Esophagus, Stomach & Duodenum, Biliary System, Liver, Spleen, Pancreas, Peritoneum, Appendix, Small & Large Intestine, Anal Canal, Review Subjects, Hernia, Testis & Scrotum, Pediatric surgery

Esophagus

  • Starts at the level of C6.
  • Esophageal Anatomy:
    • Cervical part lies behind the trachea.
    • Thoracic esophagus lies behind the left main bronchus and pericardial sac; related to lung, pleura, and vagus nerve.
    • Pierces the diaphragm via esophageal hiatus at T10, extending ~2.5 cm into the abdomen before joining the stomach.
  • Venous Drainage: Inferior thyroid, azygos, hemiazygos, and left gastric veins.
    • Venous anastomosis (Porto-systemic) in the sub-mucosa of the lower esophagus drains to the azygos veins and hence to the vena cava, or to the gastric veins and hence to the liver via the hepatic portal vein.
  • Physiological Narrow Areas:
    • Cricopharyngeus sphincter.
    • Behind the aortic arch and the left main bronchus.
    • At the esophageal hiatus.

Dysphagia

  • Dysphagia: Difficulty in swallowing.
  • Odynophagia: Painful swallowing.
  • Causes:
    • Mouth: Stomatitis, glossitis, neoplasms of the tongue and cheek.
    • Pharynx: Pharyngitis, retropharyngeal abscess, Plummer Vinson syndrome, pharyngeal diverticulum, post-cricoid carcinoma.
    • Esophagus:
      • Mechanical:
        • Lumen: Foreign bodies.
        • Wall:
          • Congenital: Atresia.
          • Traumatic: Corrosive or post-operative stricture.
          • Inflammatory: Reflux esophagitis.
          • Neoplastic: Carcinoma.
          • Schatzki's ring: Distal esophageal ring of unknown etiology, treated by dilation if symptomatic.
        • Compression from outside: Malignant thyroid, malignant lymph nodes, aortic aneurysm, mediastinal tumors.
      • Neuromuscular:
        • Achalasia of the cardia.
        • Diffuse esophageal spasm.
        • Paralysis of glossopharyngeal or vagus nerves.
        • Tetanus.
        • Myasthenia gravis.
        • Hysteria.
  • Investigations:
    • Chest X-ray.
    • Barium swallow.
    • Pharyngoscopy and esophagoscopy.
    • Manometric studies.
    • CT scan of the chest.

Esophageal Atresia

  • Newborn with frothy saliva should be considered to have esophageal atresia until proved otherwise.
  • Incidence: 1:4000.
  • Etiology: Defect in division of proximal foregut into ventral tracheobronchial tube and dorsal esophageal tube.
  • Pathology:
    • Saliva and milk fill upper pouch, trickle into trachea causing bronchopneumonia and frothy saliva.
    • Acidic gastric juice regurgitates through tracheo-esophageal fistula into lungs causing acid pneumonia.
  • Types: Proximal blind atresia with distal tracheo-esophageal fistula (85%) is the commonest type. Other rare types include atresia without fistula.
  • Associated Anomalies (VACTERL):
    • Vertebral.
    • Anorectal.
    • Cardiac.
    • Tracheal.
    • Esophageal.
    • Renal.
    • Limb anomalies.
  • Clinical Picture:
    • Antenatal diagnosis: Maternal polyhydramnios, dilated upper pouch on ultrasound.
    • At birth:
      • General: Frothy saliva, milk regurgitation, attacks of cyanosis.
      • Chest: Pneumonia.
      • Abdomen: Abdominal distention with air if the fistula is large, or scaphoid abdomen if there is atresia without fistula.
  • Investigations:
    • Passage of a rigid, radio-opaque (F 10) tube down the esophagus.
    • Plain X-ray of chest and abdomen after inserting a nasogastric tube; presence of gastric air bubble confirms fistula.
  • Treatment:
    • Diagnosis before or immediately after birth is essential.
    • Atresia with fistula: Right thoracotomy, ligation of fistula, primary anastomosis of esophageal ends.
    • Atresia without fistula: Gastrostomy at birth, further surgery months later to restore esophageal continuity.

