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Stomach DiseasesStomach DiseasesSuryadarmaSuryadarma
GastroenterologyGastroenterology--hepatology Division,hepatology Division,Udayana universityUdayana university--Sanglah HospitalSanglah Hospital20062006
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ResourcesResources
Sleisenger & Fordtrans gastrointestinalSleisenger & Fordtrans gastrointestinaland liver disease, 2002and liver disease, 2002
Textbook of gastroenterology, Ed.Textbook of gastroenterology, Ed.Yamada, 2003Yamada, 2003
Current diagnosis & treatment inCurrent diagnosis & treatment ingastroenterology, 2003gastroenterology, 2003
Crash course gastroenterology,2004Crash course gastroenterology,2004
Netters gastroenterology, 2005Netters gastroenterology, 2005
Gastroenterology and liver disease,Gastroenterology and liver disease,Ed.Richard G. Long, 2005Ed.Richard G. Long, 2005
Clinical gastroenterology and liverClinical gastroenterology and liverdisease,Ed. Wilfred M Weinstein, 2005disease,Ed. Wilfred M Weinstein, 2005
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DYSPEPSIADYSPEPSIA
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Nonulcer dyspepsiaNonulcer dyspepsia
Diagnostic approach :Diagnostic approach :Usefull : cereful history and physical Ex.Usefull : cereful history and physical Ex.
endoscopy UGIendoscopy UGILab :fool bood count, ESR, BSLab :fool bood count, ESR, BS
renal,liver function,thyroid.frenal,liver function,thyroid.f
Optional: H.pylori testOptional: H.pylori testUSG HepatobiliaryUSG HepatobiliaryEsophageal pH testEsophageal pH test
Uncertain valueUncertain value
Gastric emptying studyGastric emptying studyFundus relaxation studyFundus relaxation studyElectrogastrographyElectrogastrographyGastroduodenal manometryGastroduodenal manometryWater load testWater load test
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Pathogenesisofnonulcer dyspepsiaPathogenesisofnonulcer dyspepsia
Disturbed of motor functionDisturbed of motor function
Disturbed of sensory functionDisturbed of sensory function
Duodenogastric refluxDuodenogastric refluxPost infectionPost infection
Psychososial factor and Alteration ofPsychososial factor and Alteration of
CNSCNSEnviromental factorEnviromental factor
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Principles management NUDPrinciples management NUD
Make true diagnosisMake true diagnosis
Minimize invasive investigationMinimize invasive investigation
Education (reassurance, reinforce)Education (reassurance, reinforce)Dietary modificationDietary modification
Realistic treatment (strategies)Realistic treatment (strategies)
Symtomatic treatmentSymtomatic treatmentPsychoterapyPsychoterapy
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Management strategiesManagement strategies
In patien > 45 y, with alarm symptom :In patien > 45 y, with alarm symptom :Endoscopy immediatelyEndoscopy immediately
If young and no alarm signIf young and no alarm sign
Option 1. Empiric therapy strategiesOption 1. Empiric therapy strategies
Option 2. Test and Treat strategiesOption 2. Test and Treat strategiesOption 3. Endoscopy strategiesOption 3. Endoscopy strategies
Option 4. Pharmacological strategiesOption 4. Pharmacological strategies
first linefirst line
second linesecond lineOption 5. Complementary strategiesOption 5. Complementary strategies
Option 6. Psychological strategiesOption 6. Psychological strategies
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DrugforNUDDrugforNUD
Acid inhibitionAcid inhibition
CytoprotectionCytoprotection
ProkineticProkineticFundus relaxingFundus relaxing
Viseral analgesicViseral analgesic
AntispasmodicAntispasmodic
AntinausiantAntinausiant
AntidepresantAntidepresant
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GASTRITISGASTRITIS
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GastritisGastritis
Definition : Gastric mucosa inflammationDefinition : Gastric mucosa inflammation(acute or chronic)(acute or chronic)
Etiology : multifactorialEtiology : multifactorialLocation : gastritis antral dominantLocation : gastritis antral dominant
pangastritispangastritis
Classification : modified Sydney SystemClassification : modified Sydney System
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GastritisGastritis
Inflammation of the mucosa of theInflammation of the mucosa of thestomachstomach
AcuteAcute
Often due to dietary intakeOften due to dietary intake Can last few hours to few daysCan last few hours to few days
