Diseases of stomach

1. DISEASES OF STOMACH
By
Laraib Jamil

2. FUNCTIONAL DISORDER OF STOMACH
STOMACH ULCER
Stomach ulcers (gastric ulcers) are open sores that
develop on the lining of the stomach.
 Ulcers can also occur in part of the intestine just
beyond the stomach. (outside the stomach) These
are called duodenal ulcers.
 If ulcer is present inside the stomach then it is
called peptic ulcers.

5.  CAUSES:
1. Helicobacter pylori (Bacteria)
2. non-steroidal anti-inflammatory drugs (NSAIDs).
H-Pylori:
H. pylori bacteria live in the stomach lining. The
bacteria can irritate the stomach lining and make it
more vulnerable to damage from stomach acid.

6. H-pylori: pathomechanism of infection caused
by H. pylori, including various enzymes
(e.g., urease, catalase, lipase, phospholipase and
proteases) produced by H. pylori.
Urease: Urease is the most important enzyme
produced by H. pylori, since it enables survival of the
organism in a low-pH environment, and also aids
colonisation of the stomach mucous membrane. The
enzyme catalyses the degradation of urea
to ammonia and carbon dioxide. Ammonia alkalises
the environment, leading to neutralisation of the acid
fluid in the stomach, which allows bacterial survival.

7. 2. the maximal concentration found in gastric fluid) by
urease liberates ammonia, which is reported to
induce cell injury.
 The two enzymes phospholipase A and C are
responsible for destruction of the protective mucous
zone, and these two enzymes are present in all
strains of H. pylori

8. VACUOLATING CYTOTOXIN
 It is present in H. pylori
 The VacA cytotoxin belongs to the AB group of
toxins, which are made up of an A-subunit,
responsible for enzymic activity, and a B-subunit,
responsible for recognising and binding to receptors
on the surface of target cells.
 The production of VacA cytotoxin has been linked to
the in-vivo destruction of epithelial cells and the
development of peptic ulcer

9.  It has been established that infection
with H. pylorican lead to an imbalance between
proliferation (production) and apoptosis (process of
programmed cell death-as occurs during growth &
development of organism, as a part of normal cell
injury.), which can result in severe clinical
consequences, and even lead to gastric cancer

10. 2- NSAID:
 ibuprofen
 aspirin
 naproxen
 Diclofenac
 Many people take NSAIDs without having any side
effects. But there's always a risk the medication could
cause problems, such as stomach ulcers, particularly if
taken for a long time or at high doses.
 You may be advised not to use NSAIDs if you currently
have a stomach ulcer or if you've had one in the
past. Paracetamol is a safer painkiller to use.

11. 3- Life style factors:
There's little evidence that stomach ulcers are caused
by:
 spicy foods
 stress
 alcohol
 But these can make the symptoms worse.
 However, smoking can:
 increase your risk of developing stomach ulcers
 make treatment less effective

12. Symptoms:
 Tummy pain
 The pain caused by a stomach ulcer can either travel:
 out from the middle of your tummy up to your neck
 down to your belly button
 through to your back
And:
 can last from a few minutes to a few hours
 often starts within a few hours of eating
 can cause you to wake up during the night (nocturnal
attacks)
 Taking antacids (indigestion medication) may
temporarily relieve the pain, but it will keep coming back
if the ulcer isn't treated.

13. Less common symptoms of a stomach ulcer
include:
 indigestion
 heartburn
 loss of appetite
 feeling and being sick
 weight loss
 burp or become bloated after eating fatty foods.

14. Diagnosis:
If your GP thinks you have an ulcer, they will want to
know
 if you're taking non-steroidal anti-inflammatory
drugs (NSAIDs)
 might test you for an Helicobacter pylori (H. pylori)
infection

15.  Testing for H. pylori infection
 If your GP thinks your symptoms might be caused by an H. pylori
infection, you'll be offered a:
 urea breath test
 stool antigen test – a small stool sample is tested for the bacteria
 blood test
 Urea breath test
 You'll be given a special drink containing a chemical that's broken
down by H. pylori. Your breath is then analysed to see whether or
not you have an H. pylori infection.
 Blood test
 A sample of your blood's tested for antibodies to the H. pylori
bacteria. Antibodies are proteins produced naturally in your blood
to help fight infection.
 This test's now largely been replaced by the stool antigen test

16.  Gastroscopy
 A gastroscopy is a procedure that involves passing a thin,
flexible tube (an endoscope) with a camera at one end into
your mouth and down into your stomach and first section of
the small intestine (duodenum).
You may:
 be given a mild sedative injection before the procedure
 have your throat sprayed with a local anaesthetic to make it
more comfortable to pass the endoscope
 The images taken by the camera will usually confirm or rule
out an ulcer. A small tissue sample may also be taken from
your stomach or duodenum to test for the H. pylori bacteria.
 You'll have this procedure as an outpatient in hospital. This
means you won't have to spend the night.
 You may have a repeat gastroscopy after 4 to 6 weeks to
check that the ulcer's healed.

