This document discusses several causes of gastric bleeding and disorders, including gastric tumors like gastrointestinal stromal tumors (GISTs) and gastric lymphoma. GISTs are sensitive to the drug imatinib and tumors over 5 cm in diameter have metastatic potential. Primary gastric lymphoma is usually treated with chemotherapy or surgery alone for early-stage disease, while widespread lymphoma involves chemotherapy.

1. STOMACH cont
Dr ARUNABHA SINHA

2. Other causes of gastric bleeds:
Tumours:
●All of the gastric tumours described may present with
chronic or acute upper gastrointestinal bleeding.
Bleeding is not normally torrential but can be
unremitting. Gastric stromal tumours commonly present
with bleeding and have a characteristic appearance, as
the mucosa breaks down over the tumour in the gastric
wall.

3. Portal hypertension and portal
gastropathy
The management of bleeding gastric varices is very
challenging. Fortunately, most bleeding from varices is
oesophageal and this is much more amenable to
sclerotherapy, banding and balloon tamponade. Gastric
varices may also be injected, although this is technically
more difficult.

4. ●Banding can also be used, again with difficulty. The gastric
balloon of the Sengstaken–Blakemore tube can be used to
arrest the haemorrhage if it is occurring from the fundus of
the stomach or gastro-oesophageal junction.
●Octreotide is a somatostatin analogue that reduces portal
pressure in patients with varices, and trials suggest that it is
of value in arresting haemorrhage in these patients,
although its overall effect on mortality remains in doubt.
Glypressin is also said to be of use.

5. Portal gastropathy
●Portal gastropathy is essentially the same disease process
as described above. The mucosa is affected by the
increased portal pressure and may exude blood, even in the
absence of well-developed visible varices.

6. • Aortoenteric fistula
●Aortoenteric fistula This diagnosis should be considered in any
patient with haematemesis and melaena that cannot be
otherwise explained. Contrary to expectation, the bleeding
from such patients is not always massive.

7. ● Very often there is nothing much to distinguish between the
bleeding from the aortic enteric fistula and any other
recurrent upper gastrointestinal bleeding.
● The vast majority of patients will have had an aortic graft and
in the absence of this, the diagnosis is unlikely. However, it
is occasionally seen in patients with an untreated aortic
aneurysm.

8. GASTRIC OUTLET OBSTRUCTION
●The two common causes of gastric outlet obstruction
are gastric cancer and pyloric stenosis secondary to
peptic ulceration. Previously, the latter was more
common .
●The term ‘pyloric stenosis’ is normally a misnomer. The
stenosis is seldom at the pylorus. Commonly, when the
condition is due to underlying peptic ulcer disease, the
stenosis is found in the first part of the duodenum, the
most common site for a peptic ulcer.

9. ●True pyloric stenosis can occur due to fibrosis around a
pyloric channel ulcer. However, in recent years the most
common cause of gastric outlet obstruction has been gastric
cancer.
● In this circumstance the metabolic consequences may be
somewhat different from those of benign pyloric stenosis
because of the relative hypochlorhydria found in patients
with gastric cancer.

10. Clinical features
●In benign gastric outlet obstruction there is usually a long
history of peptic ulcer disease. Nowadays, as most patients
with peptic ulcer symptoms are treated medically, it is easy to
understand why the condition is becoming much less .

11. ●The vomitus is characteristically unpleasant in nature and is
totally lacking in bile. Very often it is possible to recognize
foodstuff taken several days previously. The patient commonly
complains of losing weight, and appears unwell and dehydrated.
●When examining the patient, it may be possible to see the
distended stomach and a succussion splash may be audible on
shaking the patient’s abdomen.

12. Metabolic effects
●These are most interesting, as the metabolic
consequences of benign pyloric stenosis are unique. The
vomiting of hydrochloric acid results in hypochloraemic
alkalosis. Initially the sodium and potassium may be
relatively normal.

13. ●However, as dehydration progresses, more profound metabolic
abnormalities arise, partly related to renal dysfunction. Initially,
the urine has a low chloride and high bicarbonate content,
reflecting the primary metabolic abnormality .
●This bicarbonate is excreted along with sodium, and so with time
the patient becomes progressively hyponatraemic and more
profoundly dehydrated.

