PROBLEM - 2A (ADULT)
LO 1
Capable to explain
Histology(stomach & duodenum),
Anatomy (stomach – ileum),
Function:
continue the digestion of carbohydrates
add an acidic fluid to the ingested food
Regions:
Cardia, fundus, corpus (body), pylorus
Rugae of stomach Gastroesophageal junction
Gastric pits & glands
FUNDUS & CORPUS
Mucous neck cells mucus secretion; Parietal cells HCl & Intrinsic factors
OTHER CELLS
Chief (zymogenic) cells
lower region of the tubular glands
contain the inactive enzyme pepsinogen
Enteroendocrine cells
secrete a variety of hormones, almost all short polypeptides
In the fundus enterochromaffin cells (EC cells) are found on
the basal lamina of gastric glands serotonin (5-
hydroxytryptamine)
Gcells which produce the polypeptide gastrin
Stem cells
found in the neck region of the glands (low columnar cells with
basal nuclei and divide asymmetrically)
SYNTHESIS OF HIDROCHOLRIC ACID
HCO3- Na+
PYLORUS
Thoracoabdominal nerves
distal, abdominal parts of the anterior rami of the inferior six
thoracic spinal nerves (T7 – T11)
the former inferior intercostal nerves distal to the costal
margin
Lateral (thoracic) cutaneous branches
of the thoracic spinal nerves T7 - T9 or T10
Subcostal nerve
the large anterior ramus of spinal nerve T12
Iliohypogastric & ilioinguinal nerves
terminal branches of the anterior ramus of spinal nerve L1
Anterior abdominal cutaneous branches of
thoracoabdominal nerve
T7 – T9 skin superior to the umbilicus
T10 skin around the umbilicus
jejunum,
begins at the
duodenojejunal flexure
where the alimentary
tract resumes an
intraperitoneal course
ileum,
ends at the ileocecal
junction, the union of the
terminal ileum and the
cecum
ARTERIES & VEINS
LYMPH DRAINAGE
NERVES
1ST LO (3)
Gastric’s motility
Filling, storage, mixing, emptying
GASTRIC FILLING
Volume about 50 ml; can expand to 1l during a
meal
Folds of gastric get smaller & nearly flatten out as
stomach relaxes slightly (receptive relaxation)
enhance stomach to accomodate the extra
volume of food with little rise in stomach
pressure
Triggered
by the act of eating & mediated by the
vagus nerve
GASTRIC STORAGE (BODY OF STOMACH)
Gastric factor
Amount of chyme; stomach distention strecth of
smooth muscle, intrinsic plexuses, vagus nerve,
gastrin gastric motility >>
Degree of fluidity
Duodenum factor
Fat, acid, hypertonicity, & distention
MECHANISM OF H & CL IONS SECRETION
Function of HCl:
-. Activate pepsiongen
pepsin
-. Aids breakdown of
connective tissue & muscle
fibers, reducing food into
smaller particles
-. Denaturates protein
-. Once oral intake is tolerated, nutrients are restarted with liquids that are low in fat
INDIGESTION
Indigestion is a nonspecific term that
encompasses a variety of upper abdominal
complaints including nausea, vomiting,
heartburn, regurgitation, and dyspepsia (the
presence of symptoms thought to originate in
the gastroduodenal region)
Dyspepsia
Epigastricburning, gnawing discomfort, or pain
postprandial fullness, early satiety, bloating, eructation
(belching), and anorexia
MECHANISM
Gastroesophageal Acid Reflux
Reduced lower esophageal sphincter (LES) tone is an
important cause of reflux in scleroderma and pregnancy
frequent transient LES relaxations during which acid bathes
the esophagus
Overeating and aerophagia can transiently override the barrier
function of the LES
Gastric Motor Dysfunction
Disturbed gastric motility acid reflux in some cases of
indigestion
Delayed gastric emptying is also found in 25–50% of functional
dyspeptics
bloating, nausea, and early satiety
Visceral Afferent Hypersensitivity
dyspeptic patients experience discomfort with fundic
distention to lower pressures than healthy controls
Some patients with heartburn exhibit normal esophageal acid
exposure
Other Factors
Helicobacter pylori has a clear etiologic role in peptic ulcer
disease, but ulcers cause a minority of cases of dyspepsia
functional dyspepsia is associated with a reduced sense of
physical and mental well-being and is exacerbated by stress,
suggesting an important role for psychological factors
Analgesics cause dyspepsia
nitrates, calcium channel blockers, theophylline, and
progesterone promote acid reflux
ethanol, tobacco, and caffeine LES relaxation
DIFFERENTIAL DIAGNOSIS
GERD
Functional Dyspepsia
Ulcer disease
Malignancy
GASTROESOPHAGEAL REFLUX DISEASE
Symptoms
15% heartburn &/ regurgitation at least once a
week; 7% daily
Caused by backflow of gastric acid and other gastric
contents into the esophagus due to incompetent
barriers at the gastroesophageal junction
PATHOPHYSIOLOGY
LES incompetence / transient decrease in LES tone (tLESR),
caused by
scleroderma-like diseases,
myopathy associated with chronic intestinal pseudo-
obstruction,
pregnancy,
smoking,
anticholinergic drugs,
smooth-muscle relaxants (β-adrenergic agents, aminophylline,
nitrates, calcium channel blockers, and phosphodiesterase
inhibitors),
surgical
esophagitis
Gastric contents are most likely to reflux when
gastric volume is increased (after meals, in pyloric
obstruction, in gastric stasis, during acid
hypersecretion states)
