This document discusses disorders of the stomach, including anatomy, physiology, dyspepsia, and peptic ulcer disease (PUD). It covers the anatomy and layers of the stomach, as well as its functions like storage, digestion, and secretion. Gastric secretion and the phases of secretion are described. Dyspepsia is defined and its etiology, differential diagnosis, and approaches to evaluation and management are outlined. PUD and its causes like Helicobacter pylori infection and NSAID use are also summarized. Key signs and symptoms of duodenal and gastric ulcers are provided.
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Evaluation and management of patients with Dyspepsia.
Dyspeptic symptoms.
Causes of dyspepsia
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Newer advancement about diagnosing dyspepsia causes.
GERD and peptic ulcer and many more organic diseases.
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Evaluation and management of patients with Dyspepsia.pptxgarvitnanecha
Evaluation and management of patients with Dyspepsia.
Dyspeptic symptoms.
Causes of dyspepsia
Approach to adult with Dyspepsia.
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Prepare a presentation or a paper using research, basic comparative analysis, data organization and application of economic information. You will make an informed assessment of an economic climate outside of the United States to accomplish an entertainment industry objective.
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The US House of Representatives is deeply concerned by ongoing and pervasive acts of antisemitic
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This Congress will not stand idly by and allow an environment hostile to Jewish students to persist. The House believes that your institution is in violation of Title VI of the Civil Rights Act, and the inability or
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Postsecondary education is a unique opportunity for students to learn and have their ideas and beliefs challenged. However, universities receiving hundreds of millions of federal funds annually have denied
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The House of Representatives will not countenance the use of federal funds to indoctrinate students into hateful, antisemitic, anti-American supporters of terrorism. Investigations into campus antisemitism by the Committee on Education and the Workforce and the Committee on Ways and Means have been expanded into a Congress-wide probe across all relevant jurisdictions to address this national crisis. The undersigned Committees will conduct oversight into the use of federal funds at MIT and its learning environment under authorities granted to each Committee.
• The Committee on Education and the Workforce has been investigating your institution since December 7, 2023. The Committee has broad jurisdiction over postsecondary education, including its compliance with Title VI of the Civil Rights Act, campus safety concerns over disruptions to the learning environment, and the awarding of federal student aid under the Higher Education Act.
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7. Gastric Secretion
mucus-secreting cells that line the entire surface of the stomach
two other important types of tubular glands.
oxyntic ( gastric glands) cells - HCl ,pepsin ,intrinsic factor
,mucus
pyloric (chief) cells - mucus for protection of the pyloric mucosa
from the stomach acid & gastrin.
The oxyntic glands are located on the inside surfaces of the body
and fundus of the stomach, constituting the proximal 80% of the
stomach.
-The pyloric glands are located in the antral portion of the stomach
& the distal 20% of the stomach.
3/4/2018 GK,MD 7
8. Secretion phases:
Cephalic phase:
» 20 % of secretions
» Vagus nerve.
Gastric phase:
» 70% of gastric acid secretion
» vagovagal reflex, local enteric reflexes, and gastrin.
Intestinal phase:
» 10 % of secretions.
» Distension of the duodenum.
3/4/2018 GK,MD 8
9. PHYSIOLGY OF GASTRIC ACID
SECRETION
• Hydrochloric acid and pepsinogen are the two
principal gastric secretery products capable of
inducing mucosal injury
• Gastric acid and pepsinogen play a physiologic
role in protein digestion, absorption of iron and
vitamin B12 as well as killing ingested bacteria.
• Acid secretion:- Basal or Stimulated (cephalic,
gastric, and intestinal)
3/4/2018 GK,MD 9
14. Dyspepsia
• persistent or recurrent pain or discomfort
centered in the upper abdomen.
• The term discomfort refers to symptoms such
as early satiety, postprandial fullness, bloating,
and nausea.
• Clinically relevant dyspepsia is defined as a
relapsing or chronic condition, present for at
least 12 weeks in the prior year
3/4/2018 GK,MD 14
15. Dyspepsia
• Dyspepsia is a common symptom with an
extensive differential diagnosis and a
heterogeneous pathophysiology.
• It occurs in 25% of the population each year, but
most affected people do not seek medical care.