14. ●Because of the dehydration, a phase of sodium retention follows
and potassium and hydrogen are excreted in preference.
● This results in the urine becoming paradoxically acidic and
hypokalaemia ensues. Alkalosis leads to a lowering in the
circulating ionised calcium, and tetany can occur.

15. Management
●Treating the patient involves correcting the metabolic abnormality
and dealing with the mechanical problem. The patient should be
rehydrated with intravenous isotonic saline with potassium
supplementation.
●Replacing the sodium chloride and water allows the kidney to
correct the acid–base abnormality. Following rehydration, it may
become obvious that the patient is also anaemic, the
haemoglobin being spuriously high on presentation.

16. Other causes of gastric outlet
obstruction
●Adult pyloric stenosis :
●This is a rare condition and its relationship to
the childhood condition is unclear, although
some patients have a long history of problems
with gastric emptying. It is commonly treated by
pyloroplasty rather than pyloromyotomy.

17. ●Pyloric mucosal diaphragm :
●The origin of this rare condition is unknown. It usually
does not become apparent until middle life. When
found, simple excision of the mucosal diaphragm is
all that is required.

18. INFANTILE HYPERTROPHIC PYLORIC STENOSIS
Pyloric stenosis presents with non-bilious projectile vomiting
starting between 2 and 6 weeks of age. Its presentation difers
from infective causes of vomiting (e.g. meningitis, urinary tract
infections [UTIs]) because of postprandial hunger. Once vomiting
starts, its frequency and forcefulness increase daily,
distinguishing it from gastro-oesophageal reflux disease.

19. If the presentation is early, clinical findings are unremarkable; if
late, weight loss and dehydration requiring resuscitation
predominate. The diagnosis is made on a test feed or on
abdominal ultrasound showing a thickened and lengthened
pylorus. In a test feed, gastric peristalsis is seen passing from left
to right across the abdomen, and in a relaxed (feeding) baby, the
pyloric ‘tumor’ is palpable as an ‘olive’ in the right upper
quadrant.

20. Ramstedt’s pyloromyotomy is performed laparoscopically or
through a supraumbilical or right upper quadrant incision. A
pyloric serosal incision is made, and the ‘tumor’ spread (Figure
17.9), leaving an intact submucosa from the duodenal fornix to
gastric antrum. The incision must extend onto the stomach;
short incisions cause an early recurrence.

22. GASTRIC POLYPS
●A number of conditions manifest as gastric polyps.
Their main importance is that they may actually
represent early gastric cancer. Biopsy is essential.
The most common type of gastric polyp is
metaplastic. These are associated with H. pylori
infection and regress following eradication therapy.
Inflammatory polyps are also common.

23. ●Fundic gland polyps deserve particular attention.
They seem to be associated with the use of proton
pump inhibitors and are also found in patients with
familial polyposis. None of the above polypoid lesions
has proven malignant potential.

24. ●True adenomas have malignant potential and should
be removed, but they account for only 10% of polypoid
lesions. Gastric carcinoids arising from the ECL cells
are seen in patients with pernicious anemia and
usually appear as small polyps.

25. GASTROINTESTINAL STROMAL
TUMOURS
●Gastrointestinal stromal tumours (GISTs) may arise in any
part of the gastrointestinal tract but 50% will be found in the
stomach. Previously named leiomyoma and
leiomyosarcoma, the term GIST is now used, recognising
their particular distinct phenotype.

26. ●They are tumours of mesenchymal origin and are observed
equally commonly in males and females. The tumours are
universally associated with a mutation in the tyrosine kinase
c-kit oncogene. These tumours are sensitive to the tyrosine
kinase antagonist imatinib, and an 80% objective response
rate can be observed.

27. ●Tumours with mutations in exon 11 of c-kit are particularly
sensitive to this drug. The biological behaviour of these
tumours is unpredictable but size and mitotic index are the
best predictors of metastasis. Peritoneal and liver
metastases are most common but spread to lymph nodes
is extremely rare.

28. ●The only ways that many stromal tumours are recognised are
either that the mucosa overlying the tumour ulcerates , leading
to bleeding, or that they are noticed incidentally at endoscopy.
Because the mucosa overlying the tumour is normal,
endoscopic biopsy can be uninformative unless the tumour has
ulcerated. Targeted biopsy by endoscopic ultrasound is more
helpful.

29. Tumours over 5 cm in diameter should be considered to
have metastatic potential. If easily resectable, surgery is
the primary mode of treatment. Smaller tumours can be
treated by wedge excision although .

