Stomach & Duodenum 1 anatomy blood supply

STOMACH AND DUODENUM

1. ANATOMY

The stomach is the most dilated portion of the entire digestive

tubular system.

*  It has a fundus, body and antrum and its proximal end is

   continuous with the abdominal oesophagus. The antrum opens

   through the pylorus into the duodenum. (fig above)

*  The cardia (opening of the oesophagus) lies to the left of the

   midline at the level of the tenth dorsal vertebra.

*  The pylorus is situated to the right of the midline at the level

   of the space between first and second lumbar vertebra

   (transpyloric plane).

1.1 The blood supply of the stomach is mainly through six vessels

(fig above).

*  The left and right gastric arteries supply the lesser

   curvature.

*  The left and right gastroepiploic arteries supply the greater

   curvature.

*  The splenic artery through the short gastric arteries supplies

   the fundus

*  The gastroduodenal artery supplies the pylorus

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Carcinoma Esophagus 4 Treatment

TREATMENT

There are three available modes of treatment for this condition :

*  Surgery

*  Radiotherapy

*  Chemotherapy

None  of  these has improved the results when  used  alone.  Some

improvement is being obtained if the lesion is detected early.

 

Curative surgery can be performed in the early cases.

 

Stage  I  tumours  where the tumour is  confined  to  the  lamina

propria, submucosa and surgery can ensure a 60% 5 year survival.

 

In  all  other tumours a combination of  surgery  and  adjunctant

radiotherapy  and chemotherapy are utilised.   Different  regimes

have yet not produced an acceptable cure rate.

Palliation  can be obtained by passing tube (Celestin)  past  the

tumour in the lumen of the oesophagus, this allows the patient to

eat a soft diet, the average survival in these cases is less than

six months. 

In early cases the tumour bearing oesophagus can be excised and

stomach  mobilised for anastomosis with the  proximal  oesophagus

for continuity (Fig. above).

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Carcinoma Esophagus 3 Diagnosis Evaluation

Diagnosis  can be  confirmed in  any patient  with  perisistent

dysphagia  by a barium study or oesophagoscopy.Biopsy  will  als

provide  diagnosis regards the type of carcinoma  (squamous  or

adenocarcinoma).

EVALUATION

Since 1980 endoscopy ultra sound has made it possible to  define         

invasion  of muscle  of  oesophagus  and establish  lymph  node

involvement.   This mode of examination is however  limited  to

those where  the ultra sound probe canpass  through  the lumen

beyond the  tumour.  However, barium study should be  the first

mode of examination.  Chest Xray mayalso give information  such

as:

*  air fluid level in oesophagus

*  abnormal mediastinal soft tissue mass

*  mass pulmonary effusion or lung secondaries

CT  scanning   permits  retrieval  of   information   regarding

oesophageal   wall thickening  and  tumour  spread   into   the

mediestinum   and lymph  nodes,  pulmonary liver   or   adrenal

metastasis can also be identified.

Bronchoscopy  should be  done  in all cases  to  eliminate the

possibility of extension to the respiratorypassages.

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Carcinoma esophagus 2 Presentation

CLINICAL PRESENTATION

The  predominant  symptom is dysphagia and may be preceded  by  a

vague  retrosternal or epigastric discomfort on intake  of  food. 

Weight  loss is manifest as the dysphagia becomes  more  complete

and continuous.

 

Box

Presenting symptoms of Esophageal carcinoma

Symptom                                                                                          Incidence (%)

Dysphagia                                                                                                    87

Weight loss                                                                                                  71

Substernal or epigastric pain/burning                                                          46

Vomiting or regurgitation                                                                             28

Aspiration pneumonia                                                                                  14

Palpable cervical nodes                                                                                14

Hoareseness                                                                                                   7

Coughing and choking                                                                                   3

 

Diagnosis  can  be  confirmed in  any  patient  with  perisistent

dysphagia  by a barium study or oesophagoscopy. Biopsy  will  als

provide  diagnosis  regards the type of  carcinoma  (squamous  or

adenocarcinoma).

