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Pathology of

the Stomach Aiman Zaher, MD



Objectives

• At the end of this segment, when given a

clinical presentation, gross specimen and/or

photomicrograph, students will be able to: !ompare and contrast the clinical presentations,

etiologies, pathogenesis, gross and microscopic

changes found in developmental, inflammator",

circulator", mechanical, and neoplastic disordersof the stomach#



Objectives

• At the end of this segment, when given aclinical presentation, gross specimen and/or

photomicrograph, students will be able to: $redict the clinical complications associated withdiseases of the stomach#

Define the words in the glossar"#



%lossar"

• Acute gastric ulceration

• &'cavated

• &'oph"tic

• Helicobacter pylori

• ("pertrophic gastropath"

• )initis plastica

• $eptic ulcers

• $h"tobe*oars

• $"loric stenosis

• +ugae

• richobe*oars

• -lcers in cancer



Robbin’s

7th Edition,

Fig. 17-12a

.ormal Anatom"

• +ugae longitudinal

infoldings of both mucosa

and submucosa on the

inner surface of thestomach

• %astric wall comprised of a

mucosa, submucosa,

muscularis propria, andserosa



Congenital

Anomalies



!ongenital Anomalies• Heterotopic rests

$ancreatic rests located in the p"lorus become

inflamed leading to obstruction

%astric rests in duodenum or more distal sites

undergo peptic ulceration, leading to bleeding %astric rests in upper esophagus lead to

inflammation and discomfort

• Diaphragmatic hernia +esults from defective closure of the diaphragm,

usuall" on the left

Ma" be as"mptomatic or cause respirator"

problems for newborns



!ongenital Anomalies• Pyloric Stenosis 0!ongenital ("pertrophic $"loric 1tenosis2

3ncidence 4/5667866 live births

M:9 57:4

Ma" be associated with urner 1"ndrome, risom" 4;and esophageal atresia

$resents as regurgitation and persistent projectile

vomiting at 2-3 weeks of age

+esults from h"pertroph" and possibl" h"perplasia ofmuscularis propria of p"lorus

0$"loric stenosis can also be ac<uired in adults as a

complication of antral gastritis, peptic ulcer, carcinoma,

or prolonged p"loric spasm#2



PJ Goldblatt, MD

$"loric 1tenosis

7Morpholog"

("pertroph" of

Muscularis $ropria



Inflammatory

Diseases



%astritis

• Definition

3nflammation of the gastric mucosa

Histologic diagnosis=

• Often clinicall" overused term and, at the

same time, under diagnosed

Most patients with chronic gastritis are

as"mptomatic#



Acute %astritis• Definition

An acute mucosal inflammator" process, with

neutrophilic infiltrate, that is usuall" transient#

here ma" be hemorrhage into the mucosa orsloughing of the mucosa#

1evere erosive form is an important cause of

severe %3 bleeding



Acute %astritis• &tiolog"

9re<uentl" associated with, among others:

• heav" use of .1A3D1, especiall" aspirin

• e'cessive alcohol consumption

• heav" smo>ing

• severe stress e#g# trauma, burns, surger"

• 3schemia

• 1"stemic infection

Often, idiopathic



Acute %astritis 7

$athogenesisIn concert or

inivi!allyAci secretion

" #ack iff!sion"

$icar#onate

#!ffer

"

$loo flow

Disr!ption

of

%!c!s layer"

Direct

%!cosal

Inj!ry

Ac!te &astritis

%



Acute %astritis 7 Morpholog"

PJ Goldblatt, MD

+anges from edema with neutrophil infiltration, vascular congestion, and an

intact epithelium, to erosion 0mucosal defect that does not cross the muscularis

mucosa2 and hemorrhage#

%



Acute %astritis 7 Morpholog"

