Modul Gastritis_edit Terbaru

8/13/2019 Modul Gastritis_edit Terbaru

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CLINICAL SCIENCE:

DYSPEPSIA, GASTRITIS AND PEPTIC ULCERS

(Course Period : 7 th Semester)

Contri utor!s :

Dr" Su#riono, S#PD$%GE&Dr" 'o i Pr tomo, S#PD$%GE&

Pro*" DR" Dr" & ri+ono A hm d, S#PD$%GE&

-EDICAL .ACULTY /. 'RA0I1AYA UNI2ERSITY

SAI.UL AN0AR &/SPITAL -ALANG

3455

STUDENT GUIDANCE


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Le6e o* Com#eten ies

No" Dise sesLe6e o* Com#eten ies

Indonesi n -ediCoun i 8 3449

-edi * u t o*'r ;i+ $ Uni6ersit

1 Candidiasis 4 3-A

2 Dyspepsia ,Gastritis and ulcuspepticum 4 4

Modul MKK berisi:A. Tujuan Pembelajaran ModulB. Topic and Topic TreeC. Module OverviewD. Tugas Modul

Penugasan kepada ma asiswa sebelum memasuki !u!orial" dimaksudkan un!uk

men#iapkan prior knowledge ma asiswa sebelum kegia!an belajar mengajar Blok.Misaln#a: Modul !en!ang $%c!erus&" maka !ugas modul an!ara lain adala !en!ang s!ruk!urnormal sis!im epa!obilier" mekanisme bilirubin dsb. Ma asiswa akan mengerjakan !ugasini dalam Buku 'og ma asiswa . Pada saa! dosen membelajarkan kulia pakar !en!angmodul ini" asumsin#a adala ma asiswa suda menge!a ui lebi da ulu !en!ang s!ruk!urnormal" mekanisme bilirubin dan sebagain#a.

(. )e*erensi" berisi da*!ar buku !eks+ba an bacaan wajib #ang diacu ma asiswa un!ukmengerjakan !ugas modul dia!as.


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Des ri#tion-odu e n me

Le rnin -ethods Self-Directed Learning (SDL) !"dule tas#Small-class Discussi"n $ut"rialC""perati%e Learning (CL)Lectures ($eac&ing ' Learning r"cess)

E


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Contents

Le6e o* Com#eten ies 555555555555555555555555555Des ri#tion o* the modu e 55555555555555555555555555

A / +e ti6e o* the modu e 5555555555555555555555555'" -odu e o6er6ie;

1 Dyspepsia a 6pidemi"l"gy 55555555555555555555555555

6ti"-pat&"genesis 555555555555555555555555 5c Clinical !anifestati"n 55555555555555555555555d !anagement 555555555555555555555555555e C"mplicati"ns 55555555 555555555555555555

2 Gastritis and peptic ulcers 55 55555555555555555555a 6pidemi"l"gy 55555555555555555555555555

6ti"-pat&"genesis 555555555555555555555555 5c Clinical !anifestati"n 55555555555555555555555d !anagement 555555555555555555555555555e C"mplicati"ns 55555555 555555555555555555

C -odu e t s= 5555555555555555555555555555555D Re*eren es nd su ested *urther re din 5555555555555555


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A" / +e ti6e o* the modu e


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5" D s#e#si Dyspepsia is a sensati"n "f pain "r disc"mf"rt in t&e upper a d"men7 it "ften is

recurrent 8t may e descri ed as indigesti"n, gassiness, early satiety, p"stprandial

fullness, gna ing, "r urning

6ti"l"gy$&ere are se%eral c"mm"n causes "f dyspepsia

$a le 2

S"me Causes "f DyspepsiaCause Suggesti%e 9indings Diagn"stic Appr"ac&

Ac&alasia Sl" ly pr"gressi%e dysp&agia,

s"metimes n"cturnalregurgitati"n "f undigestedf""d, c&est disc"mf"rt

0arium s all"

6s"p&ageal man"metry6nd"sc"py

Cancer (eg, es"p&ageal,gastric)

C&r"nic, %ague disc"mf"rtLater, dysp&agia (es"p&ageal)"r early satiety (gastric):eig&t l"ss

;pper end"sc"py

C"r"nary isc&emia Sympt"ms descri ed as ausea, l"ating, fullness Scintigrap&ic test "fgastric emptying

Drugs (eg,isp&"sp&"nates,

eryt&r"mycinand "t&er macr"lideanti i"tics, estr"gens ,ir"n, >SA8Ds, p"tassium)

;se apparent "n &ist"ry,sympt"ms c"incident it& use

Clinical e%aluati"n

6s"p&ageal spasm Su sternal c&est pain it& "rit&"ut dysp&agia f"r li?uids

and s"lids

0arium s all"6s"p&ageal man"metry

Gastr"es"p&ageal refludisease

@eart urn, s"metimes reflu "facid "r st"mac& c"ntents int"

Clinical e%aluati"nS"metimes end"sc"py
http://www.merckmanuals.com/podcast/home.html#Dyspepsiahttp://www.merckmanuals.com/podcast/home.html#Dyspepsia


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m"ut&Sympt"ms s"metimes triggered

y lying d" nelief it& antacids

S"metimes 24-& p@testing

eptic ulcer disease 0urning "r gna ing painrelie%ed y f""d, antacids

;pper end"sc"py

!any patients &a%e findings "n testing (eg, du"denitis, pyl"ric dysfuncti"n, m"tilitydistur ance, @elic" acter pyl"ri gastritis, lact"se deficiency, c&"lelit&iasis) t&atc"rrelate p""rly it& sympt"ms (ie, c"rrecti"n "f t&e c"nditi"n d"es n"t alle%iatedyspepsia)

Nonu er (*un tion ) d s#e#si is defined as dyspeptic sympt"ms in a patient&" &as n" a n"rmalities "n p&ysical e aminati"n and upper G8 end"sc"py

E6 u tion

@ist"ry &istor o* #resent i ness s&"uld elicit a clear descripti"n "f t&esympt"ms, including &et&er t&ey are acute "r c&r"nic and recurrent Bt&er elementsinclude timing and fre?uency "f recurrence, any difficulty s all" ing, and relati"ns&ip"f sympt"ms t" eating "r ta#ing drugs 9act"rs t&at "rsen sympt"ms (particularlye erti"n, certain f""ds "r alc"&"l) "r relie%e t&em (particularly eating "r ta#ing antacids)are n"ted

Re6ie; o* s stems see#s c"nc"mitant G8 sympt"ms suc& as an"re ia, nausea,%"miting, &ematemesis, eig&t l"ss, and l""dy "r lac# (melan"tic) st""ls Bt&ersympt"ms include dyspnea and diap&"resis

P st medi histor s&"uld include #n" n G8 and cardiac diagn"ses, cardiac ris#fact"rs (eg, &ypertensi"n, &yperc&"lester"lemia), and t&e results "f pre%i"us tests t&at&a%e een d"ne and treatments t&at &a%e een tried Drug &ist"ry s&"uld includeprescripti"n and illicit drug use as ell as alc"&"l

&ysical e aminati"n e%ie "f %ital signs s&"uld n"te presence "f tac&ycardia "rirregular pulse

General e aminati"n s&"uld n"te presence "f pall"r "r diap&"resis, cac&e ia, "r aundice A d"men is palpated f"r tenderness, masses, and "rgan"megaly ectale aminati"n is d"ne t" detect gr"ss "r "ccult l""d

ed flags $&e f"ll" ing findings are "f particular c"ncern Acute epis"de it& dyspnea, diap&"resis, "r tac&ycardia An"re ia


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>ausea "r %"miting :eig&t l"ss 0l""d in t&e st""l Dysp&agia "r "dyn"p&agia 9ailure t" resp"nd t" t&erapy it& @ 2 l"c#ers "r pr"t"n pump in&i it"rs ( 8s)

8nterpretati"n "f findings S"me findings are &elpful A patient presenting it& asingle, acute epis"de "f dyspepsia is "f c"ncern, particularly if sympt"ms areacc"mpanied y dyspnea, diap&"resis, "r tac&ycardia7 suc& patients may &a%e acutec"r"nary isc&emia C&r"nic sympt"ms t&at "ccur it& e erti"n and are relie%ed y restmay represent angina

G8 causes are m"st li#ely t" manifest as c&r"nic c"mplaints Sympt"ms ares"metimes classified as ulcer-li#e, dysm"tility-li#e, "r reflu -li#e7 t&ese classificati"nssuggest ut d" n"t c"nfirm an eti"l"gy ;lcer-li#e sympt"ms c"nsist "f pain t&at is

l"cali ed in t&e epigastrium, fre?uently "ccurs ef"re meals, and is partially relie%ed yf""d, antacids, "r @ 2 l"c#ers Dysm"tility-li#e sympt"ms c"nsist "f disc"mf"rt rat&ert&an pain, al"ng it& early satiety, p"stprandial fullness, nausea, %"miting, l"ating,and sympt"ms t&at are "rsened y f""d eflu -li#e sympt"ms c"nsist "f &eart urn"r acid regurgitati"n @" e%er, sympt"ms "ften "%erlap

