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Peptic ulcer disease. Gastritis. Complications.

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Gastritis can occur suddenly (acute gastritis) or gradually (chronic gastritis). Causes Gastritis can be caused by infection, irritation, autoimmune disorders, ... – PowerPoint PPT presentation

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Title: Peptic ulcer disease. Gastritis. Complications.


1
Peptic ulcer disease. Gastritis. Complications.
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  • Gastritis is an inflammation of the lining of the
    stomach. There are many possible causes of this
    disorder including an infection, an irritant, an
    autoimmune disorder, or a backup of bile into the
    stomach. Gastritis can occur suddenly (acute
    gastritis) or gradually (chronic gastritis).

4
  • Causes
  • Gastritis can be caused by infection, irritation,
    autoimmune disorders, or backflow of bile into
    the stomach (bile reflux). Gastritis can also be
    caused by a blood disorder called pernicious
    anemia.
  • Infections can be any of the following types
  • Bacterial (usually Helicobacter pylori)
  • Viral
  • Parasitic
  • Fungal

5
  • Irritation can be caused by a number of things,
    such as the following
  • Long-term medication use (for example, aspirin,
    ibuprofen or other anti-inflammatory drugs
    called NSAIDS)
  • Alcohol use
  • Cigarette smoking
  • Chronic vomiting
  • Coffee and acidic beverages
  • Excess gastric acid secretion (such as from
    stress)
  • Eating or drinking caustic or corrosive
    substances (such as poisons)

6
  • Risk Factors
  • Infection with H. pylori
  • Acquired immunodeficiency syndrome (AIDS)
  • Any condition that requires relief from
    persistent pain using NSAIDS
  • Alcoholism
  • Cigarette smoking
  • Older age
  • Genetic abnormalities

7
  • CLASSIFICATION OF CHRONIC GASTRITIS
  • ADOPTED AT THE 9TH INTERNATIONAL CONGRESS OF
    GASTROENTEROLOGISTS
  • ( SYDNEY 1990) , MODIFICATED IN HOUSTON IN 1994
  • 1. CHRONIC NONATROPHIC ( CHRONIC HELICOBACTERIC
    GASTRITIS , CHRONIC ANTRIAL , TYPE B) , WHICH
    REPRESENTS ALMOST 70 OF ALL GASTRITS TYPES.
  • 2. CHRONIC ATROPHIC GASTRITIS ( AUTOIMMUNE ,
    DIFFUSE GASTRITIS OF STOMACH CORPUS , ASSOCIATED
    WITH PERNICIOUS ANEMIA , ATROPHIC , TYPE A ) ,
    PRESENT IN 15 18 CASES OF CHRONIC
    GASTRITIES CHRONIC MULTIFOCAL GASTRITIS.
  • 3. SPECIAL FORMS OF CHRONIC GASTRITIS
  • CHEMICAL ( REACTIVE CHRONIC GASTRITIS , WHICH
    OCCURS IN CASE OF BILE REFLUX ( ABOUT 15 )
    , AFTER NSAID THERAPY ( ABOUT 10 )
  • GRANULOMATOUS ( IN CASE OF CROHNS DISEASE ,
    SARKOIDOSIS , TUBERCULOSIS )
  • EOZINOPHILIC ( IN CASE OF BRONCHIAL ASTHMA ,
    FOOD ALLERGY )
  • LYMPHOCYTIC ( WITH MANIFESTED LYMPHOCYTIC
    INFILTRATION OF EPITHELIUM )
  • GIGANT HYPERTROPHIC GASTRITIS ( MENETRIERS
    DISEASE )
  • RADIATION GASTRITIS

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  • Type B (Chronic antral gastritis)
  • It principally affects the antrum and is
    associated with the presence of Helicobacter
    pylori on the surface epithelium. If organism is
    not present serological tests show antibodies
    against Helicobacter pylori.
  • Pathology
  • Presence of inflammatory cells such as
    lymphocytes, plasma cells.
  • Gastric atrophy destruction of antral mucus
    glands
  • Intestinal metaplasia.
  • Proliferation or lymphoid tissue within the
    gastric mucosa.

9
  • Type A (autoimmune gastritis)
  • It is an autoimmune disorder involving the fundic
    glands of stomach that secretes both the
    intrinsic factor and acid. The antibodies destroy
    the parietal cells with loss of acid and
    intrinsic factor.
  • Intrinsic factor deficiency leads to pernicious
    anemia because intrinsic factor is required for
    the absorption of vitamin B12.
  • Loss of acid secretion leads to achlorhydria.
    Achlorhydria leads to hypergastinemia that may
    lead to carcinoid tumors in about 5 of patients.

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  • Signs and Symptoms
  • Abdominal pain
  • Indigestion (also called dyspepsia)
  • Heartburn
  • Hiccups
  • Loss of appetite
  • Nausea
  • Vomiting, possibly of blood (called hematemesis)
    or material that looks like coffee-grounds
  • Dark stools

11
  • Diagnosis
  • There are several tests that may be done to make
    a diagnosis.
  • These include endoscopy of the stomach. This
    allows the doctor to see into stomach and, if
    necessary, take samples (called a biopsy) from
    the lining.

