Main symptoms and syndromes in diseases of a stomach and intestine Methods of clinical, laboratory and instrumental examinations in acute and chtonic gastritis, peptic stomach and duodenal ulcers, enteritis and colitis. 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.

CLASSIFICATION OF CHRONIC GASTRITIS ADOPTED AT THE 9TH INTERNATIONAL CONGRESS OF GASTROENTEROLOGISTS ( SYDNEY 1990) , MODIFICATED IN HOUSTON IN 1994 1. CHRONIC NONATROPHIC ( CHRONIC HELICOBACTERIC GASTRITIS , CHRONIC ANTRIAL , TYPE «B») , WHICH REPRESENTS ALMOST 70 % OF ALL GASTRITS TYPES. 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. 3. SPECIAL FORMS OF CHRONIC GASTRITIS : CHEMICAL ( REACTIVE CHRONIC GASTRITIS , WHICH OCCURS IN CASE OF BILE REFLUX ( ABOUT 15 % ) , AFTER NSAID THERAPY ( ABOUT 10 % ) ; GRANULOMATOUS ( IN CASE OF CROHN’S DISEASE , SARKOIDOSIS , TUBERCULOSIS ) ; EOZINOPHILIC ( IN CASE OF BRONCHIAL ASTHMA , FOOD ALLERGY ) ; LYMPHOCYTIC ( WITH MANIFESTED LYMPHOCYTIC INFILTRATION OF EPITHELIUM ) ; GIGANT HYPERTROPHIC GASTRITIS ( MENETRIER’S DISEASE ) ; 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

Diagnosis There are several tests that may be done to make a diagnosis. These include endoscopy of the stomach. 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 stomach to determine the cause of discomfort. A breath test may detect H. pylori, or samples from stomach may be taken to look for this organism.

Normal mucous coat of stomach Acute gastritis

Type B (Chronic antral gastritis) Type A (autoimmune gastritis) Type B (Chronic antral gastritis)

Chronic gastritis Type B

A breath test

H. Pylori

H. Pylori

pH-metry

Treatment 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. 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.

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 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

Signs and Symptoms Abdominal pain with a burning or gnawing sensation Heartburn Indigestion (dyspepsia) Belching Nausea Vomiting Poor appetite Weight loss

PAIN 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: 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

COMPLICATIONS: Hemorrhage melena

Penetration

Perforation

Malignization

malignant [neoplastic] transformation

Pyloric obstruction

Investigation One of two tests will be performed to try to identify an ulcer: Endoscopy Upper gastrointestinal (GI) series 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 Lumen of the duodenum of a healthy human male. White spots are reflections of the light source.

Endoscopy

Endoscopy

X-ray Study

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 "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. 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

Enteritis is an inflammation of the small intestine caused by a bacterial or viral infection. Types of enteritis include: Food poisoning Salmonella enteritis Shigella enteritis Staph aureus food poisoning Campylobacter enteritis E. coli enteritis Bacterial gastroenteritis Radiation enteritis Crohn's disease and regional enteritis

Campylobacter jejuni Enteritis

Colitis is an inflammation of the large intestine that can be caused by many different disease processes. These processes include acute and chronic infections, inflammatory disorders (ulcerative colitis, Crohn's colitis, lymphocytic and collagenous colitis), lack of blood flow (ischemic colitis), and history of radiation to the large bowel.

Procedures Sigmoidoscopy - May be diagnostic in ulcerative colitis Colonoscopy - Helps by ruling out more serious disorders.(Tissue biopsy and further studies may help in diagnosis.) Other studies that can identify colitis include: Barium enema Abdominal CT scan Abdominal MRI Abdominal x-ray