17. COMPLICATIONS:
 internal bleeding
Internal bleeding's the most common complication of stomach
ulcers. It can occur when an ulcer develops at the site of a blood
vessel.
SEVERE BLEEDING-ANAEMIA
you're vomiting blood – the blood can appear bright red or have
a dark brown, grainy appearance like coffee grounds
Treatment:
1. surgery is needed to repair the affected blood vessel
2-Bloood transfusion to overcome the blood lose
 perforation - the lining of the stomach splits open
 This can be very serious because it lets the bacteria that live
in your stomach escape and infect the lining of your abdomen
(peritoneum). This is known as peritonitis.

18. Peritonitis
 In peritonitis, an infection can rapidly spread into
the blood (sepsis) before spreading to other organs.
This carries the risk of multiple organ failure and
can be fatal if left untreated.
SEPSIS: Sepsis is a potentially life-threatening
condition caused by the body's response to an
infection. The body normally releases chemicals
into the bloodstream to fight an
infection. Sepsis occurs when the body's response
to these chemicals is out of balance, triggering
changes that can damage multiple organ systems

19. Gastric outlet obstruction
 In some cases, an inflamed (swollen) or scarred
stomach ulcer can obstruct the normal passage of food
through your digestive system. This is called a gastric
outlet obstruction.
 Symptoms include:
 vomiting large amounts of undigested food
 a constant feeling of bloating or fullness
 feeling more full than usual after eating less food
 unexplained weight loss
 Treatment: If the obstruction's caused by scar tissue,
surgery may be needed. This can involve passing a
small balloon through an endoscope and inflating it to
widen the site of the obstruction.

20. TREATMENT:
 Treating Helicobacter pylori (H. pylori) infection
If your stomach ulcer's caused by a Helicobacter pylori (H.
pylori) bacterial infection, you'll be given:
a course of antibiotics
 amoxicillin
 clarithromycin
 metronidazole
 Ulcers caused by NSAIDs
If your stomach ulcer's caused by taking NSAIDs:
 your use of NSAIDs will be reviewed, and you may be advised
to use an alternative painkiller (paracetamol) & COX-2
inhibitors
 Proton pump inhibitors

21.  PPIs work by reducing the amount of acid your
stomach produces. This prevents further damage to
the ulcer as it heals naturally.
 The most commonly used PPIs are:
 omeprazole
 pantoprazole
 lansoprazole
H2-receptor antagonists
These also reduce the amount of acid your stomach
produces.
 Ranitidine

22. Antacids and alginates
 Antacids:
 neutralise your stomach acid
 provide immediate, but short-term, symptom relief
 should be taken when you experience symptoms or
when you expect them, such as after meals or at
bedtime
 Some antacids also contain a medicine called an
alginate, which produces a protective coating on
the lining of your stomach. Antacids containing
alginates are best taken after meals.

23. Lifestyle changes
 There aren't any special lifestyle measures you
need to take during treatment.
 However, avoiding stress, alcohol, spicy foods and
smoking may reduce your symptoms while your
ulcer heals.

24. 2-DYSPEPSIA
Definition: Dyspepsia, also known as indigestion, is
a term that describes discomfort or pain in the upper
abdomen.
 Dyspepsia is a group of symptoms rather than a
specific condition or disease.
 Most people with indigestion feel pain and
discomfort in the stomach or chest. The sensation
generally occurs soon after consuming food or
drink. It may make a person feel full or
uncomfortable during a meal, even if they have not
eaten a large amount of food.

25. DYSPEPSIA
Causes:
 Indigestion is usually caused by the lifestyle of an
individual and the foods they eat. It can also be
related to an infection or other digestive conditions.
 The symptoms are normally triggered by stomach
acid coming into contact with the mucosa. Stomach
acids break down the mucosa, causing irritation
and inflammation. This triggers the uncomfortable
symptoms of indigestion.

