GASTRITISES ULCEROUS ILLNESS, CANCER of STOMACH, APPENDECITIS V.Voloshyn 1

Gastritis is inflammation of mucus membrane of stomach. According to motion can be acute and chronic forms. Acute gastritis: Develops as a result of irritation of a mucus membrane by alimentary products, toxic and microbial factors. According to the features of morphological changes there are selected following forms of acute gastritis: CATARRHAL (can be with erosions) FIBRINOUS (crupous, diphteretic) PURULENT (phlegmonous) NECROTIZING (chemical) According to affected area there are distinguished: —Acute diffuse gastritis; —Acute focal gastritis, (fundal part, antral, piloroantral and pyloroduodenal). 2

Erosive gastritis (endoscope research) is erosive hemorrhage damage of gastric mucosa. The reason of it can be frequent use of nonsteroidal anti- inflammatory drugs.) 3

Erosive gastritis (gross) 4

Chronic gastritis Chronic gastritis (gastritis chronica) – multi-etiologic inflammatory-dystrophic diseases of the stomach, which is displayed by violation of the physiological regeneration of the epithelium, atrophy of the mucous membrane, disorders of secretory, motor and endocrine function Violation of regeneration and structural transformation of mucus membrane take part in the morphogeny of chronic gastritis. Such changes leads to slow of parietal cells differentiation. Immature cells appear. They die quickly before completion of their differentiation. That is why chronic gastritis is NOT inflammatory process, but a manifestation of degeneration and violation of regeneration. 5

Morphological classification of chronic gastritis According to topography principle: chronic gastritis is divided into fundal, antral and diffuse According to Houston classification :there are 3 types of chronic gastritis: nonatrophic, atrophic and special forms. 6

Clinical-morphological forms of chronic gastritis Autoimmune gastritis (chronic gastritis type A, “A” chronic gastritis) is more rarer than H.pylori gastritis (in 1-15% cases). The main etiological factor of “A” chronic gastritis is a present of antibodies against parietal cells of stomach or/and again intrinsic factor of Castle’s – gastromucousprotein. Chronic gastritis which caused by Helicobacter pylori, belongs to H. pylori or bacterial (type B). It occurs in about 80% of all cases of chronic gastritis. Chronic reflux-gastritis (chronic chemical gastritis, type C gastritis) is developed at regular regurgitation of bile into stomach in patients after operations on the stomach antrum and at pyloric sphincter deficiency. Special forms of chronic gastritis, such as disease of Menetries, lymphocytic, eosinophilic, granulomatous gastritis. 7 According to etiology and pathogeny features there are selected gastritis A, B and C.

Gastritis A Autoimmune gastritis. Called at appearance of antibodies to gastroprotein of parietal cells (intrinsic factor of Castle’s ). This antibodies block the connection of parietal cells gastroprotein with B12 vitamin. One often meets with other autoimmune diseases (Thyroiditis, Adisson illness). It is localized in a fundal part of stomach. It is observed mainly in the children and old men. It is characterized by fast decreasing of hydrochloric acid secretion (anacidity, achlorhydria), hyperplasia of G-cells and gastrinemia. 8

Gastritis B (unimmune, bacterial gastritis ) Etiology: Helicobacter pilori, which it is found out in 100% of patients; Association with the varied endogenous and exogenous factors (intoxication, violation of nutrition, alcohol abuse); It is localized in antrum part, but can spread to all stomach (i.e. variants: antral, fundal, pangastritis); According activity: acute, remission. 9

Gastritis C (chemical ) reflux-gastritis Related with regurgitation of duodenum maintenance into the stomach. Often arises up in people which had the stomach resection It is localized in antrum part The secretion of HCl is not damaged and the amount of gastrinum is norm. 10

According to morphological manifestation thay select superficial (no atrophy) and atrophy gastritis Superficial Gastritis is characterized by presence of limpho-plasmocell infiltrates in superficial layers of mucus membrane of stomach on the level of platens. Prognosis is favourable. Some time can pass into the gastratrophia. 11

Atrophic Gastritis A mucus membrane is refined, the amount of glands is diminished. There are limphoid- plasmocell infiltrates in an own plate and expressed sclerosis. Characteristic structural alteration with focuses of intestinal and pyloric metaplasia appearance. Intestinal villi appear on the place of rugal folds. Mucus membrane consist of intestinal epithelium with numerous goblet cells. There are focuses of displasia often. The cancer of stomach can develop at heavy epithelium displasia. 12 morphological manifestation

Menetrier Disease (Hypertrophy gastritis) - is a special form of chronic gastritis. The mucous membrane is considerably thickened and has the form of brain gyri. 13

Ulcerous illness This is independent (primary) disease. The chronic recurrence ulcer of stomach or duodenum is the morphological substrate of this disease. Symptomatic ulcers : endocrinal; discirculatoric-hypoxic; toxic; allergic; specific; iatrogenic. 14

Pathogeny of ulcerous illness Hypertone of vagus nerve with increasing of activity of acid-peptic factor. Dysmotility stomach and duodenum. Increasing of level of ACTH and glucorticoid hormones. Considerable predominance of acid-peptic aggression factor above the factors of mucus membrane defense. 15

