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Stomach

 

Gastric Ulcer and Cancer of the Stomach

 

Where is the stomach located?

The food reaches the stomach of the human being through the mouth, the cavity of the throat, and the oesophagus (gullet). It is located in the middle upper abdomen between the liver to the right side and the spleen to the left side. The junction between the gullet and the entrance of the stomach is about 2 - 3 cm below the diaphragm and was called "cardia" already during the times of Hippocrates. This transitional zone has an important barrier function between lower gullet and the entrance of the stomach by preventing the chyme and the gastric acid from flowing back into the gullet. The stomach itself has about the form of a bean. The long side of its curvature stretches to the left and towards the spleen, and the short side rests against the liver on the right and, in the back towards the spine, covers the tender tissue of the pancreas. An extensive network of partly strong arterial vessels supplies the tissue of the stomach with blood. The entrance of the stomach is followed by the biggest part of this organ, the body (corpus), and then by the bottom (gastric fundus). It connects to the gastric outlet (antrum), which again opens into the duodenum. This transitional zone is called pylorus or "gatekeeper". The stomach itself is covered by a strong layer of orbicular muscles, which are responsible for a thorough mixing of the chyme. The innermost layer of the stomach wall is formed by the mucous membrane of stomach, which again consists of various types of cells. These cells produce characteristic substances (especially gastric acid) that cooperate in the chemical processing of food, or they produce mucus for the natural protection of the stomach amongst other things.

Functions of the stomach

The stomach is a storage organ, in which the food is split up into different substances by chemical procedures. This enables the duodenum to absorb fats, proteins, and sugar after having added bile and pancreatic juice. The stomach produces about three litres of gastric secretion per day, most of which is very sour. In addition, it contains pepsin and important hormones (gastrin and somatostatin), which affect the complex regulation of the production of acid. However, our nervous system also influences the release of sour gastric secretion from the relevant cells: by smelling or tasting food, but also by stress factors, the vagus nerve is activated, which in turn triggers the release of gastric acid in the stomach. Other cells of the mucous membrane of the stomach continuously secrete mucus and thereby protect the mucous membrane from gastric acid. Alcohol and coffee stimulate the release of acid in the stomach whereas pain killers reduce the release of protective gastric mucus, so that the balance of acid and mucus may be disturbed. Excess acid and/or inadequate production of mucus cause, along with helicobacter pylori, the inflammation of the mucous membrane of the stomach or of ulcers. It has been known since 1982 that a bacterium in the mucous membrane, which is named helicobacter pylori and identified in more than a third of the patients with stomach troubles, plays an important role in the formation of gastric ulcer and of inflammations of the mucous membrane of the stomach. In the meantime, there are indications that the presence of this bacterium considerably increases the risk of taking ill with gastric cancer. If gastric ulcers have been gastroscopically proved along with the presence of the bacterium, the consequent treatment consists of an antibiotic and acid blocking therapy.

The most common diseases of the stomach

Most patients who consult a doctor because of considerable stomach ache, suffer from a chronic or acute inflammation of the mucous membrane of the stomach (gastritis), caused by wrong nutrition, pain killers, alcohol, stress, and/or bacterial colonization by helicobacter pylori. After appropriate diagnostics (gastroscopy, evidence of bacteria) and initiated medicinal therapy, e.g. with antibiotics and acid blockers, gastritis can be quickly healed by the gastroenterologist. If there is a deeper defect of the mucous tissue (ulcus), an injury of the vessels in the stomach wall may result, possibly causing life-threatening bleedings. But even then, a conservative treatment is first choice, i.e. a gastroscopy is carried out, stopping the bleeding simultaneously. Along with it, antibiotics and acid blockers are administered. In the statistics of fatalities caused by cancer, the gastric carcinoma takes fourth place. Whereas its incidence in the lower third of the stomach has clearly diminished in the last few years, the number of carcinomas around the cardia has increased. The causes and risk factors to develop a gastric carcinoma are as follows: high family frequency of the carcinoma, chronic gastritis, and helicobacter pylori infection as well as subacidity of the stomach. In most cases, the tumour is of a tissue that descended from glandular cells (adenocarcinoma), which then is called, medically correct, a primary malignant tumour of the stomach. If the tumour is sufficiently big, it may release colonisations of metastases, which might then settle in the liver.

How do I recognize a disease of the stomach?

A patient will normally consult his doctor if he suffers from reappearing or permanent stomach pain, lack of appetite, heartburn, nausea, vomiting, or bloating. The symptoms may appear in very different manifestations, alone or in combination, and they do not give any clear indication as to type and severity of the disease. More than half of the patients with stomach trouble suffer from it without any organic causes to be found. Nevertheless, one has to carefully rule out other diseases.

