Gastric anatomy. (With permission from Mulholland MW, Lillemoe KD, Doherty GM, Maier RV, Upchurch GR, eds. Greenfield’s Surgery.4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2005.)

Gastric Anatomy

•Cardia

•Immediately distal to GE junction

•Cell types: Surface epithelial cells, mucous cells

•Fundus

•Most superior portion of stomach

•Separated from stomach by the angle of His

•Cell types: Mucous cells, some parietal and chief cells

•Corpus

•Extends from the fundus to the antrum/pylorus

•Cell types: Mucous cells, parietal cells, chief cells, ECL cells, D cells

•Antrum

•Begins at the angularis incisura and goes to the pylorus

•Cell types: Mucous cells, G cells, some D cells

Gastric Cell Types

•Chief cells (40% of gastric epithelium): Pepsinogen

•Pepsinogen produced in response to food

•Pepsinogen pepsin at pH < 5

•Pepsin breaks down protein

•Parietal cells: HCl, IF (intrinsic factor)

•Intrinsic factor binds B12, aiding its absorption in the distal ileum

•Mucous cells: Mucous, HCO₃

•G cells: Gastrin

•D cells: Somatostatin

•ECL cells: Serotonin

•ECL-like cells: Histamine

Pernicious Anemia

•Due to autoimmune disease against the parietal cells

•Leads to B12 deficiency megaloblastic anemia

•Diagnosis: Endoscopy with biopsy; have ulcers in the fundus

•Treatment: Vitamin B12 injection

A 67-year-old man develops overt gastric bleeding 3 days following an open surgical debridement for infected pancreatic necrosis. Gastroscopy reveals diffuse bleeding from the fundus and body of the stomach. What measure could have prevented this condition?

Early prophylaxis with an H2 receptor antagonist or a proton pump inhibitor is often effective in treating bleeding secondary to stress gastritis.

Stress Gastritis

•Mucosal ischemia that typically occurs 3 to 10 days after a stress event (e.g., operation, shock, and sepsis).

•Cushing ulcer occurs with severe head trauma

•Due to increased gastrin and HCl hypersecretion

•Curling ulcer occurs with severe burns

•Due to mucosal ischemia

•Develops in only 10% of critically ill patients receiving prophylactic therapy

•Treatment options include endoscopic injection or coagulation, angiographic embolization, vasopressin infusion, subtotal/total gastrectomy, or a gastric devascularization procedure

The major supply of the stomach arises from five sources: left gastric artery arising from the celiac axis, right gastric artery typically arising from the hepatic artery proper, the right gastroepiploic artery sourced from the gastroduodenal artery, the short gastric arteries and left gastroepiploic artery sourced from the splenic artery.

Alkaline Reflux Gastritis

•Due to bile reflux into the stomach

•Most commonly seen after pyloroplasty or Billroth II reconstruction

•Symptoms: Postprandial abdominal pain

•Diagnosis: Endoscopy

•Treatment: Roux-en-Y reconstruction

Histamine induces acid production by binding to adenylate kinase to increase cAMP and protein kinase A.

A 41-year-old woman presents with recurrent epigastric pain and new onset gastric bleeding. She is hemodynamically stable and has an endoscopy, which reveals an actively bleeding vessel within an ulcer base in the pre-pyloric region. What is the most appropriate initial intervention?

This is a Dieulafoy lesion, which is seen with a submucosal artery at the base of an ulcer. Endoscopic injection therapy and coagulation are effective in treating most bleeding gastric ulcers. Remember that all gastric ulcers should be biopsied.

Gastric Ulcer

•Causes

•Helicobacter pylori infection—60% to 90%

•Nonsteroidal anti-inflammatory drug (NSAID) overuse

•Zollinger-Ellison syndrome

•Gastric cancer

•Types of gastric ulcer

•Type I—distal lesser curvature

•Normal to decreased acid secretion

•Type II—distal lesser curvature and duodenal ulcer

•Acid hypersecretion

•Type III—prepyloric or pyloric

•Acid hypersecretion

•Type IV—proximal lesser curvature

•Normal to decreased acid secretion

•Type V—anywhere

•Medication induced

•Treatment

•H. pylori: proton pump inhibitor (PPI) + amoxicillin + clarithromycin or metronidazole

•Infusional PPI therapy is used for active ulcer disease

•Indications for surgical management after failed medical/endoscopic therapy include bleeding, perforation, or obstruction

•Surgical options (depending on location of the ulcer) include

•Omental plication for perforated ulcers in unstable patients (but remember to biopsy gastric ulcers)

•Simple ulcer excision

•Gastrotomy with ulcer oversewing, vagotomy, and pyloroplasty

•Antrectomy and vagotomy

•Subtotal gastrectomy

•Highly selective vagotomy

•The right vagus nerve travels posterior to the stomach and gives off the Criminal nerve of Grassi (if undivided during vagotomy, can have recurrent ulcers)

•Unlike a highly selective vagotomy, a standard vagotomy must be done in conjunction with a pyloroplasty or at least an antral resection (in order to prevent an unopposed absence of vagal tone)

•ALWAYS send tissue from a gastric ulcer to pathology, given the increased risk of malignancy compared to duodenal ulcers.

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