Morphogeny of chronic ulcer A forming of chronic ulcer passes the stages: 1-erosion, 2- acute ulcer, 3- chronic ulcer. 16 Erosion is a superficial defect which arises up as a result of mucus membrane necrosis. An acute ulcer is more deep defect, which takes place not only in a mucus membrane but also other membranes of stomach wall. It has a wrong rounded- oval form and soft edges

Morphology of chronic ulcer in a stomach is localized on small curvaturen more frequent; in duodenum - on a back wall of a bulb. It has the appearance of deep defect of oval or rounded form, destroys mucus and muscular membranes. The edges of ulcer are dense. Proximal edge is towered and a mucus membrane is hanged over ulcer. Distal one is declivity and has the appearance like terrace. 17

A microscopic manifestation depends from stage of ulcer At the remission stage. The cicatrice tissue situated on the ulcer bottom and ousts the muscle layer with single sclerosed and obliterated vessels. At the stage of acute condition: 4 layers are differentiated expressly on the ulcer bottom: fibrinoid- purulent exsudate, fibrinoid necrosis, granulation and fibrotic tissue whith sclerosed vessels. 18

The complications of ulcerous illness I. Ulcerous-cicatrical: stenosis of the entrance and initial openings of stomach; stenosis and deformation of duodenum bulb. II. Ulcerous-destructive: perforation of ulcer; penetration (in a pancreas, wall of colon, liver); bleeding. III. Malignization of ulcer. IV. Inflammatory: Gastritis, perigastritis; Duodenitis, periduodenitis. V. Combined complications. 19

20 Bleeding from ulcer

The diseases which are belong to the group of enhanceable risk of stomach cancer development : Adenoma of stomach (adenomatous polypus); Chronic atrophic gastritis; Pernicious anaemia (Adisson-Birmer disease); Chronic ulcer; Stump of stomach. 21 Tubular Adenoma ONLY HEAVY DYSPLASIA of epithelium is the precancer process in a stomach.

Classification of stomach cancer According to localization: 1. Pyloric (50%) gastric carcinoma. 2. Lesser curvature of the stomach (27%) with the transition on back and front walls 3. Cardial gastric carcinoma (15%). 4. Greater curvature of the stomach (3%). 5. Fundal gastric carcinoma (2%). 6. Total gastric carcinoma (3%). 22

Macroscopic forms of cancer Cancer with mainly exophitic expansive growth:  Superficial spreading type (like plate);  Pulipous type;  Fungating (resembling a mushroom) type;  Ulcerative type (primary- ulcerative, cancer-ulcer, ulcer- cancer (cancer from chronic ulcer). 23

 Ulcerative-invasive; (infiltrating type);  Diffusely spreading type (Linitis plastica);  Diffuse;  Carcinoma with exophytic and endophytic growth (mixed types of carcinoma). Macroscopic forms of cancer (continue) 24 Cancer mainly with endophytic infiltrating growth:

According to the histological signs there are the following types of gastric carcinoma Adenocarcinoma: tubular, papillary, mucoid, trabecular (well-differentiated). Squamous-cell carcinoma. Adenosquamous carcinoma. Solid carcinoma (poorly-differentiated). Undifferentiated carcinoma (medullar, fibrotic cancer – scirrhous (characterized by endophytic diffuse growth forms). 25

Signet-ring cell Adenocarcinoma Adenocarcinoma (is the form of more differentiated cancer) and situated at exophytic growth of tumour more frequently 26

Clinic-anatomic (macroscopic ) forms of stomach cancer 27

Metastases ways of stomach cancer 28 There are: -lymphogenic, -haematogenic, -implant ways of metastases.

Retrograde metastases have the role as the diagnostic moment among distant lymphogenic metastases: - In both ovaries (Krukenberg tumor); - In a pararectal tissue (Shnitsler metastases); - In the left supraclavicular lymphnode (Virchow's gland). 29 The first metastases arise up in regional lymphatic ways along large and lesser curvature of stomach. Haematogenic metastases arise up in a liver and in lungs.

Implant metastases Implant metastases result to canceromatosis of peritoneum, pleura, pericardium, diaphragm. 30 Metastatic carcinoma (paraaortic)

Appendicitis – the inflammation of appendix vermiformis of cecum Reasens of Acute appendicitis Obstruction of appendix with the resistance decline of mucus membrane and the wall invasion by microorganisms Unobstructive appendicitis can arise as the secondary at generalized infectious diseases (viral). 31

Morphological forms Simple (it is accompanied by disorders of blood circulation, small hemorrhages, a little leucocytes accumulation – primary affect; Superficial is characteristic by hearth of purulent inflammation in a mucus membrane; Destructive (irreversible damage of the wall of appendix). 32

Phlegmonous Phlegmonous-ulcerous Apostematic Gangrenous (1- at a thrombosis and thrombembolus of artery - is primary gangrenous; 2- at periappendicitis and purulent mesenteriolitis - secondary gangrenous. Morphological forms (continuous) 33 Destructive forms:

Complication of acute appendicitis Perforation With development of suppurative peritonitis; With development of periappendicular abscess. Empyema of appendix Spread of infection by portal vein branches may propagate to the liver; this was formerly an important cause of portal pyemic abscesses in the liver 34

Chronic Appendicitis Develops after the acute appendicitis. It is characterized by sclerotic and atrophy processes, lympho-histiocell infiltrations. Sometimes obliteration of appendix leads to hydropsy or Mucocele of Appendix. Myxoglobules can be formed in it (myxoglobulosis). 35

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