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  • normal mucous coat of stomach
  • acute gastritis

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  • Type B (Chronic antral gastritis)
  • Type A (autoimmune gastritis)

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  • The laboratory tests may need will depend on the
    specific cause of gastritis.
  • A stool test may be used to check for the
    presence of blood, or a biopsy may be taken of
    the tissues of stomach to determine the cause of
    discomfort.
  • A breath test may detect H. pylori, or samples
    from stomach may be taken to look for this
    organism.

17
  • Treatment
  • The treatment of gastritis depends on the cause
    of the problem. The cure for gastritis caused by
    ingesting irritating substances is to stop the
    long-term use of these substances, which may
    include
  • Alcohol
  • Tobacco
  • Acidic beverages such as coffee, carbonated
    beverages, and fruit juices with citric acid
  • NSAIDS, such as aspirin and ibuprofen switch to
    other pain relievers (like acetominophen)
  • Eat a fiber-rich diet
  • Avoid high fat .

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  • Medications
  • Medications are often necessary to relieve
    symptoms, eradicate an infection such as H.
    pylori, and prevent or treat complications from
    gastritis such as an ulcer.
  • Helicobactor pylori infestation, a common
    bacterial cause of gastritis and ulcers, is
    typically treated with a combination of drugs.
    The typical combination includes antibiotics, a
    bismuth compound, and a proton pump inhibitor.
    (Proton pump inhibitors reduce stomach acid
    secretion.)

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  • In addition to the medications used for
    Helicobacter pylori infection, other medications
    that may be used to relieve symptoms of gastritis
    include those that reduce stomach acid secretion
  • Antacids such as calcium carbonate and magnesium
    hydroxide with aluminum salts
  • H2 blockers such as ranitidine, cimetidine,
    nizatidine, and famotidine
  • Proton pump inhibitors such as omeprazole and
    lansoprazole

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  • In case of atrophic gastritis, either stimulating
    or replacement therapy is administered.
    Stimulating therapy includes metabolic drugs,
    replacement therapy includes gastric juice or
    acidin pepsin.

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  • Peptic Ulcer
  • Peptic ulcer is a general chronic and relapsing
    disease characterized by seasonal exacerbations
    with ulceration of the stomach wall or the
    duodenum.

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  • Causes
  • When the stomach's natural protections from the
    damaging effects of digestive juices (including
    acid and pepsin an enzyme that helps breakdown
    protein) stop working or the acid production is
    too overwhelming for these protective defenses to
    work properly, person can get an ulcer.
  • There are a few different ways this happens.
  • Helicobacter pylori (H. pylori), a bacterial
    organism, is responsible for most ulcers. This
    organism weakens the protective coating of the
    stomach and duodenum and allows the damaging
    digestive juices to irritate the sensitive lining
    below.

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  • Non-steroidal anti-inflammatory drugs (NSAIDs)
    ongoing use of this class of medications is the
    second most common cause of ulcers.
  • These drugs are acidic and they block
    prostaglandins, substances in the stomach that
    help maintain blood flow and protect the area
    from injury.
  •  

25
  • ZollingerEllison syndrome people with this
    uncommon condition have tumors in the pancreas
    and duodenum that produce gastrin, a hormone that
    stimulates gastric acid production.
  • Other causes of ulcers are conditions that can
    result in direct damage to the wall of the
    stomach or duodenum such as heavy use of alcohol,
    radiation therapy, burns, and physical injury.

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  • Risk Factors
  • Genetic factors may predispose to developing an
    ulcer
  • Chronic pain, from any cause such as arthritis,
    fibromyalgia, repetitive stress injuries or
    persistent back pain, leading to ongoing use of
    aspirin or NSAIDs
  • Alcohol abuse
  • Diabetes may increase risk of having H. pylori

27
  • Living in crowded, unsanitary conditions
    increases the risk of H. pylori infection
  • Immune abnormalities may, in theory, make it more
    likely for H. pylori or other factors to cause
    damage to the lining of the stomach or duodenum.
  • Lifestyle factors, including chronic stress,
    coffee drinking and smoking.
  •  

28
  • PATHOGENESIS
  • An ulcer forms when there is an imbalance between
    aggressive factors (e.g. acid and pepsin) and
    defense factors.
  • In peptic ulceration, initial damage to defensive
    mucosal barrier results from Helicobacter pylori
    infection, NSAIDS, smoking and other factors.
    This damage of mucosal barrier facilitates the
    damaging effect of acid and pepsin.
  • Ulcers occur only in the presence of acid and
    pepsin they are never found in achlorhydric
    patients (i.e. no acid, no ulcer). Therefore we
    can say that aggressive factors (Helicobacter,
    NSAIDS, smoking) break the defensive mucosal
    barrier and then acid pepsin cause destruction
    and ulceration.