26. Types:
1. biological
2. physiological
3. psychological
4. environmental

28. DYSPEPSIA
Common causes of indigestion include:
 eating too much or too rapidly
 eating fatty, greasy, or spicy foods, drinking too
much caffeine or alcohol, consuming too much
chocolate or soda
 Obesity
 Smoking
 nervousness
 emotional trauma

29. DYSPEPSIA
Disease which causes dyspepia
 gallstones
 gastritis, or inflammation of the stomach
 hiatus hernia
 infection, especially with a bacteria called Helicobacter
pylori (H. pylori)- peptic ulcer
 pancreatitis, it release powerful digestive enzymes when
theses enzyme are activated before they release in small
intestine & begins attacking to pancreasstomach cancer
 Gastroparesis (a condition where the stomach doesn't empty
properly; this often occurs in people with diabetes)
 Because it is function of vagus nerve & in diabetic patient this
nerve is damaged due to high blood glucose level)
 certain medications, such as antibiotics and non-steroidal anti-
inflammatory drugs (NSAIDs)

30.  Indigestion is not caused by excess stomach
acid.
 Swallowing excessive air when eating may increase
the symptoms of belching(to expel gas loudly from
stomach through mouth) and bloating(to extend),
which are often associated with indigestion.

31. DYSPEPSIA
Symptoms:
 People with indigestion may have one or more of the following symptoms:
 Early fullness during a meal. You haven't eaten much of your meal, but you
already feel full and may not be able to finish eating.
 Uncomfortable fullness after a meal. Fullness lasts longer than it should.
 Discomfort in the upper abdomen. You feel a mild to severe pain in the area
between the bottom of your breastbone and your navel.
 Burning in the upper abdomen. You feel an uncomfortable heat or burning
sensation between the bottom of your breastbone and your navel.
 Bloating in the upper abdomen. You feel an uncomfortable sensation of tightness
due to a buildup of gas.
 Nausea. You feel as though you want to vomit.
Less frequent symptoms include vomiting and belching.
 Sometimes people with indigestion also experience heartburn, but heartburn and
indigestion are two separate conditions. Heartburn is a pain or burning feeling in
the center of your chest that may radiate into your neck or back during or after
eating. It is due to acid reflux

32. Diagnosis:
 Symptoms
 After patient symptoms Dr examine the reason Ex-if
patient is suffering from peptic ulcer then he will go
though urea breath test, if H-Pylori is present then
peptic ulcer is the reason of dyspepsia.
 Same other diagnosis with respect to cause which
are mentioned in previous slides.
 Blood test, x-ray, endoscopy

33.  Abdominal CT scan: This may involve injecting a
dye into the veins. The dye shows up on the
monitor. The CT scan takes a series of X-ray
images to produce a 3D image of the inside of the
abdomen.
 Liver function test: If the doctor suspects a
problem with the bile ducts in the liver(gallstone),
they may request a blood test to assess how the
liver is working. (for certain enzymes which are
present in blood so mean this is blood test)

34. DYSPEPSIA
Risk factors:
People of all ages and of both sexes are affected by
indigestion. It's extremely common. An individual's
risk increases with:
 Excess alcohol consumption
 Use of drugs that may irritate the stomach, such
as aspirin and other pain relievers
 Conditions where there is an abnormality in the
digestive tract, such as an ulcer
 Emotional problems, such as anxiety or depression

35. DYSPEPSIA
Complications:
 Dyspepsia is mild and infrequent in most cases. However, severe
indigestion can occasionally cause the following complications.
 Esophageal stricture: Acid reflux can cause indigestion. This is
a condition in which stomach acids leak back up into the
esophagus and irritate the sensitive lining of the stomach, known
as the mucosa. The irritation can scar the esophagus, which then
becomes narrow and constricted.
 People with esophageal stricture may start to find swallowing
difficult. Food can get stuck in the throat, causing chest pain.
Esophageal dilatation is sometimes needed to widen the
esophagus.
 Pyloric stenosis: This occurs when stomach acid causes long-
term irritation of the lining of the digestive system. The pylorus is
the passage between the stomach and the small intestine. In
pyloric stenosis, it becomes scarred and narrowed. As a result,
food is not properly digested.
 Surgery may be required to widen the pylorus.

36. Preventions:
 Eat small meals so the stomach does not have to work
as hard or as long.
 Eat slowly.
 Avoid foods that contain high amounts of acids, such as
citrus fruits and tomatoes.
 Reduce or avoid foods and beverages that
contain caffeine.
 If stress is a trigger for your indigestion, learn new
methods for managing stress, such as relaxation
and biofeedback techniques.
 If you smoke, quit. Smoking can irritate the lining of the
stomach.
 Cut back on alcohol consumption, because alcohol can
also irritate the stomach lining.

