Gi: Gastritis And Pud

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5 regions of stomach

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cardia, fundus, body, antrum, pylorus

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mucosa of stomach

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deep tan, simple columnar epithelium; rugae folds of mucosa and submucosa

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Normal stomach histology

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simple columnar epithelium w/ gastric pits/glands that vary in different stomach regions

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mucosa of body/fundus

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In pits: upper parietal cells, lower chief cells

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parietal cells

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stain pink, secrete HCl, intrinsic factor

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chief cells

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stain blue, secrete pepsinogen

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histology of cardia, antrum, pylorus

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In pits: mucous cells, plus G cells in antrum

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H pylori

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gram-negative spiral rod that lives in the mucus layer adherent to gastric foveolar cells only. Lives where urea levels are highest.

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H pylori environmental adaptation

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binds foveolar epithelial cells and gastric mucin; synthesizes urease to break down urea >> ammonia >> local pH buffer

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pathogenesis of H pylori

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Source of direct epithelial cell injury via ammonia/cytotoxins and indirect via the proteases that it produces which degrade mucus >> cause acute inflammation

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How to visualize H pylori

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stains black on silver stain

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Gastritis sx

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dyspepsia, N/V, **chronic gastitis often asx

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Acute Gastritis

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acute inflammation of mucosa (PMN's)

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causes of acute gastritis

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NSAIDS, alcohol, chemo, H pylori, other infections, things that cause mucosal hypoxia (surgery, burns, shock, trauma -- decrease blood flow to stomach)

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2 mechanisms of acute gastritis

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injury or loss of protective mechanisms

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spectrum of gastritis

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acute gastritis >> acute erosive gastritis >> acute erosive hemorrhagic gastritis

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gross pathology of gastritis

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PMN's, patchy mucosal necrosis (erosions), petechial hemorrhage

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chronic gastritis causes

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h pylori, autoimmune

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gross path of chronic gastritis

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spectrum from normal to thin, atrophic gastric wall. atrophic stomach loses its rugae

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histopath of chronic gastritis

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chronic inflammation, atrophy of gastric glands/mucosa, intestinal metaplasia

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chronic inflammatory cells

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lymphocytes, plasma cells, macrophages

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intestinal metaplasia

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change from 1 to 2 cell types - dense pink absorptive cells and goblet cells

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autoimmune gastritis

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AD inheritance; AutoAB for parietal cells leads to their destruction, atrophy of glands

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loss of parietal cells

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leads to atrophy of glands, decreased acid production, decreased synthesis of Intrinsic Factor

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complications of gastritis

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pernicious anemia, gastric carcinoids

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Pernicious Anemia

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Less IF means less B12 is absorbed >> megaloblastic anemia

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gastric carcinoids

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lack of acid >> G cell hyperplasia >> lack of acid stimulates more gastrin secretion >> hypergastrinemia >> gastric carcinoids

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ulcer

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defect in mucosal surface penetrating thru muscularis mucosa.

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PUD

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chronic ulcers in GI regions exposed to peptic acid (duodenum/stomach most common)

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PUD etiology

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h pylori, NSAIDS, Zollinger-Ellison

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gross path

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usually single, cookie cutter ulcer

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most common ulcer sites

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Duodenum (#1) or distal stomach

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4 zones of ulcer

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fibropurulent exudate, necrotic tissue, granulation tissue, fibrotic tissue/scar

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PUD complications

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hemorrhage, perforation, obstruction

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perforation

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most common in duodenum

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obstruction

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most common in pylorus

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PUD pathophys

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imbalance of aggressive/defensive factors

h pylori, NSAIDS, gastric acid, alcohol, smoking vs mucus barrier, bicarb secretion, prostaglandins, cellular resistance, mucosal blood flow

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Mucus layer

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water + mucin glycoprotein secreted by surface cells and aheres to surface. degraded by pepsin, slows diffusion of H+, secretes bicarb to neutralize acid

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prostaglandins

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stimulate mucus and bicarb, reduce acid secretion. NSAIDS decrease mucosal PGs by COX-1 inhibition

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uncomplicated PUD presentation

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epigastric pain, nonspecific nausea, bloating, early satiety

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complicated PUD presentation

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perforation, obstruction, bleeding

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perforation sx

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toxic appearance, shock, peritoneal signs

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obstruction sx

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vomiting, succussion splash

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bleeding sx

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melena, hematemesis, hematochezia

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PUD Dx

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endoscopy, radiography

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managing uncomplicated PUD

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PPI for 4-8wks, eradication of H pylori, reduce NSAIDS, quit smoking

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managing complicated PUD

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endoscopic therapy for bleeding, NG suction for obstruction, surgery

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surgical indications

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perforation, refractory bleeding, obstruction

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Zollinger Ellison Syndrome

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severe ulcer disease and gastric acid hypersecretion due to non-beta islet cell tumors of pancreas. Rare cause of ulcers

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gastrinoma

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hypersecretion of gastrin, association w/ MEN I (tumor in pancreas, pituitary, parathyroid

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ZE presentation

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multiple/refractory/recurrent ulcers, steatorrhea, reflux

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cause of steatorrhea

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hypersecretion of acid >> duodenum becomes more acidic >> pancreatic enzymes don't work as well >> steatorrhea

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DX of ZE

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serum gastrin >1000 is "definite," try to find tumor w/ somatastatin receptor scintigraphy