The Stomach and Duodenum

The Stomach and Duodenum Gastritis

Type A gastritis

This is an autoimmune condition in which there are circulating antibodies to the parietal cell. This results in the atrophy of the parietal cell mass, resulting in hypochlorhydria and ultimately achlorhydria. As intrinsic factor is also produced by the parietal cell there is malabsorption of vitamin B12, which, if untreated, may result in pernicious anaemia . Patients with type A gastritis are predisposed to the development of gastric cancer, and screening such patients endoscopically may be appropriate.
Type B gastritis It is associationed with H. pylori infection. Most commonly, type B gastritis affects the antrum, causing peptic ulcer disease. Helicobacter-associated pangastritis is also a very common manifestation of infection. Patients with pangastritis seem to be most prone to the development of Intestinal metaplasia and gastric cancer.
Intestinal metaplasia associated with dysplasia has significant malignant potential and, if this condition is identified, endoscopic screening may be appropriate.
Reflux gastritis
This is caused by enterogastric reflux and is particularly common after gastric surgery. Its histological features are distinct from those of other types of gastritis. Although commonly seen after gastric surgery, it is occasionally found in patients with no previous surgical intervention..
Bile-chelating or prokinetic agents may be useful in treatment and as a temporising measure to avoid the consideration of revisional surgery. Operation for this condition should be reserved for the most severe cases.
Erosive gastritis
This is caused by agents that disturb the gastric mucosal barrier; NSAIDs and alcohol are common causes. The NSAID-induced gastric lesion is associated with reduction of the production of cytoprotective prostaglandins in the stomach.
Stress gastritis
This is a common sequel of serious illness or injury and is characterized by a reduction in the blood supply to superficial mucosa of the stomach. Although common, it is not usually recognized unless stress ulceration and bleeding supervene, in which case treatment can be extremely difficult

peptic ulcer disease
Clinical features of peptic ulcers
the clinical features of gastric and duodenal ulceration, they cannot be differentiated on the basis of symptoms.
Pain The pain is epigastric, often described as gnawing, and may radiate to the back. Eating may sometimes relieve the discomfort. The pain is normally intermittent rather than intractable.
Periodicity One of the classic features of untreated peptic ulceration is periodicity. Symptoms may disappear for weeks or months to return again. This periodicity may be related to the spontaneous healing of the ulcer.
Vomiting Although this occurs, it is not a notable feature unless stenosis has occurred.
Alteration in weight Weight loss or, sometimes, weight gain may occur. Patients with gastric ulceration are often underweight but this may precede the occurrence of the ulcer.
Bleeding All peptic ulcers may bleed. The bleeding may be chronic and presentation melaena.
Clinical examination Examination of the patient may reveal epigastric tenderness but, except in extreme cases (for instance gastric outlet obstruction), there is unlikely to be much else to find.
Investigation of the patient with suspected peptic ulcer
Gastroduodenoscopy
This is the investigation of choice in the management of suspected peptic ulceration In the stomach, any abnormal lesion should be multiply biopsied and, in the case of a suspected benign gastric ulcer, numerous biopsies must be taken to exclude, as far as possible, the presence of a malignancy. Commonly, biopsies of the antrum will be taken to see whether there is histological evidence of gastritis and a CLO test performed to determine the presence of H. pylori. A ‘U’ manoeuvre should be performed to exclude ulcers around the gastro-oesophageal junction. This is important as the increasing
incidence of cancer at the gastro-oesophageal junction requires that all mucosal abnormalities in this region should undergo multiple biopsy. Similarly, if a stoma is present, for instance after gastroenterostomy or Billroth II gastrectomy, it is important to
enter both afferent and efferent loops. Attention should be given to the pylorus to note whether there is any pre-pyloric or pyloric channel ulceration, and also whether it is deformed, which is often the case with chronic duodenal ulceration
Complications of management of peptic ulcer:
Recurrent ulceration
As with other peptic ulcers, recurrent ulcers may present with complications, particularly bleeding and perforation.
Small stomach syndrome
Early satiety follows most ulcer operations to some degree, including highly selective vagotomy, in which, although there is no anatomical disturbance of the stomach, there is a loss of receptive relaxation. Fortunately, this problem does tend to get better with
time and revisional surgery is not necessary.
Bile vomiting
Bile vomiting can occur after any form of vagotomy with drainage or gastrectomy. Commonly, the patient presents with vomiting of a mixture of food and bile or sometimes bile alone after a meal.
Often, eating will precipitate abdominal pain and reflux symptoms are common. Bile-chelating agents can be tried but are usually ineffective. In intractable cases, revisional surgery may be indicated. The nature of the revision depends very much on the
original operation. Following gastrectomy, Roux-en-Y diversion is probably the best treatment. In patients with a gastroenterostomy, the drainage may be taken down and, in most circumstances, a small pyloroplasty can be performed. In patients with a pyloroplasty, reconstruction of the pylorus has been attempted but, in general terms, the results have been rather poor. Antrectomy and Roux-en-Y reconstruction may be the better option.
Early and late dumping
Although considered together because the symptoms are similar, early and late dumping have different aetiologies A common feature, however, is early rapid gastric emptying. Many patients have both early and late dumping.
Features of early and late dumping
Early Late
Incidence 5–10% 5%
Relation to meals Almost immediate Second hour after
Duration of attack 30–40 min 30–40 min
Relieved by Lying down Food
Aggravated by More food Exercise
Precipitating factor: Food, especially carbohydrate-rich and wet same
Major symptoms: Epigastric fullness, sweating, Tremor, faintness tachycardia, prostration, colic -, lightheadedness,

Post-vagotomy diarrhoea
This can be the most devastating symptom to afflict patients having peptic ulcer surgery. Most patients will suffer looseness of bowel action to some degree (with the exception of highly selective vagotomy) but, in about 5%, it may be intractable.
Despite much investigation, the precise aetiology of the problem is uncertain. It is partly related to rapid gastric emptying.In all probability, the denervation of the upper gastrointestinal tract as a result of the vagotomy is also important. Exaggerated
gastrointestinal peptide responses may also aggravate the condition.
The diarrhoea may take several forms. It may be severe and explosive, with the patient experiencing a considerable degree of
urgency. The patient sometimes describes the diarrhoea as feeling like passing boiling water. At the other extreme, some patients
only have minor episodes of diarrhoea, which are not as directly related to food.
The condition is difficult to treat. The patient should be managed as for early dumping and anti-diarrhoeal preparations
may be of some value. Octreotide is not effective in treating this condition and the results of revisional surgery are too unpredictable to make this an attractive option.
Malignant transformation
operations such as gastrectomy or vagotomy and drainage are independent risk factors for the development of gastric cancer. The increased risk appears to be approximately four times that of the control population.
It is not difficult to understand the increased incidence of gastric cancer, as bile reflux gastritis, intestinal metaplasia and
gastric cancer are linked. The lag phase between operation and the development of malignancy is at least 10 years. Highly selective vagotomy does not seem to be associated with an increased incidence.
Nutritional consequences
Nutritional disorders are more common after gastrectomy than after vagotomy and drainage. Weight loss is common after
gastrectomy and the patient may never return to their original weight. Eating small meals often may help.
The complications of peptic ulceration
The common complications of peptic ulcer are perforation,
bleeding and stenosis.