Stomach and Duodenum  
Stomach  
The stomach is connected to the oesophagus and located below the diaphragm. It is an extension of the digestive tract in the upper left part of the epigastric (upper abdominal) region between the liver and the spleen. It lies on top and in front of the pancreas. The stomach has two main functions. It is the first organ of the digestive system and, through its motor function, transports the food which it has broken up into the duodenum, to which it is connected.  
 
   
 
   
   
Duodenum  
Definition
The duodenum is the first short section of the small intestine and has the shape of the letter U lying on its side and facing left. The bile duct and the secretory duct of the pancreas are joined to the upper part of the duodenum. Here, with the aid of the digestive juices from the duodenum, the liver (bile) and the pancreas, the process of breaking down food into its constituent elements begins.
 
   
 
The stomach has been omitted from this illustration in order to show the entirety of the pancreas which lies behind the stomach.
 
   

Methods of Examination
In the following section, the main methods used for the investigation and diagnosis of disorders of the stomach and duodenum are explained. In addition, x-ray and ultrasound examinations can be carried out.

Endoscopy
Illumination and inspection of body cavities and hollow organs the aid of an endoscope. At the same time, a tissue sample (biopsy) can be taken for further examination, possibly in combination with an ultrasound examination (endosonography), and minor surgical procedures can be carried out (e.g. electro or laser coagulation, endoscopic implantation of stents to expand the digestive tract).

Gastroduodenoscopy
Endoscopic examination of the stomach and duodenum using a special flexible endoscope (gastroscope) with the facility to carry out a biopsy (removal of a tissue sample) and minor surgical procedures (above all the cauterisation (haemostasis) of bleeding from any ulcers in the stomach or duodenum, removal of small tumours (polyps), laser therapy, etc.).

When should a gastroscopy be carried out?
- in the case of persistent discomfort of unclear origin in the upper abdomen
- in the case of any repeated discharge of blood or anaemia of unclear origin
- in the case of suspicion of gastric or duodenal ulcers
- in the case of gastric polyps or malignant tumours (gastric carcinoma)

How is a Gastroscopy or Oesophagogastroduodenoscopy carried out?
Following anaesthetisation of the mucous membrane of the throat, a flexible endoscope is passed via the mouth, throat and oesophagus into the stomach and duodenum. If patients wish, they can be given a strong sedative in order that they remain largely unaware of the procedure. The advantage of this form of examination is that changes which indicate disease can immediately be seen and biopsied in order to conduct a fine-tissue analysis of the mucous membrane. Minor surgical procedures, such as cauterisation (haemostasis) can also be carried out via the endoscope.

2. Major Disorders of the Stomach and Duodenum

- Gastritis
- Ulcers (gastric and duodenal ulcers)
- Gastric and duodenal haemorrhages
- Benign and malignant tumours
- Celiac disease (non-tropical sprue)
- Lactose intolerance

3. Complications and Risks
Gastritis is significant because it lays the ground for subsequent diseases such as gastric ulcers and (very occasionally) gastric tumours.

4. Diagnosis / Preliminary Investigations
Usually, a special diagnosis is not required. In most cases the diagnosis is made by chance during a gastroscopy.

5. Therapy / Treatment
In the case of simple gastritis, no treatment is required.

6. After-care
No after-care or follow-up examinations are required.

Disorder 2 Gastric and Duodenal Ulcers

1. Definition and Cause
Gastric and duodenal ulcers are highly localised deep lesions in the mucous membrane, which reach deep into the wall of the stomach or duodenum. In most cases, ulcers are caused by infection through the helicobacter pylori bacterium. In addition, anti-rheumatic drugs are often the cause of gastric ulcers and also, but to a lesser extent, duodenal ulcers.

