Benign and malign diseases of Stomach Prof Dr

Benign and malign diseases of Stomach Prof. Dr. Öge TAŞCILAR

MİDE n Mukoza Submukoza Muskularis Propria Seroza n Mukoza n n n İntraepitelyal Mukoza Epitel Bazal Membran Lamina Propria Muskularis Mukoza

MİDE n Fonksiyon: Alınan gıdaların sindirimi ve emilimi n Reseptif relaksasyon ve gastrik adaptasyon n İntragastrik basınç düşer. n n 100 cc-------1500 cc

MİDE n Mallory-Weiss Sendromu n n Kusma ile ÖG bileşke mukoza submukoza yırtık ve kanama Endoskopi Alkol, diyabet, gebelik, üremi, Tam kat olursa Booerhaave sendromu

MİDE n n n n Bezoarlar Midede oluşan yabancı cisimler. Trikobezoar-fitobezoar Mide operasyonu sonrası Antrumun öğütücü işlevinin kaybolması HCL azalmasına bağlı Candida Albicans bezoar Tanı: Radyoloji-endoskopi Tedavi: Endoskopik-Cerrahi

MİDE n n n n n Menetrier Hastalığı Hipertrofik mukozal gastropati Fundus ve korpusta dev rugalar Foveolar hiperplazi Hipoklorhidri ve Hipoalbüminemi 50> erkekler Epigastrik ağrı, kilo kaybı, (özellikle protein) , kanama, diare, ödem Medikal tedavi PPI Destek tedavisi Çok ciddi olgularda rezeksiyon

Acute gastritis n Drugs (non-steroidal anti-inflammatory drugs NSAID), alcohol cause acute erosion (loss of mucosa superficial to muscularis mucosae). Can result in severe haemorrhage

Chronic gastritis ABC n A – autoimmune(associated with vitamin B 12 malabsorption (pernicious anaemia) n B – bacterial (helicobacter) n C – chemical(bile reflux, drugs)

Autoimmune chronic gastritis Autoantibodies to gastric parietal cells n Hypochlorhydria/achlorhydria n n Loss of gastric intrinsic factor leads to malabsorption of vitamin B 12 with macrocytic, megaloblastic anaemia

Helicobacter pylori n n n Adapted to live in association with surface epithelium beneath mucus barrier Causes cell damage and inflammatory cell infiltration In most countries the majority of adults are infected

Peptic ulcer disease n n A surface breach of mucosal lining of GI tract occurring as a result of acid and pepsin attack Sites: – – – Duodenum (DU) Stomach (GU) Oesophagus Gastro-enterostomy stoma Related to ectopic gastric mucosa (e. g. in Meckel’s diverticulum)

Pathogenesis n n n In normal acid/pepsin attack is balanced by mucosal defences Increased attack by hyperacidity Weakened mucosal defence – the major factor (H. pylori related)

MİDE n n n Duodenal Ülser: Duodenal HCO 3 sekresyonu azalmış Gece asit sekresyonu artmış Duodenal asit yükü artmış Bazal ve postprandial gastrin artmış Tamamına yakın HP gastrit saptanmıştır.

Morphology of peptic ulcers n n n Clean, non-elevated edge Granulation tissue base (floor) Underlying fibrosis

MİDE n n n n Klinik: Yanıcı, kemirici, açlık ağrısı. Epigastrium Antiasit ve gıda ile hafifler. Mevsimsel bir ağrı. İlkbahar, sonbahar, stress dönemleri Penetre olursa ağrı özellikleri değişir.

MİDE n n n Anamnez, Radyoloji Endoskopi, biyopsi n Tedavi: n Medikal tedavi Antiasit Sükralfat H 2 blokör PPI Prostoglandin analogları

MİDE DÜ Cerrahi Tedavi: n BTV-PP n BTV-Distal gastrektomi+GJ n PGV n

MİDE n Mide Ülseri

Complications of peptic ulcer n n n Perforation leading to peritonitis Haemorrhage by erosion of vessel in base Penetration of surrounding organ (liver/pancreas) Obstruction (by scarring) – pyloric stenosis (Cancer – rare event in true peptic ulcer)

NEOPLASMS OF STOMACH n. BENIGN__ 10% n. MALIGNANT__90% n. BENIGN n. Polyps n. Lipomas n. Leiomyomas

