Lecture notes for medical students

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2. Introduction & History.

3. Introduction & History.
• It is a muscular, highly vascular bag-shaped
organ that is distensible and may take
varying shapes, depending on the build and
posture of the person and the state of
fullness of the organ

4. Parts

5. Parts
• The esophagogastric junction (cardia),
• The cardiac notch (incisura cardiaca gastri)
• fundus
• body (corpus)
• pyloric antrum
• pyloric canal,
• convex greater curvature
• concave lesser curvature
• The junction of the vertical and horizontal
parts of the lesser curvature is called

6. Arterial Supply

7. Arterial Supply
celiac trunk (axis)- common hepatic artery, splenic
artery, and the left gastric artery
• left gastric artery
• right gastric artery branch from the proper or
common hepatic artery
Pancreaticoduodenal artery-
• right gastro-omental (gastroepiploic) artery
splenic artery
• left gastro-epiploic (gastro-omental) artery
• short gastric arteries from splenic art.

8. Arterial Supply

9. Venous Drainage

10. Venous Drainage
• Portal Vein
• left gastric (coronary) vein
• right gastric
• right gastro-omental veins
• left gastro-omental vein
• short gastric veins splenic vein,

11. Lymphatic Drainage

12. Lymphatic Drainage
4 levels-
• Level I (perigastric lymph nodes) - Right
paracardiac (1), left paracardiac (2), along
lesser curvature (3) along greater curvature
(4), suprapyloric (5), infrapyloric (6)
• Level 2 - Along LGA (7), along CHA (8),
along celiac axis (9), at splenic hilum (10),
along splenic artery (11)

13. Lymphatic Drainage
4 levels-
• Level 3 - In hepato-duodenal ligament (12),
behind duodenum and pancreas head (13),
at the root of small bowel mesentery (14)
• Level 4 - Mesocolic (15), paraaortic (16)

14. Nerve Supply

15. Nerve Supply
• Parasympathetic-
– Right and left Vagus
• Sympathetic- celiac ganglia (T5-T9).

16. Relations

17. Relations
• Anterior
– left lobe (segments II, III and IV) of the liver
– anterior abdominal wall
– the distal transverse colon.
• Posterior(stomach bed).
– left hemidiaphragm
– Spleen
– left kidney (and adrenal)
– pancreas
– The omental bursa (lesser sac) lies behind the
stomach and in front of the pancreas;

18. Attachments/Supports

19. Attachments/Supports
• To liver by the hepatogastric ligament (the left
portion of the lesser omentum)
• to the left hemidiaphragm by the gastrophrenic
ligament,
• to the spleen by the gastrosplenic/gastrolienal
ligament
• to the transverse colon by the gastrocolic
ligament (part of the greater omentum
• Few peritoneal bands may be present between the
posterior surface of the stomach and the anterior
surface of the pancreas.

20. Microscopic Anatomy

21. Microscopic Anatomy
• columnar epithelium
• chief (zymogenic) cells in the fundus
secrete protein digesting pre-enzyme
pepsinogen;
• parietal (oxyntic) cells in the body (corpus)
of the stomach secrete acid (H+ ions) and
intrinsic factor
• G cells in the antrum secrete gastrin

22. Pediatric Hypertrophic Pyloric
Stenosis

23. Etiology

24. Etiology
• Idiopathic
• Congenital
• Traumatic
• Infections /Infestation
• Autoimmune
• Neoplastic (Benign/Malignant)
• Degenerative

25. Etiology
• Now believed to be aquired.
• Early exposure to erythromycin (at 3-13 days of
life
• decreased expression of neuronal NOS
• genes on loci 11q14-22 and Xq23.
• genetic predisposition is suggested in families
with occurrences of pyloric stenosis reported in at
least three generations
• Involvement in twins has been reported, with an
85.7% concordance rate in monozygotic twins and
an 8.4% concordance rate in dizygotic twins.

26. Pathophysiology

27. Pathophysiology
• Hypertrophy of the circular muscle of the
pylorus, resulting in narrowing and
obstruction of the pyloric channel
• Grossly, the pylorus is enlarged, resembling
a tumor approximating the size and shape of
an olive (ie, 2 cm long and 1 cm in
diameter)
• Microscopically, the circular muscle
hypertrophies, with increased connective
tissue in the septa between the muscle
bundles.

28. Pathophysiology
• Gastric fluid loss is associated with the loss of
H+and Cl–
• This fluid loss is unlike that in conditions caused
by vomiting with an open pylorus, which involves
losses of gastric, pancreatic, biliary, and intestinal
fluid.
• Hypochloremic hypokalemic metabolic alkalosis
is the characteristic biochemical disturbance
• Paradoxic aciduria-urinary excretion of K+ and
H+increases in an attempt to preserve Na+ and
volume..

29. Clinical Features

30. Clinical Features
• Demography
• Symptoms
• Signs
• Prognosis
• Complications

31. Demography

32. Demography
• 1 case per 3000-4000 live births to as many
as 8.2-12 cases per 1000 live births
• rarely found in patients of Asian
• more common in males than in females
(male-to-female ratio, 4:1)

33. Symptoms

34. Symptoms
• most often occurs in neonates and infants
aged 1-10 weeks (mean, 5 weeks; range, 5
days to 5 months).
• projectile vomiting always nonbilious but
may have brown discoloration or a coffee-
ground appearance
• The vomiting occurs within 30-60 minutes
after feeding
• The infant remains hungry and usually
attempts to feed immediately after
vomiting.

35. Signs

36. Signs
• Weight loss and evidence of dehydration
(eg, decreased tearing and urinary output,
with poor skin turgor)
• visible gastric contractions occurring in a
wavelike manner from left to right across
the abdomen.
• oblong, smooth, hard mass that is 1-2 cm in
lengthin the epigastrium just above the
umbilicus, either in the midline or just to the
right

37. Prognosis

38. Prognosis
• Good if operated

39. Investigations

40. Investigations
• Laboratory Studies
– Routine
– Special
• Imaging Studies
• Tissue diagnosis
– Cytology
• FNAC
– Histlogy

41. Investigations
• Laboratory Studies
– An electrolyte panel
– Urinalysis with normalization of urinary pH
(correction of paradoxic aciduria)

42. Diagnostic Studies

43. Diagnostic Studies
Imaging Studies
• X-Ray
• USG
• CT
• Angiography
• MRI
• Endoscopy
• Nuclear scan

44. Diagnostic Studies
Imaging Studies
• On ultrasonography
– Pyloric diameter >14 mm
– Muscular thickness >4 mm
– Length >16 mm
• Upper gastrointestinal (UGI) contrast
studies

45. Differential Diagnosis

46. Differential Diagnosis
• gastroesophageal reflux
• duodenal atresia
• malrotation
• pyloric spasm
• central nervous system (CNS) lesions

47. Management

48. Management
• Resucitation + - cimetidine
• Ramstedt’s pyloromyotomy
• laproscopic pyloromyotomy
• endoscopic pyloromyotomy
• oral atropine

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