37. DYSPEPSIA
 Avoid wearing tight-fitting garments, because they
tend to compress the stomach, which can cause its
contents to enter the esophagus.
 Don't exercise with a full stomach.
Rather, exercise before a meal or at least one hour
after eating a meal.
 Don't lie down right after eating.
 Wait at least three hours after your last meal of the
day before going to bed.
 Sleep with your head elevated (at least 6 inches)
above your feet and use pillows to prop yourself up.
This will help allow digestive juices to flow into
the intestines rather than to the esophagus.

38. Diet: A high-fiber diet is a good way to manage
digestive health. It has the effect of clearing out the
intestine and making digestion a smoother, cleaner
process.
 Fruits, nuts, legumes, and wholegrain foods are
packed with fiber and an excellent choice for
protecting against indigestion. Many yogurts and
cereals have also been fortified with fiber.

39. Treatment:
 Medications
 In severe or frequent cases of indigestion, a doctor may prescribe medication.
 Antacids: These counter the effects of stomach acid. Examples include Alka-
Seltzer, Maalox, Rolaids, Riopan, and Mylanta. These are over-the-counter (OTC)
medicines that do not need a prescription. A doctor will usually recommend an
antacid medication as one of the first treatments for dyspepsia.
 H-2-receptor antagonists: These reduce stomach acid levels and last longer than
antacids. However, antacids act more quickly. Examples include Zantac, Tagamet,
Pepcid, and Axid. Some of these are OTC, while others are only available on
prescription.
 Some people may experience nausea, vomiting, constipation, diarrhea,
and headaches after taking these. Other side effects may include bruising or
bleeding.
 Proton pump inhibitors (PPIs): Examples include Aciphex, Nexium, Prevacid,
Prilosec, Protonix, and Zegerid. PPIs are highly effective for people who also have
gastroesophageal reflux disease (GERD). They reduce stomach acid and are
stronger than H-2-receptor antagonists.

40. DYSPEPSIA
 Prokinetics: This medication is helpful for stomachs that empty slowly.
One example of a prokinetic drug is Reglan. Side effects may
include tiredness, depression, sleepiness, anxiety, and muscle spasms.
 Antibiotics: If H. pylori is causing peptic ulcers that result in indigestion,
an antibiotic will be prescribed. Side effects may include an upset
stomach, diarrhea, and fungal infections.
 Antidepressants: If the doctor finds no causes for indigestion after a
thorough evaluation, and the person with dyspepsia has not responded
to treatments, the doctor may prescribe low-dose antidepressants.
 Antidepressants sometimes ease discomfort by reducing the sensation
of pain. Side effects may include nausea, headaches, agitation,
constipation, and night sweats.
 Psychological therapy: For people with functional dyspepsia,
psychological therapy can help manage the cognitive aspects of
indigestion. Cognitive behavioral therapy (how to change behaviour
through awareness) biofeedback(without drugs ex- how to decrease bp),
hypnotherapy(through medicines+ how to focus on things) and relaxation
therapy may be recommended.

41. FLATULENCE
 Definition: Flatulence is passing gas from the
digestive system out of the back passage. It's more
commonly known as "passing wind
 Synonym: Farting
 Causes: When you swallow food, water or saliva,
you also swallow small amounts of air, which
collects in the digestive system. Gases can also
build up when you digest food. The body needs to
get rid of the build-up by farting (flatulence)
or burping (belching).

42. FLATULENCE
 Mechanism: Some individuals consider excessive gas to be
excessive belching or others excessive passing of gas
(flatulence)
 Belching: The most common normal cause of belching is
excessive gas in the stomach that comes from swallowed air.
 Difference: However, discomfort in the abdomen for any
reason also may lead to excessive belching. Therefore,
belching does not always indicate the presence of excessive
gas in the stomach. It is not difficult usually to differentiate
between excessive gas in the stomach and other causes of
excessive gas. If the problem is gas in the stomach, belching
brings relief. If it is not gas in the stomach belching does not
bring relief.
 Rarely excessive belching (burping a lot) is due to swallowed
air during acute psychiatric issues associated with anxiety.

