3. GE Junction
• Z – line / Squamocolumnar jn.
• Rugal folds
• Fat pad
• Collar of Helvetius / Loop of Willis
(where the circular muscular fibers of
the esophagus join the oblique fibers
of the Stomach)
4. PYLORUS
• Pre-pyloric vein of Mayo
• Prevent intestinal contents from
reentering the stomach when the
small intestine contracts and to limit
the passage of large food particles or
undigested material into the
intestine.
7. LYMPHATICS
4 zones--- Celiac group--- Thoracic duct
• D1 resection: Removal of perigastric
lymph node within 3 cm of stomach
serosa (N1 node). 1 to6
• D2 resection: D1 resection + removal
of second tier of lymph node along
main arterial trunk (N2 nodes). 7 to 11
• D3 resection: D2 resection + lymph
nodes resection of 12 to 16
8. Japaneese classification (18 lymph node stations)
1. Right cardiac node
2. Left cardiac node
3. Lymph nodes along the lesser curvature
4. Lymph nodes along greater curvature:-(4sa)-lymph nodes along short gastric
vessels. (4sb)-lymph nodes along left gastroepiploic vessels. (4d)-lymph nodes
along right gastroepiploic vessels
5. Suprapyloric lymph nodes
6. Subpyloric lymph nodes
7. Lymph nodes along left gastric artery
8. Lymph nodes along common hepatic artery
9. Lymph nodes along the coeliac axis
9. 10. Lymph nodes at the splenic hilum
11. Lymph nodes along the splenic artery
12. Lymph nodes at hepatoduodenal ligament
13. Retroperitoneal duodenal lymph nodes
14. Lymph nodes at root of mesentery
15. Lymph nodes around middle colic artery
16. Lymph nodes around aorta—paraaortic lymph nodes
17. Around lower esophagus
18. Supradiaphragmatic nodes.
• In addition lymph nodes around the lower esophagus, lymph nodes at the
esophageal hiatus, supradiaphragmatic and infradiaphragmatic nodes also
receive lymphatics from the cardiac end of the stomach.
16. • Anterior- in contact with Left hemi-diaphragm, left lobe and anterior segment of
right lobe of the liver and the anterior parietal surface of the abdominal wall
• Posterior- Left diaphragm, Left kidney, Left adrenal gland, and neck, tail and body
of pancreas, greater curvature is near the transverse colon and transverse colon
mesentery, concavity of the spleen contacts the left lateral portion of the
stomach
17. Microscopic Anatomy
• Mucosa has three types of gastric glands
• Cardiac:- Location- Cardia
• Contain mucous
• Function- secrete mucous (provides a protective coat for lining of stomach)
• Oxyntic:- Most distinctive feature of the stomach
• Location- Fundus and Corpus
• Contains many cell types
18. • Parietal cells:- Location- neck of gastric pit
• Stimulated by Ach, Histamine and Gastrin
• Secretes HCl + Intrinsic Factor
• Chief Cells:- Location- base of gastric pit
• Stimulus- Vagal
• Secretes Pepsinogen (eventually leads to pepsin- digestive
19. • Antral Glands
• Gastrin cells:- Location- mucosa of distal stomach
• Stimulus- amino acids
• Secretion- Gastrin (stimulates HCl production by way of parietal cells)
• Somatostatin:- Location- mucosa of distal stomach + Duodenum
• Stimulus- HCl or low pH in duodenum
• Actions- Inhibits gastric emptying, Pancreatic secretions, and gallbladder
contraction
20. • The two peptides of greatest importance to human disease and clinical surgery are
1. Gastrin:- Most important stimulus is a meal amino acids that results from proteolysis
• Fat and carbohydrates are not stimuli for gastrin secretion
• Gastric distention that occurs from a meal will stimulate cholinergic neurons thereby
releasing gastrin
• Gastrin will then prompt Parietal cell to secrete HCl
• Once Gastric distention diminishes, VIP-containing neurons are activated causing
stimulation of somatostatin, thus attenuating Gastrin secretion
• Overall, a lumen pH >3.0 will potentiate gastrin release, whereas a pH <3.0 will inhibit
its release
21. • Somatostain:- Like Gastrin, plays an integral role in gastric physiology
• Also, used for important therapeutic applications in treatment of digestive
diseases
• Main stimulus is a low or acidic (<3.0) luminal pH
• Many peptides have shown to release somatostatin Ex. Secretin, Cholecystokinin
and gastrin
• In contrast, stimulation of Vagal nerves along with cholinergic neurons inhibit
somatostatin
• Overall, the most important gastric function of somatostatin is to regulate acid
secretion and gastrin release
22. Gastric Carcinoma:- Incidence
• Japan 70 in100,000/year
• Europe 40 in 100,000/year
• UK 15 in 100,000/year
• USA 10 in 100,000/year
• Can occur at any age but peak incidence Is 50-70 years old.