29
  • Signs and Symptoms
  • Abdominal pain
  • Heartburn
  • Indigestion (dyspepsia)
  • Belching
  • Nausea
  • Vomiting
  • Poor appetite
  • Weight loss

30
  • PAIN
  • Site Epigastrium
  • Character Burning in character
  • Radiation
  • Pain is localized and patient is able to point it
    with his one finger "pointing sign".
  • Time of pain
  • Soon after eating within 15-30 minutes in gastric
    ulcer while 2-3 hours after eating in duodenal
    ulcer that frequently awakens the patient at
    night.
  • Relation with food
  • Patient with gastric ulcer are afraid to eat
    because it causes pain due to release of acid in
    response to food. Patients with duodenal ulcer
    feel pain in empty stomach and get relief after
    taking food which causes partial neutralization
    of acid. Then in response to food there is
    increased acid secretion which causes pain after
    2-3 hours.

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  • Aggravating factors
  • Smoking
  • Excessive intake of coffee and tea
  • Alcohol
  • Eating precipitates pain in gastric ulcer while
  • missing a meal in duodenal ulcer.
  • Relieving factors
  • Antacids and milk
  • Vomiting relieves pain in gastric ulcer
  • Intake of food relieves pain in duodenal ulcer
  • Periodicity
  • Pain comes and goes in a 2-3 month cycle in
    gastric ulcer
  • In duodenal ulcer episode occurs with 4-6 month
    cycle, often worse in spring and autumn.
  • Relapse occurs more frequently in smokers than in
    non smokers.
  • Duration of attack
  • A few weeks in gastric ulcer
  • A month or two in duodenal ulcer

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  • VOMITING
  • Vomiting relieves pain of gastric ulcer and some
    patients force themselves to vomit after eating
    to relieve symptoms. It is uncommon in duodenal
    ulcer.
  • Other symptoms
  • Few patients present with haematemasis, due to
    perforation of the ulcer even in the absence of
    prior history of epigastric pain. Take history of
    melena also.
  • Some patients may not have pain. They may
    complain of nausea and retrosternal burning.
  • ON CLINICAL EXAMINATION
  • Deep tenderness in epigastrium is present in most
    of the cases.

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  • COMPLICATIONS
  • Hemorrhage
  • Perforation
  • Penetration
  • Pyloric obstruction
  •  Malignization

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  • Perforation

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  • Penetration

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Pyloric obstruction
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  • Malignization

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malignant neoplastic transformation
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  • Investigation
  • One of two tests will be performed to try to
    identify an ulcer
  • Upper gastrointestinal (GI) series
  • Endoscopy
  •  
  • For the upper GI, patient drink a chalky liquid
    called barium and then a series of x-rays may
    reveal an ulcer.

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  • The endoscopy, which is more accurate, allows
    both direct visualization of organs for an ulcer
    or other problems and sampling of tissue from the
    walls (called biopsies) of the stomach and small
    intestines to test for H. pylori.

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  • Lumen of the duodenum of a healthy human male.
    White spots are reflections of the light source.

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DIAGNOSIS OF H.PYLORI
  • Histology
  • Rapid urease activity test
  • Culture  
  • Urea breath test with BC or 14C
  • Serological test
  • The breath test, which is the least invasive, is
    proving to be at least 95 accurate.

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  • Urea breath test

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  • Treatment
  • The main goals for treating a peptic ulcer
    include eliminating the underlying cause
    (particularly H. pylori infection or use of
    NSAIDs), preventing further damage and
    complications, and reducing the risk of
    recurrence. Medication is almost always needed to
    alleviate symptoms and must be used to eradicate
    H. pylori.

57
  • Doctors used to recommend eating bland foods with
    milk and only small amounts of food with each
    meal. Dietary and other lifestyle measures that
    should help, however, include
  • Eat a diet rich in fiber, especially from fruits
    and vegetables.
  • Foods containing flavonoids, like apples, celery,
    cranberries and tea may inhibit the growth of H.
    pylori.
  • Quit smoking
  • Receive treatment for alcohol abuse.

58
  • Medications
  • "Triple therapy" (including a proton pump
    inhibitor for example, omeprazole to reduce
    acid production and two antibiotics to get rid of
    the organism) is commonly used to treat H.
    pylori-related ulcers. Instead of one of the
    antibiotics, bismuth salicylate may be the third
    medication recommended.

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  • Some of the same drugs are used for non-H. pylori
    ulcers as well as for symptoms (like indigestion)
    due to ulcers of any cause
  • Antacids, available over the counter, may relieve
    heartburn or indigestion but will not treat an
    ulcer
  • H2 blockers, such as cimetidine, ranitidine,
    nizatidine, and famotidine, reduce gastric acid
    secretion.
  • Misoprostol can be used preventively if patient
    take a lot of NSAIDs because it helps to protect
    the stomach from the damaging effects of these
    pain killers.
  • Proton-pump inhibitors, including lansoprazole,
    omeprazole, pantoprazole, and rabeprazole,
    decrease gastric acid production. This is the
    number one choice of medications for treating
    ulcers.
  • Sucralfate makes a coating over the ulcer crater,
    protecting it from further damage.
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