ChronicChronic Usually associated with peptic ulcer diseaseUsually associated with peptic ulcer disease
95% of patients with pernicious anemia have95% of patients with pernicious anemia havechronic gastritischronic gastritis
DiagnosisDiagnosis Made by clinical history; EndoscopyMade by clinical history; Endoscopy
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AcuteGastritisAcuteGastritisClinical feature :Clinical feature :
**nausea,vomiting,indigestion,nausea,vomiting,indigestion,*gastrointestinal bleeding,*gastrointestinal bleeding,*asymtomatic*asymtomatic
Diagnosis : History (alcohol,NSAID)Diagnosis : History (alcohol,NSAID)Acute illnness patientAcute illnness patientEndoscopic: erotion,bleedingEndoscopic: erotion,bleeding
Patology: inflammatory infiltrat,predominantly neutrophilsPatology: inflammatory infiltrat,predominantly neutrophils
Treatment : antacid and causalTreatment : antacid and causal
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Chronic gastritisChronic gastritis
Can progression of acute gastritisCan progression of acute gastritis
Common etiology H. pyloriCommon etiology H. pylori
Autoimmun gastritis associatedAutoimmun gastritis associated
autoimmune diseases.autoimmune diseases.
Clinical feature:Clinical feature:
>> asymtomatic>> asymtomatic
similar to acute G (long period)similar to acute G (long period)
pernicious anemiapernicious anemia
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EtiopatologyEtiopatology
Etiology:Etiology:
H. pyloriH. pylori
NSAIDNSAID
AlcoholAlcoholReflux of bileReflux of bile
Patology:Patology:
Lost of parietal and chief cell,Lost of parietal and chief cell,
plasma cell and lymphocyte infiltration,plasma cell and lymphocyte infiltration,
chronic atrophic changes.chronic atrophic changes.
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DiffuseCorporal Atrophic GastritisDiffuseCorporal Atrophic Gastritis
Disease PathogenesisDisease Pathogenesis
Antibodies against gastric fundic region antigens
Atrophy of fundic glands with antral and intestinal metaplasia
Decreased acid Decreased intrinsic factor
Hypo- or a-chlorhydria
G cell stimulation in antrum
Hypergastrinemia
Fundic ECL cell hyperplasia and +/- carcinoids
Decreased B-12 absorption
B-12 deficiency
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Clinical ManifestationsClinical Manifestations
AnorexiaAnorexia
Nausea/vomitingNausea/vomiting
Epigastric tendernessEpigastric tendernessAbnormal full feelingAbnormal full feeling
Signs of vitamin BSigns of vitamin B1212 deficiencydeficiency
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Chronic superficial gastritis(Histological gastritis)
Cover,T.L.,et al.:ASM News, 61(1),21,1995
H.pyloriinfection
weeks to months
years
Peptic
ulcerdisease
Peptic
ulcerdisease
Chronic
atrophicgastritis
Chronic
atrophicgastritis
Chronic
superficialgastritis
Chronic
superficialgastritis
MALT
lymphoma
MALT
lymphoma
Gastric
cancer
Gastric
cancer
Natural history of H.pylori infection
H.pyloriH.pylori
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Natural history H pyloriinfectionNatural history H pyloriinfection
Duodenal ulcer
lymphoma
Gastric ulcer
Gastric ca
Acutegastritis
CHRONIC ACTIVE GASTRITIS
AntralPredominantgastritis
MultifocalAtrophic
gastritis
Enviromentfactors
lymphoma
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DiagnosisDiagnosisEndoscopy:Endoscopy:
atropic mucosa,atropic mucosa,erythema, erotion mucosaerythema, erotion mucosa
Lab: pernicious anemiaLab: pernicious anemia
antiparietal cell antibodiesantiparietal cell antibodiesComplication :Complication :
Intestinal metaplasia predisposesIntestinal metaplasia predisposesmalignancy( adeno ca )malignancy( adeno ca )
Treatment :Treatment :underlying causeunderlying causeH. pylori eradicationH. pylori eradicationVit B12Vit B12
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ManagementManagement
Depends on severityDepends on severity
MildMild
Symptoms relievedSymptoms relievedMonitor for dehydrationMonitor for dehydration
Monitor for signs of bleedingMonitor for signs of bleeding
ChronicChronicLifestyle modificationLifestyle modification
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PEPTICULCERPEPTICULCER
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Definition:Definition:
Ulceration (breach in mucosa) due toUlceration (breach in mucosa) due to
acid & pepsin attack.acid & pepsin attack.Deeper than just mucosaDeeper than just mucosa
Single, punched out, clean base.Single, punched out, clean base.