Necessary clarifications and diagnostic possibilities

Patients with an acute gastritis, a gastric ulcer, or a gastric carcinoma unfortunately show very similar symptoms. A careful questioning and examination by the specialist is therefore imperative for an exact diagnosis. Essential is also an exact anamnesis, asking for diseases in the family, consumption of alcohol, nicotine, and use of pain killers. It is also important for the doctor to know whether there is a connection between eating and pain or its alleviation respectively and whether the patient has significantly lost weight or observed a decrease of fitness. Afterwards, an intensive physical examination should follow, including a palpitation of the abdomen to clarify whether there are any enlargements of organs or point tenderness that could be triggered. A blood examination is part of the basic diagnosis, so that e.g. diseases of the liver could be ruled out or a suspected anaemia be confirmed. If a patient has got a bleeding gastric ulcer, he must of course receive emergency diagnosis and treatment. The basic principle of procedure remains, however, about the same: if indicated by the anamnesis, a gastroscopy is made, including.

spotting of the ulcer, the inflamed mucous membrane, or the source of bleeding

taking of tissue samples (biopsy) to prove the existence of helicobacter pylori and/or tumour cells

Only rarely, an X-ray examination of the stomach with contrast medium becomes necessary. If there is the suspicion that the finding might be a gastric carcinoma, the diagnostics are extended: a CT or MRI and a sonography of the abdomen must be conducted to assess the extension of the tumour, of the lymphatic nodes, and of the tissue of the liver.

How can gastric ulcers and gastric carcinomas be treated?

If a bleeding is diagnosed during a gastroscopy, no matter whether there is a defect of the mucous membrane or a single ulcer, the specialist tries to inject vasoconstrictive substances into the bleeding mucous membrane. At the same time, the patient receives an intravenous injection of large-dosed and acid-blocking medicaments. If a bleeding becomes menacing in spite of it, or if a "hole" in the gastric wall is found at the place of the ulcer with connection into the abdominal cavity, an urgent operation has to be carried out. The principle of the operation (Billroth II) consists of a resection of the lower two thirds of the stomach, where ulcers are most frequently found or, simultaneously, various defects of the mucous membrane. The operation is split into two phases:

Excision of the lower two thirds of the stomach along with transection of the connection to the duodenum

Side-to-side connection of a section of the small bowel with the gastric stump

After preparation and induction of the narcosis, access to the abdominal cavity is made by a vertical incision from the lower end of the breastbone down to the navel. If necessary, the navel is passed round to the left. After the dissection of the abdominal wall and a relevant preparation, the duodenum is severed from the stomach and closed as a false end, but it remains in its normal anatomic position as the bile and the pancreas secretion still flow into the duodenum.

To safeguard a good flow of the chyme in the digestive system, a loop of the small bowel is pulled up from below the duodenum in front or behind the horizontal large bowel. It is then opened and sutured side-to-side to the gastric stump. About 30 cm below the new connection between stomach and small bowel, a "short circuit" is installed between the duodenum and the small bowel, so that the secretions of the duodenum can drain well. For this purpose, one small opening in the intestinal wall of each of the two bowels is made, and they are sutured next to each other. In the area of the new bowel-stomach connection, a drain is installed and run off to the outside through the abdominal wall. Finally, the abdominal wall is closed layer by layer.

In the therapy of gastric carcinomas, surgical treatment is the rule. Depending on the size and location of the tumour in the stomach, either only one part of the stomach or the whole stomach between lower gullet and duodenum is removed (total gastrectomy). All the relevant lymphatic nodes are also excised and examined in the process. Whether the spleen, situated near the stomach at the left side, has also to be removed in the course of this operation depends on the location of the tumour in the stomach. This long operation asks for an intensive preparation, e.g. a detailed preliminary discussion with the anaesthesist and possibly additional heart and lung examinations. The surgical sequence of a total gastrectomy also consists of two phases:

Complete removal of the stomach

Formation of a substitute stomach (Ulmer stomach) from small bowel loops

Access to the abdominal cavity is made by an incision from the breastbone down to the navel. After this, the surgeon severs all layers of the abdominal wall and palpates the abdominal cavity carefully with his hand in order to assess the extension of the tumour and a possible metastasis into the lymphatic nodes and the liver. After this, the duodenum and the stomach including the lower part of the gullet are exposed, so that the stomach can be severed near the gullet and at the pylorus. All lymphatic nodes in the region are removed and sent to a histological examination (rapid cut) along with the removed stomach. Now the surgical phase of forming a substitute stomach follows. For that purpose, a 60 cm piece of the small bowel, located close to the duodenum, is taken out, and the small bowel is again immediately joined together. The removed piece of the small bowel (bridging graft) is doubled up at one end at a length of 10 cm. The folded-up intestinal walls are opened and fitted together by means of a special suture technique in such a way that a new storage organ is formed: the substitute stomach. The substitute stomach is then opened at the top and sutured to the gullet. This is done either manually or with a special linear stapling device. The other end of the bridging graft is now joined to the duodenum, so that the chyme can take its normal course again. Drains are laid at the two places of suture between gullet and bridging graft and between bridging graft and duodenum to allow blood and pus to be run off to the outside through the abdominal wall. The abdominal wall is then closed layer by layer, and the patient is taken to the intensive care unit for close observation.