NEOPLASMS OF STOMACH MALIGNANT Adenocarcinoma 95% Lymphoma 4% Others 1% (sq. cell ca, angiosarcoma, carcinosarcoma, Gist)

Less common gastric neoplasms Gastrointestinal stromal tumour (GIST) n Lymphoma n Neuroendocrine (carcinoid) tumours n

GIST n n n Risk categories were assigned according to current recommended NIH criteria. Tumors <2 cm and<5 mitosis per 50 highpower fields (HPF) were classified as very low risk. Tumors ranging from 2 to 5 cm and having <5 mitoses/50 HPF were classified as low risk.

n n Tumors <5 cm but having 6 to 10 mitoses/50 HPF were intermediate risk, as were tumors from 5 to 10 cm with <5 mitoses/50 HPF. Tumors >5 cm with >5 mitoses/50 HPF was defined as high risk, as was any tumor >10 cm or any tumor with >10 mitoses/50 HPF.

GASTRIC STROMAL TUMOURS PRESENTATION; n n n Mass abdomen Upper GI bleeding Obstruction PATHOLOGY; n n Difficult to ascertain benign or malignant nature Size & Histology is the criteria TREATMENT; n n Surgical resection Lymph node resection not necessary.

MİDE LENFOMA Non-Hodgkin Lenfoma(NHL) klasik olarak lenf nodlarından gelişir. n Ama NHL %30 olguda ekstranodal(Solid organ kaynaklı) olarak gelişebilir. n GI sistem tüm NHL %20 n

MİDE LENFOMA n GI lenfoma; oral kaviteden rektuma En sık; Mide n Sonra ince barsak n Kolon n Pankreas n

MİDE LENFOMA NHL, ekstranodal lenfoma ve GI lenfomanın en sık görülen tipi diffüz B hücre lenfoması. n MALT lenfoma n Burkitt lenfoma n T- hücre lenfoma n

Gastric lymphoma n n Malignant neoplasm of mucosa associated lymphoid tissue (MALT) A (usually) low grade B-cell (marginal cell) lymphoma

MİDE LENFOMA n n n Antrum ve distal mide Proksimal yerleşebilir. Karın ağrısı, erken doyma Bulantı, kusma, halsizlik Abdominal dolgunluk Kronik kan kaybı, anemi melena

Gastric lymphoma (maltoma) n n Neoplastic cells infiltrate the epithelium (lymphoepithelial lesions) Strongly associated with chronic H. pylori and can be cured by eliminating infection.

MİDE LENFOMA n n n n n Tedavi HP tedavi edilmeli. Bir zamanlar cerrahi Şimdi Konservatif, bazı olgularda cerrahi Low grade lenfoma(MALT) HP eradikasyonu, KRT, High Grade: Antihelikobakter tedaviye cevap vermeyen erken evre PGL, ileri evre lenfoma, diffüz büyük hücreli lenfoma ise cerrahi tedavi KT-RT Residual hastalık: KT-cerrahi

Neuroendocrine tumours Carcinoids are tumours of resident neuroendocrine cells in gastric glands n Usually seen in context of chronic atrophic gastritis (driven by gastrin) n Clinical behaviour variable n

GASTRIC CANCER

ETIOLOGY 1. HELICOBACTER PYLORI CA of body & distal stomach Ø Gastritis Ø Gastric atrophy Ø Intestinal metaplasia 2. PERNICIOUS ANEMIA 3. GASTRIC POLYPS 4. Pt. with surgery of peptic ulcer disease Ø Billroth II gastrectomy Ø Gastroenterostomy Ø Pyloroplasty Ø 4 times increased risk

5. Cigarette smoking &dust ingestion 6. Diet Ø Consumption of potatoes, pickled vegetables, dried/salted fish & less milk Ø Alcohol ingestion Ø Excessive salt intake Ø Deficiencies of anti oxidants Ø Exposure to N- Nitrosocompounds 7. Familial predisposition Ø Relatives of CA stomach pt. are 4 times more at risk Ø Genetically H-ras, C-erb B 2 & APC gene mutations have some role in pathogenesis of CA stomach Ø Blood group A 8. Gastric ulcer 3 -5% of cases? ? 9. İntestinal metaplazi n Tip 1, 2 ve 3 n En tehlikeli olanı Tip 3