31. ●The appropriate management of asymptomatic diminutive
tumours found incidentally at endoscopy is unclear. Larger
tumours may require a gastrectomy or duodenectomy but
lymphadenectomy is not required. Larger tumours which require
multivisceral resection may be better treated with 3–6 months of
imatinib prior to operation as this will usually radically reduce
the size and vascularity of the tumours .

32. ●Adjuvant imatinib for large resected tumours of high
malignant potential should probably be continued
indefinitely. The prognosis of advanced metastatic GISTs
has been dramatically improved with imatinib chemotherapy
but resection of metastases, especially from the liver, still
has an important role.

33. GASTRIC LYMPHOMA
●Gastric lymphoma is an interesting disease and some
aspects of its management are controversial. It is first
important to distinguish primary gastric lymphoma from
involvement of the stomach in a generalised
lymphomatous process.

34. This latter situation is more common than the former.
Unlike gastric carcinoma, the incidence of lymphoma
seems to be increasing. Primary gastric lymphoma
accounts for approximately 5% of all gastric neoplasms

35. ●Gastric lymphoma is most common in the sixth decade and the
presentation is no different from gastric cancer, the common
symptoms being pain, weight loss and bleeding. Acute
presentations of gastric lymphoma such as haematemesis,
perforation or obstruction are not common. Primary gastric
lymphomas are B-cell derived, the tumour arising from the
mucosa-associated lymphoid tissue (MALT).

36. ●Primary gastric lymphoma remains in the stomach for a
prolonged period before involving the lymph nodes. At an
early stage, the disease takes the form of a diffuse mucosal
thickening, which may ulcerate. Diagnosis is made as a result
of the endoscopic biopsy and seldom on the basis of the
endoscopic features alone, which are not specific .

37. ●No benefit has been shown from adjuvant chemotherapy,
although some oncologists contend that primary gastric
lymphoma can be treated by chemotherapy alone.
Chemotherapy alone is appropriate for patients with
systemic disease .

38. Lymphocytes are not found to any degree in normal gastric
mucosa, but are found in association with Helicobacter
infection. It has also been shown that early gastric lymphomas
may regress and disappear when the Helicobacter infection is
treated.

39. Gastric involvement with diffuse
lymphoma
●These patients are treated with chemotherapy, sometimes
with dramatic and rapid responses. Surgeons are frequently
asked to deal with the complications of gastric involvement.
The two common complications are bleeding and
perforation.

40. ● Both may occur at presentation, but more usually may
follow the chemotherapy when there is rapid regression
and necrosis of the tumor. These operations can be
technically very challenging and normally require
gastrectomy.

41. The appearances are similar to those adenomas arising in
the colon and, as they have malignant potential, they should
be locally excised with histologically clear margins.

42. Zollinger–Ellison syndrome
●This syndrome is mentioned here because the gastrin producing
endocrine tumour is often found in the duodenal loop, although it
also occurs in the pancreas, especially the head. It is a cause of
persistent peptic ulceration. Before the development of potent
gastric antisecretory agents, the condition was recognised by the
sometimes fulminant peptic ulceration which did not respond to
gastric surgery short of total gastrectomy.

43. ●It was also recognizable from gastric secretory studies in
which the patient had a very high basal acid output but no
marked response to pentagastrin, as the parietal cell mass
was already nearly maximally stimulated by pathological
levels of gastrin.

44. ●Gastrinomas may be either sporadic or associated with the
autosomal dominantly inherited multiple endocrine neoplasia
(MEN) type I (in which a parathyroid adenoma is almost
invariable). The tumours are most commonly found in the
‘gastrinoma triangle’. Many are found in the duodenal loop,
presumably arising in the G cells found in Brunner’s glands. It is
extremely important that the duodenal wall is very carefully
inspected endoscopically and also at operation. Very often all
that can be detected is a small nodule that projects into the
medial wall of the duodenum.

45. Volvulus of the stomach
●Rotation of the stomach usually occurs around the axis and
between its two fixed points, i.e. the cardia and the pylorus.
In theory, rotation can occur in the horizontal (organoaxial)
or vertical (mesenteroaxial) direction but, commonly, it is the
former which occurs. This condition is usually associated
with a large diaphragmatic defect around the oesophagus
(paraoesophageal herniation) .