• Dyspepsia is responsible for substantial health
care costs and considerable time lost from work
3/4/2018 GK,MD 15
16. DEFINITION
• Rome III - one or more of the following
symptoms
Postprandial fullness(postprandial distress
syndrome)
Early satiation (meaning inability to finish a
normal sized meal)
Epigastric pain or burning (termed epigastric
pain syndrome)
3/4/2018 GK,MD 16
18. ETIOLOGY
-Approximately 25% of patients with dyspepsia
have an underlying organic cause.
-However, up to 75% of patients have functional
(idiopathic or non ulcer) dyspepsia with no
underlying cause on diagnostic evaluation
-We need to R/O structural disease by
endoscopy to diagnose non ulcer dyspepsia.
3/4/2018 GK,MD 18
19. Differential diagnosis of upper
abdominal pain
Diagnosis
Functional dyspepsia (up to 75 percent)
Dyspepsia caused by structural or biochemical disease
Peptic ulcer disease
Gastroesophageal reflux disease (GERD)
Biliary pain
Chronic abdominal wall pain
Gastric or esophageal cancer
Gastroparesis
Pancreatitis
Carbohydrate malabsorption
3/4/2018 GK,MD 19
21. Functional dyspepsia
-Functional (idiopathic or non ulcer) dyspepsia is
defined as the presence of one or more of the
following:
postprandial fullness,
early satiation,
epigastric pain or burning, plus
no evidence of structural disease to explain the
symptoms.
-These criteria should be fulfilled for the last three
months with symptom onset at least six months
before diagnosis.
-A diagnosis of functional dyspepsia can therefore
only be established exclusion of other causes of
dyspepsia
3/4/2018 GK,MD 21
22. History
PUD-Upper abdominal pain or discomfort is the most
prominent symptom in patients with peptic ulcers.
-Although discomfort from ulcers is usually centered in the
epigastrium, it may occasionally localize to the right or left upper
quadrants.
-While the pain may radiate to the back, back pain as the primary
symptom is atypical of peptic ulcer disease.
-While classic symptoms of duodenal ulcer occur when acid is
secreted in the absence of a food buffer ( 2-5 hours after meals or
on an empty stomach), peptic ulcers can be associated with food-
provoked symptoms.
-Peptic ulcers can also be associated with postprandial belching,
epigastric fullness, early satiation, fatty food intolerance, nausea,
and occasional vomiting.
GERD -The most common symptoms of GERD :retrosternal
burning pain and regurgitation.
-GERD should be suspected when these symptoms accompany
dyspepsia and are the predominant complaints.
3/4/2018 GK,MD 22
23. History
•A dominant history of heartburn, regurgitation, or
cough is suggestive of GERD.
•NSAID use raises the possibility of NSAID dyspepsia
and peptic ulcer disease.
•Radiation of the pain to the back, a personal or family
history of pancreatitis may be indicative of underlying
chronic pancreatitis.
•Significant weight loss, anorexia, vomiting, dysphagia,
odynophagia, and a family history of gastrointestinal
cancers suggest the presence of an underlying
malignancy.
•The presence of severe episodic epigastric or right
upper quadrant abdominal pain lasting more than an
hour or pain that occurs at any time is suggestive of
symptomatic cholelithiasis
3/4/2018 GK,MD 23
24. CLINICAL APPROACH
History — Three common patterns of dyspepsia
Ulcer-like or acid dyspepsia (eg, burning,
epigastric hunger pain with food, antiacid, and
antisecretory agent relief)
Dysmotility-like dyspepsia (with predominant
nausea, bloating, and anorexia)
Unspecified dyspepsia
3/4/2018 GK,MD 24
25. • Physical examination — The physical
examination is usually normal, except for
epigastric tenderness..
• Routine laboratory tests — Routine blood
counts and blood chemistry determinations
are commonly obtained. They can be
requested selectively depending upon patient
features such as age, symptom duration, and
other factors.
3/4/2018 GK,MD 25
26. Alarm features…UGI endoscopy & biopsy
Age older than 55 years with new-onset dyspepsia
Family history of upper gastrointestinal cancer
Unintended weight loss
Gastrointestinal bleeding
Progressive dysphagia
Odynophagia
Unexplained iron deficiency anemia
Persistent vomiting
Palpable mass or lymphadenopathy
Jaundice
3/4/2018 GK,MD 26
27. • Diagnostic strategies
New onset dyspepsia not caused by drugs have
been evaluated
Dyspepsia caused by drugs –stop drug
Noninvasive testing for H. pylori infection
Endoscopy in all patients alarm features & age
>55yrs
3/4/2018 GK,MD 27
28. dyspepsia
Age <55 & no alarm feature
• H. pylori TEST & treat
• Empiric PPI
Alarm feature or age>55
• UGI endoscopy
• Biopsy
• Treat specific cause.