PATHOLOGY MACROSCOPIC CLASSIFICATION 1. 2. 3. 4. Schirrous (lintis plastica) Ulcerative Polypoid Superficial spreading HISTOLOGICALLY (W. H. O) Papillary Tubular Mucin secreting Signet ring cell n

Clinical Features GASTRIC CANCER n n n n Early feeling of fullness after meal Bloating , distention Vomiting Pallor – iron deficiency anemia due to tumour bleed Dysphygia –epigastric fullness or vomiting due to obstrution of gastric outlet Epigastric mass – ¼ of cases Non metastatic effects ; thrombophlebitis Deep venous thrombosis ( by affecting thrombotic & haemostatic mechanism)

n Ascites n Jaundice n Trosier sign(virchows node) n Sister mary joseph nodule n krukenberg tumour n Blummer Shelf

INVESTIGATIONS 1. 2. 3. 4. 5. 6. 7. 8. 9. BLOOD COMPLETE EXAM. ------ Anemia STOOL EXAM. --- for occult blood in ½ of pts. CARCINOEMBRYONIC (CEA) LEVEL--- elevated in 65% of cases GASTRIC JUICE ANALYSIS--- 20% are achlorhydric after maximal stimulation DOUBLE CONTRAST BARIUM MEAL--- mucosal irregularities and to assess the size , shape, margins of lesions GASTROSCOPY & BIOPSY---minimum of 6 biopsies for accuracy --- brush cytology C. T. SCAN ENDOSCOPIC USG LAPAROSCOPY

Advanced Gastric CA

STAGING TNM Staging of Gastric CA Tis tumour limited to mucosa without penetration through basement memb into lamina propria T 1 Tumour limited to mocosa or mucosa and submucosa T 2 Tumour extendind into muscularis propia and may extend into but not through the serosa T 3 Tumour penetrates serosa without invadind contiguous strutures T 4 Tumour invading adjacent strutures N 0 No metastasis to regional lymph nodes N 1 Involvement of perigastric lymph nodes within 3 cm of primary tumour N 2 Involvement of regional lymph nodes more than 3 cm from the primary tumour including nodes along left gastric, splenic, celiac and common hepatic arteries N 3 Involvement of other nodes such as para-aortic, hepatoduodenal, retropancreatic and mesenteric nodes. M 0 No distant metastases M 1 Distant metastasis present N 1— 1 -6. . REGIONAL NODES INVOLVED N 2 --- 7 -15 NODES INVOLVED N 3– MORE THAN 15 NODES INVOLVED

CT STAGING OF GASTRIC CA STAGE I Intraluminal mass without wall thickening STAGE II Wall thickening greater than 1 cm STAGE III Direct invasion of adjacent structures STAGE IV Metastatic disease STAGING IA T 1 N 0 MO IB T 1 N 1 M 0 II T 1 N 2 M 0 III T 2 N 2 M 0 IIIB T 3 N 2 M IV Any. T Any N M 1

SPREAD 1. 2. n n 3. n n 4. n n n DIRECT : LYMPHATIC : By permeation Emboli Trosier, s sign BLOOD BORN METASTASIS Liver Lung, bones TRANSPERITONEAL SPREAD Indicates incureability Manifests as ascities Krukenberg tumour Sister joseph nodule Blumer, s shelf

TREATMENT 1. SURGERY; --curative --palliative 2. RADIOTHERAPY 3. CHEMOTHERAPY SURGICAL TREATMENT n n n Incurable disease is not subjected to radical surgery Evidence of incureability are; --Haematogenous spread --Distant peritoneal involvement --N 4 nodal disease & disease beyond N 4 nodes --Fixation to structures that can not be removed Cure resection should be considered in remaining pts.

Total Gastrectomy

Subtotal Gastrectomy

3. PALLIATIVE SURGERY; n n In symptoms of obstruction & bleeding Only tumour is removed &GIT continuity is restored by ROUX LOOP Gastric exclusion & oesophagojejunostomy Palliative intubation & stenting (for inoperable cardia tumours) RADIOTHERAPY; n n Results are disappoiting in CA stomach But have benefits in painful bony metastasis CHEMOTHERAPY; n n Epirubacin + cispltinium+5 -FU Mitomycin C– impregnated charcoal in intraperitoneal route ( in Japan) RELAPSE & METASTASIS; n n Common site of relapse is Gastric bed Metastasis occur in –intra peritoneal & distal LNs -- liver -- lungs & bones