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Stomach pathology

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  • 1. STOMACH www.freelivedoctor.com
  • 2.
    • CONGENITAL ABNORMALITIES
    • Pyloric stenosis
    • a) males 3:1 vs. females
    • b) may occur with Turner syndrome,
    • trisomy 18, esophageal atresia
    • c) clinical:
    • i) narrowing of pyloris
    • - hypertrophy and possibly
    • hyperplasia (muscularis)
    • ii) regurgitation (projectile !!)
    • - dehydration of concern
    www.freelivedoctor.com
  • 3. iii) oval (“olive”) palpable mass iv) surgical splitting is curative www.freelivedoctor.com
  • 4.
    • DIAPHRAGMATIC HERNIA
    • Bochdalek hernia A Bochdalek hernia involves an opening on the left side of the diaphragm. The stomach and intestines usually move up into the chest cavity.
    • M orgagni hernia A Morgagni hernia involves an opening on the right side of the diaphragm. The liver and intestines usually move up into the chest cavity.
    www.freelivedoctor.com
  • 5. www.freelivedoctor.com
  • 6.
    • ACUTE GASTRITIS
    • Gastritis (inflammation of gastric
    • mucosa)
    • transient inflammation (usually)
    • a) bleeding and erosion i) sloughing of mucosa
    • Pathogenesis not clear: associations
    • a) NSAID (e.g., aspirin)
    • b) alcohol
    • c) smoking
    • d) stress (trauma, burns, surgery)
    • e) uremia, infections
    www.freelivedoctor.com
  • 7.
    • Several factors involved: (1 or more)
    • a)  acid secretion with back diffusion
    • b)  HCO 3 - buffer
    • c)  blood flow
    • d) disruption of mucus layer
    • e) damage to epithelium
    • f) lots of patients have idiopathic acute gastritis without any of the listed disorders !!
    • g) neutrophils above basement membrane  active inflammation
    www.freelivedoctor.com
  • 8.
    • Clinical:
    • a) may be asymptomatic
    • b) nausea, vomiting
    • c) variable epigastric pain
    • d) in severe cases:
    • i) hemorrhage
    • - may be fatal
    • ii) severe hematemesis
    • - alcoholics
    • iii) melena
    www.freelivedoctor.com
  • 9.
    • CHRONIC GASTRITIS
    • presence of chronic mucosal
    • inflammation
    • a) leading to mucosal atrophy
    • b) intestinal metaplasia
    • c) usually no erosion
    • d) epithelial changes may  dysplasia
    • i) basis for CA
    www.freelivedoctor.com
  • 10.
    • Pathogenesis:
    • a) chronic infection (H. pylori)
    • b) autoimmune (pernicious anemia)
    • c) alcohol, smoking
    • d) post surgery (i.e., gastric)
    • e) radiation
    • 1. Helicobacter pylori
    • most important etiologic association
    • with chronic gastritis
    www.freelivedoctor.com
  • 11.
    • plays role in other diseases:
    • a) peptic ulcer
    • b) gastric carcinoma
    • c) gastric MALT lymphoma
    • i) “ mucosa-associated lymphoid tissue”
    • characteristics:
    • a) flagellated (swim through mucus)
    • b) urease +
    • i) produces NH 3 and CO 2 from urea
    • - buffers H +
    www.freelivedoctor.com
  • 12. c) H. pylori-induced gastritis i) antral-type - high H + production -  risk of peptic ulcer ii) pangastritis - multifocal gastric atrophy - lower H + production -  risk of adenocarcinoma d) IL-1 β (inflammatory cytokine) i) inhibits gastric acid ii)  IL-1 β  pangastritis iii)  IL-1 β  antral-type www.freelivedoctor.com
  • 13. e) clinical: i) serologic test for Ab ii) fecal bacteria detection iii) urea breath test iv) gastric biopsy (culture) - histology visualization www.freelivedoctor.com
  • 14.