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Etiology:Etiology:
Helicobacter pyloriHelicobacter pylori most common.most common.HyperacidityHyperacidity -- eg. zollinger ellison.eg. zollinger ellison.
DrugsDrugs -- antianti--inflammatory (NSAIDs)inflammatory (NSAIDs)
& Corticostroids.& Corticostroids.
Cigarette smoking, Alcohol,Cigarette smoking, Alcohol,
Rapid gastric emptyingRapid gastric emptyingPersonality and psychological stressPersonality and psychological stress
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Peptic ulcerPeptic ulcer
Included :Included :
Esophageal ulcerEsophageal ulcer
Gastric ulcerGastric ulcerDuodenal ulcerDuodenal ulcer
Definition: breaches of mucosa withDefinition: breaches of mucosa with
tissue destruction at list totissue destruction at list tomuscularis mucosamuscularis mucosa
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PathophysiologyPathophysiology
There is a breakdown in the mucosal layer.There is a breakdown in the mucosal layer.
Increase in acidIncrease in acid--pepsin production frompepsin production from Increase in number of cells that produce HCLIncrease in number of cells that produce HCL
and pepsinand pepsin Increase in the sensitivity of parietal cells toIncrease in the sensitivity of parietal cells to
food and other stimulifood and other stimuli
Excessive vagal stimulationExcessive vagal stimulation
Gastric mucosal barrier is impairedGastric mucosal barrier is impaired RefluxReflux
Helicobacter pyloriHelicobacter pylori
Stress/AnxietyStress/Anxiety
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Pathogenesis of gastric ulcerationPathogenesis of gastric ulceration
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Clinical ManifestationsClinical Manifestations
Gastric:Gastric:
Burning or gassyBurning or gassysensation in highsensation in highepigastric areaepigastric area
Occurs within hr.Occurs within hr.after eating, foodafter eating, foodcan worsencan worsensymptomssymptomsRarely occurs atRarely occurs atnightnightVomiting may easeVomiting may easediscomfortdiscomfortMay lose weightMay lose weightPyrosisPyrosis
Duodenal:Duodenal:
More cramplikeMore cramplikediscomfortdiscomfort
Occurs on emptyOccurs on emptystomach, food relievesstomach, food relievessymptomssymptoms
Often occurs at nightOften occurs at night
Vomiting uncommonVomiting uncommonMay gain weightMay gain weight
PyrosisPyrosis
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DiagnosisDiagnosis
Endoscopy is preferred procedureEndoscopy is preferred procedure
Hemoccult stoolsHemoccult stools
CLO (campylobacterCLO (campylobacter--like organism)like organism)Helicobacter Pylori IgG AntibodyHelicobacter Pylori IgG Antibody
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PUDPUD -- DiagnosisDiagnosisEndoscopyEndoscopyBarium mealBarium meal contrast xcontrast x--rayray
BiopsyBiopsy bacteria & malignancybacteria & malignancy
H.Pylori:H.Pylori:Endoscopy cytologyEndoscopy cytology
BiopsyBiopsy Special stainsSpecial stains
CultureCulture -- difficultdifficult
Urease Breath testUrease Breath test
Stool antigenStool antigen
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Peptic ulcerPeptic ulcer
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Location of gastric ulcers
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Type I gastric ulcerType I gastric ulcer
60% of GU60% of GU
Large volume ofLarge volume ofsecretion with lowsecretion with lowor normal acidor normal acidsecretionsecretion
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Type II gastric ulcerType II gastric ulcer
25%25% of GUof GU
Usually acidUsually acidhypersecretorhypersecretor
DU usually precedesDU usually precedesGUGU
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Type III gastric ulcerType III gastric ulcer
23% of GU23% of GUPrepyloric ulcerPrepyloric ulcer
Typically acidTypically acidhypersecretorhypersecretor
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Type IV gastric ulcerType IV gastric ulcer
Less than 10% ofLess than 10% ofGUGU
HighHigh--lying ulcerlying ulcer
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Complications:Complications:
BleedingBleeding ChronicChronic--IDA, Acute,IDA, Acute,MassiveMassive
Fibrosis, Stricture obstruction.Fibrosis, Stricture obstruction.