PJ Goldblatt, MD PJ Goldblatt,MD



Acute %astritis

• !linical 9eatures

broad range of signs and s"mptoms that depend on the

severit" of the the condition

• As"mptomatic

• &pigastric pain, nausea ? vomiting

• (emorrhage, massive hematemesis, melena, or fatal blood loss

One of the major causes of massive hematemesis,

particularl" in alcoholics# @BC patients ta>ing aspirin for rheumatoid arthritis will

develop acute gastritis, and some will bleed



!hronic %astritis

• Definition

!hronic mucosal inflammator" changes leading to

atroph" and metaplasia 0usuall" without erosions2

• D"splasia and ultimate neoplasia are

complications#



!hronic %astritis• &tiolog"

Man" causes but two important t"pes:

86C of patients with antral chronic gastritis:

Helicobacter pylori infected

• Motile, gram negative curvilinear rods that elaborateurease 0buffers gastric acid2 ? to'ins and have adhesins

to bind to the epithelium

• !oloni*ation rate increases with age: B6C of adults over

B6 in the -1

Autoimmune 7 antibodies to parietal cells, gastrin

receptor, intrinsic factor, and (D,ED A$ase

• F46C of cases of chronic gastritis

• $ossible autosomal dominant inheritance



!hronic %astritis

• $athogenesis

H. pylori 0urease → .(:D to'ins2 (ost 0acid peptic

en*"mes2 → !hronic 3nflammation

Antibodies → %land destruction Mucosal atroph" → ↓

acid ± ↓ intrinsic factor 0which can lead to pernicious

anemia2



!hronic %astritis• Morpholog"

Gar"ing degrees of mucosal damage possible

Mucosal lesions are reddened, with thic>ened rugae

Atrophied rugae in long7standing cases

)"mphoc"tes and plasma cell infiltrateH neutrophilsindicate IactiveJ inflammation 0ma" or ma" not be present2

'egeneration 7 constant feature

%etaplasia 7 mucosa of antral and bod"7fundic regionsconverts to columnar absorptive cells and goblet cells

0intestinal metaplasia2 Atrophy 7 mar>ed loss of glands

Dysplasia precursor lesion to gastric cancer in atrophicgastritis



H. pylori %astritis 7 Morpholog"

Web Path

H. pylori organisms along

superficial mucus la"er of

antral biops"

A t i % t iti M h l



Autoimmune %astritis 7Morpholog"

PJ Goldblatt, MD

Diffuse mucosal damage of the #oy an f!nic

m!cosa# Antrum less involved#



• !linical 9eatures -suall" onl" a few s"mptoms: nausea, vomiting,

upper abdominal discomfort

H. pylori

• Most infected person have gastritis, but areas"mptomatic

• ("pochlorh"dria, but .O achlorh"dria and perniciousanemia 0parietal cells never completel" destro"ed2

• %astrin normal to slightl" elevated

• Antibiotics are treatment of choice Autoimmune 9orm

• ("po to achlorh"dria 0severe loss of parietal glands2

• ("pergastrinemia

• 46C have pernicious anemia

!hronic %astritis



!hronic %astritis

• !linical !omplications

H. pylori

• H. pylori predisposes to peptic ulcers in duodenum and

stomachKMost patients with a peptic ulcer are infected#• +is> of gastric carcinoma and lymphoma

Autoimmune 9orm

• Often seen in association with other autoimmune

disorders 0(ashimoto th"roiditis, Addison disease, and

t"pe 3 diabetes2

• 1ignificant ris> for the development of gastric

carcinoma 07C2 and enocrine t!mors 0carcinoid

tumor2



$eptic -lcers• Definition

A breach in the mucosa that e'tends into thesubmucosa or deeper#

!hronic relapsing and solitar" lesions, F cm

diameter 0e'cept in Zollinger7&llison 1"ndrome2

• )ocation

!an occur an"where in the %3 tract where there is

e'posure to acid/peptic juices, but most common

in the !oen!m and stomach



$eptic -lcers

• About 46C of American men and C American women will develop them#

• Diagnosed middle7aged to older adults#

• M:9H gastric 4#B7:4H Duodenal 5:4H womenafter menopause#

• +ecentl", decreased incidence of duodenal

ulcers for un>nown reasons, but not gastric

ulcers



$eptic -lcers• (tiology an Pathogenesis

Appear to be produced b" imbalances between

the gastroduodenal mucosal defense mechanisms

and the damaging forces of gastric acid and

pepsin#

("peracidit" is not a pre7re<uisite since onl" aminorit" have it with duodenal ulcers, and even