46. ●What commonly happens is that the transverse colon moves
upwards to lie under the left diaphragm, thus taking the
stomach with it, and the stomach and colon may both enter the
chest through the eventration of the diaphragm.

47. The condition is commonly chronic, the patient presenting with
difficulty in eating. An acute presentation with ischaemia may
occur. Endoscopically, it can be extremely difficult to sort out
the anatomy, and this is one situation in which the contrast
radiograph is superior.

48. Treatment
●If the problem is causing symptoms then surgical
treatment is the only satisfactory approach. Traditionally,
open surgery has been employed but this problem is
suitable for laparoscopic treatment if appropriate skill is
available. If there is a hernia, the sac and its contents
(usually the stomach) should be reduced.

49. ●The defect in the diaphragm should be closed, if necessary,
with a mesh. It is advisable to separate the stomach from the
transverse colon and then perform an anterior gastropexy to fix
the stomach to the anterior abdominal wall. The results from
this treatment are good .

51. GASTROINTESTINAL STROMAL TUMOURS
●Gastrointestinal stromal tumours (GISTs) may arise
in any part of the gastrointestinal tract but 50% will
be found in the stomach. Previously named
leiomyoma and leiomyosarcoma, the term GIST is
now used, recognising their particular distinct
phenotype.

52. ●They are tumours of mesenchymal origin and are
observed equally commonly in males and females.
The tumours are universally associated with a
mutation in the tyrosine kinase c-kit oncogene. These
tumours are sensitive to the tyrosine kinase
antagonist imatinib, and an 80% objective response
rate can be observed.

53. ●Tumours with mutations in exon 11 of c-kit are
particularly sensitive to this drug. The biological
behaviour of these tumours is unpredictable but
size and mitotic index are the best predictors of
metastasis. Peritoneal and liver metastases are
most common but spread to lymph nodes is
extremely rare.

54. ●Tumours over 5 cm in diameter should be considered
to have metastatic potential. If easily resectable,
surgery is the primary mode of treatment. Smaller
tumours can be treated by wedge excision.

56. GASTRIC LYMPHOMA
It is first important to distinguish primary gastric lymphoma from
involvement of the stomach in a generalised lymphomatous
process. Following diagnosis, adequate staging is necessary,
primarily to establish whether the lesion is a primary gastric lym -
phoma or part of a more generalised process. CT scans of the
chest and abdomen and bone marrow aspirate are required, as
well as a full blood count.

57. Although the treatment of primary gastric lymphoma is
somewhat controversial, it seems most appropriate to use
surgery alone for the localised disease process.
Chemotherapy alone is appropriate for patients with systemic
disease.

59. Neuroendocrine tumours:
A number of neuroendocrine neoplasms occur in the duodenum.
It is a common site for primary gastrinoma (Zollinger– Ellison
syndrome).
The tumours are most commonly found in the ‘gastrinoma
triangle’ (Passaro) defined by the junction of the cystic duct and
common bile duct superiorly, the junction of the second and third
parts of the duodenum inferiorly, and the junction of the neck and
body of the pancreas medially (essentially the superior
mesenteric artery).

60. Duodenal obstruction in the adult is usually due to
malignancy, and cancer of the pancreas is the most
common cause. About one-fifth of patients with
pancreatic cancer treated with endoscopic stenting
will develop obstruction. Treatment is usually by
gastroenterostomy.
DUODENAL OBSTRUCTION

61. Acute gastric dilatation
●This condition usually occurs in association with pyloroduodenal
disorders or postsurgery without nasogastric suction. The
stomach, which may also be atonic, dilates enormously. Often
the patient is also dehydrated and has electrolyte disturbances.
● Failure to treat this condition can result in a sudden massive
vomit with aspiration into the lungs. The treatment is nasogastric
suction, with a large-bore tube, fluid replacement and treatment
of the underlying condition.

62. Trichobezoar (hair balls)
●Are unusual and are virtually exclusively found in female
psychiatric patients, often young. It is caused by the
pathological ingestion of hair, which remains undigested in
the stomach.
● The diagnosis is made easily at endoscopy or, indeed, from
a plain radiograph. Treatment consists of removal of the
bezoar, which may require open surgical treatment.

64. Foreign bodies in the stomach
●A variety of ingested foreign bodies reach the stomach, and very
often these can be seen on a plain radiograph. If possible, they
should be removed endoscopically but, if not, most can be left to
pass normally.

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