Alternating c"nstipati"n and diarr&ea it& dyspepsia suggests irrita le " elsyndr"me "r e cessi%e use "f B$C la ati%es "r antidiarr&eals$esting atients in &"m sympt"ms suggest acute c"r"nary isc&emia, particularlyt&"se it& ris# fact"rs, s&"uld e sent t" t&e emergency department f"r urgente%aluati"n, including 6CG and serum cardiac mar#ers

9"r patients it& c&r"nic, n"nspecific sympt"ms, r"utine tests include C0C (t"e clude anemia caused y G8 l""d l"ss) and r"utine l""d c&emistries 8f results area n"rmal, additi"nal tests (eg, imaging studies, end"sc"py) s&"uld e c"nsidered0ecause "f t&e ris# "f cancer, patients E 4* and t&"se it& ne -"nset red flag findingss&"uld underg" upper G8 end"sc"py 9"r patients F 4* it& n" red flag findings, s"meaut&"rities rec"mmend empiric t&erapy f"r 2 t" 4 # it& antisecret"ry agents f"ll" ed

y end"sc"py in treatment failures Bt&ers rec"mmend screening f"r @ pyl"ri infecti"nit& a C 14-urea reat& test "r st""l assay @" e%er, cauti"n is re?uired in using @

pyl"ri "r any "t&er n"nspecific findings t" e plain sympt"ms6s"p&ageal man"metry and p@ studies are indicated if reflu sympt"ms persist

after upper G8 end"sc"py and a 2- t" 4- # trial it& a 8


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Tre tmentSpecific c"nditi"ns are treated atients it&"ut identifia le c"nditi"ns are " ser%ed

"%er time and reassured Sympt"ms are treated it& 8s, @ 2 l"c#ers, "r acyt"pr"tecti%e agent r"#inetic drugs (eg, met"cl"pramide , eryt&r"mycin ) gi%en as ali?uid suspensi"n als" may e tried in patients it& dysm"tility-li#e dyspepsia@" e%er, t&ere is n" clear e%idence t&at matc&ing t&e drug class t" t&e specificsympt"ms (eg, reflu %s dysm"tility) ma#es a difference !is"pr"st"l andantic&"linergics are n"t effecti%e in functi"nal dyspepsia Drugs t&at alter sens"rypercepti"n (eg, tricyclic antidepressants) may e &elpful

2. G stritisGastritis is inflammati"n "f t&e gastric muc"sa caused y any "f se%eral c"nditi"ns,

including infecti"n (@elic" acter pyl"ri), drugs (>SA8Ds, alc"&"l), stress, andaut"immune p&en"mena (atr"p&ic gastritis) !any cases are asympt"matic, ut

dyspepsia and G8 leeding s"metimes "ccur Diagn"sis is y end"sc"py $reatment isdirected at t&e cause ut "ften includes acid suppressi"n and, f"r @ pyl"ri infecti"n,anti i"tics

Gastritis is classified as er"si%e "r n"ner"si%e ased "n t&e se%erity "f muc"salin ury 8t is als" classified acc"rding t" t&e site "f in%"l%ement (ie, cardia, "dy,antrum) Gastritis can e furt&er classified &ist"l"gically as acute "r c&r"nic ased "nt&e inflammat"ry cell type >" classificati"n sc&eme matc&es perfectly it& t&epat&"p&ysi"l"gy7 a large degree "f "%erlap e ists S"me f"rms "f gastritis in%"l%e acid-peptic and @ pyl"ri disease Additi"nally, t&e term is "ften l""sely applied t"n"nspecific (and "ften undiagn"sed) a d"minal disc"mf"rt and gastr"enteritis

Acute gastritis is c&aracteri ed y !> infiltrati"n "f t&e muc"sa "f t&e antrum and"dy

Acute Gastritis

C&r"nic Gastritis

C&r"nic gastritis implies s"me degree "f atr"p&y ( it& l"ss "f functi"n "f t&emuc"sa) "r metaplasia 8t pred"minantly in%"l%es t&e antrum ( it& su se?uent l"ss "fG cells and decreased gastrin secreti"n) "r t&e c"rpus ( it& l"ss "f " yntic glands,leading t" reduced acid, pepsin, and intrinsic fact"r)
http://www.merckmanuals.com/professional/sf/multimedia/v891940/t/sec02-ch013-ch013c.htmlhttp://www.merckmanuals.com/professional/sf/multimedia/v891946/t/sec02-ch013-ch013c.htmlhttp://www.merckmanuals.com/professional/sf/multimedia/v891946/t/sec02-ch013-ch013c.htmlhttp://www.merckmanuals.com/professional/sf/multimedia/v891940/t/sec02-ch013-ch013c.htmlhttp://www.merckmanuals.com/professional/sf/multimedia/v891940/t/sec02-ch013-ch013c.htmlhttp://www.merckmanuals.com/professional/sf/multimedia/v891946/t/sec02-ch013-ch013c.html


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Erosi6e G stritis6r"si%e gastritis is gastric muc"sal er"si"n caused y damage t" muc"sal

defenses 8t is typically acute, manifesting it& leeding, ut may e su acute "rc&r"nic it& fe "r n" sympt"ms Diagn"sis is y end"sc"py $reatment is supp"rti%e,

it& rem"%al "f t&e inciting cause Certain 8C; patients (eg, %entilat"r- "und, &eadtrauma, urn, multisystem trauma) enefit fr"m pr"p&yla is it& acid suppressantsCauses "f er"si%e gastritis include >SA8Ds, alc"&"l, stress, and less c"mm"nlyradiati"n, %iral infecti"n (eg, cyt"megal"%irus), %ascular in ury, and direct trauma (eg,nas"gastric tu es)

Superficial er"si"ns and punctate muc"sal lesi"ns "ccur $&ese may de%el"p ass""n as 12 & after t&e initial insult Deep er"si"ns, ulcers, and s"metimes perf"rati"nmay "ccur in se%ere "r untreated cases Lesi"ns typically "ccur in t&e "dy, ut t&eantrum may als" e in%"l%ed

A ute stress stritis, a f"rm "f er"si%e gastritis, "ccurs in a "ut * "f critically illpatients $&e incidence increases it& durati"n "f 8C; stay and lengt& "f time t&epatient is n"t recei%ing enteral feeding at&"genesis li#ely in%"l%es &yp"perfusi"n "ft&e G8 muc"sa, resulting in impaired muc"sal defenses atients it& &ead in ury "r

urns may als" &a%e increased secreti"n "f acid

S m#toms nd Si nsatients it& mild er"si%e gastritis are "ften asympt"matic, alt&"ug& s"me c"mplain

"f dyspepsia, nausea, "r %"miting Bften, t&e first sign is &ematemesis, melena, "r

l""d in t&e nas"gastric aspirate, usually it&in 2 t" * days "f t&e inciting e%ent0leeding is usually mild t" m"derate, alt&"ug& it can e massi%e if deep ulcerati"n ispresent, particularly in acute stress gastritis Acute and c&r"nic er"si%e gastritis arediagn"sed end"sc"pically

Di nosis Acute and c&r"nic er"si%e gastritis are diagn"sed end"sc"pically$reatment

9"r leeding 6nd"sc"pic &em"stasis 9"r acid suppressi"n A pr"t"n pump in&i it"r "r @ 2 l"c#er

8n se%ere gastritis, leeding is managed it& 8H fluids and l""d transfusi"n asneeded 6nd"sc"pic &em"stasis s&"uld e attempted, it& surgery (t"tal gastrect"my)a fall ac# pr"cedure Angi"grap&y is unli#ely t" st"p se%ere gastric leeding ecause"f t&e many c"llateral %essels supplying t&e st"mac& Acid suppressi"n s&"uld estarted if t&e patient is n"t already recei%ing it


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9"r milder gastritis, rem"%ing t&e "ffending agent and using drugs t" reduce gastricacidity, may e all t&at is re?uired

Pre6entionr"p&yla is it& acid-suppressi%e drugs can reduce t&e incidence "f acute stress

gastritis @" e%er, it mainly enefits certain &ig&-ris# 8C; patients, including t&"se it&se%ere urns, C>S trauma, c"agul"pat&y, sepsis, s&"c#, multiple trauma, mec&anical%entilati"n f"r E 4I &, &epatic "r renal failure, multi"rgan dysfuncti"n, and &ist"ry "fpeptic ulcer "r G8 leeding

r"p&yla is c"nsists "f 8H @ 2 l"c#ers, pr"t"n pump in&i it"rs, "r "ral antacids t"raise intragastric p@ E 4 + epeated p@ measurement and titrati"n "f t&erapy are n"tre?uired 6arly enteral feeding als" can decrease t&e incidence "f leeding

Acid suppressi"n is n"t rec"mmended f"r patients simply ta#ing >SA8Ds unlesst&ey &a%e pre%i"usly &ad an ulcer

Nonerosi6e G stritis>"ner"si%e gastritis refers t" a %ariety "f &ist"l"gic a n"rmalities t&at are mainly t&e

result "f @ pyl"ri infecti"n !"st patients are asympt"matic Diagn"sis is yend"sc"py $reatment is eradicati"n "f @ pyl"ri and s"metimes acid suppressi"n

