1DDX: LECTURE 27 – JANUARY 17TH 2007

GASTROINTESTINAL DISORDERS: STOMACH

3RD NOTE PACKAGE
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ACUTE GASTRITIS
Inflammation of the stomach: 2 types. Erosive and non-erosive.
Self-limiting: this characterizes acute gastritis. If it isn’t self-limiting, it isn’t acute.

CASE:
26 year-old female, generally healthy, athletic. 3-day episode of melena (stool or vomit containing black blood that has been acted upon by gastric
juices), nausea, no vomiting. Weakness, some pallor, blood tests were normal. Had gastroscopy done, observed some superficial inflammation of
gastric mucosa. Biopsies were taken, waiting on results.
From age 13-16: took about 13 ibuprofen pills per day for knee injury. Nothing happened at that time, but speculation that these pills weakened the
mucosa, and the results are being seen now.
About a month prior to this event, she started eating fish after being vegan previously. This might have caused this episode in conjunction with
ibuprofen use? Might have caused an allergic reaction?
(We don’t have a conclusive diagnosis. These are theories.)

Underlying infection, caustic ingestion can disrupt the mucosa leading to gastritis.
No symptoms in 30% of patients. First sign is usually hemorrhage.
Hemorrhage is usually painless, but can occur with pain as well. If lesion is superficial, it hasn’t reached the nerve layer and therefore the patient won’t
feel any pain. 3mm< is an ulcer. 2-3mm is still in superficial layer.

Endoscopic criteria: these can apply to chronic or acute

Giant folds gastritis: may be so big that they obstruct the lumen of the stomach

Different forms of gastritis: see “classification according to etiology”, “classification according to localization”
(“antrum” is the lower part of the stomach, “body” refers to the part of the stomach of the same name, “Pan” is all over the stomach)

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Treatment: inquire about use of NSAIDs or other medication that can cause gastritis.
Transfusions: if there is a lot of bleeding: not usually with gastritis, but possible with ulceration.
People will usually be given antacids.

Acute: Superficial erosions, redness on large area of the stomach. Patches of hemorrhage might not produce hemorrhage, but long term can lead to
anemia.
3rd picture: see large folds. They are also atrophic (flatter than normal).

CHRONIC GASTRITIS
If there are more than 1 episode, this is chronic gastritis.
Superficial lymphocyte infiltrations. (there were polymorphicnuclear (PMNs) cells in acute)
Etiology: overlap with chronic gastritis
Thermal injury? Radiation to stomach for other conditions, repeated application of heat to area (coals used by Tibetans (?) to warm selves, held close to
body, increased incidence of gastritis).
Ingested pills can get stuck in folds of stomach and cause gastritis: especially in elderly.
At site of anastomosis: because there is more inflammation in this area post-surgery (after gastrectomy)
Pernicious anemial is associated with atrophic gastritis.

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Eosinophilic: in allergic reaction: people with allergy more prone to eosinophilic gastritis.
Menetrier’s disease: loss of protein. Oncotic pressure in BV changes, fluid shift, edema in folds of stomach. Can obstruct stomach.

Type A: less common Type B: more common

Body, fundus Antrum
Autoimmune Usually in younger patients. If it is in older, 90% caused by H. pylori
SEE NOTE PACKAGE FOR THE REST OF THIS CHART
Remember that hyperthyroidism is more strongly associated with Type A: she said we should know this.

Hemorrhagic gastritis: can’t see on slide but there are areas of bleeding.

With chronic: can have severe gastritis with no symptoms (usually occurs in elderly: don’t present textbook symptoms)
OR lots of symptoms, few changes in gastric mucosa.
Signs listed are of acute/chronic gastritis, but could be signs for other organ systems too (lung, heart)

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Spicy peppers! Even though people are told not to eat this, eating capsaicin is going to increase the levels of HCl in the stomach. Countries where a lot
of spicy food is eaten, ulcers, gastritis is not common.
Anti-oxidants
Amino acids: glutamine: found in cabbage. 10 day treatment: cabbage and potato juice. Patient will hate you but it will cure an ulcer.
Glycyrrhiza glabra: careful with hypertensive patients.
Goldenseal: endangered species of plants. One of the best anti-microbial, anti-fungal, anti-viral botanicals. Berberine is the active ingredient.
Chamomile, marshmallow, slippery elm: forms mucilage in stomach.
Ginger: may have a worsening of symptoms when they first start using it.

DDX LECTURE 27, JANUARY 17TH, 2007 – PAGE 1

PEPTIC ULCER DISEASE
3mm< is characterized as an ulcer.
Ulcers NOT located on lesser curvature have an increased incidence of malignancy.
Aggravated by food (DDX with Duodenal ulcers which are relieved by food.)

Can occur at any age, even in children.

DUODENAL ULCERS
Smaller ulceration than gastric ulcers.
Occur d/t hyper AND HYPOacidity.
Almost always benign

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Peptic ulcers: Pain is usually first sign, unless there is bleeding which may be seen first. Pain BEFORE eating. See weight loss. Antacids less likely to
help than with gastritis.
Duodenal ulcers: characteristic presentation (know this): pain reoccurs about 2-3 hours after meals. These patients will eat smaller meals more often to
prevent the pain from reoccurring.

Sometimes, the first symptom will send the patient to the emergency room: they may not know that they have an ulcer until they have perforation! Then
there will be signs of peritoneal involvement.

Complications:
Penetration: Ulcer penetrates into adjacent organ
Perforation: opens into abdominal cavity, not another organ.
Hemorrhage: more common in duodenal ulcer.

PUD: treatment
Naturopathically: we don’t neutralize or decrease gastric activity!
Side effects of treatments: aluminum can lead to constipation. Antibiotics: kills flora. Surgical therapy: excision of ulcer, suture remaining part of
stomach to itself, or to small intestine.

DUODENAL ULCER

DDX:
Acute/chronic: Biopsy will show what kind of gastritis, and history will tell us.
Cholecystitis (inflammation of the gall bladder), cholelithiasis (gallstones): will cover in later lectures: Different location of pain (RUQ), steatorrhea, FAT
consumption will produce attack, quality and intensity of pain are different in these conditions (very severe pain), fever, more vomiting and bilious
vomiting.
GERD, pancreatitis: ultrasound will show inflammation, other features
Mesenteric artery ischemia: mostly in elderly with atherosclerosis. Blood clots lodge in mesenteric artery: this presents with diffuse but severe
abdominal pain. More localized in ulcer, cholecystitis.
Crohn’s: Abdominal pain, but it presents with rectal bleeding.

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Gastric carcinoma: stage 4 is when it spreads to the rest of the body.

Most commonly goes to liver.

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GALLBLADDER: Review of anatomy
Know the different names of the ducts: different pathologies at different sites.

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Bile is REUSED!

Most common location of gallbladder stones is in gallbladder, in common bile duct, in common
Will see if there is calcium deposit: will occur as radio-opaque area, but cholesterol-only gallstones may not be seen with radiography. People can have
intense biliary colic, but nothing is seen on ultrasound. GB may look normal size, no inflammation, no edema, but there may still be a problem.

DDX LECTURE 27, JANUARY 17TH, 2007 – PAGE 2