Esophageal Injuries

  • Foreign Bodies: Removed by rigid or fiberoptic esophagoscopy.
    • Three points of physiological narrowing of the esophagus: cricopharyngeus sphincter, behind the aortic arch and the left main stem bronchus, at the esophageal hiatus.
  • Esophageal Perforation:
    • Etiology:
      • Traumatic: Instrumental, foreign bodies, penetrating or blunt injuries, swallowing corrosives.
      • Pathological: Carcinoma.
      • Spontaneous: Vomiting and incoordinate esophageal motility; partial (Mallory-Weiss syndrome) or complete tear.
    • Clinical Picture:
      • Severe pain.
      • Acutely ill with fever, tachycardia, hypotension.
      • Mediastinal and subcutaneous emphysema.
    • Investigations:
      • Plain chest X-ray shows mediastinal emphysema or hydropneumothorax.
      • Gastrograffin swallow shows the site and extent of rupture.
    • Treatment:
      • Cervical: Nil by mouth, intravenous fluids, drainage, intensive antibiotics.
      • Thoracic: Early suture of perforation and chest drainage; Late esophagectomy and gastric pull-up operation with chest drainage.

Corrosive Injury of Esophagus

  • Etiology: Chemical burn due to swallowing corrosive acids or alkalis.
  • Pathology:
    • Extent of damage depends on chemical concentration and tissue contact duration; alkalis are more injurious than acids.
    • May involve oropharynx, larynx, esophagus, or stomach.
    • Injured wall replaced by scar tissue, leading to stricture.
  • Management:
    • First aid treatment:
      • Swallowing water or milk.
      • Gastric lavage is contraindicated.
      • Analgesics, corticosteroids, antibiotics.
      • Endotracheal tube in cases of stridor or dyspnea.
    • Investigations:
      • Esophagoscopy: performed after 24 hours except in patients with suspected perforation; avoid damaged area.
      • Barium swallow: Smooth, long, multiple strictures.
    • Dilatation:
      • Not started before the end of the first week.
      • Criteria of success: Subjective improvement in swallowing, progressive increase in dilator diameter, patient gaining weight.
    • Surgery:
      • Indications: Failure of dilatation, need for frequent dilatations, dilatation is hazardous or difficult.
      • Gastrostomy can improve patient's condition before definitive surgery.
      • Colon bypass operation.

Neuromuscular Abnormalities of Esophagus

  • (A) Diffuse Esophageal Spasm (Corkscrew Esophagus):
    • Normal peristaltic waves replaced by simultaneous, repetitive, prolonged contractions.
    • Main symptom is retrosternal pain rather than dysphagia.
    • Treatment: Long myotomy from aortic arch to cardia.
  • (B) Achalasia:
    • Definition: Functional disorder characterized by weak peristaltic waves and failure of the cardiac sphincter to relax during swallowing.
    • Result: Functional obstruction with progressive dilatation of the esophagus.
    • Etiology: Presumed degeneration of vagal fibers and ganglia of Auerbach's plexus.
    • Clinical Picture:
      • Incidence: More in the second to the fourth decades. Equal in males and females.
      • Dysphagia: Long standing, slowly progressive, painless, more for fluids than solids; intermittent at first, then constant.
      • Regurgitation: Foul smelling fluid, especially nocturnal.
      • Pulmonary symptoms: Aspiration, wheezing, chronic cough.
      • General condition: Usually reasonable till late.
    • Investigations:
      • Plain X-ray: May show fluid level in the thorax.
      • Barium swallow: Moderate to huge dilatation of the esophagus, tortuosity (sigmoid esophagus), smooth rounded termination (Hen's beak), absence of air in the fundus.
      • Esophagoscopy: Dilated esophagus full of retained food and fluids; cardia does not relax; excludes carcinoma.
      • Manometric studies: Weak peristaltic waves, failure of cardia relaxation.
    • Differential Diagnosis: Other causes of dysphagia, esophageal causes (mainly from carcinoma).
    • Complications: Pulmonary complications, esophagitis, ulceration, carcinoma.
    • Treatment:
      • Drugs: Nitrates (limited value).
      • Forceful dilatation: Balloon inflated at cardia region ruptures circular muscle fibers; risk of perforation.
      • Surgical myotomy (Heller's operation):
        • Esophago-Cardiomyotomy via thoracic or abdominal approach.
        • Expose lower esophagus and cut muscle fibers until mucosa bulges; anti-reflux procedure may be added.
      • Botulinum toxin injection: In wall of the esophagus at the spastic segment.

