Peptic Ulcer Disease Case File

Peptic Ulcer Disease Case File

Eugene C. Toy, MD, Lawrence M. Ross, MD, PhD, Han Zhang, MD, Cristo Papasakelariou, MD, FACOG

CASE 24

A 42-year-old male executive complains of abdominal pain that began about 6 months previously; is constant in nature, especially after meals; and is located in the upper midabdomen superior to the umbilicus. He also reports some heartburn that occurred during the previous year. He has been under significant job-related stress and has been self-medicating himself with over-the-counter antacids, with some relief. He states that his stools have changed in color over the previous 2 months and now are intermittently dark and tarry in consistency. The physician tests the patient’s stool and finds occult blood.

⯈ What is the most likely diagnosis?

⯈ What organs are likely to be affected?

ANSWER TO CASE 24:

Peptic Ulcer Disease

Summary: A 42-year-old stressed-out male executive has a 6-month history of constant upper abdominal pain and heartburn for the past year that was relieved by over-the-counter antacids. His stools have become dark and tarry, which upon examination contain occult blood.

• Most likely diagnosis: Peptic ulcer disease

• Organs likely affected: Stomach or duodenum

CLINICAL CORRELATION

This patient has a history typical for peptic ulcer disease, that is, constant midepigastric pain after meals. The patient also has symptoms consistent with gastroesophageal reflux disease. The dark and tarry stools reflect blood in the stools; that is, hemoglobin has been converted to melena. This is suggestive of an upper gastrointestinal bleeding disorder. The next step would be an upper endoscopy to visualize the suspected ulcer. If the stomach is the site, a biopsy is usually performed to assess concurrent malignancy. Treatment includes a histamine-blocking agent, proton pump inhibitor, and antibiotic therapy. The bacterium Helicobacter pylori has been implicated in most cases of peptic ulcer disease. If an ulcer occurs in the duodenum, the posterior wall of the ampulla of the duodenum (duodenal cap) is the usual site. The gastroduodenal artery lies posterior to the duodenum at this point and is at risk in the event of ulcer perforation.

APPROACH TO:

The Stomach

OBJECTIVES

1. Be able to describe the anatomy of the stomach

2. Be able to describe the anatomy of the celiac artery (trunk)

DEFINITIONS

GASTROESOPHAGEAL REFLUX DISEASE: Condition in which gastric contents are regurgitated into the esophagus

PEPTIC ULCER DISEASE: A lesion of the gastric or duodenal mucosa with inflammation

HELICOBACTER PYLORI: Bacterium found in the mucosa of humans and associated with peptic ulcer disease

ENDOSCOPY: Procedure by which the interiors of hollow organs are examined with a flexible instrument called an endoscope

DISCUSSION

The stomach, the first major gastrointestinal organ in which digestion occurs, produces digestive enzymes and hydrochloric acid (HCl). This continuation of the esophagus is a large, intraperitoneal, saccular organ that is suspended by the mesentery-like greater and lesser omenta. The stomach is divided anatomically into a cardia, fundus, body, and pylorus (pyloric antrum and canal with sphincter) and has greater and lesser curvatures. The greater omentum attaches to the greater curvature and drapes inferiorly to form a double-layer apron anterior to the abdominal cavity contents. It fuses superiorly with the transverse mesocolon. The greater omentum is subdivided into gastrocolic, gastrosplenic, splenorenal, and gastrophrenic ligament portions. The lesser omentum is attached to the lesser curvature and first part of the duodenum and extends to the visceral surface of the liver. With the stomach, it forms the anterior boundary of the omental bursa (lesser sac). The lesser omentum is divided into hepatogastric and hepatoduodenal ligaments; the latter form the anterior boundary of the epiploic foramen (of Winslow; see Figure 24-1).

The stomach is richly supplied by five sets of arteries, all of which are branches of the celiac artery (trunk). The celiac artery arises from the abdominal aorta opposite the upper portion of L1. This very short artery quickly divides into three branches.

Figure 24-1. Arterial supply to the stomach. (Reproduced, with permission, from Lindner HH. Clinical Anatomy. East Norwalk, CT: Appleton & Lange, 1989:334.)

