Disorders of the Stomach
Gastritis-Inflammation of the Gastric Mucosa
Mild to moderate chronic gastritis is exceedinglycommon in the population as a whole, especially in the middle to later years of adult life.
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The inflammation of gastritis may be only superficial and therefore not very harmful, or it canpenetrate deeply into the gastric mucosa, in many long-standing cases causing almost completeatrophy of the gastric mucosa. In a few cases, gastritis can be acute and severe, with ulcerativeexcoriation of the stomach mucosa by the stomach's own peptic secretions.Research suggests that much gastritis is caused by chronic bacterial infection of the gastric mucosa.This often can be treated successfully by an intensive regimen of antibacterial therapy.In addition, certain ingested irritant substances can be especially damaging to the protective gastricmucosal barrier-that is, to the mucous glands and to the tight epithelial junctions between the gastriclining cells-often leading to severe acute or chronic gastritis. Two of the most common of these
substances are excesses of
alcohol
or
aspirin
.
Gastric Barrier and Its Penetration in Gastritis.
Absorption of food from the stomach directly intothe blood is normally slight. This low level of absorption is mainly caused by two specific features of the gastric mucosa: (1) it is lined with highly resistant mucous cells that secrete viscid and adherentmucus and (2) it has tight junctions between the adjacent epithelial cells. These two together plusother impediments to gastric absorption are called the "gastric barrier."The gastric barrier normally is resistant enough to diffusion so that even the highly concentratedhydrogen ions of the gastric juice, averaging about 100,000 times the concentration of hydrogen ionsin plasma, seldom diffuse even to the slightest extent through the lining mucus as far as the epithelialmembrane itself. In gastritis, the permeability of the barrier is greatly increased. The hydrogen ions dothen diffuse into the stomach epithelium, creating additional havoc and leading to a vicious circle of progressive stomach mucosal damage and atrophy. It also makes the mucosa susceptible todigestion by the peptic digestive enzymes, thus frequently resulting in
gastric ulcer
.
Gastric Atrophy.
In many people who have chronic gastritis, the mucosa gradually becomes moreand more atrophic until little or no gastric gland digestive secretion remains. It is also believed thatsome people develop autoimmunity against the gastric mucosa, this also leading eventually to gastricatrophy. Loss of the stomach secretions in gastric atrophy leads to
achlorhydria
and, occasionally,to
pernicious anemia
.
Achlorhydria (and Hypochlorhydria).
Achlorhydria
means simply that the stomach fails to secretehydrochloric acid; it is diagnosed when the pH of the gastric secretions fails to decrease below 6.5after maximal stimulation.
Hypochlorhydria
means diminished acid secretion. When acid is notsecreted, pepsin also usually is not secreted; even when it is, the lack of acid prevents it fromfunctioning because pepsin requires an acid medium for activity.
Pernicious Anemia in Gastric Atrophy.
Pernicious anemia is a common accompaniment of gastricatrophy and achlorhydria. Normal gastric secretions contain a glycoprotein called
intrinsic factor
,secreted by the same parietal cells that secrete hydrochloric acid. Intrinsic factor must be present for adequate absorption of vitamin B
12
from the ileum. That is, intrinsic factor combines with vitamin B
12
inthe stomach and protects it from being digested and destroyed as it passes into the small intestine.Then, when the intrinsic factor-vitamin B
12
complex reaches the terminal ileum, the intrinsic factor binds with receptors on the ileal epithelial surface. This in turn makes it possible for the vitamin B
12
tobe absorbed.In the absence of intrinsic factor, only about 1/50 of the vitamin B
12
is absorbed. And, without intrinsicfactor, an adequate amount of vitamin B
12
is not made available from the foods to cause young, newlyforming red blood cells to mature in the bone marrow. The result is
pernicious anemia
.
Peptic Ulcer
A peptic ulcer is an excoriated area of stomach or intestinal mucosa caused principally by thedigestive action of gastric juice or upper small intestinal secretions.Figure 66-1shows the points inthe gastrointestinal tract at which peptic ulcers most frequently occur, demonstrating that the mostfrequent site is within a few centimeters of the pylorus. In addition, peptic ulcers frequently occur along the lesser curvature of the antral end of the stomach or, more rarely, in the lower end of theesophagus where stomach juices frequently reflux. A type of peptic ulcer called a
marginal ulcer
alsooften occurs wherever a surgical opening such as a gastrojejunostomy has been made between thestomach and the jejunum of the small intestine.
Basic Cause of Peptic Ulceration.
The usual cause of peptic ulceration is an
imbalance
betweenthe rate of secretion of gastric juice and the degree of protection afforded by (1) the gastroduodenalmucosal barrier and (2) the neutralization of the gastric acid by duodenal juices. It will be recalled thatall areas normally exposed to gastric juice are well supplied with mucous glands, beginning withcompound mucous glands in the lower esophagus plus the mucous cell coating of the stomachmucosa, the mucous neck cells of the gastric glands, the deep pyloric glands that secrete mainly
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