The document discusses peptic ulcers and gastric tumors. It defines a peptic ulcer and describes the etiology as being related to Helicobacter pylori infection and NSAID use. It discusses the sites of peptic ulcers as the duodenum and stomach. It also summarizes the gross and microscopic morphology of acute and chronic gastric ulcers. For gastric tumors, it classifies the main types and discusses the epidemiology, etiology, morphology, clinical features, investigations, staging, and prognostic markers for gastric carcinoma.

1. Stomach Dr. Girish Kamat

2. University Questions Peptic Ulcer Long Essay- 10M Describe the etiology, gross, and microscopy of gastric ulcer. List complications of gastric ulcer Define peptic ulcer. Mention the sites. Describe etiopathogenesis and morphology of chronic gastric ulcer Short Answers- 5M Helicobacter pylori Etiology of duodenal ulcer Short Notes- 3M Macroscopy of benign and malignant gastric ulcer

3. University Questions Tumors Short Answers- 5M Morphologic types of carcinoma of stomach Early gastric carcinoma Short Notes- 3M Morphology of gastric carcinoma Linitis plastica Signet ring cell Modes of spread of gastric cancer

4. Peptic Ulcer Definition Etiopathogenesis H.Pylori Sites Morphology- Acute, Chronic Difference between benign and malignant Clinical features Investigatuions Complications

5. Gastric Tumors Classification Carcinoma Etiology Morphology Clinical features Investigations Spread Staging Prognostic markers

6. Peptic Ulcer

7. Definition “ It is acid peptic digestion of alimentary mucosa, resulting in an ulcer, that extends through the muscularis mucosa into the submucosa or deeper.”

8. Epidemiology Men affected more than Females M: F ratio in Duodenal ulcer is 3:1 M : F ratio in Gastric ulcer is 1.5 : 1 Women most affected at or after menopause

10. Etiology H.Pylori Infection 100%- Duodenal, 70%- Gastric 10-20% infected develop gastritis Non sporing, curvilinear, flagellated, Gram – neg Swims through mucus, urease, bacterialadhesins- Bab A, Produces cytotoxin (CagA gene), Vacuolating cytotoxin (VacA) Chronic gastritis  Atrophy  Intestinal metaplasia  Dysplasia  Carcinoma Also- MALToma

11. Etiology- H. Pylori Mechanism of production of gastritis Inflammatory cytokines- IL- 1,6,8, TNF Epithelial injury- Urease, protetease, Phospholipase Impairs duodenal bicarbonate production Thrombotic occlusion of surface capillaries- Bacterial PAF

12. Etiology- H. Pylori Tests Biopsy- H&E, Geimsa, Warthin Starry, Steiner silver, Aclian yellow tuleidine blue method, IHC Serology- Elisa Urea breath test- C13/C14 urea Culture and sensitivity Bacterial DNA detection by PCR

14. Etiology- NSAIDS & Steroids Inhibit cyclo-oxygenase  Reduced PG  Reduced cytoprotection  Mucosal injury

15. Etiology Emotions Diet Pylorodudenal reflux Endocrine- Zollinger Ellison, Cushing Trauma Smoking Hereditory- Blood Gr O

16. Etiology Curling ulcer- Stress produced by hypotension, endotoxic shock, MI, Burns Cushing ulcer- Increased intracranial tension

18. Sites Duodenum- 4X- First Part Stomach- 1X- Antrum Barrette’s esophagus Jejunum in ZE syndrome Meckel’s diverticulum with ectopic gastric mucosa Margins of gatro-jejunostomy

19. Morphology- Acute Gross Multiple 1-2mm Shallow and do not invade muscular coat

20. Morphology- Acute Micro Neutrophils above basement membrane Erosion not crossing muscular mucosa Fibrinous exudate

22. Morphology-Gross Single, round to oval <2cm Lesser curvature Punched out Scarring involving entire thickness  Puckering of surrounding mucosa, borders at the levels of surrounding mucosa Base- Smooth, clean

23. Morphology-Gross Single, round to oval <2cm Lesser curvature Punched out Scarring involving entire thickness  Puckering of surrounding mucosa, borders at the levels of surrounding mucosa Base- Smooth, clean Malignancy Irregular Large Lesser curvature Heaped up, irregular margin Shaggy necrotic base Invasion of tumor tissue into surrounding area

24. Morphology- Chronic Micr0- 4 Layers Surface debris Neutrophils Granulation tissue Collagen

26. Clinical Features Abdominal pain- Epigastric, burning type, vomiting (Relieves), episodic Food aggravates- Gastric Food relieves- Duodenal Hematemesis, malena

27. Investigations Blood- Anemia Stool-Occult blood Barium meal Endoscopy- H.Pylori, Malignancy H.Pylori Gatsric function tests- Obsolete

28. Complications Bleeding- 15-20% Perforation- 5% Obstruction due to edema and scarring

29. Other gastritis Eosinophilic Lymphocytic Granulomatous Hemorrhagic CMV Radiation/ chemotherapy Autoimmune Xanthogranulomatous

30. Gastric Tumors

31. Classification Epithelial Adenoma Adenocarcinoma- Papillary, tubular, mucinous, signet ring, undifferentiated, adenosquamous Small cell carcinoma Carcinoid tumor Non Epithelial Leiomyoma Schwannoma GIST Lymphoma

32. Carcinoma of Stomach

33. Epidemiology Higher in Japan, China compared to US, UK More common in lower socio-economic groups Male to Female ratio is 2: 1 Steady decline in incidence & mortality for the past 6 decades

34. Etiology H.Pylori Diet- Salted/smoked food, nitrates Smoking and alcohol Decreased gastric acid secretion- Proton pump inhibitors, atrophic gastritis

35. Morphology Gross Sites- Antrum- 50% Body- 30% Cardiac- 20% MC site- Lesser curvature

36. Morphology Gross Cauliflower like Infiltrating with dense fibrosis- Linitis plastica Ulcerative- Heaped up beeded margins

39. Morphology Micro- (DIO/ Lauren) Diffuse- Signet ring cells Intestinal- Similar to intestinal adenoca Others

42. Early Gastric Ca (Superficial/ microinvasive Ca) Ca confined to mucosa and submucosa regardless of status ofregional lymph nodes

43. Clinical Features Ulcer like pain Weight loss, anorexia Hematemesis Palpable epigastric mass

44. Clinical Features Meatstasis to Left axillary nodes Supraclavicular nodes Umbilicus Ovaries Pouch of Douglas Called as Irish nodes Virchow nodes/ Trousier Sistem Mary Joseph Nodule Kruckenberg tumor Blummer’s shelf

45. Clinical Features Paraneoplastic syndromes Trousseaus’ sign Acanthosis nigricans Dermatomysitis

46. Investigations Endoscopy Exfoliative brush cytology Barium meal CT, USG

47. Staging T1- Submucosa T2- Muscularis Propria T3- Penetration of serosa T4- Adjacent structures N1- Regional LN N2- Distant LN M1- Distant mets

48. Staging I- T1N0M0/T1N1M0/T2NoMo II-T1N2M0/T2N1Mo/T3N0M0 III- T2N2M0/T3N1M0/T4NoM0 IV- T4N2M0/T any N any M1

49. Prognostic markers Stage Grade Hsitologic type P53, c-ERB-2 Location Inflammatory raection Perneural invasion

50. 5 year survival rate 90 - 95 % in surgically treated early carcinoma < 15 % in advanced carcinoma

51. Thank You…