The smallest is the left gastric artery, which ascends toward the gastroesophageal junction at the lesser curvature. After sending small branches to the esophagus, it curves inferiorly within the lesser omentum, parallel to the lesser curvature, to which numerous gastric branches are provided. The splenic artery is a large, tortuous branch of the celiac that passes to the left, along the superior margin of the pancreas, to reach the spleen. It sends several branches to the pancreas and, as it approaches the spleen, gives off two sets of arteries to the stomach. Passing superiorly, four to five small short gastric arteries ascend within the gastrosplenic ligament to supply the fundus. Also near the spleen, the left gastroomental (epiploic) artery arises from the splenic artery and passes inferiorly within the gastrosplenic and gastrocolic ligaments. It courses parallel to the greater curvature, to which it sends numerous branches. The last branch of the celiac is the common hepatic artery, which passes to the right to enter the hepatoduodenal ligament. The common hepatic divides into two branches. The proper hepatic artery ascends toward the liver within the hepatoduodenal ligament to supply the liver and gallbladder. The right gastric artery typically arises from the proper hepatic, descends to the gastroduodenal junction, curves superiorly and parallel to the lesser curvature, sends gastric branches to the stomach, and anastomoses with the left gastric artery. The other branch of the common hepatic artery is the gastroduodenal artery, which descends posterior to the first part of the duodenum and then divides into the pancreaticoduodenal and right gastroomental arteries. This latter vessel lies within the gastrocolic ligament and courses to the left, parallel to the greater curvature, to which gastric branches are sent. It anastomoses with the left gastroomental artery along the greater curvature.

COMPREHENSION QUESTIONS

24.1 Gastric contents exiting a posterior perforation of the stomach wall will accumulate in which of the following?

A. The left paracolic gutter

B. The left paravertebral gutter

C. The right paravertebral gutter

D. The omental bursa

E. The hepatorenal recess

24.2 Ligation of the common hepatic artery will eliminate the gastric blood supply through which of the following arteries?

A. Left gastric and short gastric arteries

B. Short gastric and right gastroomental arteries

C. Right gastroomental and right gastric arteries

D. Right gastric and left gastric arteries

E. Left gastric and left gastroomental arteries

24.3 A surgical incision through the fundus of the stomach would require you to clamp which of the following?

A. Right gastric artery

B. Left gastric artery

C. Right gastroomental artery

D. Left gastroomental artery

E. Short gastric arteries

24.4 A 45-year-old woman is brought to the emergency department (ED) with a 4-h history of vomiting dark brown emesis that has a granular component. Examination shows tenderness of the midabdomen. Upper endoscopy shows a bleeding ulcer of the duodenal bulb on the posterior aspect. Which artery has the ulcer most likely have affected?

A. Splenic

B. Right gastroepiploic

C. Left gastric

D. Gastroduodenal

E. Celiac trunk

ANSWERS

24.1 D. The omental bursa lies immediately posteriorly to the stomach.

24.2 C. Blood flow through the right gastric and right gastroomental arteries would be lost with ligation of the common hepatic artery.

24.3 E. The short gastric arteries supply the fundus of the stomach.

24.4 D. The gastroduodenal artery arises from the common hepatic artery and supplies the proximal duodenum. Although duodenal ulcers are typically anterior (which can lead to perforation), deep duodenal ulcers on the posterior aspect can erode into the gastroduodenal artery and lead to significant bleeding.

ANATOMY PEARLS

⯈ The relatively fixed points of the stomach are the gastroesophageal junction and the pylorus, which lie at vertebral levels T11 and L1, respectively.

⯈ The stomach is supplied by all three branches of the celiac artery.

⯈ The short gastric and left gastroomental arteries lie within the gastrosplenic ligament and are at risk in a splenectomy.

References

Gilroy AM, MacPherson BR, Ross LM. Atlas of Anatomy, 2nd ed. New York, NY: Thieme Medical Publishers; 2012:156−157. 

Moore KL, Dalley AF, Agur AMR. Clinically Oriented Anatomy, 7th ed. Baltimore, MD: Lippincott Williams & Wilkins; 2014:230−237, 256. 

Netter FH. Atlas of Human Anatomy, 6th ed. Philadelphia, PA: Saunders; 2014: plates 266−268, 283.

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