fewer with gastric ulcers

-lceration occurs when

• mucosal blood flow decreased

• gastric empt"ing is dela"ed

• epithelial restitution is impaired



$eptic -lcers 7 $athogenesis• (# p"lori

Onl" 4676C of infected individuals develop ulcers

$resent in virtuall" all !oenal an )*+ of

gastric !lcers

&ven without invading the tissue, this organism

causes intense inflammator" and immune

responses



$eptic -lcers 7 $athogenesis

Robbin’s

7th Edition,Fig 17-7



$eptic -lcers 7 Morpholog"• Gast majorit" located in pro'imal duodenum or the

lesser curvature of the stomach• 4676C of people with a gastric ulcer also have a

duodenal ulcer

• 3f F 6#5cm, the" are most often erosions, L 6#cmusuall" ulcers

• !hronic gastritis ? H. pylori infection almost universal

• !lassic appearance is a round to oval, sharpl"punched7out defect with straight walls and a smoothbase

• Active ulcers histologicall" have:

thin la"er of necrotic debris with fibrin

neutrophils below

monoc"tes and granulation tissue below that

solid fibrous scar

$ ti -l M h l



$eptic -lcers 7 Morpholog"

GRIPE

Chronic

Gastritis

$ ti -l M h l




GRIPE

$ ti -l M h l




GRIPE



$eptic -lcers• !linical 9eatures

&pigastric gnawing, burning or aching pain

!an present with iron7deficienc" anemia, fran> hemorrhage,

or perforation

Norse at night and 475 hours after eating

+elieved b" food or antacids most of time Other signs include belching, nausea, vomiting, chest pain

boring to the bac> 0with perforation2

!hronic, recurring lesions that impair <ualit" of life

-ntreated can ta>e an average of 4B "ears to heal versus a

few wee>s w/ treatment

Malignant transformation does .O occur with duodenal

ulcers and rare with gastric ulcers

!omplications include bleeding, perforation, and obstruction

from edema and scarring



Zollinger7&llison 1"ndrome

• Multiple peptic ulcerations in the stomach,duodenum, and jejunum

• Due to e'cess gastrin secretion b" a tumor

0gastrinoma2, leading to e'cess gastric acidproduction



Acute %astric -lceration

• Definition

Multiple lesions in stomach and occasionall" the

duodenum that range from erosions to ulcerations

he erosions are e'tensions of acute gastritis he deeper lesions are well7defined ulcers, but are

.O precursors to chronic peptic ulcers



Acute %astric -lceration• &tiolog"

.1A3D1 or severe ph"siologic stress 0IstressulcersJH shoc>, burns, sepsis, and severe trauma2

C!rling !lcers asstd w/ severe burns or traumaHoccur in pro'imal duodenum

C!shing !lcers asstd w/ intracranial injur",operations or tumorsH occur in stomach,duodenum, and esophagusH high incidence ofperforation

• $athogenesis 7 similar to acute gastritis .1A3D1 inhibit c"cloo'"genase and

prostaglandins

3ntracranial injur" directl" stimulate vagus nuclei,leading to increased acid production

Acute %astric -lceration Morpholog"



Acute %astric -lceration Morpholog"-suall" F4 cm, multiple circular lesions found an"where in the stomach and duodenum



Acute %astric -lceration

!omplications

Must remove underl"ing condition for healing to occur

• Mucosa can recover completel" in this case

Most criticall" ill patients admitted to 3!- acutel" develophistologic evidence of gastric mucosal damage