• It is more aggressive In younger ages.
• Twice more common In male than in female
23. The magnitude of problem
• Male : Lung > Prostate > Colorectal > Stomach
• Female : Breast > Cervix > Colorectal > Lung > Stomach
• 2nd most commom cause of cancer death
• Poor prognosis
• India : Kashmir - 36/1,00,000, Chennai - 15/1,00,000, Bangalore - 10.6/1,00,000
• Around 45-50% of gastric carcinoma present with an inoperable disease.
25. Nutritional
• High salt consumption
• High nitrate
consumption (N-
nitroso compounds)
• Low dietary vitamin A
& C
• Low fat / protein diet
with high complex
carbs
• Low fresh fruits and
vegs ( low ascorbic
acids)
•
Occupational
• Poor food preparation
(smoked, salt cured)
• Lack of refrigeration
• Poor drinking water
(well water)
• Rubber workers
• Coal workers
• H. Pylori infection
• Epstein-Barr virus
• Radiation exposure
• Prior gastric surgery for
benign gastric ulcer
disease
Genetic factors
• Blood group A
• Pernicious anemia
• Family history
• HNPCC
• Li-Fraumeni syndrome
Precursor lesions
• Adenomatous gastric
polyps
• Chronic atrophic
gastritis
• Dysplasia
• Intestinal metaplasia
26. • Impact of PPI on incidence of gastric cancer has not been elucidated.
• In patients with H.pylori on long term PPI, the low acid environment
allows bacteria to colonize the gastric body, leading to corpus
gastritis. 1/3rd develop atrophic gastritis (a risk factor for carcinoma)
30. Histological types of gastric cancer
• Adenocarcinoma – 90%
• Lymphoma – 5%
• GIST – Gastrointestinal stromal tumors – 2%
• SCC – Squamous cell carcinoma - <1%
• Carcinoid tumors - <1%
• Adenocanthoma - <1%
• Signet ring cell Carcinoma
• Although no normal lymphoid tissue is found in the gastric mucosa, the stomach
is the most common site for lymphomas of the gastrointestinal tract.
31. Borrmann’s classification
Based on macroscopic appearance, Useful as endoscopic finding
• Phymatoid/ polypoid/ fungating– Type 1
• Ulcerative with elevated borders– Type 2
• Infiltrative ulcerative (ulceration with invasion of
wall)– Type 3
• Diffuse infiltrative (lintis plastic)– Type 4
• Can’t be classified– Type 5
Protruded type
Depressed type
32.
