Gasrric problem (2) PDF

Oral Inflammatory Lesions  Aphthous Ulcers (Canker Sores) common superficial mucosal ulcerations they are more frequent in the first 2 decades of life, extremely painful, and often recur. cause of is unknown. ulcers can be solitary or multiple in most cases they resolve spontaneo...

Oral Inflammatory Lesions  Aphthous Ulcers (Canker Sores) common superficial mucosal ulcerations they are more frequent in the first 2 decades of life, extremely painful, and often recur. cause of is unknown. ulcers can be solitary or multiple in most cases they resolve spontaneously in 7 to 10 days but can recur  Oral Candidiasis (Thrush) the most common fungal infection of the oral cavity. Candida albicans is a normal component of the oral flora and only produces disease under unusual circumstances predisposing factors include the following:  immunosuppression the specific strain of C. albicans the composition of the oral microbial flora (microbiota) Esophagus Obstructive and Vascular Diseases  Mechanical Obstruction Atresia, fistulas and duplications : discovered shortly after birth, because of regurgitation during feeding. most commonly at or near the tracheal bifurcation associated with a fistula connecting the upper or lower esophagus to a bronchus or trachea. aspiration, suffocation, pneumonia, fluid and electrolyte imbalances  Functional Obstruction Achalasia characterized by the triad of : 1. incomplete LES relaxation. 2. increased LES tone. 3. esophageal aperistalsis. Primary Achalasia: caused by failure of distal esophageal inhibitory neurons & degenerative changes in neural innervation. idiopathic. Secondary Achalasia : Chagas disease: causes destruction of the myenteric plexus, failure of LES relaxation, and esophageal dilatation. diabetic autonomic neuropathy;  Esophagitis Chemical Esophagitis chemical irritants including: 1. alcohol. 2. corrosive acids or alkalis. 3. excessively hot fluids. 4. heavy smoking. 5. iatrogenic (cytotoxic chemotherapy, radiation therapy, graft-versus host disease) Cont….. Infectious Esophagitis most frequent in immunosuppressed. 1.Herpes simplex viruses (punched-out ulcers) 2.Cytomegalovirus (CMV), (shallower ulcerations) 3.Candida , (adherent, gray-white pseudomembranes) 4.Mucormycosis , aspergillosis. Cont. ….. Reflux Esophagitis reflux of gastric contents into the lower esophagus is the most frequent cause of esophagitis the associated clinical condition is termed gastroesophageal reflux disease (GERD) Causes: conditions that decrease LES tone or increase abdominal pressure contribute to GERD and include: 1. alcohol and tobacco use. 2. obesity. 3. pregnancy. 4. hiatal hernia. Clinical Features most common in adults, most common in those over 40 years of age heartburn. dysphagia. regurgitation of sour-tasting gastric contents.  Barrett Esophagus is a complication of chronic GERD characterized by intestinal metaplasia within the esophageal squamous mucosa. 10% of persons with symptomatic GERD. typically present between 40 and 60 years of age. Cont. …. it confers an increased risk of esophageal adenocarcinoma. majority of esophageal adenocarcinomas are associated with barrett esophagus. Clinical Features usually prompted by GERD symptoms and requires endoscopy and biopsy. Esophageal Tumors  Squamous Cell Carcinoma most common esophageal tumors. occurs > 45 years of age. males females ratio : 4:1. half occur in the middle third Risk factors: 1. alcohol, tobacco use. 2. poverty. 3. caustic esophageal injury. 4. achalasia. 5. plummer-vinson syndrome. 6. frequent consumption of very hot beverages. Clinical Features dysphagia, odynophagia and obstruction. extreme weight loss. hemorrhage. aspiration of food through a tracheoesophageal fistula.  Adenocarcinoma men to women 7:1 Risk factors: 1. Barrett esophagus and long-standing GERD. 2. tobacco use. 3. obesity. 4. previous radiation therapy. 5. reduced adenocarcinoma risk is associated with diets rich in fresh fruits and vegetables Clinical Features pain or difficulty in swallowing. progressive weight loss. chest pain or vomiting. Stomach  the stomach is divided into four major anatomic regions: the cardia, fundus, body and antrum. the cardia is lined mainly by mucin-secreting foveolar cells that form shallow glands. the antral glands are similar but also contain endocrine cells, such as G cells, that release gastrin to stimulate luminal acid secretion by parietal cells within the gastric fundus and body Cont….. the well-developed glands of the body and fundus also contain chief cells that produce and secrete digestive enzymes such as pepsin. the gastric lumen is strongly acidic, (pH :one) this acidity contributes to digestion but also has the potential to damage the mucosa. Mechanisms that protect the gastric mucosa: 1. the mucus layer protect the epithelium 2. mucosa has a neutral pH as a result of bicarbonate ion secretion. 