Disorders of the stomach

and duodenum
Bett S.K.
ACUTE GASTRITIS
 Inflammation of gastric mucosa
 Gastritis is a histological diagnosis
 Characterized by erosion and hemorrhage
 Neutrophils are the predominant cells in the

submucosa
 Commonly results from NSAID ingestion
…cont.
 Symptoms include anorexia, nausea, vomiting,
hematemesis, malaena stool or may be
assymptomatic
 Endoscopy and biopsy rarely indicated
 Treatment is by treating the cause. PPIs, prokinetics

and antiemetics may be necessary

CHRONIC GASTRITIS
Can be caused by:
 H pylori infection
 Autoimmune gastritis

Predominant cells in the sub mucosa are lymphocytes

and plasma cells
 Usually asymptomatic
 Autoimmune gastritis may result in atrophy of

gastric mucosa and antibodies towards intrinsic

factor and parietal cells have been demonstrated
 It’s a histological diagnosis
..cont.
 Correlation between pathologic or endoscopic
findings and symptoms in H pylori gastritis is poor
 Autoimmune gastritis may lead to pernicious

anemia
 Chronic gastritis may predispose to gastric

carcinoma
 Treatment is unnecessary but lifestyle modification

and H pylori eradication is crucial.

…cont.
PEPTIC ULCER DISEASE (PUD)
 Refers to an ulcer forming in any of these regions:
lower esophagus, stomach, duodenum, rarely jejunum
and rarely ileum in presence of Meckel’s diverticulum
 Duodenal and gastric ulcers are the most prevalent
forms of peptic ulcers and they both penetrate the
muscularis mucosae
 Prevalence of PUD is declining in the west due to use
of H pylori eradication kit (0.1-0.2%)
 More prevalent in the developing countries and men
are affected more than women
…cont.
 Chronic gastric ulcer is routinely single and is
located in the lesser curvature
 Chronic duodenal ulcer is commonly found in the

first part of the duodenum and 50% are located

anteriorly
 Gastric and duodenal ulcers coexist in 10% of

patients and more than one DU is found in 10-15%

of patients.
Risk factors
 Smoking
 Genetic susceptibility
 Blood group O and personality type A
 Caffeine consumption
 Alcohol consumption
 Advanced age
 NSAID use
 Pathophysiology
Factors involved in gastro duodenal defense
Pathophysiology
Gastric and duodenal epithelium is protected from the
corrosive effects of acid and pepsin by;
 Mucus bicarbonate layer
 Intercellular tight junctions of the epithelial cells
 Prostaglandins
 Mucosal microcirculation (blood flow)

PUD results when there is imbalance between

acid/pepsin secretion and mucosal defense properties
…pathophysiology
H pylori
 There is a strong association between H pylori and PUD
 It’s a gram negative bacteria which invades gastric

mucosa and induces damage by producing toxins e.g.

cag A
 The causation of GU by H pylori is direct in that it

destroys the protective mucosal barrier

 The causation of DU by H pylori is indirect in that it

facilitates excess acid release by inhibiting

somatostatin release.
…pathophysiology
NSAIDs
 One of the protective mechanisms from corrosive

effects of acid is local prostaglandin release.

 NSAIDs inhibit prostaglandin synthesis hence

favoring ulcer formation

Other contributory environmental factors include;
smoking, alcohol consumption, caffeine intake,
psychogenic stress, burns, etc.
…cont.
…cont.
Clinical features
 Episodic epigastric abdominal pain which has a
relationship to food ingestion. Radiates to the ribs
and back
 Pain in DU is relieved by food while in GU it is

aggravated by food.
 Anorexia, nausea and vomiting with or without

hematemesis
 Malaena stool for hemorrhagic ulcers
…clinical features
 Epigastric tenderness
 May present for the first time with complications
 Others may be asymptomatic
 PUD is a chronic disease with natural history of

healing and recurrence for decades or for life

Investigations
 H pylori stool antigen test
 H pylori serological test – antibody detection
 Urea breath test- for H pylori detection
 Endoscopy with or without biopsy- to visualize

ulcerated mucosa and rule out malignancy

 Barium meal shows a crater for ulcer and filling

defect for a tumor.