P tho oSuperficial gastritis Lymp&"cytes and plasma cells mi ed it& neutr"p&ils are t&e

pred"minant infiltrating inflammat"ry cells 8nflammati"n is superficial and may in%"l%et&e antrum, "dy, "r "t& 8t is usually n"t acc"mpanied y atr"p&y "r metaplasia

re%alence increases it& ageDeep gastritis Deep gastritis is m"re li#ely t" e sympt"matic (eg, %ague

dyspepsia) !"n"nuclear cells and neutr"p&ils infiltrate t&e entire muc"sa t" t&e le%el"f t&e muscularis, ut e udate "r crypt a scesses seld"m result, as mig&t e e pected

y suc& infiltrati"n Distri uti"n may e patc&y Superficial gastritis may e present, asmay partial gland atr"p&y and metaplasia

Gastric atr"p&y Atr"p&y "f gastric glands may f"ll" in gastritis, m"st "ften l"ng-standing antral (s"metimes referred t" as type 0) gastritis S"me patients it& gastricatr"p&y &a%e aut"anti "dies t" parietal cells, usually in ass"ciati"n it& c"rpus (type

A) gastritis and pernici"us anemia Atr"p&y may "ccur it&"ut specific sympt"ms 6nd"sc"pically, t&e muc"sa may

appear n"rmal until atr"p&y is ad%anced, &en su muc"sal %ascularity may e %isi le As atr"p&y ec"mes c"mplete, secreti"n "f acid and pepsin diminis&es and intrinsicfact"r may e l"st, resulting in %itamin 0 12 mala s"rpti"n

!etaplasia $ " types "f metaplasia are c"mm"n in c&r"nic n"ner"si%e gastritismuc"us gland and intestinal


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!uc"us gland metaplasia (pseud"pyl"ric metaplasia) "ccurs in t&e setting "fse%ere atr"p&y "f t&e gastric glands, &ic& are pr"gressi%ely replaced y muc"usglands (antral muc"sa), especially al"ng t&e lesser cur%e Gastric ulcers may epresent (typically at t&e uncti"n "f antral and c"rpus muc"sa), ut &et&er t&ey are t&ecause "r c"nse?uence "f t&ese metaplastic c&anges is n"t clear

8ntestinal metaplasia typically egins in t&e antrum in resp"nse t" c&r"nic muc"salin ury and may e tend t" t&e "dy Gastric muc"sa cells c&ange t" resem le intestinalmuc"saJ it& g" let cells, end"crine (enter"c&r"maffin "r enter"c&r"maffin-li#e) cells,and rudimentary %illiJand may e%en assume functi"nal (a s"rpti%e) c&aracteristics8ntestinal metaplasia is classified &ist"l"gically as c"mplete (m"st c"mm"n) "rinc"mplete :it& c"mplete metaplasia, gastric muc"sa is c"mpletely transf"rmed int"small- " el muc"sa, "t& &ist"l"gically and functi"nally, it& t&e a ility t" a s"rnutrients and secrete peptides 8n inc"mplete metaplasia, t&e epit&elium assumes a&ist"l"gic appearance cl"ser t" t&at "f t&e large intestine and fre?uently e &i its

dysplasia 8ntestinal metaplasia may lead t" st"mac& cancer

S m#toms nd Si ns!"st patients it& @ pyl"ri'ass"ciated gastritis are asympt"matic, alt&"ug& s"me

&a%e mild dyspepsia "r "t&er %ague sympt"ms Bften t&e c"nditi"n is disc"%eredduring end"sc"py perf"rmed f"r "t&er purp"ses $esting "f asympt"matic patients isn"t indicated Bnce gastritis is identified, testing f"r @ pyl"ri is appr"priate

Di nosis 6nd"sc"py

Bften, t&e c"nditi"n is disc"%ered during end"sc"py d"ne f"r "t&er purp"ses$esting "f asympt"matic patients is n"t indicated Bnce gastritis is identified, testing f"r@ pyl"ri is appr"priate

Tre tment 6radicati"n "f @ pyl"ri S"metimes acid-suppressi%e drugs

$reatment "f c&r"nic n"ner"si%e gastritis is @ pyl"ri eradicati"n $reatment "fasympt"matic patients is s"me &at c"ntr"%ersial gi%en t&e &ig& pre%alence "f @pyl"ri'ass"ciated superficial gastritis and t&e relati%ely l" incidence "f clinicalse?uelae (ie, peptic ulcer disease) @" e%er, @ pyl"ri is a class K carcin"gen7eradicati"n rem"%es t&e cancer ris# 8n @ pyl"ri'negati%e patients, treatment isdirected at sympt"ms using acid-suppressi%e drugs (eg, @ 2 l"c#ers, pr"t"n pumpin&i it"rs) "r antacids

Post stre tom G stritis


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"stgastrect"my gastritis is gastric atr"p&y de%el"ping after partial "r su t"talgastrect"my (e cept in cases "f gastrin"ma)

!etaplasia "f t&e remaining c"rpus muc"sa is c"mm"n $&e degree "f gastritis isusually greatest at t&e lines "f anast"m"sis

Se%eral mec&anisms are resp"nsi le ile reflu , &ic& is c"mm"n after suc&surgery, damages t&e gastric muc"sa7 l"ss "f antral gastrin decreases stimulati"n "fparietal and peptic cells, causing atr"p&y7 and %ag"t"my may result in a l"ss "f %agaltr"p&ic acti"n

$&ere are n" specific sympt"ms "f gastritis "stgastrect"my gastritis "ftenpr"gresses t" se%ere atr"p&y and ac&l"r&ydria r"ducti"n "f intrinsic fact"r maycease it& resultant %itamin 0 12 deficiency ( &ic& may e "rsened y acterial"%ergr" t& in t&e afferent l""p) $&e relati%e ris# "f gastric aden"carcin"ma seems t"increase 1* t" 2+ yr after partial gastrect"my7 &" e%er, gi%en t&e l" a s"luteincidence "f p"stgastrect"my cancer, r"utine end"sc"pic sur%eillance is pr" a ly n"t

c"st effecti%e, ut upper G8 sympt"ms "r anemia in suc& patients s&"uld pr"mptend"sc"py

Un ommon G stritis S ndromes! n trierMs disease $&is rare idi"pat&ic dis"rder affects adults aged 3+ t" /+ and is

m"re c"mm"n am"ng men 8t manifests as a significant t&ic#ening "f t&e gastric f"lds"f t&e gastric "dy ut n"t t&e antrum Gland atr"p&y and mar#ed f"%e"lar pit&yperplasia "ccur, "ften acc"mpanied y muc"us gland metaplasia and increasedmuc"sal t&ic#ness it& little inflammati"n @yp"al uminemia (t&e m"st c"nsistentla "rat"ry a n"rmality) caused y G8 pr"tein l"ss may e present (pr"tein-l"sing

gastr"pat&y) As t&e disease pr"gresses, t&e secreti"n "f acid and pepsin decreases,causing &yp"c&l"r&ydria

Sympt"ms are n"nspecific and c"mm"nly include epigastric pain, nausea, eig&tl"ss, edema, and diarr&ea Differential diagn"sis includes (1) lymp&"ma, in &ic&multiple gastric ulcers may "ccur7 (2) muc"sa-ass"ciated lymp&"id tissue (!AL$)lymp&"ma, it& e tensi%e infiltrati"n "f m"n"cl"nal 0 lymp&"cytes7 (3) N"llinger-6llis"nsyndr"me it& ass"ciated gastric f"ld &ypertr"p&y7 and (4) Cr"n#&ite-Canadasyndr"me, a muc"sal p"lyp"id pr"tein-l"sing syndr"me ass"ciated it& diarr&eaDiagn"sis is made y end"sc"py it& deep muc"sal i"psy "r full-t&ic#nesslapar"sc"pic gastric i"psy

Hari"us treatments &a%e een used, including antic&"linergics, antisecret"ry drugs,and c"rtic"ster"ids, ut n"ne &a%e pr"%ed fully effecti%e artial "r c"mplete gastricresecti"n may e necessary in cases "f se%ere &yp"al uminemia

6"sin"p&ilic gastritis 6 tensi%e infiltrati"n "f t&e muc"sa, su muc"sa, and musclelayers it& e"sin"p&ils "ften "ccurs in t&e antrum 8t is usually idi"pat&ic ut may resultfr"m nemat"de infestati"n Sympt"ms include nausea, %"miting, and early satiety


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Diagn"sis is y end"sc"pic i"psy "f in%"l%ed areas C"rtic"ster"ids can e successfulin idi"pat&ic cases7 &" e%er, if pyl"ric " structi"n de%el"ps, surgery may e re?uired!uc"sa-ass"ciated lymp&"id tissue (!AL$) lymp&"ma $&is rare c"nditi"n isc&aracteri ed y massi%e lymp&"id infiltrati"n "f t&e gastric muc"sa, &ic& canresem le ! n trierMs disease

Gastritis caused y systemic dis"rders Sarc"id"sis, $0, amyl"id"sis, and "t&ergranul"mat"us diseases can cause gastritis, &ic& is seld"m "f primary imp"rtanceGastritis caused y p&ysical agents adiati"n and ingesti"n "f c"rr"si%es (especiallyacidic c"mp"unds) can cause gastritis 6 p"sure t" E 1/ Gy "f radiati"n causesmar#ed deep gastritis, usually in%"l%ing t&e antrum m"re t&an t&e c"rpus yl"ricsten"sis and perf"rati"n are p"ssi le c"mplicati"ns "f radiati"n-induced gastritis

