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Stomach diseases

Among gastric diseases, chronic gastritis, peptic ulcer and cancer are of the greatest importance.

Gastritis

Gastritis is an inflammation of the gastric mucosa.

With the passage of gastritis can be acute and chronic.

Acute gastritis

• It develops due to irritation of the mucous membrane by alimentary, toxic, microbial factors.

• Depending on the characteristics of morphological changes, the following forms of acute gastritis are distinguished:

a. Catarrhal (simple).

b. Fibrinous.

in. Purulent (phlegmonous).

Necrotic (corrosive).

• The most common form is catarrhal gastritis (see “General course”, topic 6 “Inflammation”).

Chronic gastritis

• In the morphogenesis of chronic gastritis, an important role is played by a violation of regeneration and structural rearrangement of the mucous membrane.

Classification of chronic gastritis.

1- According to the etiology and characteristics of pathogenesis, gastritis A, B and C are distinguished. Gastritis B predominates, gastritis A and C are rare.

1) Gastritis A - autoimmune gastritis.

• Autoimmune disease associated with the appearance of autoantibodies to the lipoprotein of parietal cells and an internal factor blocking its binding to vitamin B12.

• Often combined with other autoimmune diseases (thyroiditis, Addison's disease).

• Manifested mainly in children and the elderly.

• It is localized in the fundal department.

• Characterized by a sharp decrease in the secretion of HCl (achlorhydria), G-cell hyperplasia and gastrinemia.

• Accompanied by the development of pernicious anemia.

2) Gastritis B - non-immune gastritis.

• The most common form of gastritis.

• The etiology is associated with Helicobacter pylori, which is found in 100% of patients.

• Various endogenous and exogenous factors also play a role in development (intoxication, disturbance of the rhythm of nutrition, alcohol abuse).

• It is localized in the antrum, can spread to the entire stomach.

3) Gastritis C - reflux gastritis.

• It is associated with the discharge of the contents of the duodenum into the stomach.

• Often occurs in people who have undergone a resection of the stomach.

• It is localized in the antrum.

• HCl secretion is not impaired and the amount of gastrin is not changed.

2. According to the topography of the process, antral, fundal gastritis and pangastritis are distinguished.

3. Depending on the morphological picture, superficial (atrophic) and atrophic gastritis is distinguished.

• Each of these forms is characterized by lymphoplasmacytic infiltration of the mucous membrane.

• Depending on the intensity of cellular infiltrate, mild, moderate and severe gastritis is distinguished.

• Gastritis can be active and inactive. The active phase is characterized by plethora, stromal edema, the appearance in the infiltrate of PN and leukopadesis (penetration of PN into the epithelial cells).

a. Superficial gastritis.

• Lymphoplasmacytic infiltrate is located in the superficial parts of the gastric mucosa at the level of the ridges.

• The forecast is usually favorable. In some cases, it can turn into atrophic gastritis.

b. Atrophic gastritis.

• The mucous membrane is thinned, the number of glands is reduced.

• In their own plate diffuse lymphoid-plasmacytic infiltrate, severe sclerosis.

• Structural restructuring with the appearance of foci of intestinal and pyloric metaplasia is characteristic. In the first case, instead of gastric ridges, intestinal villi appear lined with intestinal epithelium with numerous goblet cells. In the second case, the glands resemble mucous, or pyloric.

• Often there are tricks of dysplasia. Against the background of severe dysplasia of the epithelium, gastric cancer can develop.

Peptic ulcer

Peptic ulcer is a chronic disease whose morphological substrate is a chronic recurrent ulcer of the stomach or duodenum.

• Peptic ulcer must be differentiated from symptomatic ulcers arising from other diseases and conditions (steroid, aspirin, toxic, hypoxic ulcers, etc.).

• Chronic ulcers with peptic ulcer can be localized in the body of the stomach, pyloric antrum and duodenum.

The pathogenesis of body ulcers of the stomach and pyloroduodenal ulcers is different.

1. Pathogenesis of pyloroduodenal ulcers:

° vagus nerve hypertonicity with increased activity of acid-peptic factor,

° violation of motility of the stomach and duodenum,

° increase in the level of ACTH and glucocorticoids,

° a significant predominance of the acid-peptic factor of aggression over the protective factors of the mucous membrane.

2. The pathogenesis of stomach ulcers:

° suppression of the functions of the hypothalamic-pituitary system, decreased tone of the vagus nerve and activity of gastric secretion,

° weakening of the protective factors of the mucous membrane.

Morphogenesis of chronic ulcers. During the formation, a chronic ulcer goes through the stages of erosion and acute ulcers.

a. Erosion is a surface defect resulting from necrosis of the mucous membrane.

b. Acute ulcer is a deeper defect that captures not only the mucous membrane, but also other membranes of the wall of the stomach.
It has an irregular rounded oval shape and soft edges.