• 47C will bleed and re<uire transfusion



%echanical



%astric Dilation• &tiolog" and $athogenesis

Outlet obstruction• p"loric stenosis

• paral"tic ileus

• intralumenal concretions e#g# be*oars 1tomach ma" hold up to 4674B liters of fluid, leading to

rupture

1tomach is the primar" site for development of luminalconcretions of indigestible ingested material

• Phyto#e,oars concretions of plant matter

• richo#e,oars AEA IhairballsJ

• i*arre be*oars associated with illicit drug ta>ers, glueswallowers, and neurops"chiatric patients 0pins, nails, ra*orblades, etc#2



PJ Goldblatt, MD

!"i#hobe$oa" %the" be$oa"s



("pertrophic %astropath"

• Definition

!haracteri*ed b" cerebriform enlargement of the

gastric rugal folds

!aused b" mucosal epithelial h"perplasia, withoutinflammation

• hese conditions ma" mimic infiltrative

carcinoma or l"mphoma on e'amination

• &'cess acid secretion associated with thesedisorders predisposes to peptic ulcers



("pertrophic %astropath"

• "pes MPnPtrierQs disease:

• occurs in males in the th7th decades

• h"perplasia of mucous cells, with atroph" of glands

• gastric secretions contain e'cessive mucus and little acid

protein loss h"poproteinemia 0protein7losinggastropath"2

("pertrophic7h"persecretor" gastropath":• h"perplasia of parietal and chief cells in gastric glands

%astric %land ("perplasia:• secondar" to e'cessive gastrin secretion from

gastrinoma 0Zollinger7&llison 1"ndrome2

$arietal cell h"pertroph" without e'cess acid seenin chronic use of acid secretion inhibitors



Morpholog"

PJ Goldblatt, MD



.eoplasms

enign $rocesses



enign $rocesses

• ("perplasic $ol"ps

Mucosal masses that project above the level of

the surrounding mucosa, single or multiple

Majorit" in patients with achlorh"dria, atrophic

gastritis and pernicious anemia

Most often seen with chronic gastritis

.o malignant potential

enign $rocesses



enign $rocesses• Adenomas

rue neoplasms with proliferative d"splasticepithelium

Have malignant potential

-suall" single and in the antrum

1essile or pedunculated

3ncidence goes up with age, especiall" the R6s

M:9 :4

6C have malignant foci when removed and ris> ofmalignanc" in adjacent mucosa as high as 56C

Associated with chronic gastritis with intestinalmetaplasia and autoimmune gastritis

• Hyperplastic an aenomato!s polypscannot #e ifferentiate enoscopically/

they m!st #e #iopse0



%astric !arcinoma• &pidemiolog"

8678BC of malignant tumors of the stomach are

carcinoma

1econd most common tumor in the world

• 3ncidence particularl" high in Sapan, parts of 1outh America, !hina, $ortugal, +ussia, and ulgariaH but 7T

less common in the -1, -E, !anada, Australia

)ower socioeconomic groups

M:9 :4 3ncidence has declined in most countries

#BC of all cancer deaths in -#1# and leaing

ca!se of cancer eath worlwie

B "ear survival F 6C in the -1

% t i ! i



%astric !arcinoma

• +is> 9actors &nvironmental: .itrites 0from food preservatives2,

smo>ed and salted foods, pic>led vegetables,

deficienc" of fresh fruits and vegetables, cigarette

smo>ing

(ost 9actors: chronic atrophic gastritis,

adenomatous pol"ps, partial gastrectom" and H.

pylori infection 0ris> increased B7T2

%enetic 9actors: more common in persons withblood group A, famil" histor" of gastric cancer



