26

CASE 26


A 55-year-old man presented with complaints of epigastric pain that was of burning quality. He stated that the pain occurred on an empty stomach about 3 hours after meals and at bedtime. When prompted by the physician, he commented that the pain was relieved by meals and antacids. The ensuing endoscopic examination (Fig. 3-43) and biopsy revealed a peptic ulcer in the stomach that was positive for Helicobacter pylori. The physician prescribed amoxicillin and metronidazole to eradicate the H. pylori and omeprazole, a proton-pump inhibitor.


image

FIGURE 3-43 Gastric ulcer (appears white) with bleeding vessel.


(Goldman L and Ausiello D: Cecil Textbook of Medicine, 22e. WB Saunders, 2004. Fig. 138-2.)



WHAT IS THE ARTERIAL SUPPLY TO THE STOMACH?


The stomach is richly supplied with arterial vessels. These vessels are the:


• Left gastric artery, a branch of the celiac trunk. The left gastric artery courses along the lesser curvature of the stomach. In some individuals, a branch from the left gastric artery is the primary or secondary supply of the left lobe of the liver. A surgeon must evaluate this potential supply to the liver before ligating the left gastric artery.

• Right gastric artery, a branch of the common hepatic artery. The right gastric artery travels along the lesser curvature of the stomach to anastomose with the left gastric artery.

• Right gastro-omental artery, springing from the gastroduodenal artery, passes along the greater curvature of the stomach.

• Left gastro-omental artery, takes origin from the splenic artery and courses along the greater curvature of the stomach to anastomose with the right gastro-omental artery.

• Short gastric arteries, branches of the splenic artery. The short gastric arteries supply the fundus of the stomach and anastomose with the left gastric and left gastro-omental arteries.


IF A THROMBUS OR EMBOLUS OCCLUDED THE CELIAC TRUNK, WOULD THE STOMACH STILL RECEIVE ARTERIAL BLOOD?


If the celiac trunk was occluded, the stomach would become dependent on its collateral circulation from the superior mesenteric artery. Springing from the superior mesenteric artery or its first jejunal branch is the inferior pancreaticoduodenal artery. The inferior pancreaticoduodenal artery promptly divides into anterior and posterior branches that anastomose with the superior anterior and posterior pancreaticoduodenal branches of the gastroduodenal artery. The gastroduodenal artery issues from the common hepatic artery, a branch of the celiac trunk. Thus, the superior mesenteric artery, through its anastomoses, may supply the stomach with some blood flow even if the celiac trunk is occluded.



WHAT IS THE VENOUS DRAINAGE OF THE STOMACH?


The veins of the stomach are the:


• Left gastric vein, which empties directly into hepatic portal vein

• Right gastric vein, which also drains directly into the hepatic portal vein

• Right gastro-omental vein empties into the superior mesenteric vein or it may join the splenic vein or hepatic portal vein

• Left gastro-omental vein usually empties into the splenic vein

• Short gastric veins drain into the splenic vein


WHAT IS THE INNERVATION OF THE STOMACH?


The stomach is innervated by parasympathetic nerve fibers from the vagus and sympathetic nerve fibers that originate from the lateral gray horns of spinal cord segments T6 to T9 or T10.


The left and right vagus nerves become the anterior and posterior vagal trunks as they descend through the thoracic cavity. The vagal innervation of the stomach is depicted in Figure 3-44. The anterior (left) vagal trunk divides near the gastroesophageal junction into the hepatic branch, which supplies the liver and the pylorus by the pyloric branch. The other branch follows the ventral surface of the stomach along its lesser curvature as the anterior nerve of Latarjet. The posterior (right) trunk of the vagus gives rise to a celiac branch and the criminal nerve of Grassi. The criminal nerve of Grassi supplies the gastric glands in the fundus. If this nerve is left undivided after a vagotomy to surgically treat ulcers, the procedure may prove to be ineffective as ulcers are likely to recur. After issuing these branches, the nerve continues on the dorsal surface of the stomach along the lesser curvature as the posterior nerve of Latarjet. Functionally, parasympathetic stimulation increases glandular secretions and contraction of the stomach.

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Jun 16, 2016 | Posted by in ANATOMY | Comments Off on 26

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