PerforationPerforation Peritonitis.Peritonitis.
Gastric carcinoma.Gastric carcinoma.
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ManagementManagement
MedicationsMedications
AntacidsAntacids
Histamine ReceptorHistamine Receptor
AntagonistsAntagonists Proton pumpProton pump
inhibitorsinhibitors
CytoprotectiveCytoprotective
MedicationsMedications Treating H. PyloriTreating H. Pylori
StressStressmanagementmanagement
Smoking cessationSmoking cessation
Diet ChangesDiet Changes
SurgicalSurgicalInterventionIntervention
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Surgical InterventionSurgical Intervention
Vagotomy w/ pyloroplastyVagotomy w/ pyloroplasty
Bilroth IBilroth I gastroduodenostomygastroduodenostomy
Partial gastrectomy with removal ofPartial gastrectomy with removal ofdistal 2/3 of stomach & anastamosis todistal 2/3 of stomach & anastamosis toduodenumduodenum
Bilroth IIBilroth II gastrojejunostomygastrojejunostomy
Partial gastrectomy with removal ofPartial gastrectomy with removal ofdistal 2/3 of stomach & anastamosis todistal 2/3 of stomach & anastamosis tojejunumjejunum
C C li ti fC C li ti f
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CommonComplicationsfromCommonComplicationsfrom
Peptic Ulcer SurgeryPeptic Ulcer Surgery
Dumping SyndromeDumping Syndrome
Postprandial hypoglycemiaPostprandial hypoglycemia
Bile reflux gastritisBile reflux gastritis
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DUODENALULCERDUODENALULCER
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Clinical ManifestationsClinical Manifestations
Gastric:Gastric:
Burning or gassyBurning or gassysensation in highsensation in highepigastric areaepigastric area
Occurs within hr.Occurs within hr.after eating, foodafter eating, foodcan worsencan worsensymptomssymptomsRarely occurs atRarely occurs atnightnightVomiting may easeVomiting may easediscomfortdiscomfortMay lose weightMay lose weightPyrosisPyrosis
Duodenal:Duodenal:
More cramplikeMore cramplikediscomfortdiscomfort
Occurs on emptyOccurs on emptystomach, food relievesstomach, food relievessymptomssymptoms
Often occurs at nightOften occurs at night
Vomiting uncommonVomiting uncommonMay gain weightMay gain weight
PyrosisPyrosis
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Pathogenesis of duodenal ulcerationPathogenesis of duodenal ulceration
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Pathogenesis of duodenal ulcerationPathogenesis of duodenal ulceration
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Duodenal ulcerDuodenal ulcer
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ZollingerZollinger--EllisonsyndromeEllisonsyndrome
Clinical features suspicious ZESClinical features suspicious ZES
* post bulbar duodenal ulcer* post bulbar duodenal ulcer
* multiple duodenal ulcer* multiple duodenal ulcer
* PUD associated Chronic diarrhea* PUD associated Chronic diarrhea
* refractory PUD* refractory PUD
* PUD + nefrolithiasis* PUD + nefrolithiasis
* recurrent PUD without H.pylori,NSAID* recurrent PUD without H.pylori,NSAID* PUD + hypercalsemia* PUD + hypercalsemia
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DiagnosisZESDiagnosisZES
Clinical featuresClinical featuresSerum gastrin level > 1000pg/mLSerum gastrin level > 1000pg/mLHyperparathyroidismHyperparathyroidism
DD/ carsinoidDD/ carsinoidinsulinomainsulinomaglucagonomaglucagonoma
somatostatinomasomatostatinomaVIPomaVIPomaTreatment : PPITreatment : PPI