Pathology of Stomach

Dr. Saifeldenn Hussein Pathologist IMS-MSU

PATHOLOGY DEPARTMENT

TOPICS

1) CONGENITAL ABNORMALITIES

2) ACUTE GASTRITIS

3) CHRONIC GASTRITIS

4) PEPTIC ULCER DISEASE

5) BENIGN TUMORS

6) GASTRIC CARCINOMA

CONGENITAL ABNORMALITIES

Pyloric stenosis: Males 3:1 vs. females May occur with Turner syndrome, trisomy 18, esophageal

atresia Clinical features: i) Narrowing of pyloris - hypertrophy and possibly

hyperplasia (muscularis) ii) Projectile vomiting within first 3 week after birth-

dehydration iii) Palpable mass iv) Surgical splitting is curative

Diaphragmatic Hernia:

• Congenital opening defect on the diaphragm keep the stomach and intestines move up into the chest cavity.

ACUTE GASTRITIS

• Gastritis (inflammation of gastric mucosa) usually transient inflammation lead to bleeding and erosion of mucosa

Pathogenesis: associated factors: a) NSAID (e.g., aspirin)

b) Alcohol c) Heavy smoking d) Stress (trauma, burns, surgery) e) Trauma to CNS Acid secretion damage to epithelium active inflammation HCO3

CLINICAL FEATURES:

a) Asymptomatic

b) Nausea, vomiting

c) Epigastric pain

d) In severe cases: hemorrhage = severe hematemesis - melena

Pathology : • Erosion of the superficial epithelial with petechial hemorrahge

any where in the stomach

• Patchy mucosal necrosis

CHRONIC GASTRITIS

Presence of chronic mucosal inflammation leading to: a) mucosal atrophy b) intestinal metaplasia c) usually no erosion

Etiology: a) Chronic infection (Helicobacter pylori) b) Autoimmune (Pernicious anemia) c) Alcohol, smoking d) Post surgery (i.e., gastric) e) Radiation

• Helicobacter pylori most important etiologic association with chronic gastritis( Gram –ve rods with polar flagella) found only on the epithelial surface and dose not invade.

• Urease +ve (produces NH 3 and CO2 from urea)

• Plays role in other diseases:

a) Peptic ulcer

b) Gastric carcinoma

c) Gastric MALT

• H. pylori-induced gastritis: i) Pangastritis – (multifocal gastric atrophy) high level of IL-B

(potent pro-inflammatory cytokines) inhibit gastric acid- lower H + production - risk of adenocarcinoma

ii) Antral-type – low level of IL-B - high H + production - risk of peptic ulcer

Investigation:

i) Serologic test for Ab

ii) Fecal bacteria detection

iii) Urea breath test

iv) Gastric biopsy- histology visualization

PATHOLOGY :• lymphocytes and plasma cells seen in the lamina propria

• Lymphoid hyperplasia

• H. pylori seen on the surface mucus of epith cells

Autoimmune gastritis:

Chronic diffuse inflammatory disease of the body and fundus of the stomach

High risk of gastric CA.

• < 10% of gastritis cases due to Ab against parietal cell and IF lead to:

a) mucosal atrophy loss of acid production ( achlorhydria)

b) increased serum gastrin (G- cell hyperplasia)

c) Pernicious anemia seen with other autoimmune diseases

i) Type 1 diabetes

ii) Addison disease

iii) Hashimoto thyroiditis

PEPTIC ULCER DISEASE

• PU is chronic lesions, solitary occur any part of the alimentary tract due to exposed to the aggressive acid-peptic juices

Sites :

Duodenum = 1st part

Stomach usually = antrum

Gastroesophageal junction = reflux

Duodenum, stomach in Zollinger-Ellison syndrome

Etiology:

1) H.pylori infection: 100% in duodenal ulcers and 75% in gastric ulcers

Other factors promoting peptic ulceration:

• Zollinger-Ellison syndrome – multiple ulcers in stomach, duodenum due to excess gastrin

• Chronic NSAID use – suppress prostaglandin syn

• Cigarette smoking – impair mucosal blood flow

• Corticosteroids

• Alcoholic cirrhosis, COAD – duodenal ulcer

• Chronic renal failure and hyperparathyroidism = hypercalcemia – stimulate gastrin – acid prod.

Pathogenesis :• Imbalance between defense and damaging forces• Severe inflammation - IL-1, IL-6, IL-8,TNF - IL-8

recruits neutrophils • H. pylori produces proteases and phospholipases enzymes

i) break down protective actions of mucus vi) HCO 3 - in duodenum v) H + secretion in stomach vi) damage to mucosa and epithelial cells leakage of

nutrients (sustain H. pylori)

Pathology: gross Gastric ulcer:

Site: Lesser gastric curvature in the antral and prepyloric region= a/e chronic gastritis

Great curvature = NSAID

Size: Single, round, less than 4 cm

Edges: Sharp, not heaped-up

Base of ulcer: Smooth and clean due to peptic digestion

Duodenal ulcer:

Site : anterior or posterior wall of the first part of the duodenum

Size : solitary some time paired ulcer on both wall (kissing ulcer)

Edges: sharply demarcated

Microscopically:

• 4 zones identifiable:

• Superficial necrotic layer

• Zone of inflammation

• Layer of granulation tissue

• Underlying fibrous scar

Clinical features: Epigastric pain is main presentation.

• The classic duodenal ulcer is characterized by epigastric pain 1 to 3 hours after a meal.

• Gastric ulcer pain relieved by food

Complications:

1) Hemorrhage

2) Perforation

3) Pyloric obstruction (gastric outlet obstruction) :caused by muscular spasm, edema, muscular hypertrophy or contraction of scar tissue,

4) Development of combined ulcers

5) Malignant transformation of benign gastric ulcer and dose not occur in DU.

TREATMENT:

• Antibiotics to eliminate H. pylori

• Blocking gastric acid secretion with histamine-receptor blockers and proton pump inhibitors.

Acute gastric ulceration:• Focal acutely development of gastric mucosal defect due to:

1) NSAID

2) Physiological Stress (stress ulcer)

3) Severe burn or trauma (Curling ulcer)

4) Intracranial injury (Cushing ulcer)

• Gross: Small and multiple ulcer found any where in stomach and duodenum .

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