8nfecti"us (septic) gastritis 6 cept f"r @ pyl"ri infecti"n, acterial in%asi"n "f t&est"mac& is rare and mainly "ccurs after isc&emia, ingesti"n "f c"rr"si%es, "r e p"suret" radiati"n Bn -ray, gas "utlines t&e muc"sa $&e c"nditi"n can manifest as an

acute surgical a d"men and &as a %ery &ig& m"rtality rate Surgery is "ften necessaryDe ilitated "r immun"c"mpr"mised patients may de%el"p %iral "r fungal gastritis it&cyt"megal"%irus, Candida, &ist"plasm"sis, "r muc"rmyc"sis7 t&ese diagn"ses s&"uld

e c"nsidered in patients it& e udati%e gastritis, es"p&agitis, "r du"denitis

Pe#ti U er Dise se A peptic ulcer is an er"si"n in a segment "f t&e G8 muc"sa, typically in t&e st"mac&

(gastric ulcer) "r t&e first fe centimeters "f t&e du"denum (du"denal ulcer), t&atpenetrates t&r"ug& t&e muscularis muc"sae >early all ulcers are caused y@elic" acter pyl"ri infecti"n "r >SA8D use Sympt"ms typically include urning

epigastric pain t&at is "ften relie%ed y f""d Diagn"sis is y end"sc"py and testing f"r@ pyl"ri $reatment in%"l%es acid suppressi"n, eradicati"n "f @ pyl"ri (if present), anda%"idance "f >SA8Ds

;lcers may range in si e fr"m se%eral millimeters t" se%eral centimeters ;lcers aredelineated fr"m er"si"ns y t&e dept& "f penetrati"n7 er"si"ns are m"re superficial andd" n"t in%"l%e t&e muscularis muc"sae ;lcers can "ccur at any age, including infancyand c&ild&""d, ut are m"st c"mm"n am"ng middle-aged adults

Etio o@ pyl"ri and >SA8Ds disrupt n"rmal muc"sal defense and repair, ma#ing t&e

muc"sa m"re suscepti le t" acid @ pyl"ri infecti"n is present in *+ t" .+ "f patientsit& du"denal ulcers and 3+ t" *+ "f patients it& gastric ulcers 8f @ pyl"ri is

eradicated, "nly 1+ "f patients &a%e recurrence "f peptic ulcer disease, c"mparedit& .+ recurrence in patients treated it& acid suppressi"n al"ne >SA8Ds n"

acc"unt f"r E *+ "f peptic ulcersCigarette sm"#ing is a ris# fact"r f"r t&e de%el"pment "f ulcers and t&eir

c"mplicati"ns Als", sm"#ing impairs ulcer &ealing and increases t&e incidence "f


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recurrence is# c"rrelates it& t&e num er "f cigarettes sm"#ed per day Alt&"ug&alc"&"l is a str"ng pr"m"ter "f acid secreti"n, n" definiti%e data lin# m"derate am"unts"f alc"&"l t" t&e de%el"pment "r delayed &ealing "f ulcers Hery fe patients &a%e&ypersecreti"n "f gastrin (N"llinger-6llis"n syndr"me)

A family &ist"ry e ists in *+ t" /+ "f c&ildren it& du"denal ulcer

S m#toms nd Si nsSympt"ms depend "n ulcer l"cati"n and patient age7 many patients, particularly

elderly patients, &a%e fe "r n" sympt"ms ain is m"st c"mm"n, "ften l"cali ed t" t&eepigastrium and relie%ed y f""d "r antacids $&e pain is descri ed as urning "rgna ing, "r s"metimes as a sensati"n "f &unger $&e c"urse is usually c&r"nic andrecurrent Bnly a "ut &alf "f patients present it& t&e c&aracteristic pattern "fsympt"ms

G stri u er sympt"ms "ften d" n"t f"ll" a c"nsistent pattern (eg, eating

s"metimes e acer ates rat&er t&an relie%es pain) $&is is especially true f"r pyl"ricc&annel ulcers, &ic& are "ften ass"ciated it& sympt"ms "f " structi"n (eg, l"ating,nausea, %"miting) caused y edema and scarring

Duoden u ers tend t" cause m"re c"nsistent pain ain is a sent &en t&epatient a a#ens ut appears in mid-m"rning, is relie%ed y f""d, ut recurs 2 t" 3 &after a meal ain t&at a a#ens a patient at nig&t is c"mm"n and is &ig&ly suggesti%e"f du"denal ulcer 8n ne"nates, perf"rati"n and &em"rr&age may e t&e firstmanifestati"n "f du"denal ulcer @em"rr&age may als" e t&e first rec"gni ed sign inlater infancy and early c&ild&""d, alt&"ug& repeated %"miting "r e%idence "f a d"minalpain may e a clue

Di nosis 6nd"sc"py S"metimes serum gastrin le%els

Gastric ;lcer

Diagn"sis "f peptic ulcer is suggested y patient &ist"ry and c"nfirmed yend"sc"py 6mpiric t&erapy is "ften egun it&"ut definiti%e diagn"sis @" e%er,end"sc"py all" s f"r i"psy "r cyt"l"gic rus&ing "f gastric and es"p&ageal lesi"ns t"distinguis& et een simple ulcerati"n and ulcerating st"mac& cancer St"mac& cancermay manifest it& similar manifestati"ns and must e e cluded, especially in patients
http://www.merckmanuals.com/professional/sf/multimedia/v891951/t/sec02-ch013-ch013e.htmlhttp://www.merckmanuals.com/professional/sf/multimedia/v891951/t/sec02-ch013-ch013e.htmlhttp://www.merckmanuals.com/professional/sf/multimedia/v891951/t/sec02-ch013-ch013e.html


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&" are E 4*, &a%e l"st eig&t, "r rep"rt se%ere "r refract"ry sympt"ms $&e incidence"f malignant du"denal ulcer is e tremely l" , s" i"psies "f lesi"ns in t&at area aregenerally n"t arranted 6nd"sc"py can als" e used t" definiti%ely diagn"se @ pyl"riinfecti"n, &ic& s&"uld e s"ug&t &en an ulcer is detected

Gastrin-secreting cancer and N"llinger-6llis"n syndr"me s&"uld e c"nsidered&en t&ere are multiple ulcers, &en ulcers de%el"p in atypical l"cati"ns (eg,

p"st ul ar) "r are refract"ry t" treatment, "r &en t&e patient &as pr"minent diarr&ea"r eig&t l"ss Serum gastrin le%els s&"uld e measured in t&ese patients

Com# i tions@em"rr&age !ild t" se%ere &em"rr&age is t&e m"st c"mm"n c"mplicati"n "f

peptic ulcer disease Sympt"ms include &ematemesis (%"miting "f fres& l""d "r


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Sympt"ms may e less stri#ing in elderly "r m"ri und patients and t&"se recei%ingc"rtic"ster"ids "r immun"suppressants

Diagn"sis is c"nfirmed if an -ray "r C$ s&" s free air under t&e diap&ragm "r int&e perit"neal ca%ity ;prig&t %ie s "f t&e c&est and a d"men are preferred $&e m"stsensiti%e %ie is t&e lateral -ray "f t&e c&est Se%erely ill patients may e una le t" situprig&t and s&"uld &a%e a lateral decu itus -ray "f t&e a d"men 9ailure t" detect freeair d"es n"t e clude t&e diagn"sis

8mmediate surgery is re?uired $&e l"nger t&e delay, t&e p""rer is t&e pr"gn"sis:&en surgery is c"ntraindicated, t&e alternati%es are c"ntinu"us nas"gastric sucti"nand r"ad-spectrum anti i"tics

Gastric "utlet " structi"n B structi"n may e caused y scarring, spasm, "rinflammati"n fr"m an ulcer Sympt"ms include recurrent, large-%"lume %"miting,"ccurring m"re fre?uently at t&e end "f t&e day and "ften as late as / & after t&e lastmeal L"ss "f appetite it& persistent l"ating "r fullness after eating als" suggests

gastric "utlet " structi"n r"l"nged %"miting may cause eig&t l"ss, de&ydrati"n, andal#al"sis8f t&e patientMs &ist"ry suggests " structi"n, p&ysical e aminati"n, gastric aspirati"n,

"r -rays may pr"%ide e%idence "f retained gastric c"ntents A succussi"n splas&&eard E / & after a meal "r aspirati"n "f fluid "r f""d residue E 2++ mL after an"%ernig&t fast suggests gastric retenti"n 8f gastric aspirati"n s&" s mar#ed retenti"n,t&e st"mac& s&"uld e emptied and end"sc"py d"ne "r -rays ta#en t" determine site,cause, and degree "f " structi"n

6dema "r spasm caused y an acti%e pyl"ric c&annel ulcer is treated it& gastricdec"mpressi"n y nas"gastric sucti"n and acid suppressi"n (eg, 8H @ 2 l"c#ers)