3/4/2018 GK,MD 28
29. EVALUATION OF PERSISTENT SYMPTOMS
-some patients continue to have symptoms of
dyspepsia despite the above approach.
-Patients with continued symptoms of dyspepsia fall
into the following categories:
-patients with persistent H. pylori infection,
-patients with an alternate diagnosis, and
-patients with functional dyspepsia.
-Patients with continued symptoms of dyspepsia should be carefully
reassessed, paying specific attention to the
-type of ongoing symptoms
- the degree to which symptoms have improved or worsened
- compliance with medications
- upper endoscopy
- H. pylori with biopsy for histology
- Gastric emptying time
- Abdominal U/S e.t.c should be done.
3/4/2018 GK,MD 29
30. -Approximately 75 percent of patients have functional (idiopathic or
non ulcer) dyspepsia with no underlying cause on diagnostic
evaluation.
-Functional dyspepsia is classified into
-postprandial distress syndrome and
-epigastric pain syndrome
-The management of functional dyspepsia
.test and treat for H. pylori
.treat if the local prevalence of H. pylori is >10 percent
.PPIs in patients who test negative for H. pylori
.H2 receptor antagonists
.Antidepressants - (try with TCA if no improvement after 8wks
of PPI)
.Psychological therapy
.Dietary modification
3/4/2018 GK,MD 30
31. PEPTIC ULCER DISEASE
An ulcer is defined as disruption of the
mucosal integrity(>5mm in size) of the
stomach and/or duodenum leading to a local
defect or excavation due to active
inflammation.
Ulcers occur within the stomach and/or
duodenum and are often chronic in nature.
Can be: gastric or duodenal
3/4/2018 GK,MD 31
33. Duodenal Ulcers
• DUs occur most often in the first portion of
the duodenum (>95%), with ~90% located
within 3 cm of the pylorus.
• They are usually 1 cm in diameter but can
occasionally reach 3–6 cm (giant ulcer)
• H. pylori and NSAID-induced injury account for
the majority of DU .
• Associated with increase acid secretion &
decrease bicarbonate secretion
3/4/2018 GK,MD 33
34. Gastric ulcer
• Tends to occur in late age(median age 60)
• mostly silent & present with complication
• GUs can represent a malignancy and should be
biopsied upon discovery
• Gastric acid output (basal and stimulated) tends
to be normal or decreased in GU patients.
3/4/2018 GK,MD 34
35. Gastric ulcers
• have been classified based on their location:
Type I -gastric body and
-low gastric acid production;
Type II -antrum and
-gastric acid can vary from low to normal
Type III
-within 3 cm of the pylorus and are commonly
accompanied by duodenal ulcers and
-normal or high gastric acid production
Type IV -cardia
-low gastric acid production.
3/4/2018 GK,MD 35
37. ETIOLOGY
The two most common causes of PUD are:
– Helicobacter pylori infection ( 70-80%)
– Non-steroidal anti-inflammatory drugs (NSAIDS)
• One half of world’s population has H.pylori (80-90 %
developing world)
• The annual incidence H. pylori infections in
industrialized countries is 0.5% compared with ≥ 3% in
developing countries
3/4/2018 GK,MD 37
38. H. Pylori infection
• Gastric infection with the bacterium H. pylori
accounts for the majority of PUD
• Is a gram-negative micro aerophilic rod found
most commonly in the deeper portions of the
mucous gel coating the gastric mucosa or
between the mucous layer and the gastric
epithelium.
• higher colonization rates in poor
socioeconomic status.
3/4/2018 GK,MD 38
39. Other risk factors for H. pylori
infection
-Birth or residency in developing country.
