GASTROINTESTINAL FUNCTIONAL TESTS 15.

Helicobacter pylori
- A bacterium found in the mucous layer of the stomach
Terminologies: - All strains secrete:
1. Acute Pancreatitis : a. Proteins that cause inflammation of the mucosa and
- Acute episode of enzymatic destruction of the pancreatic b. The enzyme urease that produces ammonia from urea
substance due to the escape of active pancreatic enzymes into the - Some strains produce toxins that injure the gastric cells
pancreatic tissue 16. Lactose Intolerance
A condition due to lactase deficiency leading to malabsorption of
2. Breath Tests: lactose and causing symptoms after drinking milk or foods
- Tests that detect products of bacterial metabolism in the gut or containing lactose:
products of human metabolism by measuring CO2 and H2 in the a. Flatulence
breath b. Abdominal Discomfort
c. Bloating
3. Celiac Disease (Gluten – Sensitive Enteropathy) d. Diarrhea
- A disease caused by the destructive interaction of gluten with the 17. Malabsorption
intestinal mucosa causing malabsorption - An abnormality in the absorption of nutrients

4. Cholecystokinin 18. Maldigestion

- 33 – amino acid peptide secreted by the upper intestinal mucosa
and also found in the central nervous system
- It causes gallbladder contraction and release of pancreatic
exocrine (or digestive) enzymes
- Affects other gastrointestinal functions
- An abnormality of the digestive process due to dysfunction of the
pancreas or small intestine
19. Peptic Ulcer Disease (PUD)
- The collective name given to duodenal and gastric ulceration

5. Chronic Pancreatitis 20. Post-gastrectomy Syndrome

- An inflammatory disease characterized by persistent and - A syndrome following surgery for peptic ulcer disease that
progressive destruction of the pancreas includes:
a. Dumping syndrome
6. Chyme b. Diarrhea
- Food which has been acted upon by the churning action of the c. Maldigestion
stomach and by stomach juices, but has not yet been on into the d. Weight Loss
intestine e. Anemia
7. Crohn Disease f. Bone Disease
- A chronic inflammatory disease that may affect any part of the g. Gastric Cancer
intestine from the mouth to the anus 21. Secretin
- A peptide hormone of the gastrointestinal tract (27 amino acid
8. Cystic Fibrosis residues) found in the mucosal cells of the duodenum
- An inherited disease caused by genetic alteration of a - It inhibits gastric acid secretion
transmembrane conductance regular protein (CTFR) that leads to - It stimulates:
chronic pancreatic and obstructive pulmonary disease a. Pancreatic
b. Pepsin
9. Diarrhea c. Bile Secretion
- The passage of loose or liquid stools more than 3 times daily and 22. Steatorrhea
/or a stool weight greater than 200 d/day - A condition of excessive fat in feces (>5 g/day, >18 mmol/day)

10. Digestion 23. Ulcerative Colitis

- The conversion of food in the stomach and intestines, into soluble
and diffusible products, capable of being absorbed
11. Digestive Process
- A 3-phase process – neurogenic, gastric, and intestinal
- The neurogenic (vagal) phase is initiated by the sight, smell, and
taste of food
- The intestinal phase begins when the partly digested food enters
the duodenum from the stomach
12. Gastrin
- Group of peptide hormones secreted by gastrointestinal mucosa
(GIM) in response to MS or high pH
- Gastrin stimulates the stomach parietal cells to produce
hydrochloric acid
13. Gastrinoma
- A tumor of the Pancreatic Islet cells that results in an
overproduction of gastric acid, leading to fulminant ulceration of
the esophagus, stomach, duodenum, and jejunum
- Recurrent inflammatory disease of the large bowel that always
involves the rectum and spreads to involve a variable amount of
colon
- Like Crohn disease, it is a form of inflammatory bowel disease
24. Vasoactive Intestinal Peptide (VIP)
- A peptide of 28 amino acids found in the central and peripheral
nervous system where it acts as a neurotransmitter
- It is located in the enteric nerves in the gut
- It relaxes smooth muscle in the gut and increase water and
electrolyte secretion from the gut
25. Zollinger-Ellison (Z-E) Syndrome
- A condition resulting from a gastrin-producing tumor
(Gastrinoma) of the Pancreatic Islet cells that results in an
overproduction of gastric acid, leading to ulceration of the
esophagus, stomach, duodenum and jejunum and causing:
a. Hypergastrinemia
b. Diarrhea
c. Steatorrhea