43.  Flatulence:
 Undigested food moves from the small intestine to the large intestine.
Once it gets there, the bacteria go to work, making hydrogen, carbon
dioxide, and methane, which then leave your body.
 Not everyone will get gas from the same foods.
 You also swallow air when you eat and drink. This helps make gas. You
usually release swallowed air by burping it. Whatever isn't released by
burping goes into the small or large intestine, where it’s released as
flatulence.
 The source of excessive gas is intestinal bacteria.
a) The bacteria produce the gas (primarily hydrogen and/or methane)
when they digest foods, primarily sugars and non digestible
polysaccharides (for example, rice, starch in potatoes, wheat, grains,
cellulose), that have not been digested during passage through the
small intestine.
b) The bacteria also produce carbon dioxide, but the carbon dioxide is so
rapidly absorbed from the intestine that very little passes in flatus (gas
generated in digestive tract).

44. So small amounts of air are continuously being swallowed and
bacteria are constantly producing gas. Contractions of the
intestinal muscles normally propel the gas through the intestines
and cause the gas to be expelled. Flatulence (passing intestinal
gas) prevents gas from accumulating in the intestines.
 However, there are two other ways in which gas can
escape(to get free) the intestine besides flatulence.
1. First, it can be absorbed across the lining of the intestine
into the blood. The gas then travels in the blood and
ultimately is excreted by the lungs in the breath.
2. Second, gas can be removed and used by certain types of
bacteria within the intestine. In fact, most of the gas that is
formed by bacteria in the intestines is removed by other
bacteria in the intestines.

45. FLATULENCE
Foods that cause gas in one person might not cause it in
another. Common gas-producing foods and substances
include:
 Beans and lentils
 Vegetables such as cabbage, broccoli, cauliflower, bok
choy and brussels sprouts (cruciferous vegetables)
 Bran
 Dairy products containing lactose
 Fructose, which is found in some fruits and used as a
sweetener in soft drinks and other products
 Sorbitol, a sugar substitute found in some sugar-free
candies, gums and artificial sweeteners
 Carbonated beverages, such as soda or beer

46.  Flatulence can also b a symptom of Digestive disorders
such as:
 Crohn's disease
 Diabetes
 Dumping syndrome
 Eating disorders
 Gastroesophageal reflux disease (GERD)
 Gastroparesis (a condition in which the muscles of the
stomach wall don't function properly, interfering with
digestion)
 Intestinal obstruction
 Lactose intolerance
 Peptic ulcer

47. FLATULENCE
 Reasons for Excessive production of gas :
 Theoretically bacteria can produce too much gas in three
ways.
1. First, the amount of gas that bacteria produce may vary
from individual to individual. In other words, some
individuals may have bacteria that produce more gas, either
because there are more of the bacteria or because their
particular bacteria are better at producing gas.
2. Second, there may be poor digestion and absorption of
foods in the small intestine, allowing more undigested food
to reach the bacteria in the colon. The more undigested
food the bacteria have, the more gas they produce.
Examples of diseases of that involve poor digestion and
absorption include lactose intolerance, pancreatic
insufficiency, and untreated celiac disease (gluten
malabsorption)

48. 3- Third, bacterial overgrowth can occur in the small
intestine. Under normal conditions, the bacteria that
produce gas are limited to the colon. In some
conditions, these bacteria spread back into the small
intestine. When this bacterial spread occurs, food
reaches the bacteria before it can be fully digested
and absorbed by the small intestine. Therefore, the
colonic-type bacteria that have moved into the small
intestine have a lot of undigested food from which to
form gas. This condition in which the gas-producing
bacteria move into the small intestine is called
bacterial overgrowth of the small intestine or small
intestinal bacterial overgrowth (SIBO).

49. FLATULENCE
 Diagnosis:
Since diet is the main cause of gas, your doctor will
want to know about the foods you eat and your
symptoms. He may ask you to keep a record of what
you eat and drink to help him identify foods that
cause you trouble. He may also ask you to keep track
of how often you pass gas.

50. Preventions & Treatment:
 Avoid food/drinks which causes flatulence
 eating smaller and more frequent meals
 eating and drinking slowly
 exercising regularly
 There are also some over-the-counter medications
that can help if your flatulence is troublesome, such
as charcoal tablets(bind to poison to prevent
stomach & intestinal absorption)
 simethicone (anti-foaming agent) collapse of gas
bubble thus allowing easier passage of gas. Also
available in drops for children.

51. HICCUP/HICCOUGH
 Definition: A hiccup is an automatic action (a
reflex) that the body can't control. During a hiccup
your diaphragm (the muscle under your lungs that
helps you breathe) contracts. Immediately after this
the top of your windpipe (your glottis) closes,
making the typical 'hic' sound.

