Upper GIT 4 Dr. Mahbuba - PowerPoint Presentation

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Upper GIT

4

Dr.

Mahbuba

Begum

Presentation

:Elderly

patient presented with

dull aching upper abdominal pain, abdominal fullness

/ discomfort after meal &

non bilious vomiting

– usually after meal, projectile in nature, sometimes induced to get relief of

abd

. discomfort & content is partially digested food materials or foods taken many hrs earlier.

Pt complains of sensation of something moving in abdomen usually after taking meal –

Patient 1

: initially pain was periodic for few yrs –

occuring

in empty stomach & relieved by taking food. Now pain is constant for few months. Associated

heart burn

may be present. Pt may have h/o taking

antiulcerant

drugs irregularly or pt may be diagnosed as

PUD

& on irregular treatment.

Patient 2

: presented with h/o short duration, may not have previous h/o PUD. Occasional

hematemesis

&

melaena

may be present. Complains of generalized

weakness

, loss of appetite

& significant

weight loss

within few months.

►

Gastric

outlet obstruction

due to

Pyloric

stenosis

caused by Ch. DU

Carcinoma stomach (

antral

Ca)

Other causes or D/D

External compression to pylorus by enlarged LN due to secondary metastasis / lymphoma / TB

Ca head of pancreas

Gastric lymphoma

GIST

PS

– misnomer as

stenosis

is found in the 1

st

part of duodenum.

Other

modes

of presentation of Ca stomach

New dyspepsia after 40 ( pain /

epigastric

discomfort, Nausea, vomiting, early satiety )

Insidious onset (

anaemia

, anorexia, asthenia, weight loss )

Epigastric

lump ►

►

Obstructive –

dysphagia

,

Acute – perforation,

haemorrhage

Features of metastasis

–

Jaundice ( hepatic / LN in

porta

hepatis

)

Ascites

Supraclavicular

LN

Krukenberg’s

tumour

Metastatic skin nodule

Others ( non metastatic)

Thrombophlebitis

migrans

( Trousseau’s sign )

Deep vein thrombosis

Acanthosis

nigricans

(

axilla

, groin ).

On examination

:

G/E

– poor body built with poor nutritional status, pallor , marked dehydration.

►

in patient 2

–

anaemia

is marked, jaundice ±, ankle edema ,LN ± (cervical ) – Virchow’s gland (

Troisier’s

sign ).

Abdomen

–

fullness

in

epigastrium

, visible

peristalsis

( Lt to

Rt

), palpable

distended

stomach in Lt HCR,

epigastrium

,

Rt

HCR,

succussion

splash

is present,

auscultopercussion

revealed dilated stomach with greater curvature lying below the umbilicus ( PS )

In Ca stomach

- visible

lump

(

intraabdominal

in

epigastric

region, moves with respiration, irregular with

illdefined

margin, hard in consistency, non tender, not mobile,

ascites

±, liver – met ± ,

D/R/E

– pelvic deposit (

Blummer

shelf ),

P/V

(premenopausal women –

Krukenberg

tumour

),

Investigations

Endoscopy

of upper GIT(after gastric

lavage

) ± biopsy- scope not passed into duodenum in PS

- multiple biopsy in

Ca stomach

( ulcerated with raised &

everted

margin, proliferative /

polypoid

, cauliflower ).

►

Ba

meal X-ray

– hugely distended stomach almost reaching the pelvis, multiple negative shadows indicative of residual food particles, dye not passed beyond the pylorus

- in

Ca stomach

: stomach not as much distended – persistent irregular filling defect.

For staging

/ to know the extent of lesion in Ca stomach

USG of W/A

: metastasis in liver,

paraaortic

LN,

ascites

, pelvic deposits, growth (origin & extent ), ovaries in premenopausal women.

LFT

: s.

bilirubin

, SGPT, alkaline

phosphatase

CXR

: metastasis in lung, ribs, spine, pleural effusion

CT scan

(contrast enhanced) of

abd

: for added information than USG

Tumour

marker

: CA 19 – 9

Receptor analysis

: HER2 ( gastric biopsy ).

Inv. For general assessment

CBC, FBS & 2 hrs ABF, S.

creatinine

, urine R/E, ECG, S. electrolytes, blood grouping &

Rh

typing

Metabolic

effects of vomiting in Gastric outlet obstruction

Hyponatraemia

,

hypokalaemia

,

hypochloraemia

Metabolic alkalosis ( ↑HCO3 )

Hypocalcaemic

tetany

- ↓circulating ionized calcium due to alkalosis

Oliguria

→

polyuria

Urine – initially alkaline → paradoxical

aciduria

.

Management

Preoperative preparation

Correction

of dehydration & electrolyte imbalances with normal saline ( repeat S. electrolytes) + K+ supplement if necessary.

Correction of

anaemia

by blood transfusion

Nutritional support – correction of

hypoalbuminaea

,

vitamine

suppliments

.

►

Gastric

lavage

– insertion of wide bore

nasogastric

tube → aspiration – irrigation with N/S continue until the stomach is completely emptied

. ( At least 3 consecutive days before operation. )

For pt with benign GOO

IV gastric

antisecretory

agent

► early cases – settle with conservative Rx as edema around ulcer diminishes with healing of ulcer.

Surgical Rx

– severe cases / not improved on conservative Rx.

-

Bilateral

truncal

vagotomy

with

gastrojejunostomy

( posterior,

retrocolic

).