gastric contents are near the gastroesophageal
junction (in recumbency, bending down, hiatal
hernia)
gastric pressure is increased (obesity, pregnancy,
ascites, tight clothes)
CLINICAL FEATURES
Heartburn and regurgitation of sour material into the
mouth
Angina-like or atypical chest pain occurs in some patients
Persistent dysphagia suggests development of a peptic
stricture
Rapidly progressive dysphagia and weight loss may indicate
the development of adenocarcinoma in Barrett's esophagus
Bleeding occurs due to mucosal erosions or Barrett's ulcer
Antireflux surgery
the gastric fundus is wrapped around the esophagus
(fundoplication) creates an antireflux barrier
Idealcandidates for fundoplication are those who have
classical GERD with good response to PPI therapy and in
whom motility studies show poor LES pressures but normal
peristaltic contractions in the esophageal body
Laparoscopic or endoscopic antireflux procedures
should be considered as alternatives in young
patients who require long-term, high-dose PPIs
PEPTIC ULCER DISEASE
Burning epigastric pain exacerbated by fasting and
improved with meals is a symptom complex associated
with peptic ulcer disease
Ulcer disruption of the mucosal integrity of the
stomach and/or duodenum leading to a local defect or
excavation due to active inflammation
Epidemiology
Lifetime prevalence of PUD in the United States is ~12% in
men and 10% in women
estimated 15,000 deaths per year occur as a consequence of
complicated PUD
GASTRODUODENAL MUCOSAL DEFENSE
PHYSIOLOGY OF GASTRIC SECRETION
PATHOLOGY
Duodenal ulcers
first portion of duodenum (>95%), with ~90% located within 3
cm of the pylorus
1 cm in diameter but can occasionally reach 3–6 cm (giant
ulcer)
base of the ulcer often consists of a zone of eosinophilic
necrosis with surrounding fibrosis
Gastric ulcers
can represent a malignancy
most often found distal to the junction between the antrum
and the acid secretory mucosa
Benign GUs associated with H. pylori are also associated with
antral gastritis
NSAID-related GUs are not accompanied by chronic active
gastritis but may instead have evidence of a chemical
gastropathy
PATHOPHYSIOLOGY
Duodenal ulcers
H. pylori and NSAID-induced injury account for the
majority of Dus
average basal and nocturnal gastric acid secretion
appears to be increased in DU patients as compared
to controls
Bicarbonate secretion is significantly decreased in the
duodenal bulb of patients with an active DU as
compared to control subjects
Gastric ulcers
majority of GUs can be attributed to either H. pylori or NSAID-
induced mucosal damage
occur in the prepyloric area or those in the body associated
with a DU or a duodenal scar are similar in pathogenesis to
Dus
Gastric acid output (basal and stimulated) tends to be normal
or decreased in GU patients
develop in the presence of minimal acid levels, impairment of
mucosal defense factors may be present
Abnormalities in resting and stimulated pyloric sphincter
pressure with a concomitant increase in duodenal gastric
reflux
Delayed gastric emptying of solids has been described in GU
patients but has not been reported consistently
H. PYLORI & ACID PEPTIC DISORDERS
The bacterium
initially
named Campylobacter pyloridis
gram-negative microaerophilic rod found most
commonly in the deeper portions of the mucous gel
coating the gastric mucosa or between the mucous
layer and the gastric epithelium
Virulency
outer membrane protein (Hop proteins), urease, and the
vacuolating cytotoxin (Vac A)
cag pathogenicity island (cag-PAI) Cag A into host cells;
Cag A activates a series of cellular events important in cell
growth and cytokine production
Risk factor for H. Pylori
birthor residence in a developing country
domestic crowding
Risk factors
advanced age, history of ulcer, concomitant use of
glucocorticoids, high-dose NSAIDs, multiple NSAIDs,
concomitant use of anticoagulants, and serious or multisystem
disease
infection with H. pylori, cigarette smoking, and alcohol
consumption
PATHOPHYSIOLOGY
OTHERS ETIOLOGY OF PEPTIC ULCERS
CLINICAL FEATURES
Abdominal pain
Epigastric pain described as a burning or gnawing
discomfort can be present
ill-defined, aching sensation or as hunger pain
DU
Pain that awakes the patient from sleep (between midnight
and 3 A.M.) is the most discriminating symptom
typical pain pattern in DU occurs 90 min to 3 h after a meal
and is frequently relieved by antacids or food
GU
The pain pattern in GU patients discomfort may actually be
precipitated by food
PHYSICAL EXAMINATION
Barium study
Endoscopy
H. Pylori tests
TREATMENT
ERADICATION OF H. PYLORI
THERAPY OF NSAID-RELATED GASTRIC OR
DUODENAL INJURY
APPROACH & TREATMENT (SUMMARY)
REFERENCES
Dalley, Arthur F. Keith L Moore. Clinically Oriented
Anatomy. 5th edition. Lippincott Williams & Wilcins;
2006
Fauci. Braunwald. Dkk. Harrison’s Principles of
Internal Medicine. 17th edition. United State: The
McGraw-Hills; 2008
L. Mescher, Anthony. Junquera’s Basic Histology Text
and Atlas. 20th edition. United State: The McGraw-
Hills; 2010
Sherwood,Lauralee. Fisiologi Manusia dari Sel ke
Sistem. Cetakan pertama edisi 2. Jakarta: EGC; 2001