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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