Stomach and Duodenum L 3 Hawler Medical University

Stomach and Duodenum L 3 Hawler Medical University College of Medicine Department: Surgery Rawand M. Haweizy Senior Lecturer M. B. Ch. B, MSc, MRCS e. mail: rawand_haweizy@yahoo. com

Objectives l l l To learn types of Gastritis and its aetiology and clinical pictures. To learn treatment of variable types of Gastritis. To learn Peptic Ulcer and its clinical features.

Contents • Gastritis Ø Ø Type A gastritis Type B gastitis Reflux gastritis Erosive gastritis Stress gastritis Miscelaneous types • Peptic ulcers: Ø Duodenal ulcer Gastric Ulcer Ø Ø Ø

Introduction l l l Gastritis is most common disease that affecting gastric mucosa, may be acute or chronic Recently NSAIDs and H. Pylori major cause of gastritis. Many types can be prevented especially stress and erosive gastritis. Peptic ulcer still occur commonly despite advance in medical treatment. H. Pylori most important agent in pathogenesis of PU Recently , nearly all cases can be treated by proton pump inhibitor and to prevent recurrence eradication therapy should be used in all cases.

Gastritis l l l Produces inflammation of the mucosa. Can be associated with erosions and bleeding. Causes: – H. pylori, NSAIDS, bile reflux, radiation, local trauma, physiologic stress.

Type A gastritis l l l Autoimmune condition circulating antibodies to the parietal cell. Results = atrophy of the parietal cell mass= hypochlorhydria = achlorhydria. Intrinsic factor = malabsorption of vitamin B 12= pernicious anaemia. Antrum not affected = hypochlorhydria = high levels of gastrin. Chronic hypergastrinaemia=hypertrophy of the ECL cells( not affected by the autoimmune damage). Microadenomas ( ECL cells of the stomach).

Type A gastritis cont, d l l Sometimes becoming identifiable tumours. Very rarely become malignant. Type A gastritis predisposed to gastric cancer. Screening by endoscopy.

Type B gastritis l l l Associations with H. pylori infection. Most commonly affects the antrum Prone to peptic ulcer disease.

Type B gastritis cont, d l l l Data suggest that Helicobacter may initiate the process. Patients with pangastritis most prone to gastric cancer. Intestinal metaplasia associated with chronic pangastritis= atrophy. Intestinal metaplasia associated with dysplasia = significant malignant potential. Endoscopic screening may be appropriate.

Reflux gastritis l l l Caused by enterogastric reflux. Particularly common after gastric surgery. Its histological features are distinct. Occasionally found in patients with no previous surgical intervention or Who have had cholecystectomy.

Reflux gastritis cont, d l l l Bile-chelating or prokinetic agents useful in treatment. Measure to avoid the consideration of revisional surgery. Operation should be reserved for the most severe cases.

Erosive gastritis l l Caused by agents that disturb the gastric mucosal barrier. NSAIDs and alcohol are common causes. NSAID-induced gastric lesion=inhibition of the cyclooxygenase type 1 (COX-1) enzyme. Reducing the production of cytoprotective prostaglandins in the stomach.

Stress gastritis l l Common sequel of serious illness or injury. Characterized = reduction in the blood supply to superficial mucosa of stomach. Not usually recognized unless stress ulceration and bleeding supervene. Treatment can be extremely difficult.

Stress gastritis cont, d l l Sometimes follows cardiopulmonary bypass. Prevention is much easier than treating it. Routine use of H 2 -receptor antagonists, barrier agents (sucralfate), in intensive care. These measures reduce the incidence of bleeding from stress ulceration.

Ménétrier’s disease l l l Unusual condition. Characterized by gross hypertrophy of the gastric mucosal folds. Increase mucus production and hypochlorhydria. Pre-malignant. May present with hypoproteinaemia and anaemia. Treatment = gastrectomy.

Menetrier’s Disease cont, d l l l Patient’s usually present with: – Pain, N/V, occult hemorrhage, anorexia, wt loss and diarrhea. Disease progression is marked by protein-losing gastropathy. DX: UGI endoscopy w/ biopsy.

Menetrier’s Disease

Lymphocytic gastritis l l Seen rarely. Characterised by the infiltration of the gastric mucosa by T cells. Probably associated with H. pylori infection. The pattern of inflammation( coeliac disease or lymphocytic colitis).

Other forms of gastritis l l Eosinophilic gastritis: an allergic basis , treated with steroids and cromoglycate. Granulomatous gastritis seen rarely in Crohn’s disease and tuberculosis. Acquired immunodeficiency syndrome (AIDS) gastritis is secondary to infection with Cryptosporidium. Phlegmonous gastritis rare bacterial infection of the stomach ( patients with severe intercurrent illness)

Gastritis cont, d l l S&S: – Nausea, emesis, hematemesis, melena, hematochezia, etc. Treatment: – Prevention, removal of offending agent, acid supression, occ gastric decompression and support.

Peptic Ulcer Disease

Peptic Ulcer Disease cont, d l Peptic ulcer suggests pepsin, essentially unimportant l In the absence of acid(type A gastritis with atrophy, peptic ulcers do not occur). l All peptic ulcers healed by proton pump inhibitors. l Render a patient virtually achlorhydric.

Peptic Ulcer Disease cont, d l Common sites first part of the duodenum and the lesser curve of the stomach. l Occur on the stoma following gastric surgery l The oesophagus. l Meckel’s diverticulum, which contains ectopic gastric epithelium.

Aetiology l l l l Ulcer in the epithelium least resistant to acid damage. Gastric acid levels are higher in the ulcer group. Gastrinoma (Zollinger–Ellison syndrome). Genetic factors. Social stress. Infection with H. pylori. NSAIDs. Cigarette smoking.

Gastric ulceration Incidence: l H. pylori and NSAIDs important factors. l Gastric ulceration associated with smoking. l Marked differences between populations affected.

Gastric ulceration cont, d l l l Gastric ulceration less common than duodenal ulceration. Incidence equal between the sexes. Population tends to be older. More prevalent in low socioeconomic groups. More common in the developing world.

Gastric Ulcers cont, d

Gastric Ulcers cont, d Pathology l l l Gastric ulcers larger than duodenal ulcer. Fibrosis= hourglass deformity. Large chronic ulcers erode posteriorly into the pancreas. Major vessels such as the splenic artery. May erode into other organs (transverse colon). Chronic gastric ulcers more common on lesser curve.

Gastric ulcers cont, d

Summary Ø Ø Ø Gastritis, inflammation of gastric mucosa can be caused by bacteria, viruses, physical, chemical and even trauma Gastritis precursor for gastric ulcer , can lead to severe bleeding and perforation. No PU without acid(NO ACID, NO ULCER). H. Pylori , main aetiology in pathogenesis of PU. First part of Duodenum commonest area affected by PU. Next lecture: malignancy of gastric ulcer and management of PU.