2. Symptoms / Signs
The pain caused by ulcers consists of a dull burning sensation which is difficult to localise, but which lies somewhere in the middle of the upper abdomen. Sometimes the pain radiates into the back or towards the navel. A feeling of general malaise, nausea and vomiting can also occur as a result of ulcers. A gastric ulcer often causes discomfort after meals, while a duodenal ulcer is more prone to cause discomfort when the stomach is empty.

3. Complications and Risks
Around 10% of ulcers lead to complications. The most common complication is a haemorrhage or a perforation into the abdominal cavity or into neighbouring organs.

4. Diagnosis
A gastroduodenoscopy is the best method of investigation as, in addition to enabling a diagnosis to be made, certain treatments can be carried out, such as cauterisation (haemostasis). Tissue samples can also be taken, to assist in distinguishing between benign and (rare) malignant ulcers. At the same time, confirmation can be obtained as to whether a helicobacter pylori infection is present.

5. Therapy / Treatment
Nowadays, excellent treatment is available for ulcers using drugs which inhibit the production of gastric acid. Normally, ulcers become pain-free within a few days and heal within 4-6 weeks. If there is a helicobacter pylori infection, a course of antibiotics must also be taken. If the ulcers have been caused by medication (e.g. anti-rheumatic drugs), the patient should stop taking these, or only take them along with medication which reduces the production of gastric acid.

6. After-care
A follow-up examination is only required in the case of a gastric ulcer after 6 to 8 weeks, so that it is certain that the ulcer has healed and is not malignant. However, in the event of certain complications, occasional check-ups must be carried out.

 

Disorder 3 Gastric and Duodenal Haemorrhages

1. Definition
Haemorrhages from the oesophagus (cf.), the stomach and the duodenum are classified as upper gastro-intestinal bleeding, as in many cases there is also vomiting of blood.
The most common causes are:
- Gastric and duodenal ulcers
- Superficial mucositis (erosions)
- Varicose veins in the oesophagus or in the stomach (mainly in conjunction with disorders of the liver - cf.)
- Rupture of the mucous membrane of the stomach (Mallory-Weiss Syndrome) in the case of serious vomiting
- Tumours
- Vascular defects
- Other rarer causes

2. Symptoms / Signs
The most common symptom is the vomiting of blood, the passing of black stools or blood in the stools. In addition, due to anaemia, general physical weakness is experienced. Occasionally, the only symptoms of a minor haemorrhage are anaemia and iron deficiency.

3. Complications and Risks
Serious haemorrhages can be life-threatening, causing shock and circulatory collapse, and leading to death.

4. Diagnosis / Preliminary Investigations
A gastroscopy is the main method of investigation, as an immediate diagnosis can be made.

5. Therapy / Treatment
Many haemorrhages stop of their own accord. Most haemorrhages which are still ongoing can be treated during a gastroscopy. Very occasionally, surgical haemostasis is required. The specific therapy to be carried out is determined by the cause of the haemorrhage.

6. After-care
After-care is only required in serious cases. However, where the cause is related to the helicobacter plyori bacterium, tests must be carried out to confirm that the bacterium has been successfully eradicated.

 

Disorder 4 Benign and Malignant Tumours

1. Tumours
We distinguish between benign and malignant tumours. Examples of benign tumours are:
- Non-adenomatous polyps
- Adenomatous polyps
Examples of malignant tumours:
- gastric carcinomas
- primary gastric lymphomas (MALT-lymphoma)
- Carcinoid tumours (Duodenum) and other rare types of tumours such as the Gastrointestinal Stromal Tumor (GIST)

1. Gastric Polyps

Definition
A polyp is a protrusion of the tissue into the gastric cavity. They can occur with a stem, be spherical, or be broad-based and can vary considerably in their size. According to examination under a microscope, they can be classified in various categories which are significant in the treatment and prognosis.

