mechanical and chemical

Endoscopic breakage

GASTRIC VOLUVLUS

2 Types

Organo-axial
Through the organs longitudinal axis
More common and associated with hiatus hernia
Eventration of the diaphragm

Mesenterio-axial

Line through mid lesser to mid greater curvature

Clinical triade (Brochardts)

Vomiting followed by retching and inability to vomit

Epigastric distension
Inability to pass NGT

GASTRIC VOLVULUS

Treatment

Emergency surgery as any volvulus

GASTRIC DIVERTICULAE

True diverticulae uncommon

Pulsion with only mucosa and sub-mucosa

Involve all layers of the wall

Pre-pyloric in location
Within a few cm of GEJ

Asymptomatic found on routine investigations

Confused with peptic ulceration

INTODUCTION - DUODENUM

Benign
Brunners gland adenoma
Leiomyoma
Carcinoid
Heterotopic gastric mucosa
Villous adenoma

Malignant
Peri-ampullar adeno CA
Duodenum
Cholangio
Pancreatic head
Leiomyosarcomas
Lymphomas

Others
Duodenal dIverticula

DUODENUM
Benign tumors

Brunners gland adenomas

Small submucosal

Posterior wall junction D1 and D2

Symptoms due to bleeding or onstruction

Leiomyoma

Sessile and pedunculated variants

Asymptomatic

Carcinoid

Mostly active (gastrin, SS and serotonin)

Simple excision

DUODENUM
Benign tumors

Hetrotopic gastric mucosa

Multiple small mucosal lesions

No clinical significance

Villous adenoma

Intestinal bleeding
Obstruction of ampulla with jaundice
Risk of malignancy high (50%)
Endoscopic snaring or local excision

DUODENUM
Malignant tumors

Located in the descending part of the duodenum

Symptoms

Pain, obstruction bleeding and jaundice

Earlier than pancreas head

Treatment

Pancreatico-duodenectomy for localized lesions

Much better prognosis than pancreas Ca (30% 5-year as opposed to 0%)

Palliative bypass procedures if not resectable

Radiotherapy for advanced disease ?

DUODENAL DIVERTICULAE

Incidence

Pulsion diverticulae

20% at autopsy
5 10% at upper GIT investigations
90% on the medial border of the duodenum
Solitary and within 2.5 cm of the ampulla
Associated gallstones and gallbladder disease

Pseudo-diverticluae

First part of the duodenum

Scarring of PUD

DUODENAL DIVERTICULAE

Presentation

With complicated disease

Chronic post-prandial pain and dyspepsia

Bleeding and perforation
Panceatitis
Jaundice

Surgery for complicated disease

Dissection, removal and closure (even with

perforation)
With billiary involvement : cholidochoduodenostomy