For pt with

malig

. GOO

: Rx depends on

Stagging

surgery

–

laparotomy

& per operative decision for type of surgery ( assessment of operability &

resectability

).

Procedure

: Distal partial radical

gastrectomy

with

gastrojejunostomy

(

Billroth

II ).

Other modalities of treatment

Chemotherapy

–

neoadjuvant

, advanced, inoperable

Radiotherapy – controversial; palliative Rx of painful bony metastasis

Targeted therapy

–

Herceptin

for HER2 + .

Features of inoperability

H

aematogenous

distant metastasis

D

iffuse peritoneal seedlings, pelvic deposit, liver metastasis

Fixation to adjacent structures ( pancreas, T. colon,

mesocolon

) that cannot be removed

N4 nodal disease (

eg

. SC lymph node ).

Palliative surgery

: anterior

gastrojejunostomy

.

Staging

Stage-I

: involves mucosa &

submucosa

Stage- II

: invades

muscularis

propria

►

Stage- III

: muscle + regional lymph node

Stage – IV

: LN + distant metastasis or involvement of contiguous structures.

►

LN

– N1 : within 3cm of primary

tumour

N2 : more than 3cm of primary

tumour

4 tier’s (group) LN – 20 in number.

Principle of curative resection

Enbloc

removal of growth ( proximal 5cm & distal 2cm ) with

lymphatics

& lymph nodes ( corresponding to location of primary

tumour

)

Resection level should

exceede

the level of nodal involvement

Provided no

serosal

invovement

No hepatic or peritoneal seedlings

Safe & well functioning reconstruction

Resection margins – free of

tumour

by

histopathological

exam.

Aetiology

of

Ca stomach

:

multifactorial

Helicobacter pylori

infection ( type B

gastriis

, gastric atrophy & intestinal

metaplasia

).

Pernicious

anaemia

with gastric atrophy

Chronic atrophic gastritis

Gastric polyp (

hyperplastic

&

adenomatous

)

Gastric ulcer

Remnant of stomach after surgery ►

Billroth

II,

gastroenterostomy

or

pyloroplasty

– reflux gastritis ( 4 times ↑ risk ).

Cigarette smoking, spirit ► severe gastric dysplasia

Dust ingestion

Excessive salt intake

Exposure to N –

nitroso

compound ( preservative )

Deficiency of antioxidants (

vit

– E & C).

Menetrier’s

disease

– hypertrophy of gastric mucosal folds (

fundus

& body ), ↑ mucus production &

hypochlorhydria

►

hypoprotaenimia

,

anaemia

. ►

Genetic factor

– blood group A,

overexpression

of

tumour

progression gene ( C-

erb

B2),

overexpressin

of

tumour

mutation suppression gene ( APC gene, p53 ), deficiency in mismatch repair gene,

overexpression

of growth factors ( TGF

α

, EGF, VEGF

).

Pathology

Lauren classification

Intestinal

– in areas of intestinal

metaplasia

,

polypoid

tumour

/ulcer in distal stomach, elderly pt, better prognosis

Diffuse

– infiltrates deeply & widely without forming mass, young pt, worse prognosis.

Mixed

morphology

►

Early

gastric carcinoma

: is defined as cancer limited to mucosa &

submucosa

with or without lymph node involvement. (T1 & any N ). Curable, 5 yr survival – 90%.

╙

Japanese classification

–

Type I > protruding

Type II > superficial (elevated, flat, depressed)

Type III > excavated.

Advanced gastric Ca

– muscle involvement

╙

Bormann classification

Type I –

polypoid

/

fungating

Type II – ulcerated

Type III – infiltrative

Type IV – diffuse (

linitis

plastica

> enormous proliferation of fibrous tissue involves

submucosa

– mother of pearl appearances ( D/D –

crohn’s

disease, Ca pancreas ).

Spread

Direct

: penetrates through wall- pancreas, colon, liver

Lymphatic

: permeation & emboli

,

supraclavicular

node-

Troisier’s

sign

.

Blood born

: liver, lung, bone.

Transperitoneal

: when

tumour

has reached the

serosa

,

May

menifest

anywhere in peritoneal cavity

Ascites

Pelvic deposits-

Blummer’s

shelf on D/R/E

.

Krukenberg’s

tumour

– ovaries

Sister

joseph

nodule – umbilicus.

Types of

surgery in ca in other part of stomach

Total

gastrectomy

– lesion in upper 3

rd

, lesion in middle 3

rd

, lesion involving

mre

than one sector ( 2/ all 3 sectors ), diffuse Ca( borrman4) irrespective of size.

Upper partial

gastrectomy

– lesion in upper 3

rd

/

cardia

( provided tension free

anastomosis

is possible)

Macroscopic types of Ca stomach

TypeI

– proliferative / cauliflower like

Type II – ulcerated

Type III – colloid

Type IV –

schirrous

: localized, diffuse (

linitis

plastica

)

Type V – ca secondary to Ch. Gastric ulcer.

Anaemia

In Ca stomach

:

Bleeding

Achlorhydria

- ↓ iron absorption

Malignancy > release of cytokines > bone marrow depression

Nutritional impairment < anorexia

Prognosis

Depends on stage ( 5yr survival )

After curative surgery – for early gastric Ca : 90%

For advanced : 20 – 50

%

Death

: Dissemination to other organs

Progressive gastric obstruction & malnutrition.