Frequency
The proportion of benign gastric polyps in relation to all new growths in the stomach is around 15%-20%. As one gets older, this percentage increases. Multiple Polyps in the stomach occur in - Polyposis-Syndrome.
- Gardner's Syndrome
- Peutz-Jeghers Syndrome
- Cronkhite-Canada Syndrome
- Juvenile polyposis
- Hereditary adenomatous polyposis
Up to 50% of patients with hereditary adenomatous polyposis have gastric and duodenal adenomas. These have a very high tendency to become malignant. In the other syndromes, the development of malignancy is not so frequent.

Therapy
A distinction is made on examination under the microscope between adenomatous and non-adenomatous polyps. Adenomas must be completely removed due to the risk of their becoming malignant. This is normally carried out in the course of a gastroscopy. Larger tumours normally require the surgical partial excision of the stomach. The removal of non-adematous polyps is optional, as these are not expected to become malignant.

Malignant Tumours

1. Gastric Adenocarcinoma
Causes: Gastric carcinomas can be caused by a multitude of factors. Genetic (hereditary) factors appear to play a minor role. There is a clearer connection, however, with infections with the helicobacter pylori bacterium, which has been discovered to increase the risk up to sixfold. Helicobacter infections cause microscopic injuries to the mucous membrane, and, in the course of the repeated healing process, defective regeneration can occur leading to the formation of a carcinoma.

Frequency
40 in every 100 000 population develop gastric carcinomas every year. The disease is more common among men then women.

Symptoms
Gastric carcinoma is often asymptomatic for a long time, or develops only with uncharacteristic symptoms. The most common symptoms are: - Weight loss - Pain in the upper abdomen - Frequent vomiting - Intolerance of food (normally meat)

Therapy and Prognosis
The preferred treatment is radical surgical removal. In the course of the operation, the whole stomach is removed (or in certain cases only part of the stomach) and replaced by part of the small intestine. If it is not possible to remove the carcinoma in full, due to a serious spread of the tumour or metastasis, supplementary medication similar to a form of chemotherapy is used. Where there is little spread of the tumour, the chances of survival for 5 years or more are reckoned to be 80%.

2. Primary Gastric Lymphoma of MALT-type
Definition Malignant lymphomas are cancer-like tumours growing from the lymphatic tissue which is to be found in the bone marrow, the lymph glands and almost every organ of the body or which migrates to the relevant tissue in the course of an inflammation or infection. The cells of this tissue, lymphocytes, are primarily responsible for the immune defences in the body and play a significant role in the event of inflammation or infection. White blood cells also originate from the lymphatic tissue. The primary gastric lymphoma of the MALT type (mucosa-associated-lymphoid-tissue) is the most common malignant gastric lymphoma. The tumour growth is restricted to the stomach for a considerable period before spreading in its late stages to the lymph nodes and other organs. The causes have yet to be clarified, but in most cases an infection with the helicobacter pylori bacterium (see above) is present, and it is therefore assumed that this is a significant factor in the development of gastric lymphomas.

Symptoms and Signs
The most common symptoms are indigestion, pain in the upper abdomen, general malaise and vomiting. Later, patients can experience weight loss. There are no specific symptoms which permit a clear diagnosis.

Diagnosis / Preliminary Investigations
In order to make a diagnosis, a gastroscopy and biopsy must be carried out. The histological examination can then give a definitive diagnosis. Where it is suspected, clarification will also be sought as to whether a helicobacter pylori infection is present.

Therapy / Treatment
In the early stages it is often sufficient to eradicate the helicobacter pylori infection. After this has been done, the lymphoma regresses. In more advanced stages, an operation, x-ray therapy or chemotherapy will be considered.

After-care
The chances of a cure in the case of this malignant tumour are relatively good. After successful treatment, regular follow-up examinations by the family physician or a specialist are required.