54.  Diaphragm:
 The diaphragm is a thin skeletal muscle that sits at
the base of the chest and separates the abdomen
from the chest. It contracts and flattens when you
inhale. This creates a vacuum effect that pulls air
into the lungs. When you exhale,
the diaphragm relaxes (pushes up) and the air is
pushed out of lungs

55. HICCUP
 Mechanism of voice production:
 The ability to produce voice starts with airflow from
the lungs, which is coordinated by the action of the
diaphragm and abdominal and chest muscles.
The voice box (larynx) and vocal folds (sometimes
called vocal cords) comprise the vibratory system
of the voice mechanism.

59.  Hiccup can be categorized as short bouts of
hiccups and persistent hiccups (lasting longer than
48 hours). Persistent hiccups are more likely to be
linked to an underlying illness and you may need
medical tests.

60. Causes of short bouts of hiccups?
 Most people have bouts of hiccups from time to time. In most
cases they start for no apparent reason, last a short while and
then stop. Sometimes they are due to:
 Sudden excitement or emotional stress.
 A temporary swollen stomach caused by overeating or eating
too fast, drinking fizzy drinks, or swallowing air.
 A sudden change in temperature (very hot or cold food or
drinks, a cold shower, etc).
 Alcohol. (drinking alcohol promotes acid reflux & could
irritate esophagus. This could irritate the vagus nerve which
trigger hiccups)
 Carbonated beverages, , dry breads, and some spicy foods,
smoking
 Laughing (muscle spasm)= involuntary action in which muscle
contraction occurs

61. cause of long-term hiccups:
 it is damage to or irritation of the vagus nerves or phrenic
nerves(nerve supply to diaphragm), which serve the
diaphragm muscle. Factors that may cause damage or
irritation to these nerves include:
 Hiccups can also be triggered by infections (especially ear
infections)A hair or something else in your ear touching your
eardrum (reason=Tympanic membrane which is the
membrane in the ear that vibrates in response to sound waves
becomes irritated this can result in hiccup).
 A tumor, cyst or goiter in your neck(enlarged thyroid gland)
 Gastro esophageal reflux
 Sore throat or laryngitis
 Hiatal hernia (upper part of stomach swells through your
diaphragm into the chest cavity) Hiatus entrance b/w stomach
& esophagus
 infections near the diaphragm

63.  Hiccup in milk drinking mammals: A recent explanation by
Howes in 2012 suggests that hiccups may have evolved along
with other reflexes developed in mammals that allow them to
coordinate suckling milk and breathing.
 Hiccups are only found in mammals, and are most common in
infants, becoming rarer as mammals age.
 Mechanism: This may suggest that they evolved to allow air
trapped in the stomach of suckling infants to escape(to get free),
allowing more milk to be ingested. The hypothesis suggests that
the air bubble in the stomach stimulates the sensory limb of the
reflex at receptors in the stomach, esophagus and along the
diaphragm. This triggers the hiccup, which creates suction in the
chest, pulling air from the stomach up and out through the mouth,
effectively burping the animal.
 This theory is supported by the strong tendency for infants to get
hiccups, the component of the reflex that suppresses peristalsis
in the esophagus, and the existence of hiccups only in milk-
drinking mammals.

64. Risk factors
 Men are much more likely to develop long-term
hiccups than are women. Other factors that may
increase your risk of hiccups include:
 Mental or emotional issues. Anxiety, stress and
excitement have been associated with some cases
of short-term and long-term hiccups.
 Surgery. Some people develop hiccups after
undergoing general anesthesia or after procedures
that involve abdominal organs.

65.  Symptoms:
 Hiccupping is a symptom. It may sometimes be
accompanied by a slight tightening sensation in
your chest, abdomen or throat.

66.  Diagnosis
 During the physical exam, your doctor may perform a
neurological exam to check your:
 Balance and coordination
 Muscle strength and tone
 Reflexes
 Sight and sense of touch
 If your doctor suspects an underlying medical condition
may be causing your hiccups, he or she may
recommend one or more of the following tests.
 Laboratory tests
 Samples of your blood may be checked for signs of:
 Infection (ear infection, abdominal infection)
 hernia

67.  Imaging tests
 These types of tests may be able to detect anatomical
abnormalities that may be affecting the vagus nerve,
phrenic nerve or diaphragm. Imaging tests may include:
 Chest X-ray
 Computerized tomography (CT)
 Magnetic resonance imaging (MRI)
 Endoscopic tests
 These procedures utilize a thin, flexible tube containing
a tiny camera, which is passed down your throat to
check for problems in your esophagus or windpipe

