Page 165 - Medicine and Surgery

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Chapter 4: Disorders of the stomach 161

Aetiology Geography
This pattern of gastritis is seen in patients with shock, In the United Kingdom duodenal ulcers are more com-
severe illness. It may also be seen with the use of mon in North England and Scotland.
nonsteroidal anti-inflammatory drugs, steroids and
heavy alcohol ingestion. H. pylori can cause an acute Aetiology
gastritis, which typically starts in the antrum and may Factors involved include presence of H. pylori within
extend to involve the entire gastric mucosa. the stomach, the use of nonsteroidal anti-inflammatory
Curling’s ulcers are a form of stress ulcers occurring
drugs (NSAIDs) and aspirin. Rarely pathological hyper-
in patients following burns. secretion of gastrin (Zollinger–Ellinson syndrome) may
Cushing’s ulcers occur in patients with neurosurgi-
be the cause of multiple ulcers. Most duodenal ulcers oc-
cal illness possibly due to the increased intracranial cur in the proximal duodenum, most gastric ulcers occur
pressure causing an increased in vagal secretormotor on the lesser curve. Rare sites include the following:
stimulus. The oesophagus following columnar metaplasia due
to gastrooesophageal reflux.
Clinical features The jejunum in Zollinger–Ellinson syndrome.
Patients develop epigastric pain, burning in nature as- AMeckel’s diverticulum containing ectopic gastric
sociated with vomiting and occasionally haematemesis mucosa.
and perforation.
Pathophysiology
Macroscopy/microscopy Ulcerationresultsfromanimbalancebetweenthegastric
The gastric mucosa appears hyperaemic with focal loss secretion of acid and the ability of the mucosa to with-
of superficial gastric epithelium (ulceration) and small stand such secretion. Normal protective mechanisms
erosions. include mucous, bicarbonate and prostaglandins. Pa-
tients with H. pylori infection have elevated basal and
Investigations stimulated concentrations of serum gastrin and a
Diagnosis may be confirmed by endoscopy with a urease decreased concentration of somatostatin resulting in in-
(CLO) test for H. pylori. creased acid production. H. pylori also releases proteases
which degrade mucous glycoproteins which normally
Management protect the gastric mucosa.
Identification and management of the underlying cause
is required, specific interventions include the use of H 2 Clinical features
antagonists and proton pump inhibitors. Clinically patients present with dyspepsia, which they
often describe as indigestion, nausea and occasionally
Peptic ulcer disease vomiting. Gastric ulcers tend to cause pain that is worse
during the day and after meals. Duodenal ulcers tend
Definition to cause well-localised epigastric pain that may radiate
Apeptic ulcer is a break in the integrity of the stomach to the back. It occurs a few hours after meals or on an
or duodenal mucosa. empty stomach and is often worse at night or in the early
hours of the morning when circadian acid secretion is
Incidence maximal.
15% of the population will suffer from a duodenal ulcer
and 5% a gastric ulcer at some time during their life. Macroscopy/microscopy
Chroniculcershavesharplydefinedborders,withoutany
Age heaping up of the edges (which would be suggestive of a
More common with increasing age. malignant ulcer). There is a break in the integrity of the
epithelium extending down to the muscularis mucosa.
Sex Active inflammation is seen with granulation tissue and
Duodenal ulcers 4M : 1F. fibrosis.