De&ydrati"n and electr"lyte im alances resulting fr"m pr"tracted %"miting "r c"ntinuednas"gastric sucti"ning s&"uld e %ig"r"usly s"ug&t and c"rrected r"#inetic agentsare n"t indicated Generally, " structi"n res"l%es it&in 2 t" * days "f treatment

r"l"nged " structi"n may result fr"m peptic scarring and may resp"nd t" end"sc"picpyl"ric all""n dilati"n Surgery is necessary t" relie%e " structi"n in selected cases

ecurrence 9act"rs t&at affect recurrence "f ulcer include failure t" eradicate @ pyl"ri,c"ntinued >SA8D use, and sm"#ing Less c"mm"nly, a gastrin"ma (N"llinger-6llis"nsyndr"me) may e t&e cause $&e 3-yr recurrence rate f"r gastric and du"denal ulcersis F 1+ &en @ pyl"ri is successfully eradicated ut E *+ &en it is n"t $&us, apatient it& recurrent disease s&"uld e tested f"r @ pyl"ri and treated again if t&etests are p"siti%e

Alt&"ug& l"ng-term treatment it& @ 2 l"c#ers, pr"t"n pump in&i it"rs, "rmis"pr"st"lreduces t&e ris# "f recurrence, t&eir r"utine use f"r t&is purp"se is n"t rec"mmended@" e%er, patients &" re?uire >SA8Ds after &a%ing &ad a peptic ulcer are candidatesf"r l"ng-term t&erapy, as are t&"se it& a marginal ulcer "r pri"r perf"rati"n "r

leeding


18/32

St"mac& cancer atients it& @ pyl"ri ' ass"ciated ulcers &a%e a 3- t" /-f"ldincreased ris# "f gastric cancer later in life $&ere is n" increased ris# "f cancer it&ulcers "f "t&er eti"l"gy

Tre tment 6radicati"n "f @ pyl"ri ( &en present) Acid-suppressi%e drugs

$reatment "f gastric and du"denal ulcers re?uires eradicati"n "f @ pyl"ri &enpresent and a reducti"n "f gastric acidity 9"r du"denal ulcers, it is particularlyimp"rtant t" suppress n"cturnal acid secreti"n

!et&"ds "f decreasing acidity include a num er "f drugs, all "f &ic& are effecti%eut &ic& %ary in c"st, durati"n "f t&erapy, and c"n%enience "f d"sing 8n additi"n,

muc"sal pr"tecti%e drugs (eg, sucralfate ) and acid-reducing surgical pr"cedures maye used Drug t&erapy is discussed else &ere

Ad uncts Sm"#ing s&"uld e st"pped, and alc"&"l c"nsumpti"n st"pped "r limited t"small am"unts "f dilute alc"&"l $&ere is n" e%idence t&at c&anging t&e diet speedsulcer &ealing "r pre%ents recurrence $&us, many p&ysicians rec"mmend eliminating"nly f""ds t&at cause distress

Surgery :it& current drug t&erapy, t&e num er "f patients re?uiring surgery &asdeclined dramatically 8ndicati"ns include perf"rati"n, " structi"n, unc"ntr"lled "rrecurrent leeding, and, alt&"ug& rare, sympt"ms t&at d" n"t resp"nd t" drug t&erapySurgery c"nsists "f a pr"cedure t" reduce acid secreti"n, "ften c"m ined it& apr"cedure t" ensure gastric drainage $&e rec"mmended "perati"n f"r du"denal ulceris &ig&ly selecti%e, "r parietal cell, %ag"t"my ( &ic& is limited t" ner%es at t&e gastric

"dy and spares antral inner%ati"n, t&ere y " %iating t&e need f"r a drainagepr"cedure) $&is pr"cedure &as a %ery l" m"rtality rate and a%"ids t&e m"r idityass"ciated it& resecti"n and traditi"nal %ag"t"my Bt&er acid-reducing surgicalpr"cedures include antrect"my, &emigastrect"my, partial gastrect"my, and su t"talgastrect"my (ie, resecti"n "f 3+ t" + "f t&e distal st"mac&) $&ese are typicallyc"m ined it& truncal %ag"t"my atients &" underg" a resecti%e pr"cedure "r &"&a%e an " structi"n re?uire gastric drainage %ia a gastr"du"den"st"my (0illr"t& 8) "rgastr" e un"st"my (0illr"t& 88)

$&e incidence and type "f p"stsurgical sympt"ms %ary it& t&e type "f "perati"n After resecti%e surgery, up t" 3+ "f patients &a%e significant sympt"ms, including

eig&t l"ss, maldigesti"n, anemia, dumping syndr"me, reacti%e &yp"glycemia, ili"us%"miting, mec&anical pr" lems, and ulcer recurrence

0ei ht oss is c"mm"n after su t"tal gastrect"my7 t&e patient may limit f""dinta#e ecause "f early satiety ( ecause t&e residual gastric p"uc& is small) "r t"pre%ent dumping syndr"me and "t&er p"stprandial syndr"mes :it& a small gastric


19/32

p"uc&, distenti"n "r disc"mf"rt may "ccur after a meal "f e%en m"derate si e7 patientss&"uld e enc"uraged t" eat smaller and m"re fre?uent meals

- di estion and steat"rr&ea caused y pancreatic" iliary ypass, especially it&0illr"t& 88 anast"m"sis, may c"ntri ute t" eig&t l"ss

Anemi is c"mm"n (usually fr"m ir"n deficiency, ut "ccasi"nally fr"m %itamin 0 12deficiency caused y l"ss "f intrinsic fact"r "r acterial "%ergr" t&) in t&e afferent lim ,and "ste"malacia may "ccur 8! %itamin 0 12 supplementati"n is rec"mmended f"r allpatients it& t"tal gastrect"my ut may als" e gi%en t" patients it& su t"talgastrect"my if deficiency is suspected

Dum#in s ndrome may f"ll" gastric surgical pr"cedures, particularlyresecti"ns :ea#ness, di iness, s eating, nausea, %"miting, and palpitati"n "ccur

s""n after eating, especially &yper"sm"lar f""ds $&is p&en"men"n is referred t" asearly dumping, t&e cause "f &ic& remains unclear ut li#ely in%"l%es aut"n"micrefle es, intra%ascular %"lume c"ntracti"n, and release "f %as"acti%e peptides fr"m t&esmall intestine Dietary m"dificati"ns, it& smaller, m"re fre?uent meals anddecreased car "&ydrate inta#e, usually &elp

Re ti6e h #o emi "r te dum#in (an"t&er f"rm "f t&e syndr"me) resultsfr"m rapid emptying "f car "&ydrates fr"m t&e gastric p"uc& 6arly &ig& pea#s in l""dgluc"se stimulate e cess release "f insulin, &ic& leads t" sympt"matic &yp"glycemiase%eral &"urs after t&e meal A &ig&-pr"tein, l" -car "&ydrate diet and ade?uate

cal"ric inta#e (in fre?uent small feedings) are rec"mmended

-e h ni #ro ems (including gastr"paresis and e "ar f"rmati"n-may "ccursec"ndary t" a decrease in p&ase 888 gastric m"t"r c"ntracti"ns, &ic& are altered afterantrect"my and %ag"t"my Diarr&ea is especially c"mm"n after %ag"t"my, e%en

it&"ut a resecti"n (pyl"r"plasty)

U er re urren e, acc"rding t" "lder studies, "ccurs in * t" 12 after &ig&lyselecti%e %ag"t"my and in 2 t" * after resecti%e surgery ecurrent ulcers arediagn"sed y end"sc"py and generally resp"nd t" eit&er pr"t"n pump in&i it"rs "r @ 2

l"c#ers 9"r ulcers t&at c"ntinue t" recur, t&e c"mpleteness "f %ag"t"my s&"uld etested y gastric analysis, @ pyl"ri s&"uld e eliminated if present, and N"llinger-6llis"n syndr"me s&"uld e ruled "ut y serum gastrin studies

Dru Tre tment o* G stri A iditDrugs f"r decreasing acidity are used f"r peptic ulcer, gastr"es"p&ageal reflu

disease (G6 D-and many f"rms "f gastritis S"me drugs are used in regimens f"r


20/32

treating @ pyl"ri infecti"n Drugs include pr"t"n pump in&i it"rs, @ 2 l"c#ers, antacids,and pr"staglandins

r"t"n pump in&i it"rs $&ese drugs are p"tent in&i it"rs "f @ O,P O-A$ ase $&isen yme, l"cated in t&e apical secret"ry mem rane "f t&e parietal cell, plays a #ey r"lein t&e secreti"n "f @ O (pr"t"ns) $&ese drugs can c"mpletely in&i it acid secreti"n and&a%e a l"ng durati"n "f acti"n $&ey pr"m"te ulcer &ealing and are als" #eyc"mp"nents "f @ pyl"ri eradicati"n regimens r"t"n pump in&i it"rs &a%e replaced @ 2

l"c#ers in m"st clinical situati"ns ecause "f greater rapidity "f acti"n and efficacyr"t"n pump in&i it"rs include es"mepra "le, lans"pra "le, and pant"pra "le, all

a%aila le "rally and 8H, and "mepra "le and ra epra "le, a%aila le "nly "rally in t&e;S

Bmepra "le is a%aila le it&"ut a prescripti"n in t&e ;S 9"r unc"mplicateddu"denal ulcers, "mepra "le 2+ mg p" "nce day "r lans"pra "le 3+ mg p" "nce day isgi%en f"r 4 # C"mplicated du"denal ulcers (ie, multiple ulcers, leeding ulcers, t&"se