- Domestic crowding
-Unsanitary living condition
-Exposure to infected gastric content
3/4/2018 GK,MD 39
42. The particular end result of H. pylori infection
-Gastric ulcer
-PUD
-gastric MALT lymphoma
-gastric cancer is determined by a complex
interplay between bacterial and host factors
1.Host factor genetics susceptibility , durations
, location , inflammatory response
2. Bacterial structure , virulence factor & strain.
3/4/2018 GK,MD 42
43. NSAID-Induced Disease
• NSAIDs represent a group of the most commonly
used medications
• The spectrum of NSAID-induced morbidity ranges
-from nausea and dyspepsia ( 50–60%)
-serious endoscopy-documented peptic ulceration
(15–30% of individuals taking NSAIDs regularly)
-complicated by bleeding /perforation in as many as
1.5% of users per year
• no dose of NSAID is completely safe.
3/4/2018 GK,MD 43
44. Risk factor to develop PUD
• Established risk factors include
-advanced age
-history of ulcer
-concomitant use of gluco corticoids
-high-dose NSAIDs
-multiple NSAIDs
-concomitant use of anticoagulants
-psychosocial factores
-diets
-serious or multisystem disease
-concomitant H. pylori infection
-cigarette smoking
-alcohol consumption.
3/4/2018 GK,MD 44
45. NSAIDS
• The effects ; mucosal hemorrhage , erosions , acute
ulcers.
Inhibits the production of prostaglandins.
1. Decrease mucus & HCO3 production
2. Decrease mucosal blood flow
3. Reduce cell renewal
4. generate oxygen-free radicals that may contribute to
ulceration.
3/4/2018 GK,MD 45
46. C/M of DU
• Abdominal pain
• Epigastric pain : a burning or gnawing discomfort
can be present in both DU and GU .
• The discomfort : an ill-defined, aching sensation
or as hunger pain. The typical pain pattern in DU
occurs 90 minutes to 3 hours after a meal and is
frequently relieved by antacids or food.
• Pain that awakes the patient from sleep is the
most discriminating symptom, with two-thirds of
DU patients describing this complaint
3/4/2018 GK,MD 46
47. C/M Of GU
• Can be assymptomatic
• The pain : precipitated by food.
• Nausea and weight loss occur more .
• Endoscopy detects ulcers in <30% of patients
who have dyspepsia
3/4/2018 GK,MD 47
48. Symptoms that suggest complications
related to PUD include
• Penetrating ulcers classically present with a shift from the
typical vague visceral discomfort to a more localized and
intense pain that radiates to the back and is not relieved by
food or antacids.
• The sudden development of severe, diffuse abdominal pain
may indicate perforation.
• Vomiting is the cardinal feature present in most cases of
pyloric outlet obstruction.
• Hemorrhage may be heralded by nausea, hematemesis,
melena, or dizziness.
• Gastrocolic fistula, a very rare complication, can present
with halitosis, feculent vomiting, postprandial diarrhea,
dyspepsia, and sometimes weight loss
3/4/2018 GK,MD 48
49. PUD-Related Complications
• Gastrointestinal Bleeding is the most
common complication observed in PUD. It
occurs in ~15% of patients and more often in
individuals >60 years of age( likely due to the
increased use of NSAIDs in this group of age) .
• Up to 20% of patients with ulcer-related
hemorrhage bleed without any preceding
warning signs or symptoms
• Common in anterior part of DU.
3/4/2018 GK,MD 49
50. Perforation
• The second most common ulcer-related
complication is perforation ( occur in 6–7% of
PUD patients).
• DUs tend to penetrate posteriorly into the
pancreas, leading to pancreatitis, whereas
GUs tend to penetrate into the left hepatic
lobe.
3/4/2018 GK,MD 50
51. Gastric Outlet Obstruction
• Gastric outlet obstruction is the least common
ulcer-related complication, occurring in 1–2%
of patients.
3/4/2018 GK,MD 51
52. Gastric carcinoma
Alarm symptom of Gastric ca
• Unintended weight loss
• Bleeding
• Anemia
• Dysphagia
• Odynophagia
• Hematemesis
• A palpable abdominal mass or lymphadenopathy
• Persistent vomiting
• Unexplained iron deficiency anemia
• Family history of upper gastrointestinal cancer
• Previous gastric surgery
• Jaundice
3/4/2018 GK,MD 52
53. Diagnosis:
1) Diagnosis of ulcer
2) Diagnosis of H. pylori
Diagnosis of PUD depends mainly on
-endoscopic
-radiographic confirmation
3/4/2018 GK,MD 53
54. Tests for H. Pylori Infection
1 Invasive (Endoscopy/Biopsy Required)
Rapid urease
Histology
Culture
2. Noninvasive
Serology
Urea breath test
Stool antigen
3/4/2018 GK,MD 54
55. Treatment Of Peptic Ulcer Disease
• Although acid secretion is still important in
the pathogenesis of PUD,
• eradication of H. pylori and therapy &
• prevention of NSAID-induced disease is the
mainstay of treatment.