33. WHO Classification of Gastric Cancer (Classification
based on morphologic features)
• Adenocarcinoma – divided according to the growth patterns in :
- papillary
- tubular
- mucinous
- signet ring
• Adenosquamous cell carcinoma
• Squamous cell carcinoma
• Undifferentiated
• Unclassified
34. Growth pattern (Ming)
• Expanding type:- Grow en mass and by expansion resulting in the formation of
discrete tumor nodules with relatively good prognosis
• Infiltrative type:- Invades individually and having poor prognosis
35. AJCC TNM Staging
• EUS and CT are primary radiological staging modalities
• TX- Primary tumour cannot be assessed
• T0- No evidence of primary tumour
• Tis- Carcinoma in situ
• T1a- Tumour invades lamina propria or muscularis mucosae
• T1b- Tumour invades submucosa
• T2- Tumour invades muscularis propria
37. Pathologic staging – primary tumour
• Invasion of greater or lesser omentum, gastrocolic or gastrohepatic ligaments
without breach of peritoneum is T3
• Breach of peritoneum = T4
• Intramural extension along alimentary canal into oesophagus or duodenum is not
invasion of adjacent organ (ie. Not T4b)
38. Lymph nodes
• NX Regional lymph nodes(s) cannot be assessed
• N0 No regional lymph node metastases
• N1 Metastases in 1-2 regional lymph nodes
• N2 Metastases in 3-6 regional lymph nodes
• N3a Metastases in 7-15 regional lymph nodes
• N3b Metastasis in 16 or more regional lymph nodes
39. Distant metastasis (M)
• Mx distant metastasis cannot be assessed
• M0 no distant metastasis
• M1 distant metastasis
41. Spread of Gastric Cancer
Direct Spread:-
• Tumor penetrates the muscularis, serosa
& Adjacent organs (Pancreas,colon
&liver)
Lymphatic spread:-
• What is important here is Virchow’s node
(Trosier’s sign)
Blood-borne metastasis:-
• Usually with extensive Disease where
liver (mc) 1st Involved then lung & Bone
Transperitoneal spread:-
• This is common Anywhere in peritoneal
cavity (Ascitis), Krukenberg tumor
(ovaries), Sister Joseph nodule (umbilicus)
42. Clinical Presentation
• Most patients present with advanced stage.. why? They are often asymptomatic
in early stages.
• Common clinical Presentation: The patient complained of loss of appetite that
was followed by weight loss of 10Kg in 4 weeks.
• He had notice epigastric discomfort & postprandial fullness.
• He presented to the ER complaining of vomiting of large quantities of undigested
food & epigastric distension.
43. • Asymptomatic in early gastric cancer.
• Nonspecific symptoms – indigestion, vague epigastric discomfort, constant non
radiating pain which is not related to food intake.
• Specific symptoms depend on the site of tumour – obstruction, dysphagia, mass.
• Metastatic disease – liver secondaries, ascites, secondaries in ovary, rectovesical
pouch, umbilicus, supraclavicular nodes, lung and bone secondaries.
• Unusual presentations – acanthosis nigricans, Irish nodes in the axilla.
44. Clinical Features
• Loss of appetite and weight, early satiety, fatigue.
• Microcytic hypochromic anaemia.
• Upper abdominal pain.
• Vomiting with features of gastric outlet obstruction.
• Mass in pylorus lies above the umbilicus, nodular, hard, with impaired resonance,
mobile, moves with respiration, all margins well defined.
45. • Dysphagia.
• Along with jaundice, liver may be palpable with secondaries which are hard,
nodular with umbilication.
• Ascites, Haematemesis, melaena, Perforation.
• Troisier’s sign positive.
• Rectovesical secondaries (Blummer shelf) on per rectal examination.
• Trousseau sign positive – migrating thrombophlebitis.
• Sister Mary Joseph nodules, Cutaneous secondaries, Krukenberg tumors.
46. “Alarm” features suggestive of gastric cancer
1. New onset dyspepsia in patients >55 years of age
2. Family history of UGI cancer
3. Unintentional weight loss
4. Upper or lower GI bleeding
5. Progressive dysphagia
6. Iron deficiency anaemia
7. Persistent vomiting
8. Palpable mass
9. Palpable lymph nodes
10. Jaundice
• Patients ≥ 55yr with new onset dyspepsia and all those with alarm features should have
an urgent (within two weeks) gastroscopy
47. Differential Diagnosis
1. Acid peptic disease, pyloric stenosis with gastric outlet obstruction.
2. Gastritis.
3. Pancreatic mass.
4. Transverse colon mass.
5. Advanced fixed stomach mass may mimic retroperitoneal or nodal mass.
48. Investigations
• Routine Blood Investigations, Liver function tests, Kidney function tests
• Flexible Fiber Optic Upper GI Endoscopy & Biopsy
• Endoscopic Ultrasonography
• CECT Abdomen
• Laparoscopy, Laparoscopic Ultrasonography
• Double Contrast Barium Meal
• Chest X Ray
• Tumour markers (CEA, Ca19-9)
• Fecal occult blood test (FOBT)
49. • Flexible upper endoscopy is the diagnostic modality of choice.
