Transcript Disorders of the Stomach and Duodenum

Peptic Ulcer disease
I.
A.
Anatomy
Stomach
1. Regions
I.
A.
Anatomy – cont.
Stomach – cont.
5.
Layers of walls
1.
2.
3.
4.
Serosa
Muscularis
Submucosa
Mucosa
I.
A.
Anatomy – cont.
Stomach – cont.
6.
Glands in mucosa
a.
b.
Cardiac glands
Gastric glands
1) Chief cells
2) Parietal cells
3) Mucous neck cells
c.
gastrin
I.
Gastric
pit
Peptic cells
(chief, zymogen)
Pepsinogen secn
mucus neck & surface cells
Mucus & HCO3
parietal cells
(oxyntic)
H+ secretion &
intrinsic factor
I.
Functions of gastric
secretions
A. Digestion
of proteins ( pepsinogen & HCl)
B. Protection of stomach ( HCO3- & mucus)
C. Absorption of vitamin B12 ( intrinsic factor)
D. Destroy bacteria & other micro-organisms
(HCl)
~ 3 li per day
V.
A.
Peptic ulcer disease
General consideration
1. Peptic ulcers result from the corrosive
action of acid gastric juice
a. Ulcers may occur in oesophagus,
stomach,duodenum, jejunum or ileum from
ectopic gastric mucosa
2. Can be anywhere in GI tract exposed
to acid-pepsin gastric juice
a. Other factors also contribute
1)
2)
3)
4)
H. pylori
Mucosal bicarbonate secretion
Stress
Genetics
I.
GI Pathology
Helicobacter pylori
V.
Peptic ulcer disease - cont.
B.
Pathogenesis
1. Two factors prevent stomach from
digesting itself
a. Gastric mucosal barrier
1) First line of defense
2) NSAIDS cause in changes mucosa that my
facilitate its digestion by pepsin
3) Destruction of barrier believed to be important
factor in pathogenesis of gastric ulcers
a) Results of back diffusion of H+ injuring
underlying tissues
b) Antrum more susceptible to back diffusion
than fundus
c) Duodenum resistant to ulceration due to
Brunner’s glands which produce a highly
alkaline secretion
V.
Peptic ulcer disease - cont.
b. Epithelial barrier
1) Depends of abundant vascular supply and
continual, rapid regeneration of
epithelial cells (~3 days)
V.
Peptic ulcer disease - cont.
2. Other factors
a. 10-12 % incidence in population
b. Duodenal ulcers occur in much younger
group than gastric 20-40 years
c. Males affected 3X as often as women
d. Duodenal ulcers 10X as common as gastric
e. >90% of duodenal ulcers are on anterior or
posterior wall within 3 cm of pyloric ring
f. 40-60% have family history
V.
Peptic ulcer disease - cont.
C.
Clinical features
1.
Principle feature is chronic, intermittent
epigastric pain – typically relieved by food
2. ~25% have bleeding (more common with
duodenal)
3. Other signs and symptoms
a.
b.
c.
d.
e.
Vomiting
Red or “coffee-ground” emesis
Nausea
Anorexia
Weight loss
4. Pain-food-relief pattern may not be typical of
gastric ulcers – food sometimes aggravates
III. Diagnostic procedures
A.
B.
Barium radiologic studies
Gastric analysis of acid secretion
1. Aspirate gastric juices with
nasogastric tube
C.
Endoscopy
1. Photography
2. Biopsy
3. Exfoliative
cytology
III. Differential Diagnosis
A.
B.
C.
D.
Gallbladder disease
Pancreatitis
Functional indegestion
Reflux oesphagitis
V.
Peptic ulcer disease - cont.
E.
Medical treatment
1.
Primary consideration is to inhibit or buffer
acid to relieve symptoms and promote healing
a. Antacids – increase pH so pepsin isn’t activated
b. Dietary management – small frequent meals, avoid
alcohol and caffeine
c. Anticholinergics – inhibit vagal stimulation
d. Antimicrobial therapy
e. Physical and emotional rest
2. Ulcers caused by H. pylori are successfully
treated with antimicrobial agents, bismuth
salts, and H2 blockers
3. 65-95% eradication rates
I.