14. Gastritis BASIC PRINCIPLE: ANATOMY

- Mucosal inflammation of the stomach  The GI tract is a 10 meter long tube beginning with the mouth and ending
- Glucose-dependent insulin tropic Peptide (GIP, Gastric Inhibitory with the anus
Polypeptide)  The esophagus is about 25 cm in length and is a muscular tube connecting the
- A peptide hormone (42 amino acids) that stimulates insulin pharynx to the stomach
release and inhibits the release of gastric acid and pepsin  The Major Organs of the GI:
1. Stomach
2. Small and Large Intestine
3. Pancreas
4. Gallbladder
 STOMACH Composition of Gastric Juices:
3 Major Zones: 1. H2O – varying amounts (99%)
1. Cardiac Zone 2. HCl – secreted by the parietal cells which provide acidity for the
2. Body of the Stomach activation of pepsinogen
3. Pyloric Zone 3. Digestive Enzymes:
a. Pepsin – catalyzes the protein digestion to proteases; secreted by Chief
 Upper Cardiac Zone: which includes the fundus, contains mucus- Peptic Cells
secreting surface epithelial cells and several types of endocrine b. Lipase – Fats (no importance in digestion)
secreting cells c. Rennin – Milk (ability to coagulate caseinogen to milk)
 Body of the Stomach: contains cells of many different types d. Gastricsin – importance of this enzyme is not yet known in gastric
including: secretion
a. Mucus secreting cells 4. Mineral Acid – chiefly acid phosphates
b. Parietal (Oxyntic) cells 5. Mucus – fd in moderate amounts secreted by GOBLET
- Which secrete HCl and Intrinsic Factor 6. Electrolytes
 The Pyloric Zone: is subdivided into: a. Chloride
a. Antrum – the distal third of the stomach b. Potassium
b. Pylori Canal c. Sodium
c. Sphincter d. Magnesium
Note: 7. Food Particles
Cells in all three zones of the stomach produce pepsinogens, the precursors of the
enzyme pepsin which degrades proteins in the food
3 Main Types of Cells Responsible for Gastric Juice Production:
SMALL INTESTINE 1. Chief or Peptic Cells – producing the protein-splitting enzyme pepsin
- Consists of 3 Parts: 2. Parietal or Oxyntic Cells – producing HCl and Intrinsic Factor
1. Duodenum (Erythropoietic Factor) absence of which leads to Pernicious Anemia
2. Jejunum 3. Goblet or Mucous Secreting Cells – producing mucus for the
3. Ileum production of the mucosa and lubricate the food
- In the adult human, approximately 2 – 3 m long and decreases in cross-section
as it proceeds distally MACROSCOPIC EXAMINATION
- Duodenum: 25 cm long ; the shortest and widest part of the small intestine Volume:
- Jejunum & Ileum: make up the remainder of the small intestine  30 – 60ml
 Fasting Sample – contains few ml to 50 ml with an average of 30 ml
LARGE INTESTINE Color
- It is approximately 1.5 m long and includes:  Colorless
a. Cecum  Yellowish
b. Appendix  Pale Gray with varying amount of mucus and food particles
c. Colon
d. Rectum Abnormalities in Color:
e. Anal Canal  Greenish – presence of old bile
GASTRIC FUNCTION  Red – presence of small amount of blood
Gastric mucous has different types of cells: Odor
1. Surface epithelial cells: secretes Mucus  Odorless
2. Parietal cells: Secrete HCl (pH 0.8) and Intrinsic Factor  Slightly sour
3. Chief Cells: secretes Pepsinogen  Faintly Pungent
4. G-cells: secrets Gastrin (stimulates secretion of:
a. HCl Abnormalities in Odor
b. Pepsinogen 1. Fecal Odor – seen in intestinal obstruction or Gastrocolic-fistula
c. Intrinsic Factor 2. Foul or Putrid Odor – seen in carcinomatous ulcer
d. Secretin 3. Alcoholic Odor – seen in alcoholic coma, or after alcohol test meal
e. Pancreatic Enzymes 4. Ammoniacal Odor - seen in case of uremia
f. HCO2 5. Rancid Odor – due to butyric (fatty acid) and lactic acid (present in
g. Bile sour milk) indication stenosis and fermentation
- Increase:
 Gastric &Intestinal Motility pH or Reaction
 Mucosal Growth  Normal acidic: pH 1.6 to 1.8
5. Other Endocrine-Secreting cells  High Acidic: pH 1.4 or lower
 Low Acidity: pH 2.0 or 2.8
NOTE: 1. Euchlorhydria: refers to normal secretion with a pH 1.6–1.8
 Total Gastric Secretion: 200mL 2. Hyperchlorhydria: increase free HCl above normal 60 ml
 Peptic Ulcer
Importance of Detection: 3. Hypochlorhydria: decreased free HCl
 Diagnosis of gastric diseases and assist in the selection of therapy i.e. Peptic  Carcinoma of the stomach
Ulcer  Chronic Gastritis
 It measures the amount of acid produced by a patient with symptoms of peptic  Gastric Syphilis
ulcers 4. Achlorhydria: absence of free HCl
 Diagnosis of Zollinger-Ellison Syndrome (adenoma of Islet of Langerhans)  Pernicious Anemia
a condition of gastric hypersecretion produced by a gastrin secreting tumor of  Pellagra
the pancreas  Advanced Gastric Cancer