E 1 * cm, "r t&"se "ccurring in patients it& seri"us underlying illness) resp"nd ettert" &ig&er d"ses ("mepra "le 4+ mg "nce day, lans"pra "le /+ mg "nce day "r 3+ mgid) Gastric ulcers re?uire treatment f"r / t" I # Gastritis and G6 D re?uire I t" 12# "f t&erapy7 G6 D additi"nally re?uires l"ng-term maintenance

$a le 1r"t"n ump 8n&i it"rs

Drug !"st C"nditi"nsQ C"mplicated Du"denal ;lcers6s"mepra "le 4+ mg "nce day 4+ mg idLans"pra "le 3+ mg "nce day

( ediatric d"sesF 1+ #g . * mg "nce day1+'2+ #g 1* mg "nce dayR 2+ #g 3+ mg "nce day)

3+ mg

Bmepra "le

d

2+ mg "nce day( ediatric d"se 1 mg #g dayin a single d"se "r di%ided

id)

4+ mg "nce day

ant"pra "le 4+ mg "nce day 4+ mg ida epra "le 2+ mg "nce day 2+ mg id

QGastritis, gastr"es"p&ageal reflu disease, unc"mplicated du"denal ulcersepresentati%e d"ses Data are limited t" t&e use "f pr"t"n pump in&i it"rs in c&ildren

L"ng-term pr"t"n pump in&i it"r t&erapy pr"duces ele%ated gastrin le%els, &ic&lead t" enter"c&r"maffin-li#e cell &yperplasia @" e%er, t&ere is n" e%idence "fdysplasia "r malignant transf"rmati"n in patients recei%ing t&is treatment S"me mayde%el"p %itamin 0 12 mala s"rpti"n


21/32

@2 l"c#ers $&ese drugs (cimetidine, ranitidine, fam"tidine, a%aila le 8H and "rally7and ni atidine a%aila le "rally) are c"mpetiti%e in&i it"rs "f &istamine at t&e @ 2recept"r, t&us suppressing gastrin-stimulated acid secreti"n and pr"p"rti"natelyreducing gastric uice %"lume @istamine-mediated pepsin secreti"n is als" decreased@2 l"c#ers are ell a s"r ed fr"m t&e G8 tract, it& "nset "f acti"n 3+ t" /+ min afteringesti"n and pea# effects at 1 t" 2 & 8H administrati"n pr"duces a m"re rapid "nset "facti"n Durati"n "f acti"n is pr"p"rti"nal t" d"se and ranges fr"m / t" 2+ & D"sess&"uld "ften e reduced in elderly patients 9"r du"denal ulcers, "nce daily "raladministrati"n "f cimetidine I++ mg, ranitidine 3++ mg, fam"tidine 4+ mg, "r ni atidine3++ mg gi%en at edtime "r after dinner f"r / t" I # is effecti%e Gastric ulcers mayresp"nd t" t&e same regimen c"ntinued f"r I t" 12 #, ut ecause n"cturnal acidsecreti"n is less imp"rtant, m"rning administrati"n may e e?ually "r m"re effecti%eC&ildren R 4+ #g may recei%e adult d"ses 0el" t&at eig&t, t&e "ral d"sage isranitidine 2 mg #g ? 12 & and cimetidine 1+ mg #g ? 12 & 9"r G6 D, @ 2 l"c#ers are

n" m"stly used f"r pain management Gastritis &eals it& fam"tidine "r ranitidinegi%en id f"r I t" 12 #Cimetidine &as min"r antiandr"gen effects e pressed as re%ersi le gynec"mastia

and, less c"mm"nly, erectile dysfuncti"n it& pr"l"nged use !ental status c&anges,diarr&ea, ras&, drug fe%er, myalgias, t&r"m "cyt"penia, and sinus radycardia and&yp"tensi"n after rapid 8H administrati"n &a%e een rep"rted it& all @ 2 l"c#ers,generally in F 1 "f treated patients ut m"re c"mm"nly in elderly patients

Cimetidine and, t" a lesser e tent, "t&er @ 2 l"c#ers interact it& t&e -4*+micr"s"mal en yme system and may delay meta "lism "f "t&er drugs eliminatedt&r"ug& t&is system (eg, p&enyt"in, arfarin, t&e"p&ylline, dia epam, lid"caine)

Ant ids$&ese agents neutrali e gastric acid and reduce pepsin acti%ity ( &ic& diminis&es

as gastric p@ rises t" E 4 +) 8n additi"n, s"me antacids ads"r pepsin Antacids mayinterfere it& t&e a s"rpti"n "f "t&er drugs (eg, tetracycline, dig" in, ir"n)

Antacids relie%e sympt"ms, pr"m"te ulcer &ealing, and reduce recurrence $&eyare relati%ely ine pensi%e ut must e ta#en * t" . times day $&e "ptimal antacidregimen f"r ulcer &ealing seems t" e 1* t" 3+ mL "f li?uid "r 2 t" 4 ta lets 1 & and 3 &after eac& meal and at edtime $&e t"tal daily d"sage "f antacids s&"uld pr"%ide 2++t" 4++ m6? neutrali ing capacity @" e%er, antacids &a%e een superseded y acidsuppressi%e t&erapy in t&e treatment "f peptic ulcer and are used "nly f"r s&"rt-termsympt"m relief 8n general, t&ere are 2 types "f antacids a s"r a le andn"na s"r a le A s"r a le antacids (eg, >a icar "nate, Ca car "nate) pr"%ide rapid,c"mplete neutrali ati"n ut may cause al#al"sis and s&"uld e used "nly riefly (1 "r 2days) >"na s"r a le antacids (eg, aluminum "r !g &ydr" ide) &a%e fe er systemicad%erse effects and are preferred


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Aluminum &ydr" ide is a relati%ely safe, c"mm"nly used antacid :it& c&r"nic use,p&"sp&ate depleti"n "ccasi"nally de%el"ps as a result "f inding "f p&"sp&ate yaluminum in t&e G8 tract $&e ris# "f p&"sp&ate depleti"n increases in alc"&"lics,undern"uris&ed patients, and patients it& renal disease (including t&"se recei%ing&em"dialysis) Aluminum &ydr" ide causes c"nstipati"n

!g &ydr" ide is a m"re effecti%e antacid t&an aluminum ut may cause diarr&ea$" limit diarr&ea, many pr"prietary antacids c"m ine !g and aluminum antacids0ecause small am"unts "f !g are a s"r ed, !g preparati"ns s&"uld e used it&cauti"n in patients it& renal disease

Prost ndinsCertain pr"staglandins (especially mis"pr"st"l) in&i it acid secreti"n y decreasing

t&e generati"n "f cyclic A! t&at is triggered y &istamine stimulati"n "f t&e parietalcell, and en&ance muc"sal defense Synt&etic pr"staglandin deri%ati%es are used

pred"minantly t" decrease t&e ris# "f >SA8D-induced muc"sal in ury atients at &ig&ris# "f >SA8D-induced ulcers (ie, elderly patients, t&"se it& a &ist"ry "f ulcer "r ulcerc"mplicati"n, t&"se als" ta#ing c"rtic"ster"ids) are candidates t" ta#e mis"pr"st"l2++Tg p" ?id it& f""d al"ng it& t&eir >SA8D C"mm"n ad%erse effects "f mis"pr"st"lare a d"minal ramping and diarr&ea, &ic& "ccur in 3+ "f patients !is"pr"st"l is ap" erful "rtifacient and is a s"lutely c"ntraindicated in "men "f c&ild earing age

&" are n"t using c"ntracepti"n

Su r * te$&is drug is a sucr"se-aluminum c"mple t&at diss"ciates in st"mac& acid and

f"rms a p&ysical arrier "%er an inflamed area, pr"tecting it fr"m acid, pepsin, and ilesalts 8t als" in&i its pepsin-su strate interacti"n, stimulates muc"sal pr"staglandinpr"ducti"n, and inds ile salts 8t &as n" effect "n acid "utput "r gastrin secreti"nSucralfate seems t" &a%e tr"p&ic effects "n t&e ulcerated muc"sa, p"ssi ly y indinggr" t& fact"rs and c"ncentrating t&em at an ulcer site Systemic a s"rpti"n "fsucralfate is negligi le C"nstipati"n "ccurs in 3 t" * "f patients Sucralfate may indt" "t&er drugs and interfere it& t&eir a s"rpti"n

U##er GI ' eedin Acute upper gastr"intestinal (G8) leeding is c"mm"n and p"tentially life-

t&reatening and needs a pr"mpt assessment and aggressi%e medical management Allpatients need t" underg" end"sc"py t" diagn"se, assess, and p"ssi ly treat anyunderlying lesi"n 8n additi"n, patients f"und t" &a%e leeding ulcers s&"uld recei%e apr"t"n pump in&i it"r, t&e d"sage and durati"n "f treatment depending "n t&eend"sc"pic findings and clinical fact"rs