68. Treatment:
 Short bouts of hiccups
 Most cases need no treatment, as a bout of hiccups usually soon goes.
 There are many popular remedies that are said to stop a short bout of hiccups but
they are based on people's individual experiences. It is not clear how effective they
are, as they have not been tested by research trials. They include the following:
 First, block off all airways by putting fingers in your ears and blocking your nostrils.
Then, take a sip or two of water from a glass. It is possible to do this alone (looks a
bit silly - but is possible) but you may find it easier with an assistant.
 Sipping iced water.
 Swallowing granulated sugar.
 Biting on a lemon or tasting vinegar. (Vinegar may stimulate the dorsal wall of the
nasopharynx, where the pharyngeal branch of the glossopharyngeal nerve
(the afferent of the hiccup reflex arc) is located)
 Breath holding, breathing fast, or breathing into a paper bag.
 Gasping (intake of breath) after a sudden fright, or sneezing.
 Pulling your knees up to your chest and/or leaning forward to compress the chest.

69. treatment for persistent hiccups?
 If an underlying cause is found then treatment of
the underlying cause, if possible, may cure the
hiccups. For example, one research study found
that many people with persistent hiccups had a gut
condition called acid reflux. See separate leaflet
called Acid Reflux and Oesophagitis for more
details. Treating the reflux seemed to help stop
hiccups in many cases.

70.  Secondly, medication is sometimes needed to stop persistent
hiccups. Various medicines have been used for this. The
following medicines may be used for treating adults with hiccups
(for children, specialist advice is recommended):
 Chlorpromazine and haloperidol are medicines which can relax
the diaphragm muscle or its nerve supply and may stop
persistent hiccups.
 For stomach problems such as acid reflux or a stretched
(distended) stomach: anti-acid medicines (various types, such
as omeprazole or ranitidine) or medicines which help the
stomach to empty faster (such as metoclopramide).
 Baclofen - this is a medicine which helps to relax muscles.
 Gabapentin - this can help to relax the nerve supply to the
muscle under your lungs that helps you breathe in (the
diaphragm).
 Ketamine - an intravenous anaesthetic - is sometimes effective
when other treatments have failed. (to block the nerve)

71.  Giving a medication called metoclopramide by
intravenous injection has been reported to cure
hiccups occurring after anesthetic.
 For people with a terminal illness, sedatives such
as midazolam can help to control hiccups and
relieve the stress they cause.
 Referral to a specialist is often advised for
persistent hiccups, either to look for a cause, or to
offer more treatment options. Some examples of
treatments that have been successfully used for
persistent hiccups are:

72.  Surgery: for persistent hiccups is also an option, though one
that’s exercised rarely. Two examples are a “nerve block” that
stops the phrenic nerve (the major nerve supply for the
diaphragm) from sending signals so that the diaphragm stops
contracting,
1. This involves interrupting the phrenic nerve - for example,
by injecting a local anesthetic near the nerve. However, this
treatment needs to be considered carefully: it carries risks
because the phrenic nerve is important in breathing.
2. and implantation of a pacemaker to make the diaphragm
contract in a more rhythmic pattern.
A pacemaker is a small device with two parts — a generator and
wires (leads, or electrodes) — that's placed under the skin in
your chest to help control your heartbeat. It is implantable under
the skin to treat rhythms.

73. Complications:
 short bouts of hiccups do not normally cause any
problems or complications.
 Persistent hiccups may cause complications such
as tiredness, exhaustion or poor sleep. Also, they
may cause psychological distress or
embarrassment. For people who have had recent
surgery to the tummy (abdomen), persistent
hiccups may delay healing of the scar (wound),
because hiccups move the abdominal muscles.
This increases the risk of complications with the
wound.

74. VOMITING
 Definition: Expulsion of contents from stomach &
intestine
 So it is defense mechanism to get rid of bad
contents from the body. So vomiting is not
diseases, but rather are symptoms of many
different conditions.
 Synonym: Emesis.
 It may be time and location related ex- motion
sickness. Morning sickness, after eating or drinking