The bottom of acute erosion and ulcers is painted black due to the accumulation of hydrochloric acid theme.

Morphology of chronic ulcers.

• In the stomach it is often localized on the lesser curvature, in the duodenum - in the bulb on the back wall.

• It has the appearance of a deep defect of oval or round shape, capturing the mucous membrane and muscle.

• The edges of the ulcer are dense, calloused. The proximal edge is undermined and the mucous membrane hangs over it, the distal one is gentle, has the form of a terrace, the steps of which are formed by the mucous membrane, submucosal and muscle layers.

The microscopic picture depends on the stage of peptic ulcer.

a. In the stage of remission, scar tissue is visible at the bottom of the ulcer, displacing the muscle layer, with single sclerosed and obliterated vessels. Often noted ulceration of the ulcer.

b. In the acute stage at the bottom of the ulcer, 4 layers are clearly distinguishable: fibrinous-purulent exudate, fibrinoid necrosis, granulation and fibrous tissue, in which sclerosed vessels are visible. In the walls of some vessels, fibrinoid necrosis is noted.

The presence of a zone of necrosis, delimited by the inflammatory shaft, as well as fibrinoid changes in the walls of blood vessels indicate an exacerbation of the ulcerative process.

Complications of peptic ulcer.

1. Ulcer-destructive:

° perforation (perforation) of an ulcer,

° penetration (into the pancreas, colon wall, liver, etc.),

° bleeding.

2. Inflammatory:

° gastritis, perigastritis,

° duodenitis, periduodenitis.

3. Cicatricial:

° stenosis of the inlet and outlet of the stomach,

° stenosis and deformation of the duodenal bulb.

4. Minimization of gastric ulcer (not more than 1%).

5. Combined complications.

Stomach cancer

• For many years it was the most common malignant tumor, however, over the past two decades, there has been a tendency in the world to a distinct reduction in morbidity and mortality from it.

• Prevails over the age of 50, is more common in men.

• In the occurrence, endogenously formed nitrosoamines and nitrogens exogenously coming from food play a role (used in the manufacture of canned food); The possible role of Helicobacter pylori is discussed.

Diseases with an increased risk of stomach cancer include: stomach adenoma (adenomatous polyp), chronic atrophic gastritis, pernicious anemia, chronic ulcer, gastric stump.

At present, only severe epithelial dysplasia is considered to be a precancerous process in the stomach. Classification of gastric cancer.

1. Depending on the localization, cancer is isolated:

a. Pyloric department.

b. Lesser curvature with the transition to the posterior and anterior walls of the stomach.

in. Cardiac department.

d. Great curvature.

e. The bottom of the stomach.

• In the pyloric department and lesser curvature, 3/4 of all carcinomas of the stomach are localized.

• Cancer of the stomach can be subtotal and total.

2. Clinic-anatomical (macroscopic) forms of stomach cancer.

a. Cancer with predominantly exophytic expansive growth:

° plaque-like,

° polypous,

° mushroom (fungic)

° ulcerated cancer:

a) primary ulcerative,

b) saucer-like (ulcer cancer),

c) cancer from a chronic ulcer (ulcer-cancer).

b. Cancer with predominantly endophytic infiltrating growth:

° infiltrative-ulcerative,

° diffuse.

in. Cancer with endoexophytic (mixed) growth:

° transitional forms.

• From a clinical point of view, it is important to identify early gastric cancer, which grows no deeper than the submucosal layer, ie superficial cancer, in which 5-year postoperative survival is almost 100%.

3. Histological types of stomach cancer (WHO classification).

a. Adenocarcinoma:

° in structure: tubular, papillary, mucinous (mucous cancer),

° according to the degree of differentiation: highly differentiated, moderately differentiated and low-differentiated.

b. Undifferentiated cancer.

in. Squamous cell carcinoma.

glandular squamous cell carcinoma.

e. Unclassified cancer.

• Adenocarcinoma as a more differentiated form of cancer is more common with predominantly esophytic tumor growth.

• Undifferentiated forms of cancer (often with a scirrhous growth type) prevail with predominantly endophytic growth, in particular with diffuse cancer.

Metastasis of stomach cancer.

• It is carried out by a lymphogenous, hematogenous and implantation way.

• The first metastases occur in regional lymph nodes along the lesser and greater curvature of the stomach.

• Among distant lymphogenous metastases from a diagnostic point of view, retrograde metastases are important:

a. In both ovaries - Krukenberg metastases.

b. In pararectal fiber - Schnitzler metastases.

in. In the left supraclavicular lymph node - virchovsky gland.

• And implantation metastases lead to carcinomatosis of the peritoneum, pleura, pericardium, diaphragm.

• Hematogenous metastases often occur in the liver, lungs, etc.
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