Congenital Diaphragmatic Hernia

  • Newborn with cyanosis and scaphoid abdomen in the absence of heart disease should be considered as having congenital diaphragmatic hernia until proved otherwise.
  • Pathology:
    • Types: Posterior or Bochdalek (90%), anterior or Morgagni, hiatal hernia, eventration of diaphragm.
    • Complications: Ipsilateral lung hypoplasia, contralateral lung compression, ischemia of herniated abdominal contents.
  • Clinical Picture:
    • Respiratory distress, cyanosis & tachypnea.
    • Heart sounds are better heard on the right side (left sided hernia).
    • Intestinal sounds may be rarely heard on the chest.
    • The abdomen is scaphoid.
  • Investigations:
    • Antenatal ultrasound is diagnostic.
    • Chest X-ray reveals gas shadow of stomach or bowel in the thorax.
    • Blood gases.
  • Treatment:
    • Surgical: abdominal approach, reduce herniated contents, close defect directly/use mesh.
    • Recently: Intra-uterine surgical correction, ECMO, nitric oxide and toulazoline for pulmonary vasodilatation.

Esophageal Hiatus Hernia

  • May be sliding (85%), paraesophageal (5%), or mixed (10%).
  • Sliding Hiatus Hernia:
    • Due to disturbance in the mechanism responsible for the competency of the lower esophageal sphincter.
    • Lower esophageal sphincter is a physiological rather than an anatomical sphincter.
    • Gastro-esophageal competence maintained by: Intra-abdominal segment of the esophagus, oblique angle of insertion (Angle of His), fibers of the right crus of the diaphragm, mucosal rosette of the upper end of the stomach.
    • Etiology: Increased intra-abdominal pressure, decreased elasticity of the right crus.
    • Pathology:
      • Cardiac orifice and adjoining part of stomach herniate through hiatus; small empty peritoneal sac on the left side.
      • Esophago-gastric junction is no more in the abdomen; reflux of acid gastric juice leads to esophagitis or ulceration.
      • Reflex esophageal spasm, fibrous stricture, Barrett's esophagus (columnar epithelium).
    • Clinical Picture: Occurs more after the age of forty years and it is more common in females:
      • GERD Syndrome: Retrosternal discomfort, acid regurgitation, pulmonary symptoms, dysphagia.
      • Bleeding may occur due to esophagitis or ulceration.
    • Investigations:
      • Barium meal in the Trendlenburg's position: Epiphrenic bulge, widening of the esophageal hiatus, reflux of barium.
      • Esophagoscopy: Cardia opens on inspiration, reflux of gastric juice, complications as esophagitis, ulceration and stricture.
      • Manometric studies: Loss of normal high-pressure zone at the lower esophagus.
      • PH study (most important): Low PH recording during periods of symptoms.
    • Treatment:
      • Conservative measures: Reduction of body weight, elevation of bed head, frequent small meals, avoidance of citrus juices, tomatoes and chocolates, avoid lifting weights, excessive bending and wearing of tight corsets.
      • Drugs: Proton pump inhibitors, H2 blockers, antacids.
      • Indications for surgery: Failure of medical treatment, complications, presence of another condition necessitating surgery.
      • Principles of surgical interference: Reduce gastro-esophageal junction below diaphragm, reduce size of esophageal hiatus (Nissen's fundoplication).
  • Paraesophageal (rolling) hernia:
    • Hernial sac where the greater curvature of the stomach or entire stomach protrudes in the posterior mediastinum.
    • The esophago-gastric junction lies below the diaphragm and so reflux esophagitis does not occur.
    • Clinical Picture: Intermittent dysphagia, post-brandial pain, pressure on the heart, & occasionally strangulation.
    • Investigations:
      • Plain X-ray chest: May show gastric gas shadow in the chest.
      • Barium meal: Will reveal herniated stomach; the esophago-gastric junction is in its normal location.
    • Treatment: Only Surgical: The stomach is retracted downwards, the hernial sac is excised and the hernial defect is closed.

