Disease OF

Stomach &

Duodenum

By Dr. Osman Bukhari

Functions of the stomach

1- Reservoir of food

2- Grinding & mixing of food

3- Digestion

4- Absorption

5- Propulsion of contents to duodenum

6- Defensive

7-Intrinsic factor

Mucosa Surface epithelium with rich blood supply &

rapid turnover. It's covered with mucous rich in bicarbonate.

1-Parietal cells ــــــــ Hcl & intrinsic factor 2-Chief cells ــــــــ pepsinogen ـــ pepsin in the presence of Hcl. 3-Mucous secreting cellsـــــــ mucous & CHO3 4- G- cells ــــــ Gastrin---high Hcl 5- D- cell ــــــــ Somatostatin ــــــ low Hcl

* Parietal cells has receptors for Acetyl choline, Gastrin & Histamine which stimulate release of Hcl. H/K

A.T.Pase is the final pathway for acid secretion (P.P)

Acute

Gastritis

Acute Gastritis - Inflammatory disease involving superficial

epithelium ـــــــ erosion + ulceration * Causes 1-Asprin & NSAID 2-Alcohol 3-Bilary reflux 4-Infection (H.pylori, CMV, Herpes)

5-Sress (Trauma, burns, shock, MOF, Hepatic & renal disease)

Clinical Feature

1-Asymptomatic

2-Dyspepsia

3-Rarely bleeding or iron deficiency

aenmia

Diagnosis 1-Clinical in almost all cases

2-Gastroscopy if there is bleeding to exclude PU & Ca

Treatment 1-Stop offending drug

2-Treat any cause including infection

3-Symptoms settle in most cases without treatment

4-Some need anti acid, acid suppression + anti emetic

Chronic

Gastritis

Chronic Gastritis -In chronic active gastritis there is

infiltration of lamina propria with lymphocytes & plasma cells leading to atrophic gastritis & gastric atrophy with loss of parietal & chief cells & subsequent metaplasia

Causes 1-Autoimmune

2-H. pylori

3-Drugs & bile

4-T.b, Crohns, CMV & Sarcoidosis

5-Idiopathic

Type A Gastritis 1-It is autoimmune disease with circulating

Abs against parietal cells & intrinsic factor

2-Evidance of organ specific Auto immune disease

3-Gastric atrophy affecting body & fundus

4-Pernicious anemia

5-Increased incidence of Ca

Type B Gastritis 1-Affects the Antrum

2-Due to H. Pylori ــــــــ PU

Clinical feature 1-Asymptomatic

2-Dyspepsia

3-Often associated with PU

4-Diagnosed by gastroscopy

Helicoloater pylori (H.pylori) 1-Gram + spiral bacteria

2-Produces Urease

3-Found in gastric auntrum & area of gastric metaplasia in the duodenum deep to mucous layer closely adherent to epithelial surface, protected from acid & pepsin digestion by over lying mucous, bicarbonate & by release of ammonia (Urease action) ــــــ high PH

4-Prevalence increases with age & 2/3 are acquired in childhood.

5-Person to person transmission

6-Found in 90% of patients with DU & 70% with GU

Pathogenesis 1-Increases fasting & postprandial gastrin

2-Increases pepsinogen secretion

3-Decreases gastric mucosal resistance

4-Suppresses somatostatin release

5-Releases tissue damaging cytotoxins

-Cag – A (Cytotoxin associated gene)

-Vac – A (Vacillating Cytotoxin)

Clinicopath. features 1-Though 2/3 of population are infected

with H. pylori, only 10 15 ـــ % develop PU & the majority are asymptomatic

2-Lead to acute gastritis ـــــــ chronic gastritis

+_PU

3-Long standing chronic gastritis ـــــــ gastric atrophy & increased risk of metaplasia & the earlier H. pylori acquired , the greater

is risk of Ca

4-More than 90% of MALT lymphomas have H. pylori & low grade tumours regress with H. pylori eradication

5-Treat all patients with H. pylori because of associated risk of Ca

Diagnosis 1-Rapid Urease breath test:-

Used for screaming & to test for H. pylori eradication following treatment, expensive

2-Serology:-

Sensitive, specific & used for epidemiological surveys

3- Endoscpic antral biopsy for

-Rapid Urease test (CLO)

-Culture & sensitivity (Gold standard

investigations)

-Histological examination

H. pylori eradication therapy A) P.P.I based triple therapy with two

antibiotic 1-Omeprazole 20mg bid +

Metronidazole 400mg bid + Claithromycin 500mg bid for 7 days, (90% effective) OR

2-Omeprazole 20mg bid + Metronidazole 400mg bid +Amoxil 1gm bid for 7- 10 days (85- 90% effective) OR

3-Omeprazole 20mg bid + Amoxil 1gm bid + Claithromycin 250mg bid for 7-10 days. (85%) effective

B) H2 RA based triple therapy

*Bisthmus is included in some regimens