• During endoscopy, multiple biopsy samples (seven or more) should be obtained
around the ulcer crater to facilitate histological diagnosis.
• Biopsy of the ulcer crater itself may reveal only necrotic debris.
• When multiple biopsy specimens are taken, the diagnostic accuracy of the
procedure approaches 98%.
• The addition of direct brush cytology to multiple biopsy specimens may increase
the diagnostic accuracy of the study.
• The size, location, and morphology of the tumour should be noted and other
mucosal abnormalities carefully evaluated.
50. • CT scanning and endoscopic ultrasonography (EUS) are complementary.
• CT scanning is used first to stage the gastric carcinoma; if no metastases and no
invasion of local organs are found, EUS is used to refine the local stage.
• The depth of tumor invasion is not accurately assessed with CT, and the
investigation of choice for this indication is EUS.
• Unlike CT and MRI, EUS can depict individual layers of the gastric wall, with a
rotating high-frequency probe
51. • Screening typically includes the use of double-contrast barium
radiographs or upper GI endoscopy.
• Pretreatment Staging Tumor Markers: CEA & CA19-9 levels correlate with
depth of tumor invasion, presence of lymphatic metastasis, extent of
tumor stage and ultimately with patient survival.
52. Flexible Upper GI Endoscopy
EGD (esophago gastro duodenoscopy)
• Visual examination of the upper intestinal tract using a lighted, flexible fiber-optic
or video endoscope:- Gold standard
• More sensitive than conventional radiology ( 95% accuracy )
• Advantages:- Outpatient procedure
No radiation Exposure
Targeted biopsy from the lesion can be taken at the same setting.
Diagnosis can be made more accurately
53. Indications
• Ulcers in the upper GI tract
• Tumors of the stomach or esophagus
• Severe/Persistent Dysphgia
• Undiagnosed Upper abdominal pain or indigestion
• Intestinal bleeding
• Esophagitis and heartburn – unresponsive to medical therapy
• Gastritis
54. IF YOU SEE ULCER ASK UR
SELF…BENIGN OR MALIGNANT?
• Benign
• Round to oval punched out lesion with
straight walls & flat smooth base
• Smooth margins with normal
surrounding mucosa
• Mosty on lesser curvature
• Majority < 2cm
• Normal adjoining rugal folds that
extend to the margins of the base
• Malignant
• Irregular outline with necrotic or
hemorrhagic base
• Irregular & raised margins
• Anywhere
• Any size
• Prominent & edematous rugal folds
that usually do not extends to the
margins
57. Contrast Radiology
• Single Contrast/ Double Contrast
• Barium Meal
• Advantages
– Sensitivity comparable to endoscopy
– Non Invasive procedure
58. Findings in Carcinoma Stomach
• Irregular filling defect
• Loss of rugosity
• Delayed emptying
• Dilatation of stomach in carcinoma pylorus
• Decreased stomach capacity in linitis plastica
• Carmanns meniscus sign
59.
60.
61. Endoscopic / Endoluminal Ultrasound
• Useful to detect the involvement of layers of the stomach, nodal status and to
differentiate early from advanced cancer.
• Excellent at determining the T- Stage ( 90% )
• High frequency probes used to differentiate T1-2 stage
• Nodal status can also be assessed
• Limited use in advanced disease
62.
63. Computed tomography and MRI
• Every patient with a histological diagnosis of gastric Carcinoma should undergo a
Ct of the chest and abdomen.
• Provides information about
– M stage ( Liver, Lung, Peritoneum and distant nodes )
– T4 stage ( involvement of the adjacent structures )
64.
65. Laparoscopy
• To stage the disease especially in locally advanced tumours
– Peritoneal secondaries
– Occult metastases
– Organ invasion
– Peritoneal lavage for cytology
– Biopsy of peritoneum and nodes
66. Signs of inoperability
• Peritoneal deposits
• Fixity
• Liver secondaries
• Fixed iliac nodes
• Para aortic nodes
• Ascitic fluid positivity
• Sister Mary Joseph Nodule
• Left axillary lymph node secondaries