%astric !arcinoma

• !lassification Depth of 3nvasion

• %reatest impact on clinical outcome

• &arl" form confined to mucosa and submucosa# %ood

prognosis 08678BC B7"ear survival rate with surgical

treatment2

• Advanced form has e'tended into muscular wall#

1pread is b" local invasion, l"mphatics, blood 0to liver

and lungs2 and trans7celomic# ad $rognosis 0F4BC B7

"ear survival2

% t i ! i



%astric !arcinoma• !lassification

According to Macroscopic %rowth $attern:• $resent in both earl" and advanced forms

&'oph"tic mass protrudes into lumen

9lat/depressed no obvious tumor mass

&'cavated 0-lcerative2 shallow or deepl" erosive crater

1init!s Plastica broad portion of gastric wall or entirestomach is e'tensivel" infiltrated with malignanc", creatinga rigid, thic>ened appearance li>e a Ileather bottleJ

According to (istologic $attern• 3ntestinal t"pe: glandular, e'pansile growth pattern

$redominates in high7ris> areas and develops fromprecursor lesions

• %astric t"pe: infiltrating pattern of poorl" differentiatedcellsH signet ring conformation mucin e'pansion incells puts nuclei at the peripher"

3ncidence the same ever"where and no >nown precursorlesion



%astric !arcinoma

• )ocation

!urvatures

• 6C 7 )esser !urvature

• 4C 7 %reater !urvature

Other

• B676C 7 $"lorus and Antrum

• BC 7 !ardia

• +emander od" and 9undus

&arl" %astric !arcinoma



Ea"l& Gast"i# 'a"#ino(a

Defined as being confined to the mucosa and submucosa

regardless of l"mph node metastasis

)ate %astric !arcinomaDefined as e'tending below the submucosa into muscle

regardless of l"mph node metastasis Robbin’s )th Edition

*d+an#ed Gast"i# 'a"#ino(a

%astric !arcinoma 7 Morpholog"




GRIPE

&'oph"tic %rowth $attern




%astric !arcinoma Morpholog"

GRIPE




GRIPE

&'cavated %rowth $attern:

(eaped7up, beaded margins

and necrotic base

differentiate this cancer from

chronic peptic ulcer


3ntestinal Gariant 7 Morpholog"



3ntestinal Gariant Morpholog"

Web Path

!omposed of glandsresembling colonic

adenocarcinoma




Web Path


Diffuse Gariant 7 Morpholog"



Web Path

%astric7t"pe mucus cells

that donQt form glands,

but rather permeate thewall as individual cells or

clusters





Web Path


1ignet +ing !ells - Morpholog"



1ignet +ing !ells Morpholog"

Web Path



%astric !arcinoma• !linical 9eatures

3nsidious disease

As"mptomatic until late in the course

Neight loss, abdominal pain, anore'ia, vomiting, altered

bowel habits

1ometimes d"sphagia, anemia, and hemorrhage

(arly etection important

•Sapan uses endoscopic screening programs, resulting in 5BC ofnewl" diagnosed gastric carcinoma being found in an earl" stage

• -1 ? &urope onl" catch 4674BC in the earl" stage



%astric !arcinoma• !linical !omplications

)ocal invasion of pancreas, duodenum, andretroperitoneum

At death, peritoneum seeded and mets to liver and lungscommon#

Metastasis to regional and distant nodes• 9re<uentl" mets to 4irchow5s noe 0supraclavicular node2 as

the first clinical manifestation

Mets to Ovaries 6r!ken#erg !mors

• $rognosis Determined b" depth of penetration and e'tent of nodal

involvement, not histolog"

1urgical resection w/ or w/out adjuvant chemotherap"

and radiation



Other %astric .eoplasms

• )ess common gastric tumors

)"mphomas 0BC2H but the stomach is the most common

site for e7tranoal lymphoma 06C2

%3 stromal tumors

.euroendocrine cell tumorsK!arcinoids 0rare2

)ipomas

Metastatic cancers 0unusual2



+eferences

• Eumar, Abbas, ? 9austo: +O3.1 ? !O+A.

$A(O)O%3! A131 O9 D31&A1&, Rth &dition,

pp# ;467;R#

stenosis 1

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