Transcript 11_Chronic gastritis. Peptic ulcer of a stomach and duodenumof a

Chronic gastritis. Peptic ulcer of a
stomach and duodenum. Ethiology.
Clinical pattern. Daignostics.
Complications. Principles of
treatment.
Khabarova N.A.
• 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).
CLASSIFICATION OF CHRONIC GASTRITIS
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ADOPTED AT THE 9TH INTERNATIONAL CONGRESS OF GASTROENTEROLOGISTS
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( SYDNEY 1990) , MODIFICATED IN HOUSTON IN 1994
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1. CHRONIC NONATROPHIC ( CHRONIC HELICOBACTERIC GASTRITIS , CHRONIC ANTRIAL ,
TYPE «B») , WHICH REPRESENTS ALMOST 70 % OF ALL GASTRITS TYPES.
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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.
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3. SPECIAL FORMS OF CHRONIC GASTRITIS :
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CHEMICAL ( REACTIVE CHRONIC GASTRITIS , WHICH OCCURS IN CASE OF BILE REFLUX (
ABOUT 15 % ) , AFTER NSAID THERAPY ( ABOUT 10 % ) ;
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GRANULOMATOUS ( IN CASE OF CROHN’S DISEASE , SARKOIDOSIS , TUBERCULOSIS ) ;
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EOZINOPHILIC ( IN CASE OF BRONCHIAL ASTHMA , FOOD ALLERGY ) ;
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LYMPHOCYTIC ( WITH MANIFESTED LYMPHOCYTIC INFILTRATION OF EPITHELIUM ) ;
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GIGANT HYPERTROPHIC GASTRITIS ( MENETRIER’S DISEASE ) ;
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RADIATION GASTRITIS
• 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.
• 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.
Signs and Symptoms
• The most common symptoms of gastritis
are stomach upset and pain. The
following are other symptoms of
gastritis.
• Indigestion (also called dyspepsia)
• Heartburn
• Abdominal pain
• Hiccups
• Loss of appetite
• Nausea
• Vomiting, possibly of blood (called
hematemesis) or material that looks like
coffee-grounds
• Dark stools
Diagnosis
• There are several
tests that may be
done to make a
diagnosis. These
include endoscopy
of the stomach.
Normal mucous coat of stomach
Acute gastritis
Type B (Chronic antral gastritis)
Type A (autoimmune gastritis)
Chronic gastritis Type B
Type A (autoimmune gastritis)
• 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
• A biopsy may be taken of the tissues of
esophagus or stomach to determine the cause
of discomfort.
• A breath test may detect H. pylori, or samples
from esophagus or stomach may be taken to
look for this organism.
A breath test
H. Pylori
H. Pylori
Treatment
• The treatment of gastritis depends on the cause
of the problem. Some causes may resolve by
themselves over time, or may be relieved by
stopping the ingestion of irritating substances
such as alcohol, tobacco, and aspirin.
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.
Medications
• 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.
• 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
• Drugs that reduce stomach acid secretion help protect against or treat ulcers. Other
drugs used for ulcers include:
• Misoprostol – protects against the major intestinal toxicity of NSAIDS, and can
reduce the formation of ulcers
• Sucralfate – helps to heal ulcers in the stomach
• 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.
Peptic Ulcer
• Peptic ulcer is a
general chronic and
relapsing disease
characterized by
seasonal
exacerbations with
ulceration of the
stomach wall or the
duodenum.
• Causes
• When the stomach's natural protections from the damaging effects of
digestive juices stop working or the acid production is too overwhelming
for these protective defenses to work properly, you 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.
• Non-steroidal anti-inflammatory drugs (NSAIDs) – ongoing use of this
class of medications is the second most common cause of ulcers.
• Zollinger–Ellison syndrome.
• 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
PATHOGENESIS
Signs and Symptoms
• Abdominal pain with a
burning or gnawing
sensation
• Heartburn
• Indigestion (dyspepsia)
• Belching
• Nausea
• Vomiting
• Poor appetite
• Weight loss
PAIN
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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.
Aggravating factors:
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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.
Duration of attack:
A few weeks in gastric ulcer
A month or two in duodenal ulcer
• 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.
ON CLINICAL EXAMINATION
• Deep tenderness in epigastrium is present
in most of the cases. Anemia may be
present.
•COMPLICATIONS:
Hemorrhage
melena
Penetration
Penetration
Perforation
Malignization
malignant [neoplastic] transformation
Pyloric obstruction
Investigation
• One of two tests will be performed to try to identify an ulcer:
• Upper gastrointestinal (GI) series
• Endoscopy
DIAGNOSIS OF H.PYLORI
• Histology
• Rapid urease activity test
• Other tests that may be performed to look for H. pylori include
a blood test checking for antibodies to this organism, a breath
test after drinking a substance called urea, and a stool test
looking for the organism in the feces.
Lumen of the duodenum of a healthy human male.
White spots are reflections of the light source.
Endoscopy
Endoscopy
X-ray
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.
Surgery is required for certain serious or life-threatening
complications of peptic ulcers and may be considered if
medications are not working. Even with medications,
many lifestyle factors, including making changes in diet,
are important.
Medications
• If you have H. pylori, you will probably be prescribed
three different 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.
This drug, available over the counter, coats and soothes
the stomach, protecting it from the damaging effects of
acid. Two, rather than three, drug regimens are currently
being developed.
• 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
• Proton-pump inhibitors, including esomeprazole,
lansoprazole, omeprazole, pantoprazole, and
rabeprazole, decrease gastric acid production.
• Sucralfate