Stomach

Dr. Girish Kamat

University QuestionsPeptic 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

University QuestionsTumors

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

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

Gastric Tumors• Classification• Carcinoma– Etiology–Morphology– Clinical features– Investigations– Spread– Staging– Prognostic markers

Peptic Ulcer

Definition

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

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

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

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

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

Etiology- NSAIDS & Steroids

• Inhibit cyclo-oxygenase Reduced PG Reduced cytoprotection Mucosal injury

Etiology

• Emotions• Diet• Pylorodudenal reflux• Endocrine- Zollinger Ellison,

Cushing• Trauma• Smoking• Hereditory- Blood Gr O

Etiology

• Curling ulcer- Stress produced by hypotension, endotoxic shock, MI, Burns

• Cushing ulcer- Increased intracranial tension

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

Morphology- AcuteGross

• Multiple• 1-2mm• Shallow and do not invade muscular

coat

Morphology- AcuteMicro

• Neutrophils above basement membrane

• Erosion not crossing muscular mucosa

• Fibrinous exudate

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

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

Morphology- ChronicMicr0- 4 Layers

• Surface debris• Neutrophils• Granulation tissue• Collagen

Clinical Features

• Abdominal pain- Epigastric, burning type, vomiting (Relieves), episodic– Food aggravates- Gastric– Food relieves- Duodenal

• Hematemesis, malena

Investigations

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

Complications

• Bleeding- 15-20%• Perforation- 5%• Obstruction due to edema and

scarring

Other gastritis

• Eosinophilic• Lymphocytic• Granulomatous• Hemorrhagic• CMV• Radiation/ chemotherapy• Autoimmune• Xanthogranulomatous

Gastric Tumors

Classification• Epithelial– Adenoma– Adenocarcinoma- Papillary, tubular, mucinous,

signet ring, undifferentiated, adenosquamous– Small cell carcinoma– Carcinoid tumor

• Non Epithelial– Leiomyoma– Schwannoma– GIST– Lymphoma

Carcinoma of Stomach

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

Etiology

• H.Pylori• Diet- Salted/smoked food, nitrates• Smoking and alcohol• Decreased gastric acid secretion-

Proton pump inhibitors, atrophic gastritis

MorphologyGross

• Sites- – Antrum- 50%– Body- 30%– Cardiac- 20%

–MC site- Lesser curvature

MorphologyGross

• Cauliflower like• Infiltrating with dense fibrosis-

Linitis plastica• Ulcerative- Heaped up beeded

margins

MorphologyMicro- (DIO/ Lauren)

• Diffuse- Signet ring cells• Intestinal- Similar to intestinal

adenoca• Others

Early Gastric Ca(Superficial/ microinvasive

Ca)• Ca confined to mucosa and

submucosa regardless of status ofregional lymph nodes

Clinical Features

• Ulcer like pain• Weight loss, anorexia• Hematemesis• Palpable epigastric mass

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

Clinical Features

Paraneoplastic syndromes• Trousseaus’ sign• Acanthosis nigricans• Dermatomysitis

Investigations

• Endoscopy• Exfoliative brush cytology• Barium meal• CT, USG

Staging

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

Staging

• I- T1N0M0/T1N1M0/T2NoMo• II-T1N2M0/T2N1Mo/T3N0M0• III- T2N2M0/T3N1M0/T4NoM0• IV- T4N2M0/Tany Nany M1

Prognostic markers

• Stage• Grade• Hsitologic type• P53, c-ERB-2• Location• Inflammatory raection• Perneural invasion

5 year survival rate 90 - 95 % in surgically

treated early carcinoma < 15 % in advanced

carcinoma

Thank You…