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@emat"c&e ia (red l""d in t&e st""l) usually suggests a l" er G8 s"urce "fleeding, since l""d fr"m an upper s"urce turns lac# and tarry as it passes t&r"ug&

t&e gut, pr"ducing melena @" e%er, up t" * "f patients it& leeding ulcers &a%e&emat"c&e ia, . and it indicates &ea%y leeding leeding "f appr" imately 1,+++ mLint" t&e upper G8 tract is needed t" cause &emat"c&e ia, &ereas "nly *+ t" 1++ mL isneeded t" cause melena I , @emat"c&e ia it& signs and sympt"ms "f &em"dynamicc"mpr"mise suc& as sync"pe, p"stural &yp"tensi"n, tac&ycardia, and s&"c# s&"uldt&eref"re direct "ne s attenti"n t" an upper G8 s"urce "f leeding

>"nspecific features include nausea, %"miting, epigastric pain, %as"%agalp&en"mena, and sync"pe

0&AT IS T&E PATIENT!S RIS%> An assessment "f clinical se%erity is t&e first critical tas#, as it &elps in planning

treatment Ad%anced age, multiple c"m"r idities, and &em"dynamic insta ility call f"r

aggressi%e treatment Apart fr"m t&is simple clinical rule, sc"ring systems &a%e eende%el"pedThe Ro = s orin s stem, t&e m"st idely used, gi%es estimates "f t&e ris#s "f

recurrent leeding and deat& 8t is ased "n t&e t&ree clinical fact"rs menti"ned a "%eand "n t " end"sc"pic "nes, a arding p"ints f"r AgeJ+ p"ints if less t&an /+7 1 p"int if /+ t" . 7 "r 2 p"ints if I+ years "r "lder S&"c#J1 p"int if t&e pulse is m"re t&an 1++7 2 p"ints if t&e syst"lic l""d pressure

is less t&an 1++ mm @g C"m"r id illnessJ2 p"ints f"r isc&emic &eart disease, c"ngesti%e &eart failure, "r

"t&er ma "r c"m"r idity7 3 p"ints f"r renal failure, &epatic failure, "r metastaticdisease

6nd"sc"pic diagn"sisJ+ p"ints if n" lesi"n f"und "r a !all"ry-:eiss tear7 1 p"intf"r peptic ulcer, es"p&agitis, "r er"si%e disease7 2 p"ints f"r G8 malignancy

6nd"sc"pic stigmata "r recent &em"rr&ageJ+ p"ints f"r a clean- ased ulcer "r flatpigmented sp"t7 2 p"ints f"r l""d in t&e upper G8 tract, acti%e leeding, an"n leeding %isi le %essel, "r ad&erent cl"t

$&e "c#all sc"re can t&us range fr"m + t" 11 p"ints, it& an "%erall sc"re "f +, 1,"r 2 ass"ciated it& an e cellent pr"gn"sis 1+

The ' t h*ord s orin s stem uses "nly clinical and la "rat"ry fact"rs and &asn" end"sc"pic c"mp"nent ( $A0L6 1 ) 8n c"ntrast t" t&e "c#all sc"re, t&e main"utc"me it predicts is t&e need f"r clinical inter%enti"n (end"sc"py, surgery, "r l""dtransfusi"n) $&e 0latc&f"rd sc"re ranges fr"m + t" 237 m"st patients it& a sc"re "f /"r &ig&er need inter%enti"n 11

/ther s stems t&at are used less "ften include t&e 0ayl"r se%erity scale and t&e Acute &ysi"l"gy and C&r"nic @ealt& 6%aluati"n (A AC@6) 88 sc"re
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Does the # tient h 6e 6 ri es> All %ariceal leeding s&"uld e c"nsidered se%ere, since t&e 1-year deat& rate is s"

&ig& (up t" .+ ) Clues p"inting t" %ariceal leeding include pre%i"us %aricealleeding, t&r"m "cyt"penia, &ist"ry "f li%er disease, and signs "f li%er disease "n

clinical e aminati"n All patients suspected "f &a%ing leeding %arices s&"uld e admitted t" t&e

intensi%e care unit f"r cl"se m"nit"ring and s&"uld e gi%en t&e &ig&est pri"rity, e%en ift&ey are &em"dynamically sta le

Is the # tient hemod n mi st e> Appr"priate &em"dynamic assessment includes m"nit"ring "f &eart rate, l""d

pressure, and mental status $ac&ycardia at rest, &yp"tensi"n, and "rt&"static c&angesin %ital signs indicate a c"nsidera le l"ss "f l""d %"lume L" urine "utput, drymuc"us mem ranes, and sun#en nec# %eins are als" useful signs ($ac&ycardia may

e lunted if t&e patient is ta#ing a eta- l"c#er )8f t&ese signs "f &yp"%"lemia are present, t&e initial management f"cuses "ntreating s&"c# and "n impr"%ing " ygen deli%ery t" t&e %ital "rgans $&is in%"l%esrepleti"n "f t&e intra%ascular %"lume it& intra%en"us infusi"ns "r l""d transfusi"nsSupplemental " ygen als" is useful, especially in elderly patients it& &eart disease 12

Ins#e tion o* n so stri s#ir te8n t&e initial assessment, it is useful t" insert a nas"gastric tu e and inspect t&e

aspirate 8f it c"ntains rig&t red l""d, t&e patient needs an urgent end"sc"pice%aluati"n and an intensi%e le%el "f care 13,147 if it c"ntains c"ffee-gr"unds material, t&e

patient needs t" e admitted t" t&e &"spital and t" underg" end"sc"pic e%aluati"nit&in 24 &"urs

@" e%er, a n"rmal aspirate d"es n"t rule "ut upper G8 leeding Al e reen et al 1*

f"und t&at 1* "f patients it& upper G8 leeding and n"rmal nas"gastric aspirate still&ad &ig&-ris# lesi"ns (ie, %isi le leeding "r n"n leeding %isi le %essels) "n end"sc"py

ACID$SUPPRESSI/N &ELPS ULCERS &EAL Acid and pepsin interfere it& t&e &ealing "f ulcers and "t&er n"n%ariceal upper G8

lesi"ns 9urt&er, an acidic en%ir"nment pr"m"tes platelet disaggregati"n andfi rin"lysis and impairs cl"t f"rmati"n 1/ $&is suggests t&at in&i iting gastric acidsecreti"n and raising t&e gastric p@ t" / "r &ig&er may sta ili e cl"ts !"re"%er,pepsin"gen in t&e st"mac& is c"n%erted t" its acti%e f"rm (pepsin) if t&e p@ is less t&an4 $&eref"re, #eeping t&e p@ a "%e 4 #eeps pepsin"gen in an inacti%e f"rm
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&ist mine$3 re e#tor nt onists@istamine-2 recept"r antag"nists ere t&e first drugs t" in&i it acid secreti"n,

re%ersi ly l"c#ing &istamine-2 recept"rs "n t&e as"lateral mem rane "f parietalcells @" e%er, t&ese drugs did n"t pr"%e %ery useful in managing upper G8 leeding inclinical trials 1. ,1I 8n t&eir intra%en"us f"rm, t&ey "ften fail t" #eep t&e gastric p@ at / "r&ig&er, due t" tac&yp&yla is 1 $&e use "f t&is class "f drugs &as declined in fa%"r "fpr"t"n pump in&i it"rs

Proton #um# inhi itorsr"t"n pump in&i it"rs reduce "t& asal and stimulated acid secreti"n y in&i iting

&ydr"gen-p"tassium aden"sine trip&"sp&atase, t&e pr"t"n pump "f t&e parietal cell!ultiple studies &a%e s&" n t&at pr"t"n pump in&i it"rs raise t&e gastric p@ and #eepit &ig& 9"r e ample, an infusi"n "f "mepra "le ( ril"sec) can #eep t&e gastric p@a "%e / f"r .2 &"urs it&"ut inducing tac&yp&yla is 2+,21

St rted *ter endos o# " and"mi ed c"ntr"lled trials &a%e f"und pr"t"n pumpin&i it"rs t" e effecti%e &en gi%en in &ig& d"ses intra%en"usly f"r .2 &"urs aftersuccessful end"sc"pic treatment "f leeding ulcers it& &ig&-ris# end"sc"pic signs,suc& as acti%e leeding "r n"n leeding %isi le %essels 22,23

A meta-analysis indicated t&at t&ese drugs decrease t&e incidence "f recurrentpeptic ulcer leeding, t&e need f"r l""d transfusi"ns, t&e need f"r surgery, and t&edurati"n "f &"spitali ati"n, ut n"t t&e m"rtality rate 24 ,2* $&ese studies als" illustratet&e enefit "f f"ll" ing up end"sc"pic treatment t" st"p t&e leeding it& anintra%en"us infusi"n "f a pr"t"n pump in&i it"r

$&e rec"mmended d"se "f "mepra "le f"r patients it& &ig&-ris# findings "n

end"sc"py is an I+-mg "lus f"ll" ed y an I-mg &"ur infusi"n f"r .2 &"urs After t&epatient s c"nditi"n sta ili es, "ral t&erapy can e su stituted f"r intra%en"us t&erapy 8npatients it& l" -ris# end"sc"pic findings (a clean- ased ulcer "r flat sp"t), "ral pr"t"npump in&i it"rs in &ig& d"ses are rec"mmended

8n eit&er case, after t&e initial leeding is treated end"sc"pically and &em"stasis isac&ie%ed, a pr"t"n pump in&i it"r is rec"mmended f"r / t" I ee#s, "r l"nger if t&epatient is als" p"siti%e f"r Helicobacter pylori "r is "n daily treatment it& aspirin "r an"nster"idal anti-inflammat"ry drug (>SA8D) t&at is n"t selecti%e f"r cycl"-" ygenase 2(see el" )

St rted before endos o# , t&ese drugs reduced t&e fre?uency "f acti%elyleeding ulcers, t&e durati"n "f &"spitali ati"n, and t&e need f"r end"sc"pic t&erapy in

a rand"mi ed c"ntr"lled trial 2/ A meta-analysis f"und t&at significantly fe er patients&ad signs "f recent leeding "n end"sc"py if t&ey recei%ed a pr"t"n pump in&i it"r 24t" 4I &"urs ef"re t&e pr"cedure, ut it did n"t find any significant difference inimp"rtant clinical "utc"mes suc& as deat&, recurrent leeding, "r surgery 2.