2 Types of Gastric Juice Collection: Specific Gravity

 Using an Evacuated Tubes:  Varies from 1.001 – 1.010 with an average of 1.007
1. Levine Tube: inserted in the nose (Nasal Intubation)  Water pH: 1.000
2. Rehfuss Tube: inserted in the mouth (Oral Intubation)
 CHEMICAL EXAMINATION Estimation of Free & Total Acidity
 Acid contents of gastric juice are of 2 types: 1. Fasting contents are aspirated from stomach
1. Free HCl an acid with a pH less than 3.5 2. Test meal is given
2. Combined HCl or organic acid – an acid which combines with proteins or 3. Gastric juice is aspirated after every ½ hr for 2 hours
protein-like substance to form protein salts of HCl 4. Free & Total Acidity is measured in each sample by titration against
N/10 NAOH.
Test for Free HCl: 5. Free acidity measures only HCl
1. Topfer’s Method (Indicator Topfer’s: pKa – 3.5 or Methyl Orange)
2. Tubeless Gastric Analysis – Diagnex Blue 6. Total Acidity Measures HCl + Other Organic Acids
3. Boa’s Method (Indicator Phenolphthalein: pKa – 10.5)
4. Gunzburg Method
4. Augmented Histamine Test
MICROSCOPIC EXAMINATION - Histamine ( kg body weight) is given subcutaneously to
Normal Structures: stimulate acid secretion
1. Yeast Cells – small amounts Interpretation:
2. Epithelial Cells 1. If no Acid Secretion: True Hypoacidity (Pernicious Anemia)
3. Starch Granules 2. If Hypoacidity patient has acid secretion in response to Histamine:
4. Bacteria – lesser amounts False Hypoacidity
5. Fat Globules
Pathologic Structures: - Histamine Hl receptor blocker antihistamine is given prior to Histamine to
1. Fragments of tissues prevent Hypotension
2. RBC Antihistamine: Diphenhydramine (Benadryl, Diphen)
3. Yeast – large amounts - Stomach has H2 receptors: blocked by Cimetidine:
4. Pus Cells Cimetidine: cure for Peptic Ulcers
5. Muscle Fibers Other Medicine aside from Cimetidine:
6. Large number of bacteria and maybe seen are: Sarcina & Oppier- a. Famotidine
Boas Bacilli b. Ranitidine – for gallstone
HCl Secretion
- HCl is secreted by Parietal Cells under stimulation by: 5. Tubeless Gastric Analysis
a. Acetyl Choline (Neurocrine) - No need for Ryele’s Tube
b. Histamine (Paracrine) - Used as a Screening test
c. Gastrin (Endocrine Pathway) - Gastric Acid secretion stimulated by Histalogue