75. VOMITING/EMESIS
Causes:
infection ("stomach flu")= gastroenteritis is when vomiting
and diarrhea occur together and is associated with a viral
infection that is outside of the stomach.
 food poisoning: and the most common cause is a toxin
released by the bacteria Staphylococcus aureus Symptoms of
food poisoning begin within a couple hours of eating
contaminated or poorly prepared food. Other bacterial causes of
food poisoning include Salmonella
 motion sickness
 Eating disorder: Patients with bulimia will have self-induced
vomiting, purging as part of their psychiatric illness
 illness,( Diabetes): Persons with diabetes may develop nausea
because of gastroparesis, a condition in which the stomach fails
to empty properly and is likely due to the generalized neuropathy
(failure of the nerves in the body to send proper signals to and
from the brain or regeneration of nerves in the stomach) that is a
complication of the disease as this nerve is damaged due to high
blood glucose level

76.  Appendicitis: it is an inflammation of the appendix, due
to bacteria which leads the blockage of lining, it is a
finger-shaped pouch that projects from your colon(part
of large intestine) on the lower right side of your
abdomen. The appendix doesn't seem to have a specific
purpose. Appendicitis causes pain in your lower right
abdomen. However, in most people, pain begins around
the navel and then moves.
 Migraines: Many who have migraine headaches often
have stomach problems at the same time.
Migraine disease: Serotonin levels drop during migraine
attacks. This may cause your trigeminal nerve
(responsible for sensation & motor function in face) to
release substances called neuropeptides, which travel to
your brain's outer covering (meninges). The result is
migraine pain.

77.  vomiting can sometimes be symptoms of more
serious diseases such as heart attacks, kidney or
liver disorders, central nervous system disorders,
brain tumors, and some forms of
cancer(esophageal cancer).
 chemotherapy: This is because chemotherapy
agents circulating in the blood activate the CTZ in
such a way as to cause emesis. Patients receiving
chemotherapy are often prescribed antiemetic
medications.
 other stomach irritants: alcohol, smoking, and
non-steroidal anti-inflammatory drugs (NSAIDs)
such as aspirin and ibuprofen may irritate the
stomach lining and cause nausea and vomiting

78.  Vomiting in pregnancy: it is caused by hormone
level changes in the bloodstream. (HCG= Human
chorionic gonadotropin) Most women have
moderate symptoms of morning sickness,
especially during the first trimester. The symptoms
of morning sickness during pregnancy usually
resolve by the fourth month.
 Smells, sounds, and trauma: Certain smells or
sounds can cause nausea and vomiting that
originates in the brain. Whether it is the pain of
a broken bone or the emotional shock of observing
an event, vasovagal events can cause significant
symptoms.

79. concussion: (injury to part of brain)
 Damage to the CTZ can come via stroke, (blood
vessels that carry oxygen & nutrient to brain is
either blocked by clot) physical injury, or over-
excitation resulting in neuron death. Once the
damage has occurred, the effects can cause the
emetic response to disappear, or cause the emetic
response to heighten, in some cases causing
intractable vomiting that leave patients in severe
distress.

80. Difference b/w nausea & vomiting:
 Nausea is an uneasiness of the stomach that often
accompanies the urge to vomit, but doesn't always
lead to vomiting.
 Vomiting is the forcible voluntary or involuntary
emptying ("throwing up") of stomach contents
through the mouth.

81.  Physiology:
The vomiting center of the brain
 This integrates the emetic response. This is the area in
which "a final decision is made" about whether to evoke
an emetic response or not. This decision is based
heavily on the information which the CTZ relays to the
rest of the vomiting center, but also the chemoreceptors
in the GI tract, the information sent to the vomiting
center by the vestibular system, and higher order
centers located in the cortex.
 The vomiting center is not a discrete or specific place in
the brain, but rather an area consisting of many nuclei,
axons, and receptors that together cause the physical
changes necessary to induce vomiting. Also, emesis can
occur by direct neural stimulation of the vomiting center
such as chemotherapy, endotoxin etc

82. Diagnosis:
 Diagnosis often can be made when the health care
professional takes a careful history and performs a
physical examination. Any tests that need to be ordered
will be based on the information from the history and
physical exam, and sometimes no further testing is
required to make the diagnosis.
 Laboratory tests and X-rays may be ordered to assess
the stability of the patient and not necessarily to make
the diagnosis. For example, a patient with food
poisoning may need blood tests ordered to measure the
electrolytes(minerals) and other chemicals, since the
patient may lose significant amounts of sodium,
potassium, and chloride from the body from persistent
vomiting and diarrhea
 Blood test for jaundice

83. Treatment:
 promethazine (Phenergan),(anti-histamine)
 Prochlorperazine (Compazine), (block the action of
dopamine)
 droperidol (Inapsine)(D2 antagonist)
 metoclopramide (Reglan), (D2 antagonist in CTZ)
 ondansetron (Zofran).5HT3 Receptor blocker