Gastro-Oesophageal Reflux Disease (GORD)

  • Commonest upper GIT disorder (45% of population).
  • Peptic oesophagitis is the commonest endoscopic diagnosis (25% of patients doing upper endoscopy).
  • Up to 50 reflux episodes can occur every 24 h.
  • Mechanisms resisting reflux include:
    • Competence of the cardiac esophageal junction due to the effect of the lower oesophageal sphincter (LOS) maintaining a high-pressure zone of 15−25cmH2O15-25 cm H_2O physiologically.
    • Esophageal clearance of the Refluxate:
      • Volume clearance due to normal peristalsis during swallowing.
      • Chemical clearance by swallows saliva.
  • Factors promoting reflux and damage:
    • Dysfunction of the cardiac esophageal junction:
      • Primary weakness of the LOS.
      • Short length of the intra-abdominal esophagus.
    • Gastric distention impaired gastric emptying whether organic or functional.
  • Clinical Picture:
    • Typical symptoms: Heartburn, regurgitation, dysphagia and water brush.
    • Atypical symptoms:
      • Chest pain, pulmonary manifestation (simulating bronchial asthma), persistent cough, change in the voice and chocking episodes.
      • Rarely anemia or hematemesis in case of sever esophageal erosions.
  • Complications:
    • Variable degrees of erosions and ulcerations.
    • Formation of strictures and shortening of the esophagus.
    • Barrett's esophagus (columnar metaplasia).
  • Investigations:
    • Upper GIT endosopcy:
      • To evaluate the degree
      • To detect the presence of hiatus hernia
      • To take a biopsy form a suspicious lesion.
    • Esophageal manometry to test the pressure of LOS.
    • PH study.
  • Treatment:
    • Conservative treatment in the majority of cases as a 1st line of treatment:
      • Weight reduction will markedly improve the symptoms.
      • Stop smoking, alcohol.
      • Avoidance of large fatty spicy acidic meals.
      • Avoidance of recumbency after meals for at least 2 h.
      • Elevation of the head and bed 15 degree to reduce the reflux.
      • Anti-acids, H2 blockers, Proton pump inhibitors and prokinetic drugs.
    • Surgical treatment; indicated for:
      • Failure of medical treatment.
      • Development of complications; sever esophagitis, strictures or persistent anemia.
      • Atypical symptoms.
      • Non-compliance of the patient.