3/4/2018 GK,MD 55
57. General approach
• All patients with PUD should receive anti secretory
therapy.
• Patients with PUD should be tested for H. pylori
• Patients with H. pylori should be treated with a goal
of H. pylori eradication.
• Anti secretory therapy is the mainstay of therapy in
uninfected patients.
• It is essential to withdraw potential offending or
contributing agents such as NSAIDs, cigarettes, and
excess alcohol.
• There is no evidence that addressing stressful
psychosocial situations and psychological
comorbidity benefits treatment outcomes
3/4/2018 GK,MD 57
58. Treatment
• Rapid relief of symptoms
• Healing of ulcer
• Preventing ulcer recurrences
• Reducing ulcer-related complications
• Reduce the morbidity (including the need for
endoscopic therapy or surgery)
• Reduce the mortality
3/4/2018 GK,MD 58
59. General Strategy
Treat complications aggressively if present
Determine the etiology of ulcer
Discontinue NSAID use if possible
Eradicate H. pylori infection if present or strongly
suspected, even if other risk factors (e.g., NSAID
use) are also present;
Use antisecretory therapy to heal the ulcer if H.
pylori infection is not present
3/4/2018 GK,MD 59
60. • Smoking cessation should be encouraged
• If DU is diagnosed by endoscopy, Rapid urea
testing of endoscopically obtained gastric biopsy
sample, with or without histologic examination
should establish presence or absence of H. pylori
• If DU is diagnosed by x-ray , then a serologic , UBT,
or fecal antigen test to diagnose H. pylori infection
is recommended before treating the patient for H.
pylori
3/4/2018 GK,MD 60
61. Drugs Used in the Treatment of PUD
Acid-suppressing drugs
• Anti acids Mylanta, Maalox, Tums, Gaviscon
100–140 meq/L 1 and 3 h after meals.
• H2 receptor antagonists
Cimetidine 400 mg bid Ranitidine 300 mg
Famotidine 40 mg Nizatidine 300 mg
• Proton pump inhibitors Omeprazole 20
mg/d Lansoprazole 30 mg/d Rabeprazole 20
mg/d Pantoprazole 40 mg/d Esomeprazole
20 mg/d
3/4/2018 GK,MD 61
63. Therapy of H. Pylori
• H. pylori should be eradicated in patients with
documented PUD.
• No single agent is effective in eradicating the
organism.
• Combination therapy for 14 days provides the
greatest efficacy.
• The agents used with the greatest frequency
include amoxicillin, metronidazole, tetracycline,
clarithromycin, and bismuth compounds.
3/4/2018 GK,MD 63
65. Therapy of NSAID-Related Gastric or
Duodenal Injury
• Recommendations for Treatment of NSAID-
Related Mucosal Injury
• Active ulcer -NSAID discontinued
-H2 receptor antagonist or
-PPI
• Prophylactic therapy Misoprostol/ PPI
• H. pylori infection Eradication if active ulcer
present or there is a past history of peptic ulcer
disease
3/4/2018 GK,MD 65
66. Non Healing PUD
1
• Non compliance with medicines
2
• Ulcer turning malignant
3
• False –ve H.pylori – empirically treat for it
4
• Inadvertent NSAID or ulcerogenic drugs
5
• Rare causes – ZE, MALT, Chron’s, MEN 1
663/4/2018 GK,MD
67. REFRACTORY
Majority (>90%) of GUs and DUs heal with the conventional
Tx.
A GU that fails to heal after 12 weeks and a DU that does not
heal after 8 weeks of therapy should be considered refractory
Exclude –
poor compliance and persistent H. pylori infection
NSAID use, either inadvertent or surreptitious
Cigarette smoking
For a GU, malignancy must be meticulously excluded, gastric
acid hyper secretory state such as ZES .
8 weeks of Rx high dose PPI (>90% improve) . . . SURGERY
RARE ,,, Crohn's disease, amyloidosis, sarcoidosis, lymphoma,
eosinophilic gastroenteritis, or infection [cytomegalovirus
(CMV), tuberculosis, or syphilis].
3/4/2018 GK,MD 67