    • 2. Autoimmune gastritis
    • < 10% of gastritis cases
    • Ab against H + -K + -ATP ase , gastrin and IF
    • a) mucosal atrophy
    • i) loss of acid production
    • b) pernicious anemia
    • seen with other autoimmune diseases
    • a) type 1 diabetes
    • b) Addison's disease
    • c) Hashimoto thyroiditis
    www.freelivedoctor.com
  • 15.
    • high risk of gastric CA and endocrine
    • tumors (carcinoid tumors)
    • diffuse mucosal damage
    • a) fundus and body
    • b) lymphocytes and plasma cells
    • c) active inflammation  neutrophils !
    • d) atrophy is frequently associated;
    • and with pangastritis (H. pylori)
    • e) hyperplasia of G cells (  gastrin)
    • i) due to  H + production
    • ii) gastremia
    www.freelivedoctor.com
  • 16. f) dysplasia with long standing gastritis  CA in-situ i) atrophic forms of chronic gastritis - H. pylori - pernicious anemia g) clinical: i) few symptoms - only with severe cases ii) peptic ulcer disease - H.pylori (gastric CA and lymphoma) www.freelivedoctor.com
  • 17.
    • 3. Special forms
    • Eosinophilic
    • a) antral, pyloric region
    • b) middle aged women
    • c) abdominal pain
    • d) steroids effective
    • allergic
    • a) children
    • b) diarrhea, vomiting
    • c) antral eosinophils
    www.freelivedoctor.com
  • 18.
    • lymphocytic
    • a) T-lymphocytes (CD8 + mostly)
    • b) body of stomach
    • c) ~ 50% associated with celiac disease
    • granulomatous
    • a) granulomas
    • b) Crohn disease
    • c) sarcoidosis
    • d) infection (TB, histoplasmosis)
    www.freelivedoctor.com
  • 19.
    • reactive gastropathy
    • a) absence of active inflammation
    • i) no neutrophils
    • b) common gastritis
    • c) causes:
    • i) chemical (NSAID)
    • ii) bile reflux
    • iii) mucosal trauma from prolapse
    • - “gastric antral vascular ectasia”
    • (dilated capillaries with fibrin thrombi; longitudinal erythematous stripes)
    www.freelivedoctor.com
  • 20.
    • PEPTIC ULCER DISEASE
    • chronic, most often solitary lesions
    • a) duodenum (initial portion) 4:1
    • b) stomach (antrum)
    • c) gastroesophageal junction
    • i) Barrett esophagus
    • d) duodenum, stomach and/or jejunum
    • i) Zollinger-Ellison syndrome
    • in USA, ~ 4 million; 3:1 male:female
    • middle age to older adults
    www.freelivedoctor.com
  • 21. www.freelivedoctor.com
  • 22.
    • relapsing lesions
    • a) in part due to H. pylori infection
    • peptic ulcers occur:
    • a) imbalance between defense and damaging forces
    • i) most due to defense failure
    • - H. pylori
    • b) H. pylori
    • i) ~ 100% in duodenal ulcers
    • ii) ~ 75% in gastric ulcers
    • iii) antibiotic Tx  healing and prevents recurrence
    www.freelivedoctor.com
  • 23. iv) severe inflammation - IL-1, IL-6, IL-8,TNF - IL-8 recruits neutrophils v) produces proteases and phospholipases - break down protective actions of mucus vi)  HCO 3 - in duodenum v)  H + secretion in stomach vi) damage to mucosa and epithelial cells  leakage of nutrients (sustain H. pylori) www.freelivedoctor.com
  • 24. c) clinical: (table 17-3) i) epigastric pain, burning - worse at night and - 1-3 hours after meal - relieved with food or antacids ii) iron deficiency anemia iii) penetrating ulcers refer pain to back, left upper quadrant or chest (MI ?) iv) NO progression to CA (duodenal or gastric) www.freelivedoctor.com
  • 25. www.freelivedoctor.com
  • 26.
    • ACUTE GASTRIC ULCERATION
    • well known complication of Tx with
    • NSAID
    • following severe stress (“stress
    • ulcers”)
    • many lesions in stomach and
    • occasionally in the duodenum
    • range from
    • a) erosion – sloughing of mucosal epithelium
    • b) entire mucosal thickness (ulcer)
    www.freelivedoctor.com
  • 27.
