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Erect radiographic image of esophagus (lower portion), stomach and first part of duodenum after ingestion of contrast medium
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Topography and internal surface of a stomach(blue line represent notional lines marking the parts of the stomach)
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THE PARIETAL CELLS – acid secretion THE CHIEF CELLS – pepsinogen secretion
THE ENDOCRINE CELLS:◦The G-cells – gastrin secretion◦The D-cells – somatostatin secretion◦The ECL-cells – histamine production
THE MUCOUS NECK CELLS – mucus secretion
Cells
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Primary chronic recurrent disease of upper
gastrointestinal tract associated with
circumscribed ulcers within stomach and duodenum
Peptic ulcer disease
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is disruption of the mucosal integrity of the stomach and/or
duodenum leading to a local defect or excavation due to active
inflammation
Ulcer
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A break in the mucosa not penetrating muscularis mucosa
Peristalsis is not affected Heals rapidly
Erosion
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Healthy subjects 20-50% Chronic active gastritis 100% Duodenal ulcer >90% Gastric ulcer 50 - 80%
Gastric adenocarcinoma 90% Gastric lymphoma 85%
H.pylori in GI diseases
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Heredity
Emotional stress
Blood group
Predisposing
factors
Active duodenitis or gastritis
Gastric metaplasia
Producing factors
Factors
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Any area where pepsin and acid are present
Prevailing locations◦ Duodenum: duodenal bulb◦ Stomach: over lesser curvature
Locations of ulcers
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I type – ulcers of lesser curvature of stomach
II type – combined ulcers of stomach and duodenum
III type – ulcers of prepyloric part stomach IV type – ulcers of duodenum
Johnson’s classification (according to site, clinical manifestations)
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Mild
Exacerbations 1 time/year
Easily treated
Few symptoms
Medium-severe
Exacerbations 2-3 times/year
Treated by full course therapy
Severe
Frequent exacerbations
Absence of stable remission
Evident clinical manifestation
Forms(according to severity)
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Clinical features
•Gastric ulcer: in the centre of or left to epigastrium•Duodenal ulcer: to the right of midline in epigastruimLOCATION•Early: 0.5-1 h after meal, duration 1.5-2 hh, in gastric ulcers•Late: 1.5-2 hh after meal, in duodenal and pyloric ulcers•Nocturnal•Pain of “hunger”: 6-7 hh after meal and ceased after mealTIME•Burning •Gnawing•Dull •Cramplike
CHARACTER
•Cardiac area•Left scapula•Thoracic part of spinal column•Lumbar region
IRRADIATION
•Antacids•Milk•Meal•After vomiting
PAIN RELIEF
PAIN
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Clinical features
•Related with gastroesophageal reflux•After mealHEARTBURN
•More common in gastric ulcersBELCHING
•At the peak of pain•More common in gastric ulcers•Pain relief after vomiting
NAUSEA & VOMITING
•Excessive APPETITE
DYSPEPSIA
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Clinical examination Vegetative dystonia: cold, damp palms,
mottled skin, bradycardia, hypotension Palpation: tenderness Percussion: Mendel’s symptom,
succussion splash (gastric outlet obstruction)
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Non-complicated PUD – service of 1st category Complicated PUD – service of 2nd category Services of 3.1 category:
◦ Professional examination◦ Interpretation of clinical and biochemical tests◦ CBC◦ Gastric lavage◦ Diet prescription
Services of 3.2 category:◦ Analysis of gastric juice and duodenal contents◦ Ultrasound◦ Endoscopy◦ Radiologic examination◦ Biopsy
Services of 4 category:◦ Rational nutrition◦ Struggle with harmful habits◦ Personal hygiene
GP in Uzbekistan
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CBC•↑Hb•↑Erythrocyte
Secretory function of stomach
•↑BAO (N=5 mmol/h)•↑MAO (N=18-26 mmol/h)