3. the rich vascular supply to the gastric mucosa delivers oxygen, bicarbonate, and nutrients while washing away acid 4. protective effects of prostaglandins, which include enhanced bicarbonate secretion and increased vascular perfusion  Stress-Related Mucosal Disease Stress-related gastric injury occurs in patients with severe trauma, extensive burns, intracranial disease, major surgery, serious medical disease and other forms of severe physiologic stress. it appear in first 3 days of disease. Ulcers are given specific names based on location and clinical associations as follows: Stress ulcers affecting critically ill patients with shock, sepsis or severe trauma. Curling ulcers occur in the proximal duodenum and are associated with severe burns or trauma. Cushing ulcers arise in the stomach, duodenum or esophagus of those with intracranial disease and have a high incidence of perforation.  Acute Peptic Ulceration causes: 1. NSAIDs 2. Stress ulcers (critically ill patients with shock, sepsis, or severe trauma): hypoxia and reduced blood flow 3. Curling ulcers: occurring in the proximal duodenum and associated with severe burns or trauma 4. Cushing ulcers: intracranial disease, have a high incidence of perforation (direct stimulation of vagal nuclei, which causes gastric acid hypersecretion) Clinical Features: nausea, vomiting and coffee-ground hematemesis. perforation  Chronic Gastritis symptoms are less severe but more persistent than those of acute gastritis nausea and upper abdominal discomfort may occur, but hematemesis is uncommon. 1. the most common cause of chronic gastritis is Helicobacter pylori. 2. autoimmune gastritis, (atrophic gastritis), 10% of cases of chronic gastritis. 3. radiation injury and chronic bile reflux.  Helicobacter pylori Gastritis H. pylori present in 90% of chronic gastritis affecting the antrum. the increased acid secretion that occurs in H. pylori gastritis may result in peptic ulcer disease of the stomach or duodenum. H. pylori infection cause antral gastritis with high acid production, despite hypogastrinemia. Cont….. chronic antral H. pylori gastritis may progress to pangastritis, resulting in multifocal atrophic gastritis, reduced acid secretion, intestinal metaplasia, and increased risk of gastric adenocarcinoma. H. pylori infection is associated with poverty, household crowding, limited education, residence in areas with poor sanitation. Diagnosis: 1. serologic test for anti–H. pylori antibodies. 2. fecal bacterial detection. 3. urea breath test 4. gastric biopsy (analyzed by the rapid urease test, bacterial culture, or polymerase chain reaction {PCR}) Complication of chronic gastritis  Peptic Ulcer Disease (PUD) most often is associated with H. pylori infection or NSAID. PUD may occur in any portion of the gastrointestinal tract exposed to acidic gastric juices most common in the gastric antrum and first portion of the duodenum Cont. …. the imbalances of mucosal defenses and damaging forces that cause chronic gastritis are also responsible for PUD. Epidemiology PUD is common and is a frequent cause of physician visits worldwide. Gastric hyperacidity is fundamental for PUD H. pylori infection. Hypergastrinaemia (Zollinger-Ellison syndrome: PUD in the stomach, duodenum, and even jejunum, caused by tumor Cont. …… cofactors in peptic ulcer : 1. cigarette smoking( impairs mucosal blood flow and healing ) 2. high-dose corticosteroids(suppress prostaglandin synthesis and impair healing) Cont….. 3. alcoholic cirrhosis 4. chronic obstructive pulmonary disease, 5. chronic renal failure, 6. Hyperparathyroidism 7. psychologic stress may increase gastric acid production Duodenal ulcers increased production of acid. H. pylori-infected individuals secrete 2-6 times as much acid as non infected. Helicobacter does not colonize normal duodenal epithelium. peptic ulcers are four times more common in the proximal duodenum than in the stomach Cont. ….. occur within a few centimeters of the pyloric valve gastric peptic ulcers are predominantly located near the interface of the body and antrum peptic ulcers are solitary round to oval, sharply punched-out defect. Clinical Features epigastric burning or aching pain. the pain tends to occur 1 to 3 hours after meals during the day, is worse at night, and relieved by alkali or food. nausea , vomiting, bloating and belching. Complications 1. perforation, giving rise to peritonitis. 2. penetration, into an adjacent organ such as the liver or pancreas. 3. hemorrhage, from eroded vessels in the ulcer base. 4. iron deficiency anemia. 5. malignant change in gastric peptic ulcers, is a very uncommon duodenal ulcers never become malignant Neoplastic disease of the stomach  Gastric Adenoma represent up to 10% of all gastric polyps, their incidence increases with age. patients usually are between 50 and 60 years of age, and males are affected three times more often than females. carcinoma may be present in up to 30% of gastric adenomas.  Gastric Adenocarcinoma most common malignancy of the stomach more common in lower socioeconomic groups and in persons with multifocal mucosal atrophy and intestinal metaplasia. Risk Factors for Gastric Carcinoma: I. Intestinal-Type Adenocarcinoma : 1. Chronic gastritis with intestinal metaplasia. 2. Infection with Helicobacter pylori. 3. Nitrites. 4. Decreased intake of fresh vegetables and fruits. 5. Partial gastrectomy. 6. Pernicious anemia. Cont….. II. Diffuse Carcinoma: rare inherited mutation of E-cadherin. infection with H. pylori and chronic gastritis often absent.