Carcinoma of the Esophagus

  • Incidence: Usually after the age of 50 years; in males more than females, except in the cervical esophagus more common in females.
  • Predisposing Factors:
    • Chronic irritation by certain diets, excessive alcohol intake and smoking.
    • Corrosive stricture of the esophagus, achalasia, long-standing reflux esophagitis, Barrett's esophagus.
  • Pathology:
    • Site: Mid 1/3 (45-50%), lower 1/3 (33%), least = upper 1/3 and cervical esophagus.
    • Gross Appearance: Annular scirrhous lesion (commonest), malignant ulcer with raised everted edges, fungating mass.
    • Microscopic Appearance:
      • Squamous cell carcinoma (commonest); may be well differentiated with anaplastic features.
      • Adenocarcinoma may occur in the lower esophagus due to carcinoma on top of columnar-cell lined lower esophagus as in Barrett's esophagus, or upward spread of gastric carcinoma.
    • Staging:
      • Tx: Cannot be assessed.
      • Tis: Carcinoma in situ.
      • T0: No evidence of primary tumor.
      • T1: Tumor less than 5 cm in length.
      • T2: Tumor > 5 cm.
      • T3: Any size with extra esophageal spread.
      • Nx: Cannot be assessed.
      • N0: No clinical plausible LNs.
      • N1: Mobile unilateral LN affection.
      • N2: Mobile bilateral LN affection.
      • N3: Fixed LNS.
      • Mx: Cannot be assessed.
      • M0: No evidence of distant metastasis.
      • M1: Distant metastasis.
  • Spread:
    • Direct: Circumferential and longitudinal wall spread; infiltration of adjacent structures as trachea, pericardium, pleura, recurrent laryngeal nerves & the stomach.
    • Lymphatic:
      • Cervical esophagus: drains into cervical lymph nodes.
      • Thoracic esophagus: drains into tracheal, tracheobronchial & posterior mediastinal lymph nodes.
      • Lower esophagus: drains into left gastric and celiac lymph nodes.
    • Blood Spread: Late.
  • Clinical Picture:
    • Progressive continuous dysphagia is the main symptom; at first for solids, then soft diet, and lastly for fluids; patient cannot swallow his own saliva.
    • By the time patient complains of dysphagia about 2/3 of the circumference of esophagus is involved by the tumor.
    • Pulmonary problems, severe and progressive loss of weight.
    • Hematemesis is not a common symptom.
    • Symptoms due to infiltration of adjacent structures as change of voice or recurrent chocking.
    • Signs of dissemination as pleural effusion, ascites, lymph node enlargement, hepatomegaly, and jaundice.
  • Differential Diagnosis: Other causes of dysphagia esophageal causes (mainly from achalasia).
  • Investigations:
    • Barium swallow: Annular lesions show irregular narrowed segment with shouldering; cauliflower like lesions produce persistent irregular filling defects; peristaltic waves may be absent above the lesion.
    • Esophagoscopy and biopsy.
    • Bronchoscope to detect infiltration of the trachea or bronchi.
    • Plain X-ray chest to detect pulmonary deposits or malignant effusion.
    • Abdominal ultrasound can reveal liver deposits or ascites.
    • Endoluminal ultrasound can detect invasion of the mediastinum and lymph node enlargement.
    • CT scan can demonstrate the extent of the lesion, and the presence of infiltration of adjacent structures.
  • Treatment:
    • Many patients are diagnosed when the lesion has reached an advanced stage and the chance of cure is very low.
    • Inoperable cases:
      • Criteria of inoperability: Unfit patients, advanced local spread (tracheo-esophageal fistula, recurrent laryngeal paralysis, infiltration of pleura/pericardium, supraclavicular, celiac lymph nodes), distant metastases.
      • Palliative Treatment:
        • Radiotherapy: 4500 rads over 4 weeks; useful for carcinomas of the upper esophagus; complications include hemorrhage, perforation and pneumonia.
        • Intubation: Rigid tube through the stenosed segment (Souttar & Celestin).
        • Palliative surgery: Colon-by pass or gastric pull-up (high mortality).
        • Laser photocoagulation.
        • Gastrostomy: Does not relieve the patient for the inability to swallow his own saliva.
    • Operable Cases:
      • Surgery: Resect the lesion with an adequate safety margin (10 cm), and restore gastrointestinal tract continuity.
      • Post cricoid carcinoma: Either radiotherapy or total laryngeo-pharyngectomy.
      • Tumors of the lower 1/3 of the esophagus: Left thoraco-abdominal incision, esophagogastric anastomosis.
      • Tumors of the middle 1/3 (Ivor Lewis): Mobilize stomach through midline incision, open thorax through 5th intercostal space, excise esophagus down to cardia, esophagogastric anastomosis.
      • Total esophagectomy: Transhiatal approach and pulling the mobilized stomach up to the neck (gastric pull-up);
        • Advantages: Adequate safety margin, stomach can be mobilized easily, esophago-gastric anastomosis performed in the neck (technically easy; if leakage occurs, it will be in the neck and does not lead to mediastinitis).
      • Radiotherapy: Has a very important role especially in upper and middle third.
      • Surgical procedures for replacement of the esophagus: Gastric pull-up, colon replacement, pectoralis major myocutaneous flap, free jejunal replacement with microvascular anastomosis.

Congenital Hypertrophic Pyloric Stenosis

  • Incidence:
    • 3/10003/1000
    • M:F = 4:1
    • More in first born babies
    • More in babies whose mother had pyloric stenosis as a neonate
    • More during spring and autumn
  • Etiology:
    • Unknown, may be genetic or environmental. Muscular factors are probably involved
  • Pathology:
    • Gradual progressive hypertrophy of the circular pyloric muscles with gradual occlusion of the gastric outlet.
    • The thickened pylorus fades gradually towards the gastric side and ends abruptly towards its duodenal end.
    • The stomach at first hypertrophies to overcome obstruction but later it dilates.
  • Clinical picture:
    • Symptoms:
      • Projectile, progressive non-bilious vomiting, classically 2-3 weeks after birth
      • After vomiting the infant is very hungry
      • It is usually associated with firm stools and loss of weight
    • Signs:
      • General signs of dehydration
      • Abdominal:
        • Test feed: The mother is asked to feed the baby, and then the examiner inspects the abdomen for visible peristalsis passing from left to right.
        • Palpate the abdomen for the olive like pyloric mass (tumor).
  • Differential diagnosis:
    • From other causes of neonatal vomiting:
      • Gastroenteritis.
      • Gastro-esophageal reflux.
      • Feeding problems.
      • Other obstructive lesions of the gut e.g. intestinal obstruction.
  • Investigations:
    • Ultrasound: Is the imaging of choice.
    • Barium meal: Only if the tumor is not clinically palpable, or is doubtful (10%). It will show dilated obstructed stomach & may show string sign.
    • Laboratory investigations: Serum electrolytes, acid-base balance. It will show Hypokalemia, hyponatremia & alkalosis.
  • Treatment:
    • First aid:
      • Correct the dehydration and the electrolyte imbalance.
      • Stop oral feeding.
      • Usually it takes 24 hours to rehydrate the baby to be fit for surgery.
  • Operation (Ramstedt's operation):
    • The hypertrophied pylorus is grasped between the index and the thumb and a myotomy is performed until the mucosa of the pylorus bulges. If the mucous membrane is injured, the injury should be sutured and reinforced by an omental patch.
    • The results of this operation are excellent and the mortality should be around zero.