    • stress ulcers:
    • a) shock/trauma
    • b) sepsis
    • c) severe burns
    • d) intracranial injury with  ICP
    • e) intracranial surgery
    www.freelivedoctor.com
  • 28.
    • MISCELLANEOUS
    • Hypertropic gastropathy
    • a) Ménétrier disease : extensive hyperplasia of gastric mucosa with glandular atrophy
    • b) clinical:
    • i) epigastric pain
    • ii) diarrhea
    • iii) weight loss
    • c) body/fundus, antrum or entire stomach regions
    www.freelivedoctor.com
  • 29. d) gastric secretions i) excessive mucus ii) hypo- or achlohydria - due to glandular atrophy e)  protein loss i) hypoalbuminemia and edema f)  risk of gastric CA www.freelivedoctor.com
  • 30.
    • BENIGN TUMORS
    • In alimentary tract “polyp” is a mass
    • extending above mucosa
    www.freelivedoctor.com
  • 31.
    • hypereplastic in nature
    • 10% of polyps are neoplastic
    • a) dysplasia are are pre-CA
    • b) adenomatous polyps more common in colon
    • clinical:
    • a) hyperplastic polyps
    • i) often seen in chronic gastritis
    • ii) NO malignant potential
    www.freelivedoctor.com
  • 32.
    • GASTRIC CARCINOMA
    • most common malignancy in stomach
    • next are lymphomas (4%) then
    • mesenchymal tumors (2%)
    • a) Leiomyosarcoma
    • b) schwannoma
    • second most common tumor worldwide
    • High incidence in Japan, Chile, China,
    • Portugal, etc compared to USA,
    • Europe, Canada
    www.freelivedoctor.com
  • 33.
    • WHO classification (table 17-4)
    • Pathogenesis (table 17-5)
    • a) H. pylori  risk 6X for developing gastric carcinoma (intestinal type)
    • i) chronic gastritis  atrophy
    •  metaplasia  dysplasia
    •  carcinoma
    • ii) not all patients with H. pylori or chronic gastritis develop cancer
    www.freelivedoctor.com
  • 34.
    • b) environmental factors
    • i) diet suspected as 1 o
    • ii) NO link with alcohol and smoking as causative as well as antacid use
    • most important determinant of
    • outcome is the depth of invasion
    • a) mucosa and submucosa better
    • prognosis that invasion of the
    • muscularis
    www.freelivedoctor.com
  • 35.
    • types:
    • a) exophylic
    • i) protrusion into lumen
    • b) flat
    • i) NO protrusions
    • c) excavated
    • i) crater in wall of stomach
    • Early
    • Advanced
    www.freelivedoctor.com
  • 36. www.freelivedoctor.com
  • 37.
    • metastases
    • a) supraclavicular node
    • b) periumbilical region to form subcutaneous nodule
    • i) “Sister Mary Joseph nodule”
    • c) Krukenberg tumor to ovary
    • clinical:
    • a) asymptomatic until advanced stage
    • i) nonspecific CA symptoms
    • b) diffuse area covered with malignancy
    • i) “linitis plastica” leather bottle
    www.freelivedoctor.com
  • 38.
    • Krukenberg tumor to ovary
    • Usually large and associated with poor prognosis
    www.freelivedoctor.com
  • 39. Gross : Linitis plastica carcinoma diffusely infiltrates the entire gastric wall without forming an intraluminal mass. The wall of the stomach is typically thickened to about 2-3 cm. and has a leathery, inelastic consistency. www.freelivedoctor.com
  • 40.
    • c) metastasis from breast or lung can cause linitis plastica (diffuse)
    • gastric lymphoma
    • a) > 80% associated with H. pylori and chronic gastritis
    • i) 50% Tx with antibiotics
    • GI stromal tumor
    • a) originate in interstitial cells of Cajal (regulate peristalsis)
    • i) 95% stain with Ab against
    • c-KIT (CD117)
    • ii) 70% stain for CD34
    www.freelivedoctor.com