Page 167 - Medicine and Surgery

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Chapter 4: Disorders of the small bowel 163

Clinical features Aetiology/pathophysiology
Most people become colonised by H. pylori during their The condition is usually caused by a gastrinoma in the
lifetime; however, only a minority develop symptoms of Gcells of the pancreatic islets it occurs most commonly
dyspepsia. in males between 20–50 years of age. 60–90% of gastri-
nomas are malignant often with metastases at diagnosis.
Microscopy
H. pylori causes a mixed acute and chronic inflamma- Clinical features
tory reaction within the lamina propria and superficial Patients present with epigastric burning pain and with
epithelium. complications of peptic ulcer disease. The excess acid
causesinactivationofduodenal/jejunallipasesandhence
Investigations steatorrhoea also occurs.
Invasive tests are performed at time of endoscopy and
biopsy. Investigations
Rapid urease (CLO) test is performed by mixing the
A fasting serum gastrin level is taken (>150 ng/L is
biopsy specimen with a urea solution. The presence of suggestive, >500 ng/L strongly suggestive). The patient
H. pylori is detected as ammonia formation causes a shouldnotbetakingaprotonpumpinhibitorasthesein-
rise in pH changing the colour of indicator solution. crease gastrin levels. Tumour location is attempted with
Biopsy specimens can be cultured on selective media
isotope scanning and CT of the abdomen.
and the sensitivities determined.
Histological identification can also be performed. Management

Noninvasive tests can be performed if an endoscopy is Resection of the gastrinoma should be attempted but
not indicated. problems with locating the tumour, which is often mul-
The urea breath test uses ingestion of Cor C la- tifocal, makes surgery difficult. High-dose proton pump
13 14
belled urea, if the bacteria is present the urea is broken inhibitors are also used. Other treatment options in-
down releasing labelled carbon dioxide which is de- clude octreotide, interferon α,chemotherapy and hep-
tected in the breath. This test can be used to confirm atic artery embolisation.
successful eradication, but patients must not be tak-
ing proton pump inhibitors or bismuth and must not
Prognosis
have had antibiotics in the preceding 4 weeks.
In inoperable tumours 60% of patients survive 5 years
Serological testing is simple, non-invasive and widely

and 40% survive 10 years.
available, but remains positive after clearance or suc-
cessful eradication.
Disorders of the small bowel
Management and appendix
First line eradication (triple) therapy consists of a pro-
ton pump inhibitor, amoxycillin or metronidazole, and
clarithromycin for 1 week. Second line (quadruple) ther- Acute appendicitis
apy is with a proton pump inhibitor, bismuth subcitrate,
Definition
metronidazole and tetracycline. Compliance with treat-
Inflammatory disease of the appendix, which may result
mentisveryimportantforsuccessfultreatment.Ifsymp-
in perforation.
toms persist or recur a repeat urea breath test should be
performed.
Incidence
Commonest cause of emergency surgery of childhood
Zollinger–Ellinson syndrome (3–4 per 1000).
Definition
Pathological secretion of gastrin resulting in hypersecre- Age
tion of acid. Any age but usually over 5 years.