- H+ secretion into lumen is against 1 million fold concentration gradient and - After 1 hour, Dye bound Resin (Azure A) is given orally
requires H+/K+ ATPase - In presence of HCl, resin releases dye proportional to acidity
- Released dye is absorbed from stomach and excreted in urine
ROLE OF HCl: - Dye concentration in urine indicates presence/absence of HCl
1. Denaturation of proteins
2. Optimum pH for digestive enzymes Causes of Hyperacidity:
3. Activation of Pepsin by Partial Proteolysis 1. Duodenal Ulcer
4. Absorption of Calcium & Iron 2. Gastric Cell Hyperplasia
3. Carcinoid Tumor
4. ZE Syndrome
GASTRIC FUNCTION TEST 5. Multiple endocrine neoplasia
1. Fractional Test Meal 6. Excessive Histamine production as in Systemic Mastocytosis
- Fasting stomach content are aspirated and Gastric secretion is
stimulated using test meal (Porridge/ Rice gruel/ Black Coffee/Toast Causes of Hypoacidity
- Timed samples of Gastric secretion are collected and 1. Gastritis
2. Gastric Carcinoma
- It is obsolete 3. Partial Gastrectomy
4. Pernicious Anemia
2. Pentagastrin Stimulation Test
- Fasting stomach content is aspirated: Residual Secretion Other Gastric Function Test
- After 1 hour again stomach content is aspirated: Basal Secretion 1. Serum Gastrin (by RIA) Normal <10pmol/L (Never >50pmol/L)
- Pentagastrin (Gastrin Analogue: ZE Syndrome >100 pmol/L
(-COOH-Butyl-Oxy-Ala-Trp-Met-Asp-Phc-NH2) 2. Occult blood in Gastric Juice:
Given 6mg/kg body weight a. Gastric Ca
NOTE: b. Gastric Ulcer
 Gastric Secretion is collected every 15 mins for next hour c. Duodenal Ulcer
3. Bile/ Undigested food in Gastric Juice: Stagnation of food/
 Basal Acid Output (BAO): Acid (in mmol/hr) in Basal Secretion Regurgitation of bile
 Maximal Acid Output (MAO): Sum of all acid (in mmol/hr.) Secreted over 1 4. Urease enzyme in Gastric Biopsy: Helicobacter pylori
hour after Pentagastrin 5. Bacteria produce NH3 by its Urease enzyme & escapes acid attack
 Peak Acid Output (PAO): Twice the sum of acid output in 2 consecutive 6. It’s a cause of Acid Peptic Disease
samples having highest acid content

Interpretation:
1. Zollinger-Ellison Syndrome:
- Gastrin secreting tumor in pancreas.
- No feedback regulation of gastrin secretion.
- There is very high Gastric Acid + High Serum Gastrin.
BAO >15mmol/L
BAO/PAO ≥0.6
2. Chronic Duodenal Ulcers: Very high BAO, MAO, PAO
3. BAO: 4.6 mmol/L
BAO/PAO ratio >0.3