What happens after the treatment?

The patient will remain in the intensive care unit for 1 - 2 days, receiving balanced infusions and analgesic therapy. During the next 5 - 6 days, he is not allowed to eat and drink, so that the fresh sutures between gullet and small bowel and between small bowel and duodenum are not put at risk. This has to be done because a leakage in these places would cause a grave complication in the process of recovery. In spite of it all, the patient should get up from the first day after the operation and move around a little. If there is no more indication that the new sutures are still endangered, the patient may start to drink something. As soon as the bowel functions normally, that is when the doctor can hear bowel sounds through his stethoscope, cautious nutrition under the expert supervision of a nutritional counsellor can be initiated. After the nutrition has been started again, the drains are removed, and the stitches can be taken out on the tenth day.

What has to be paid attention to in future everyday life?

The removal of greater shares of the stomach, but even more so total gastrectomy, involve a deep intervention and a lasting change of the complete digestive processes of the gastro-intestinal tract. The reduction of the storage organ stomach or its substitution by a bridging graft causes the consumed solid or liquid food to move on too quickly. Therefore, various symptoms may appear which can be summarized under the term "dumping syndrome": among them are diarrhoea, nausea, perspiration, hypoglycaemia, and an inclination to suffer from collapses. If for example a meal with a lot of sugar is taken, it may happen that the glucose is too rapidly absorbed by the blood through the small bowel substitute stomach. This causes a high release of insulin, which in turn is counter-regulated by causing a hypoglycaemia. Or there is a rapid influx of liquid into the bowel after a meal, reducing the volume of the circulating blood and thus causing a collapse. In the case of a substitute stomach (Ulmer stomach), this happens more rarely as the chyme passes normally through the duodenum.

The help of the nutritional counsellor is very important for the patient. Still during his stay at hospital, the patient must learn that he should have many small meals per day, and that these should consist of specific foodstuffs. If the reservoir has enlarged after 3 - 4 months, normal food can be eaten again.

All patients must receive an intravenous injection of an ampoule of vitamin B12 every six months as the absorption of this vitamin necessary for the formation of blood is linked to the so-called gastric intrinsic factor of the mucous membrane of the stomach. If this factor is missing due to the removal of the stomach, there is the danger that anaemia develops.

If the spleen had to be removed during the operation, the patient has to face a slightly increased risk of suffering a thrombosis, which can be reduced by daily taking Aspirin 100. An inoculation against an infection of pneumococci is also necessary as it is well known today that the patient is exposed to an increased risk of infection by encapsulated bacteria after the removal of the spleen.

History

In many idiomatic expressions and proverbs of everyday life, the stomach seems to play an important role: "It affects my stomach. I have butterflies in the stomach. I am not able to stomach it". Everybody knows situations in life causing unpleasant feelings around the stomach. And we do know after all that the consumption of cigarettes, coffee, fats, and various medicaments combined with enough stress may cause heartburn or gastric ulcers. This was already known to doctors at the beginning of the 20th century, but the possibilities of treatment were limited. The patients had to stay in bed and to eat non-irritating food. Later, the gastric acid was held responsible for the formation of ulcers. Hence, the first medicaments to block the gastric acid were developed and used in standard therapy. But amazingly enough, the rate of reoccurring ulcers remained the same. It was not before 1982 that the physicians Robin Warren and Barry Marshall associated the bacterium helicobacter pylori with the formation of gastric ulcers. Since 1996, the bacterium can be removed from the mucous membrane of the stomach by the administration of three medicaments: two different antibiotics and one acid blocker. In the meantime, it has been scientifically proved that helicobacter pylori has a great share in the formation of gastric ulcers and gastritis. Moreover, there are indications that the presence of the bacterium increases the risk of the formation of gastric cancer. The surgical techniques necessary in the case of complicated bleedings of ulcers and carcinomas were developed and carried out for the first time by one of the outstanding surgeons of the 19th century, Theodor Billroth (Vienna 1874). The preconditions to achieve this were favourable at that time. Billroth adopted the methods of antisepsis and sterilization from Joseph Lister, and the narcosis with alcohol, chloroform, and ether had already been firmly established in the operation theatres. Billroth was the founder of stomach and colon surgery and developed those new surgical techniques, which are among the standard interventions of abdominal surgery up to the present day. Billroth's innovative techniques and methods of partial gastrectomy and end-to-end connection with the small bowel opened up entirely new regions of surgery and chances of recovery for the patients. A famous contemporary of Billroth, the German poet and author Theodor Storm, was unfortunately unable to profit from this progress: His work on the famous novelette "The Rider of the White Horse" was clouded by his falling ill with gastric cancer.

 

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