1. Peptic Ulcer Disease
Thomas Rosenzweig, MD

2. Acute Gastritis (has neutrophils)
Acute (Active) Gastritis
neutrophils are present above the basement membrane in direct contact with epithelial cells
Erosion
loss of the epithelium → no mucus
Seen with mucosal neutrophils and a fibrin containing purulent exudate in the lumen
Ulcers – deep erosions
Hemorrhage
cause dark punctae in hyperemic mucosa
Acute erosive hemorrhagic gastritis
BOTH Erosion and Hemorrhage

3. Acute Gastritis (has neutrophils) Normal Protection Gastritis Risk
(NSAIDs) inhibit cyclooxygenase- (COX) dependent synthesis of prostaglandins E2 and I2
Stops normal defense mechanisms
Uremic patients and those infected with urease-secreting H. pylori
Stops bicarbonate transporters via ammonium ions
Chemicals
Direct cellular damage
Excessive alcohol consumption, NSAIDs, radiation therapy, and chemotherapy
Foveolar cells
Secretes Mucin
Neutral pH from Bicarbonate
Epithelial cells
Secretes Bicarbonate
Forms a physical barrier beneath mucus
Stops back diffusion of acid and leakage of other luminal materials (including pepsin) into the lamina propria

4. Stress-Related Mucosal Disease
occurs in patients with severe physiologic stress due to local ischemia
Ex. Critically ill pt.
Stress ulcers
seen with shock, sepsis, or trauma
Curling ulcers
Seen with burns or trauma
In the proximal duodenum
Cushing ulcers
Seen with intracranial disease
Risk of perforation

5. Peptic Ulcer Disease
chronic mucosal ulceration affecting the stomach or duodenum
↓ mucosal defense and ↑ chronic gastritis risk factors
Main risks:
H. pylori infection
Most common
↑ gastric acid and ↓ duodenal bicarbonate
NSAIDs
Over 60 years old
Smoking
↓ mucosal blood flow, oxygenation, and healing

6. Peptic Ulcer Disease Round to oval, sharply punched-out defect
Risk of death from bleeding
Symptoms:
Burning or aching 1-3 hours after a meal (worse at night)
Better with alkali or food
Peptic ulcers
Proximal duodenum
Within a few centimeters of the pyloric valve
Involve the anterior duodenal wall
Gastric Peptic ulcers
Along the lesser curvature
Near the interface of the body and antrum

7. Hypertrophic Gastropathies
Ex. Ménétrier disease
Ex. Zollinger-Ellison syndrome
Giant “cerebriform” enlargement of the rugal folds from epithelial hyperplasia without inflammation
↑ growth factor release
uncommon diseases

8. Ménétrier Disease ↑ factor-α (TGF-α)
Irregular enlargement of the gastric rugae
Enlarged rugae are present in the body and fundus
antrum is spared
Hyperplasia of foveolar mucous cells
Elongated glands with a corkscrew-like appearance
Treatment:
intravenous albumin

9. Zollinger-Ellison Syndrome
Caused by gastrin-secreting tumors
Most are malignant
75% are sporadic and solitary
25% multiple endocrine neoplasia type I (MEN I)
Doubled oxyntic mucosal thickness in the stomach due to a 5x ↑ of parietal cells
found in the small intestine or pancreas
Seen with duodenal ulcers or chronic diarrhea
Treat with proton pump inhibitors

10. Key Concepts