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The stomach is bounded superiorly by the diaphragm and laterally by the spleen. The body also contains most of the parietal cells and is bounded on the right by the relatively straight lesser curvature and on the left by the longer greater curvature. At the angularis incisura, the lesser curvature abruptly angles to the right. The body of the stomach ends here and the antrum begins. Another important anatomic angle (angle of His) is the angle formed by the fundus with the left margin of the Esophagus. The gastrosplenic ligament attaches the proximal greater curvature to the spleen.
The left vagus gives off the hepatic branch to the liver and continues along the lesser curvature as the anterior nerve of Latarjet. Although not shown, the so-called criminal nerve of Grassi is the first branch of the right or posterior vagus nerve; it is recognized as a potential cause of recurrent ulcers when left undivided. The right nerve gives a branch off to the celiac plexus and continues posteriorly along the lesser curvature. A truncal vagotomy is performed above the celiac and hepatic branches of the vagi, whereas a selective vagotomy is performed below.
Prostaglandins promote gastric and duodenal mucosal protection via numerous mechanisms, including increasing mucin and bicarbonate secretion and increasing blood flow to the mucosal endothelium. The presence of NSAIDs disrupts these naturally protective mechanisms, increasing the risk of peptic ulcer formation in the stomach and the duodenum.
Antacid – oldest form of therapy – reduce gastric acdity More effective when ingested 1 hour after a meal Sucralfate – structurally related to heparin /no anticoagulant effect/ Exact mechanism is not fully understood Provide protective coating not initial treatment H2RI – Famotidine is the most potent
Perforations smaller than 1 cm can generally be closed primarily and buttressed with a wellvascularized omentum. For larger perforations or ulcers with fibrotic edges that cannot be brought together without tension, a Graham patch repair with a tongue of healthy omentum is performed. Multiple stay sutures are placed that incorporate a bite of healthy tissue on the proximal and the distal side of the ulcer. The omentum is placed underneath these sutures, and they are tied to secure it in place and seal the perforation (Fig. 48-11). For very large perforations (>3 cm), control of the duodenal defect can be difficult. The defect should be closed by the application of healthy tissue, such as omentum or jejunal serosa from a Rouxen- Y type limb. In such cases, a pyloric exclusion is typically performed by oversewing the pylorus using absorbable suture or stapling across it using a noncutting linear stapler. A gastrojejunostomy is created to bypass the duodenum in a Billroth II or Roux-en-Y fashion.
Graham patch repair of a perforated duodenal ulcer. A “tongue” of omentum is brought up to cover the ulcer defect and secured in position with a series of interrupted sutures. I
Classic truncal vagotomy, in combination with a Heineke-Mikulicz pyloroplasty, is shown in Figure 48-12. When the duodenal bulb is scarred, a Finney pyloroplasty or Jaboulay gastroduodenostomy may be a useful alternative. In general, there is little difference in the side effects associated with the type of drainage procedure performed, although bile reflux may be more common after gastroenterostomy, and diarrhea is more common after pyloroplasty.
Usually in gastric ulcer Vagotomy – eliminates cephalic phase Antrectomy – eliminates gastric phase
Answer: B he consistently largest artery to the stomach is the le t gastric artery, which usually arises directly rom the celiac trunk and divides into an ascending and descending branch along the lesser gastric curvature. Approximately 20% o the time, the le t gastric artery supplies an aberrant vessel that travels in the gastrohepatic ligament (lesser omentum) to the le t side o the liver. Rarely, this is the only arterial blood supply to this part o the liver, and inadvertent ligation may lead to clinically signi icant hepatic ischemia in this unusual circumstance. (See Schwartz 10th ed., p. 1037.)
Peptic ulcer disease
Peptic ulcers are
defined as erosions
in the gastric or
extend through the
Lifetime Prevalence = 10%
of Americans develop PUD
>10% of ER patients with
abdominal pain diagnosed
over last 30yrs
Male-to-female ratio of
PUD = 2:1
4000 deaths caused by
PUD each year.
80% to 95% of duodenal ulcers
75% of gastric ulcers are associated with H.
D cell reduction
The most common symptom is midepigastric abdominal
The pain is generally tolerable
Frequently relieved by food.
The pain may be episodic, worse during periods of
Many patients do not seek medical attention.