A.
B.
C.
D.
10 Day Regimen
clarithromycin 500 mg bid X 10
amoxicillin 1 gram bid X 10
omeprazole 20 mg bid X 10
in patients with current ulcer,
continue omeprazole 20 mg/day for
18 days
V.
kPeptic ulcer disease - cont.
F.
Complications
1.
Hemorrhage
a. Most frequent complication – 15-20%
b. Most common in ulcers of the posterior wall of
duodenal bulb due to proximity of arteries
c. Symptoms depend on severity
1)
2)
3)
4)
5)
Anemia
Occult blood in stool
Black and tarry stool
Hematemesis
Shock
d. Mortality up to 10% - higher for patients over 50
V.
Peptic ulcer disease - cont.
2. Perforation
a. Approximately 5% of all ulcers perforate accounts for 65% of deaths from peptic
ulcers
b. Usually on anterior wall of duodenum or
stomach
c. Thought to be due to excess acid and often
a result of NSAIDS
d. Characteristic presentation
1) Sudden onset of excruciating pain in
upper abdomen – chemical peritonitis
2) Patient fears to move or breath
3) Abdomen becomes silent to auscultation
and board like rigidity to palpation
e. Treatment – immediate surgery
V.
Peptic ulcer disease - cont.
3. Obstruction
a. Obstruction of gastric outlet in ~5% of patients
b. Due to inflammation and edema, pylorospasm or
scarring
c. More often with duodenal ulcers
d. Symptoms
1) Anorexia
2) Nausea
3) Bloating after eating
4) Pain and vomiting when severe
e. Treatment
1) Restore fluids and electrolytes
2) Decompress stomach with nasogastric tube
3) Surgical correction - pyloroplasty
V.
Peptic ulcer disease - cont.
4. Intractability
a.
Medical therapy fails to control symptoms
adequately, resulting in frequent, rapid recurrences
1) Typically surgery is recommended
V.
Peptic ulcer disease - cont.
G.
Surgical treatment – for patients who do
not respond to therapy
1.
For duodenal ulcers aim is to permanently
reduce stomach’s capacity to secrete acid and
pepsin
a. Vagotomy
1) Cut vagal branches to stomach
2) Eliminates cephalic phase
3) Several techniques
b. Antrectomy
1) Removal of entire antrum
2) Eliminates gastric phase
c. Vagotomy plus antrectomy
1) Eliminates both cephalic and gastric phases
V.
Peptic ulcer disease - cont.
d. Partial gastrectomy
1) Removal of distal 50-75% of stomach
2) Gastric remnant anastamosed to duodenum
(Billroth I) or jejunum (Billroth II)
2. For gastric ulcers
a. Usually partial gastrectomy and a
gastroduodenal anastomosis
b. Normally do not do vagotomy as patients
have normal to low acid production
I.
Normal
Stomach
I.
Esophagus & Stomach
Normal
I.
Gastric Ulcer
I.
Peptic ulcer - Endoscopy
I.
Duodenal Peptic Ulcer
I.
Gastric Ulcer
I.
I.
GI Pathology
Duodenal Peptic Ulcers, Gross
I.
GI Pathology
Giant gastric ulcer
I.
A.
GI Pathology
Gastric Peptic Ulcer
Gross
1.
2.
3.
4.
5.
Lesser curvature is the most common
location in the stomach; greatest frequency
is in the first part of the duodenum
Less than three centimeters in diameter
Round to oval in shape
Punched-out area with clean base
Margins are usually level with surrounding
mucosa or slightly elevated due to edema;
the mucosa is undermined at the edges
I.
A.
B.
GI Pathology
Gastric Peptic Ulcer
Up to 50% of those with gastric
peptic ulcer have concurrent
duodenal ulcer
These ulcers typically occur at
mucosal junctions exposed to acid
and
pepsin
(e.g.,
body
of
stomach/antrum)
I.
GI Pathology
Gastric peptic ulcer
A.
Associations: Chronic gastritis,
B.
Peak incidence = 50's
Location = Lesser curvature, antrum
C.
Helicobacter pylori (50-60%)
I.
GI Pathology
Anatomy of the stomach