…cont.
Treatment
 Aim is to relieve symptoms, induce healing, prevent
complications and prevent recurrence.
 Achieved through acid suppression, mucosal

protection and H pylori eradication

 Patients should also be advised to stop modifiable

risk factors e.g. smoking, alcohol consumption,

trigger foods, NSAID use, etc.
…treatment.
Acid suppression therapy
 Proton pump inhibitors e.g. omeprazole, esomeprazole

They block the final step of acid secretion by inhibiting the

proton pump.
 H2 receptor blockers
They block H2 receptors and inhibit histamine mediated acid
production
 Mucosal protective agents e.g. sacral fate and bismuth
salicylate, misoprostol
 Antacids e.g. aluminum hydroxide and calcium
carbonate
H pylori eradication
 Key in PUD management
 Indicated if ulcer is confirmed or if there is evidence

of H pylori infection
 Triple therapy is used where one PPI and 2

antibiotics is used
 Commonly omeprazole 20mgs BD and any of the

two among clarithromycin 500mgs BD,

amoxicillin1g BD and metronidazole 400mg BD are
used.
…cont.
 A combination of clarithromycin, amoxicillin plus a
PPI is recommended due to high resistance rates of
metronidazole
 Where clarithromycin resistance have been

confirmed, quadruple therapy consisting of PPI,

bismuth salycilate, metronidazole and tetracycline
should be given.
 This quadruple therapy should also be given as a

second line to triple therapy

 Duration of treatment is 10 to 14 days
…cont.
 A follow up treatment with a low dose PPI is
recommended for 4-6 weeks. It should start
immediately after completion of H pylori eradication
therapy.
…cont.
Surgery
 Rarely done at present
 Includes

Vagotomy
Partial gastrectomy (Billroths I and II)
Correction of complication e.g. hemorrhage or perforation
…cont.
Complications of gastric resection or
vagotomy
 Dumping syndrome
 Chemical gastropathy (bile reflux)
 Diarrhea and maldigestion and malabsorption
 Weight loss
 Anemia
 Metabolic bone disease (osteoporosis)
 Gastric cancer
Complications of PUD
 Perforation- common in DU
 Gastric outlet obstruction due to fibrosis or edema
 Hemorrhage
 Anemia due to chronic hemorrhage
ZOLLINGER ELLISON SYNDROME
 This is characterized by gastrin secretin tumors
(gastrinomas)
 Gastrinomas are routinely located in the pancreas
 Gastrin stimulate excess acid production by the

parietal cells
 Peptic ulcer results often in multiple sites
 Maldigestion of fats leads to steatorrhea
…ZES
 Diagnosis is by is by serum gastrin measurements
(elevated) and imaging (to check for the adenoma)
 Treatment involves:

Surgery to remove the gastrinomas

Proton pump inhibitors
Octreotide (somatostatin analogue)
CARCINOMA OF THE STOMACH
 4th leading cause of cancer death world wide
 Has marked geographical variation
 Common in Japan, China, and Korea (40:100000)
 Affects males more than females
 Incidences rises in age above 50 years
 Prognosis is poor with 5 year syrvival being less

than 30%
 Promptness of diagnosis affects outcome
Risk factors
Pathophysiology
Pathology
 Mainly adenocarcinoma
 Two types have been described

Intestinal carcinoma- most common. Results from

intestinal metaplasia
Diffuse carcinoma- infiltrates in the gastric mucosa
Clinical features
 Asymptomatic at early stages
 Discovery during endoscopy for dyspepsia
 Weight loss
 Epigastric pain
 Anorexia nausea and vomiting
 Hematemesis and malena
 Early satiety
 Dysphagia( for cardia tumors)
…clinical features
Examination may reveal
 Features of wasting
 Pallor
 Epigastric mass
 Jaundice
 Troisers sign
 Sister Mary joseph nodule

NB: Matastasis are mainly to the liver, peritoneum amd

bone marrow
...investigation
 Endoscopy with biopsy is the investigation of choice
 Barium meal may show a filling defect
 CT scan to asses intra-abdominal spread
 Laspasacopy with peritoneal washing to asses for

resectability
Management
 Surgery- for early tumors
Partial or total gastrectomy with or without distal
esophageal resection
 Palliative care- for advanced tumors
5FU with or without cisplatin may be used. Transtuzumab
for those tumors expressing HER 2 receptors
Other modalities of palliative care apply (managemant of
anemia, nutrition, pain, psychology, etc.)
…cont.
Thank you
for paying attention