Constant pain - deeper ulcer penetration. Referral of
Pain to the back - penetration into the pancreas.
Diffuse peritoneal irritation - free perforation.
-Urea breath test
Most ulcer (90%)
> single contrast
Flexible upper endoscopy
Most reliable method
Provide to sample
H.pylori testing –
From the gastric body and the antrum
Sensitivity in diagnosing infection is
greater than 90%, and specificity is
95% to 100%
Sensitivity of the test is lowered in
patients who are taking PPIs, H2
antagonists, or antibiotics.
Evaluating by Forrest classification
High-risk patients - injection of a
vasoconstrictor at the site of bleeding
Guidelines for endoscopic control of
bleeding 2010: use of epinephrine plus
an additional method or monotherapy
with either thermocoagulation or
But discourage the use of epinephrine
Nonsurgical control of
Typically complain of sudden-onset,
frequently severe epigastric pain
Highest mortality rate of any
complication of ulcer disease
Graham patch repair is performed
for duodenal ulcer
Pyloric relaxation is
mediated by vagal
stimulation, and a
vagotomy without a
can cause delayed
Classic truncal vagotomy, in
combination with a
Most ulcers are the consequence of H.
pylori infection or NSAID usage.
Usually manifest on the lesser curvature
Peak incidence: 55 to 65 years old
More likely to occur in individuals in:
a lower socioeconomic class
common in the nonwhite than white
Incidence More common Less common
Anatomy First part of duodenum –
Lesser curvature of stomach
Duration Acute or chronic Chronic
Malignancy Rare Benign or malignant
Food intake Relieved by food Worsened by food
Type 1 gastric ulcer
Wedge resection – pathology examination
Gastrectomy w/out vagotomy
Type 2&3 gastric ulcer
Ulcer + increased gastric acid
Gastrectomy w/ vagotomy
Type 4 gastric ulcer
Difficult to manage
Gastectomy / Rouxen Y/gastroduodenostomy
Secretin-stimulated gastrin level
Serum gastrin samples are measured
before and after IV secretin (2 U/kg)
administration at 5-minute intervals for
An increase in the serum gastrin level
of greater than 200 pg/mL is specific
Localize the gastrinoma is either CT or MRI of
However, these imaging modalities have a
relatively low sensitivity in detecting tumors
that are less than 1 cm in diameter as well as
small liver metastases.
Somatostatin receptor scintigraphy uses
radionucleotide labeled octreotide, which binds
to the ZES tumor cells and can detect hepatic
metastases in 85% to 95% of patients
Resection of tumor
Patients with tumor recurrence or
metastatic disease are treated with
chemotherapy (streptozotocin with 5-
fluorouracil or doxorubicin or both).
Because I already told you what
I know only if you had listened
The consistently largest artery to the
stomach is the
A. Right gastric
B. Left gastric
C. Right gastroepiploic
D. Left gastroepiploic
The consistently largest artery to the
stomach is the left gastric artery,
which usually arises directly rom the
celiac trunk and divides into an
ascending and descending branch
along the lesser gastric curvature
Which of the following inhibits gastrin
C. Amino acids
Luminal peptides and amino acids are
the most potent stimulants o gastrin
release, and luminal acid is the most
potent inhibitor of gastrin secretion.
Helicobacter pylori infection primarily
mediates duodenal ulcer pathogenesis via
A. Antral alkalinization leading to inhibition of
B. Direct stimulation of gastrin release
C. Local infammation with autoimmune
D. Upregulation of parietal cell acid production
Helicobacter pylori possess the
enzyme urease, which converts urea
into ammonia and bicarbonate, thus
creating an environment around the
bacteria that buffers the acid secreted
by the stomach. H. pylori infection is
associated with decreased levels of
Production of toxin
D cell reduction
Which of the following is the preoperative
imaging study of choice for gastrinoma?
A. CT scan
B. Magnetic resonance imaging (MRI)
C. Endoscopic ultrasound (EUS)
D. Angiographic localization
E. Somatostatin receptor scintigraphy
Currently, the preoperative imaging
study of choice for gastrinoma is
(the octreotide scan). When the
pretest probability of gastrinoma is
high, the sensitivity and specificity o
this modality approach 100%