>e%ert&eless, e elie%e t&at intra%en"us pr"t"n pump in&i it"r t&erapy s&"uld estarted ef"re end"sc"py in patients it& upper G8 leeding
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Som tost tin n o uesBctre"tide (Sand"statin), an anal"gue "f t&e &"rm"ne s"mat"statin, decreases

splanc&nic l""d fl" , decreases secreti"n "f gastric acid and pepsin, and stimulatesmucus pr"ducti"n Alt&"ug& it is eneficial in treating upper G8 leeding due t" %arices,its enefit &as n"t een c"nfirmed in patients it& n"n%ariceal upper G8 leeding

A meta-analysis re%ealed t&at "utc"mes ere etter it& &ig&-d"se intra%en"uspr"t"n pump in&i it"r t&erapy t&an it& "ctre"tide &en t&ese drugs ere started afterend"sc"pic treatment "f acute peptic ulcer leeding 2I >e%ert&eless, "ctre"tide may euseful in patients it& unc"ntr"lled n"n%ariceal leeding &" are a aiting end"sc"py,since it is relati%ely safe t" use

ALL PATIENTS NEED END/SC/PY All patients it& upper G8 leeding need an upper end"sc"pic e aminati"n t"

diagn"se and assess t&e ris# p"sed y t&e leeding lesi"n and t" treat t&e lesi"n,reducing t&e ris# "f recurrent leeding

&o; ur ent does endos o# need to e done>6nd"sc"py it&in t&e first 24 &"urs "f upper G8 leeding is c"nsidered t&e standard

"f care atients it& unc"ntr"lled "r recurrent leeding s&"uld underg" end"sc"py "nan urgent asis t" c"ntr"l t&e leeding and reduce t&e ris# "f deat&

@" e%er, &" urgently end"sc"py needs t" e d"ne is "ften de ated A multicenterrand"mi ed c"ntr"lled trial c"mpared "utc"mes in patients &" under ent end"sc"py

it&in / &"urs "f c"ming t" t&e emergency department %s it&in 24 &"urs after t&e

initial e%aluati"n $&e study f"und n" significant difference in "utc"mes et een t&et " gr"ups7 &" e%er, t&e gr"up t&at under ent end"sc"py s""ner needed fe ertransfusi"ns 2

.or etter 6ie; o* the stom hG stri 6 e impr"%es t&e %ie "f t&e gastric fundus ut &as n"t een pr"%en t"

impr"%e "utc"me 3+

Promoti it ents suc& as eryt&r"mycin and met"cl"pramide ( eglan) are als"used t" empty t&e st"mac& f"r etter %isuali ati"n 31 ' 3* 6ryt&r"mycin &as een s&" nt" impr"%e %isuali ati"n, s&"rten t&e pr"cedure time, and pre%ent t&e need f"radditi"nal end"sc"py attempts in t " rand"mi ed c"ntr"lled studies 33 ,34 9urt&erm"re, ac"st-effecti%eness study c"nfirmed t&at gi%ing intra%en"us eryt&r"mycin ef"reend"sc"py f"r acute upper G8 leeding sa%ed m"ney and resulted in an increase in?uality-ad usted life-years 3*

Endos o# to di nose eedin nd ssess ris=;pper end"sc"py is + t" * diagn"stic f"r acute upper G8 leeding 3/
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98G; 6 16nd"sc"pic stigmata "f leeding peptic ulcer (arr" s) and ris# "f recurrent leedingand deat&

9urt&erm"re, s"me "f t&e clinical sc"ring systems are ased "n end"sc"picfindings al"ng it& clinical fact"rs "n admissi"n $&ese sc"ring systems are %alua lef"r assessing patients it& n"n%ariceal upper G8 leeding, as t&ey predict t&e ris# "fdeat&, l"nger &"spital stay, surgical inter%enti"n, and recurrent leeding 3. ,3I atients

it& end"sc"pic findings ass"ciated it& &ig&er rates "f recurrent leeding and deat&(98G; 6 1 ) need aggressi%e management

Certain fact"rs, primarily clinical and end"sc"pic, predict t&at end"sc"pic treatmentill fail t" st"p ulcer leeding Clinical fact"rs include a &ist"ry "f peptic ulcer leeding

and &em"dynamic c"mpr"mise at presentati"n 6nd"sc"pic fact"rs include ulcersl"cated &ig& "n t&e lesser cur%ature "f t&e st"mac&, ulcers in t&e p"steri"r "r superi"rdu"denal ul , ulcers larger t&an 2 cm in diameter, and ulcers t&at are acti%ely

leeding at t&e time "f end"sc"py3.

Bt&er end"sc"pic findings t&at predict clinical"utc"me are summari ed in $A0L6 2atients at &ig& ris# (ie, "lder t&an /+ years, it& se%ere c"m"r idity, "r

&em"dynamically c"mpr"mised) &" &a%e acti%e leeding (ie, itnessed&ematemesis, red l""d per nas"gastric tu e, "r fres& l""d per rectum) "r an"n leeding %isi le %essel s&"uld e admitted t" a m"nit"red ed "r intensi%e careunit B ser%ati"n in a regular medical ard is appr"priate f"r &ig&-ris# patients f"und t"&a%e an ad&erent cl"t atients it& l" -ris# findings (eg, a clean ulcer ase) are at l"ris# "f recurrent leeding and may e c"nsidered f"r early &"spital disc&arge it&appr"priate "utpatient f"ll" -up

Endos o# to tre t eedin A "ut 2* "f end"sc"pic pr"cedures perf"rmed f"r upper G8 leeding include

s"me type "f treatment, 3 suc& as in ecti"ns "f epinep&rine, n"rmal saline, "rscler"sants7 t&ermal cautery7 arg"n plasma c"agulati"n7 electr"cautery7 "r applicati"n"f clips "r ands $&ey are all e?ually effecti%e, and c"m inati"ns "f t&ese t&erapiesare m"re effecti%e t&an &en t&ey are used indi%idually A recent meta-analysis f"und
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dual t&erapy t" e superi"r t" epinep&rine m"n"t&erapy in pre%enting recurrentleeding, need f"r surgery, and deat& 4+

6nd"sc"pic t&erapy is rec"mmended f"r patients f"und t" &a%e acti%e leeding "rn"n leeding %isi le l""d %essels, as "utc"mes are etter it& end"sc"pic &em"statictreatment t&an it& drug t&erapy al"ne

ALL PATIENTS S&/ULD 'E AD-ITTED All patients it& upper G8 leeding s&"uld e admitted t" t&e &"spital, it& t&e le%el

"f care dictated y t&e se%erity "f t&eir clinical c"nditi"n

TREAT-ENT AND PRE2ENTI/N /. NSAID$RELATED GI IN1URY A "ut 1 in 2+ users "f >SA8Ds de%el"p G8 c"mplicati"ns and ulcers "f %arying

degrees "f se%erity, as d" "ne in se%en >SA8D users "%er t&e age "f /* 8n fact,>SA8D use acc"unts f"r 3+ "f &"spitali ati"ns f"r upper G8 leeding and deat&s fr"mt&is cause I2 ' I* 8n additi"n, appr" imately 1* t" 3+ "f >SA8D users &a%e clinicallysilent ut end"sc"pically e%ident peptic ulcers I/

>SA8Ds c"ntri ute t" ulcer de%el"pment y depleting pr"staglandins $&us,mis"pr"st"l (Cyt"tec), a synt&etic pr"staglandin, &as een used t" reduce t&is sideeffect
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'" -odu e t s=

5" -ention the de*inition o* d s#e#si3" -ention the uses o* d s#e#si?" -ention the red * s in d s#e#si@" 0h t is the de*inition o* stritis

" 0h t is the di**eren e et;een erosi6e nd non erosi6e stritis9" 0h t is Bo in er E ison s ndrome7" -ention the de*inition o* #e#ti u ers

" 0h t is the etio o o* #e#ti u ers" 0h t is the om# i tion o* se6ere #e#ti u ers

54" &o; to tre t se6ere sho = due to m ssi6e u##er GI eedin due to #e#tiu ers

-


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C" Re*eren es nd su ested *urther re din

@arris"n s $e t ""# "f 8nternal !edicine!erc# manual

&ysical Diagn"sticDiagn"sis 9isi# ada Ana#Guyt"n $e t ""# "f &ysi"l"gy

Atlas Anat"my

Syndr"mat"l"gy 5V

0u#u A ar 8lmu enya#it dalam, 2++.

Modul Gastritis_edit Terbaru

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