 

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Carcinoma Esophagus 1 Causes Incidence Pathology

4.3 CARCINOMA OF OESOPHAGUS

The incidence of this disorder is variable.

-  In  the  United  States,it varies from  5  cases  per  100,000   

   population in whites to 20 per 100,000 in blacks per year.

-  The incidence is very high in the areas around the Caspian sea   

   North China and Russia.

-  In India the incidence is high in Kashmir and Assam.

The etiology is related to certain factors  principally :

*  Alcohol intake

*  Tobacco use

*  Malnutrition

*  Vitamin deficiency

*  Anaemia and

*  poor oral hygiene.

 

Intake  of  hot food and bevrages have also  been  implicated  in

India.

 

PATHOLOGY

 

  - The  lesion occurs most often (50%) in the mid third  of  the

    oesophagus,  about  a third of the case occur  in  the  lower

    third and upper third is involved in less than 20%

 

  - The lesion is most often (90%) a squamous cell carcinoma  but

    adenocarcinomas can occur at the lower end.

 

  - The tumour spreads through the wall of the oesophagus to  the

    adjoining structures. 

 

  - Spread to regional lymphnodes is also common.

 

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Esophageal disorders benign 4 Tumors

4. TUMOURS

4.1 LEIOMYOMA

 

This  is the most common benign tumour of the  oesophagus.   They

occur in equal frequency in males and females between the ages of

20-50  years.  The majority of these intramural tumour  occur  in

the middle and lower thirds of the oesophagus.

 

They  present  with  dysphagia  small (<5 cm="" span="" style="mso-spacerun: yes;"> 

and  may  have  no

symptoms.  Obstruction and regurgitation occurs in large tumours.

 

TREATMENT

 

The tumour is excised through a thoracotomy (left for lower third

and  right  for  middly  third).   The  longitudinal  fibres   of

oesophagus  split  and the tumours dissected out  -  leaving  the

submucosa intact.  The longitudinal fibres are stiched.

 

4.2 HEMANIGIOMAS

 

These  constitute  2-3%  of all benign  tumours  and  may  remain

symptomless.   They may sometimes cause  successive  hematemesis. 

Laser  therapy through the endoscope provide effective  means  of

treatment.

 

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ESOPHAGEAL Disorders Benign 3 Hiatus Hernia

3.4 HIATUS HERNIA

This  is  a  herniation of the stomach  through  the  oesophageal

hiatus of the diaphragm.

- Type 1 hernia is the more common variety and allows the stomach

  to slide up into the thorax (Sliding hernia)Fig. 15.7

The symptoms are of retrosternal burning after a heavy meal or on

lying down, these symptoms are because of reflux of acid  gastric

content into the oesophagus.

The  acid  gastric  content causes oesophagitis,  the  hernia  is

diagnosed  on  radiology  (barium study) and if  the  patient  is

symptomatic, requires treatment for oesophagitis.

Type  II  hernia  is  rare and also referred  to  as  rolling  or

paraoesophageal hernia,this is a true hernia and has a peritoneal

sac.  Fig. above

Symptoms  of  reflux  are usually absent and in fact  it  may  be

completely asymptomatic.

If  symptomatic  the patient complains of fullness  after  meals,

dysphagia,there may also be stasis. 

Treatment  involves surgical reduction of the hernia excision  of

the sac and repair of the defect in the diaphragm.

 

TREATMENT OF REFLUX : Medical

To reduce regurgitation

*  Elevation of Head end of bed

*  To reduce evening meal size

*  To sleep at least two hours after last meal of the day

*  Antacids to be taken 1 hour after meals

*  Cimetidine may be tried to reduce gastric acidity

 

SURGERY (ANTIREFLUX)

Surgery  is aimed at creating a valve mechanism at the cardia  by

wrapping  the  stomach  around  the  oesophagus  in  the  abdomen

(Nissens)

 

 

Operative correction of esophageral hiatal hernia should

-         return the herniated content to its anatomically correct position below the diaphragm

-         repair the hernia defect

-         prevent recurrence while mainimizing associated morbidity.

 

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