Peptic Ulcer

  • Definition: An ulcer, caused by acid-pepsin digestion of mucous membrane.
  • Sites: Duodenum (commonest), stomach, lower esophagus, jejunum after gastrojejunostomy, rarely in the small intestine adjacent to a Meckel's diverticulum containing ectopic gastric mucosa
  • Etiology:
    • The Gastro-Duodenal mucosal barrier is formed of: The mucus secreted by the mucosa, the bicarbonate secreted by the mucosa, the rapid repair of mucosal injuries, the abundant mucosal blood flow, the prostaglandins.
    • Factors that weaken the Gastro-Duodenal mucosal barrier: Drugs, e.g. Aspirin & NSAIDs have Anti-PG effect, reflux of bile, Helicobacter pylori infection, ischemia.
    • Results of its disturbance: Ulceration either acute or chronic.

Acute Peptic Ulcer

  • Two varieties: Multiple erosions, True stress ulcers
  • Etiology:
    • Multiple erosions:
      • Non-steroidal anti-inflammatory drugs.
    • True stress ulcers:
      • Failure of the gastric mucosal barrier due to: Vascular injury with ischemia of mucosa.
      • This may occur in the following conditions: Seen in patients in the ICU, severe trauma, after major burns, endotoxic shock.
  • Size: From 1 mm (erosions) to 1 cm.
  • Site: Occurs in the body and fundus.
  • Clinically:
    • Multiple erosions:
      • Indigestion (rarely recognized at this stage).
      • Acute upper GIT bleeding.
    • True stress ulcers:
      • Picture of the cause.
      • Severe upper GIT bleeding.
  • NB:
    • In burns both types of ulcers occur; true stress ulcers (Curling's ulcer) occur early in the body or fundus of the stomach while an acute duodenal ulcer occurs late during convalescence.
    • It is controversial if Cushing's ulcer that occurs after intracranial trauma or operation is true stress ulcer or not.
  • Diagnosis: Diagnosis is by endoscopy.
  • Treatment:
    • “Prophylaxis is better than cure”: H2 blockers, omeprazole, intraluminal antacids and sucralfate have an important role in prophylaxis.
    • Conservative:
      • Urgent resuscitation.
      • Withdrawing of the offending drug if any.
      • Sucralfate and IV H2 blocking agents.
      • Intraluminal antacids to maintain an intraluminal PH of at least 5 may be effective.
      • Prostaglandins have been tried for their cytoprotective role.
    • Surgery:
      • Indications: Failure to control bleeding by conservative measures.
      • Methods: Total gastrectomy (high morbidity and mortality); Lesser resection procedures are less effective.
    • Endoscopy: Recently bleeding may be controlled by: Injection of vasoconstrictors, laser photocoagulation, thermal contact.

Chronic Peptic Ulcer

  • Duodenal ulcer:
    • Age: 30-40 years.
    • Incidence: M:F = 5:1; decreasing in Egypt; many younger patients are seen; ratio of duodenal to gastric ulcer is about 25: 1.
    • Etiology: Not well resolved; is associated with increased gastric acidity, which may be due to genetic predisposition, increased vagal tone, abnormality of gastrin release and inhibition, Helicobacter pylori, hypergastrinemia, liver dysfunction, the use of NSAID's.
    • Pathology:
      • Size: Usually small.
      • Site: In the 1st part of the duodenum more commonly on the posterior wall and less on the anterior. Sometimes two ulcers occur one on the anterior, the other on the posterior wall, the so-called