3. Carcinoid Tumours
The carcinoid tumour is a common hormone-producing tumour of the gastro-intestinal tract. It affects intestinal cells which mainly produce a hormonal substance known as serotonin. The majority of these tumours are found in the duodenum (30%), the appendix (45%), or in the rectum (10%).
The main symptoms for patients are a sudden and recurring feeling of heat and reddening of the face, often combined with serious diarrhoea and tachycardia.
The clinical medical examination normally reveals nothing. However, typical indicators are found in the laboratory analysis of blood and urine. In order to locate the tumour, conventional imaging procedures are used, namely abdominal x-rays, ultrasound, CAT or MRI, at the same time locating or excluding secondary tumours (metastases), most particularly in the liver.
In order to treat the disease, the tumour and the section of the intestine affected must in the first place be surgically removed. If it is not possible to do this completely because of the spread of the tumour or metastasis, a supplementary form of chemotherapy will be used.

 

Disorder 5 Celiac Disease (Non-Tropical Sprue)

1. Definition
A disorder of the small intestine which involves atrophy of the villi (villous flattening), digestion problems and diarrhoea and which is caused by intolerance of gluten (gliadin), a constituent part of certain forms of grain. Hereditary factors are of significance in this disorder.

2. Symptoms / Signs
Most patients suffer from diarrhoea and in time experience evident weight loss. Other symptoms include general weakness, abdominal discomfort, signs of malnutrition, and, most particularly, signs of vitamin deficiency.

3. Complications and Risks
The vitamin deficiency can lead to an increased tendency to haemorrhage, which can lead to serious haemorrhages. Due to protein deficiency, oedemas can occur in the legs. The abdomen can become increasingly bloated. In childhood, the disorder can also affect growth. Skin diseases can also occur. If the disorder is left untreated for a lengthy period, malignancies can also occur in the lymph cells (lymphoma).

4. Diagnosis / Preliminary Investigations
The most important form of examination is a duodenoscopy in order to make a biopsy. A diagnosis can normally be made on examining the tissue sample under the microscope. The diagnosis can be confirmed by testing the blood for antibodies to constituent elements of grain (gliadin or endomysium antibodies). On initial diagnosis, an ultrasound examination of the abdomen should be carried out to exclude a lymphoma.

5. Therapy / Treatment
Patients must avoid eating cereals (wheat, rye, oats, barley) for the rest of their lives. They also require detailed advice on their diet. Treatment with drugs is only required in the event of complications.

6. After-care
Where there are no longer any symptoms, the family physician can carry out regular follow-up examinations at fairly lengthy intervals. If symptoms recur, the family physician or a gastro-intestinal specialist should be contacted as soon as possible. Patients are also recommended to join their regional/national support group for the disease, such as the Swiss Support Group for Celiac Disease, which regularly provide information on the latest findings and offer advice on how to deal with the condition.

Disorder 6 Lactose Intolerance

1. Definition
Patients with lactose intolerance experience difficulties in the digestion of lactose in the small intestine. The congenital deficiency of lactase, an enzyme which breaks down lactose, is known as primary lactose intolerance. Secondary lactose intolerance occurs when another disorder of the small intestine causes a reduction in the level of lactose. This can happen, for example, if celiac disease goes untreated.

2. Symptoms / Signs
The most common symptoms are diarrhoea, distension, abdominal cramps, and flatulence, most particularly after the consumption of milk and dairy products.

3. Complications and Dangers
Symptoms of malnutrition, general malaise, weight loss

4. Diagnosis / Preliminary Investigations
If the disease is suspected, a so-called lactose tolerance test can be carried out. The patient is given a precisely measured amount of lactose to drink. Thereafter, the traces of lactose in the blood are regularly measured at short intervals. If there is no increase in these traces, this indicates that the disease is present.

5. Therapy / Treatment
In the case of the primary form, the patient must follow a milk and dairy product-free diet. Yoghurt and sometimes certain varieties of cheese can however be eaten without difficulty. In the case of the secondary form, treatment of the underlying illness is also of fundamental importance.

6. After-care
After-care is not necessary if the symptoms do not recur. In the case of the secondary form, following treatment of the underlying disease, a further lactose tolerance test is advisable.