Diseases of The Stomach

Prof:Hussien Gadalla

Gastric Disorders

• Acute Gastritis• Chronic Gastritis• Peptic Ulcer Disease• These three are common and related

disorders.

Defences of Stomach

• Mucosal barrier: which comprises mucus which is alkaline and tight intercellular junctions to prevent acid from penetrating

• Good gastric blood flow• High rate of gastric mucosal turnover• Prostaglandins which stimulate secretion of mucus

(reduced by COX1 inhibition)

Acute Gastritis

• It is an acute mucosal inflammatory process• Risk factors

– Drugs• Direct irritating effect on gastric mucosa• Aspirin, NSAIDs, and corticosteroids

– Diet• Alcohol, spicy food

-- Systemic infection: salmooellosis

GastritisEtiology and Pathophysiology

• Risk factors (cont’d)– Environmental factors

• Radiation, smoking

– Pathophysiologic conditions• Burns, renal failure, sepsis

– Other factors• Psychologic stress, NG tube

Pathogenesis

• One or more of the following may play a role:• Direct damage to the epithelium• Disruption of the adherent mucous layer.• Stimulation of acid secretion with back diffusion

of hydrogen ions into the superficial layer.• Decreased production of bicarbonate buffer by

the superficial epithelium• Reduced mucosal blood flow

Acute gastritis

• A cute erosion (loss of mucosa superficial to muscularis mucosae). Can result in severe haemorrhage

• Acute Helicobacter infection has a prominent neutrophil infiltrate

Chronic gastritis

• Chronic gastritis is defined as the presence of chronic mucosal inflammatory changes leading eventually to mucosal atrophy and epithelial metaplasia.

• A – Bacterial (helicobacter)• B – Autoimmune• C - Chemical

Chronic Gastritis

• Risk factors (cont’d)– Microorganisms

• Helicobacter pylori – Important cause of chronic gastritis– Promotes breakdown of gastric mucosal barrier

• Staphylococcus organisms

Helicobacter pylori

• Adapted to live in association with surface epithelium beneath mucus barrier

• Causes cell damage and inflammatory cell infiltration

• In most countries the majority of adults are infected

Pathogenesis

• Factors permitting colonisation:• (i) Spiral shape and flagellate – for motility

within this mucous layer.• (ii) Urease activity – which generate ammonium

ions that buffer gastric activity• (iii) Micro-aerophilism – for survival within the

mucous gel• (iv) Attachment to epithelial cells• (v) Evasion of Immune response

Figure 2. Pathogen–Host Interactions in the Pathogenesis of Helicobacter pylori Infection.

Helicobacter gastritis

• Acute inflammation mediated by complement and cytokines

• Polymorphisms infiltrate epithelium and may be partly responsible for its destruction

• An immune response is also initiated (antibodies may be detected in serum)

Figure 3. Natural History of Helicobacter pylori Infection.

Chronic Gastritis

• Risk factors (cont’d)– Autoimmune atrophic gastritis

• Affects fundus and body of stomach• Associated with increased risk of gastric cancer• May be link to presence of H. pylori and development

of autoimmune chronic gastritis

Autoimmune chronic gastritis

• Autoantibodies to gastric parietal cells• Hypochlorhydria/achlorhydria• Loss of gastric intrinsic factor leads to

malabsorption of vitamin B12 with macrocytic,megaloblastic anaemia

Morphology of chronic gastritis

• Chronic inflammatory cell infiltration

• Mucosal atrophy• Intestinal (goblet cell)

metaplasiaSeen in Helicobacter and

autoimmune gastritis (not chemical)

Chemical gastritis

• Commonly seen with bile reflux (toxic to cells)

• Prominent hyperplastic response (inflammatory cells scanty)

• With time – intestinal metaplasia