Occult blood feces analysis
•Latent PUD•Exacerbation•Stomach cancer
Endoscopy
•Round or oval•Edges: sharp, hyperemic, edematous
X-ray(Barium meal)
•Niche sign•Retention of barium meal•Duodenogastric reflux•Fold convergence•Local spasm of stomach
Laboratory and instrumental examination
*BAO – basal acid output*MAO – maximal acid output •Biopsy
•Test with Insulin•Test with Histamine•pH meter•Gastrin concentration in serum
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Invasive( through endoscopy)◦ Gastric biopsy and staining◦ Culture of biopsy specimen◦ Tests using urease enzyme in biopsy specimens
Non-invasive:◦ Urea breath test◦ H.pylori antibodies◦ Stool antigen◦ Salivary antigen
Diagnosis of Helicobacter pylori infection
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Haemorrhage Perforation Penetration (pancreas, liver) Pyloric stenosis (due to scarring) Malignization
Complications
20%
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I STAGE
Actively bleeding ulcer
II STAGE
Signs of stopped fresh
haemorrhage
Thrombosed vessels at the
bottom of ulcer
Clot of blood
III STAGE
Absence of bleeding
apparent signs
Stages of bleeding by Forrest(endoscopy)
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Neoplasm of the stomach Pancreatitis Pancreatic cancer Diverticulitis Nonulcer dyspepsia (also called functional dyspepsia)
Cholecystitis Gastritis MI—not to be missed if having chest pain
Differential Diagnosis
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Diet №1: white stale bread, vegetable soups, softly boiled porridge, potato mash, fish, birds, mature fruits, berry and fruit juices, cottage cheese, milk, omelette, pudding
Banned: spicy foods, marinated and smoked products
Frequent small meals: 6-7 times a day
Treatment – Medical nutrition
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H.pylori supressors: De-nol, Metronidazole, Furazolidone, Oxacillin, Amoxycillin
Antisecretory drugs• M-anticholinergic drugs:• Nonselective: Atropine, Platyphyllin, Methacin• Selective: Gastrozepine, Pirenzepine
• H2-histamine receptor blockers: Cimetidine, Ranitidine, Famotidine
• Proton pomp inhibitors: Omeprazole, Lansoprazole, Rabeprazole
• Antagonists of gastrin receptors: Milid, Proglumide• Antacids: Magnesium hydroxide, Aluminum
hydroxide, Almagel, Maalox
Treatment - Drugs
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Gastrocytoprotectors• Cytoprotectors that stimulate mucus production:
Carbenoxolone, synthetic prostaglandins (Enprostile, Misoprostole)
• Cytoprotectors that form protective film: Sucralfate, colloid bismuth (De-nol), Smecta
• Astringents: Vicaline, Vicair Drugs that normalize motor function of
stomach and duodenum (Metoclopramide), spasmolytics (Papaverine, No-spa)
Treatment - Drugs
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H2-blockers: gynecomastia, impotence
Aluminum hydroxide: constipation
Magnesium hydroxide: diarrhea
Side effects of drugs
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De-nol1 tablet 3 times/day, 4-6 weeks
Clarythromycin250 mg, 2 times/day, 7-10 days
Metronidazole250 mg, 4 times/day, 14 days
Therapy regimensMONOTHERAPY
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De-nol [4-6 weeks] + Metronidazole [10-14 days]
De-nol [4-6 weeks] + Tetracyclin OR Amoxycillin [10 days]
Amoxycillin OR Clarythromycin [7-
10 days] + Omeprazole [40 mg, 4-6 weeks]
Therapy regimensDOUBLE THERAPY
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De-nol [4-6 weeks] + Metronidazole [10-14 days]
Tetracyclin [7-10 days]
Omeprazole + Amoxycillin OR Clarythromycin +Metronidazole
Metronidazole [10-14 days] +
Amoxycillin [10 days] + Ranitidine [150 mg, 10-14 days]
Therapy regimensTRIPLE THERAPY
A week
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Omeprazole + De-nol+
Amoxycillin OR Clarythromycin +Metronidazole
Therapy regimensQUADRUPLE THERAPY
10 days
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PRIMARY •Revelation and elimination of risk factors•Sanitary and prophylactic measures
SECONDARY •Early diagnosis and timely treatment•Screening, professional examination, questionnarires
TERTIARY •Prevention of complications
Prophylaxy