Pathoogy | Chapter 
Chronic gastritis
Definition:
Chronic inflammation of gastric mucosa.
Etiology:
‫؟‬gastrojejunostomy ‫ﺳﻤﻌﺘﻮ ﻋﻦ ﺣﺎﺟﻪ اﺳﻤﻬﺎ‬
‫ ﻟﻮ واﺣﺪ ﻋﻨﺪه‬،jejunum ‫ ﺑﺎل‬stomach ‫ ﻳﻌﻨﻰ ﺗﻮﺻﻴﻞ ال‬gastrojejunostomy
‫ ﻫ�ﺟﻊ ﻟﻞ‬bile ‫ ﻛﺪه ال‬،gastrojejunostomy ‫ ﺑﻨﻌﻤﻠﻪ‬cancer pancreas
.�‫ ﻣﺒﺘﺤﺼﻠﺶ وﻣﺶ ﺑﻨﺸﻮﻓﻬﺎ ﻛﺘ‬،active ‫ ﻫﻴﺘﺤﻮل ﻟـ‬inactive ‫و اﻟـ‬stomach
.sphincter ‫ ﺑﻨﺸﻮﻓﻬﺎ ﻟﻮ ﻓﻴﻪ ﻣﺸﻜﻠﻪ ﻓﺎل‬gastrojejunostomy ‫ﻓﺎل‬
،H. Pylori ‫ ﺑﺎﻝ‬chronic infection ‫ اﺷﻬﺮ ﺳﺒﺐ ﻟﻴﻬﺎ ال‬chronic gastritis ‫ال‬
reflux ‫ ﻋﺎده ﻣﺶ ﺑﺖ‬bile ‫ ال‬،bile reflux ‫ ﳌﺎ ﻳﺤﺼﻞ‬chemical irritation ‫ﻳﻠﻴﻬﺎ ال‬
congenital ‫ واﻛﺮﺘ ﻓﻰ ﺣﺎﻻت‬gastrojejunostomy ‫اﻣﺘﻰ ﻳﺤﺼﻞ اﻟﻜﻼم ده؟‬
.hypertrophic pyloric stenosis
:drugs ‫ﺑﻌﺪ ﻛﺪه‬
‫؟؟‬drugs ‫اﻳﻪ ال‬
.chronic ‫ اﻰﻟ ﺑﻴﺘﺎﺧﺪوا ﺑﺸﻜﻞ‬nonsteroidal ‫ وال‬steroidal ‫ال‬
‫اﻳﻪ ﻛﻤﺎن ؟‬
:S ‫ ﻧﺎﺧﺪﻫﻢ ﻛﻠﻬﻢ ﺑﺎل‬،irritation ‫ﺑﻌﺪ ﻛﺪه‬
.spirits ‫ وال‬smoking ‫ وال‬spicy food ‫ ال‬S ‫اول‬
.‫؟! ﻷ‬stomach ‫ ﺑﻴﺠﻰ ﻓﺎل‬syphilis ‫ ﻫﻮ ﻓﻴﻪ‬،‫؟؟؟ ﻫﺎ!!! ﻻ ﻃﺒﻌﺎ‬syphilis ‫وال‬
‫؟ ﻷ ﻃﺒﻌﺎ‬sharp tooth‫اﻳﻪ راﻳﻜﻢ ﻓﺎﻟـ‬
‫ ﺑﺲ ﻋﻨﺪﻧﺎ ﻓﺎﻟﺒﺎﺛﻮﻟﻮﺟﻰ‬،less common ‫ ﻓﻴﻪ أﺳﺒﺎب ﺗﺎﻧﻴﻪ ﺑﺲ‬،‫ﻫﻤﺎ دول اﻫﻢ اﻻﺳﺒﺎب‬
‫ ﻳﻀﺮﺑﻠﻨﺎ ال‬autoantibodies ‫؟ ده ﻓﻴﻪ‬pernicious anemia ‫ﺧﺪﺗﻮا ﺣﺎﺟﻪ اﺳﻤﻬﺎ‬
�‫ اﻟ‬intrinsic factor ‫؟ ﻻ ﻳﻀﺮﺑﻠﻨﺎ ال‬parietal cells ‫؟ﻳﻀﺮﺑﻠﻨﺎ ال‬parietal cells
Flash Notes in Pathoogy | From chronic gastritis to dysentery
‫ ده ﻳﻌﻤﻠﻨﺎ‬،pernicious anemia ‫ ﻓﺎﻟﻌﻴﺎن ﻳﺒﻘﻲ ﻋﻨﺪه‬،parietal cells ‫ﻃﺎﻟﻊ ﻣﻦ ال‬
.chronic gastritis
:granulomatous ‫ﺗﺎ� ﺣﺎﺟﻪ ال‬
،‫؟ ﻻ‬stomach TB ‫ ﻳﻨﻔﻊ ﻳﻴﺠﻰ ﻓﺎل‬،GIT ‫ اﻟ� ﻳﻨﻔﻊ ﺗﻴﺠﻰ ﻓﺎل‬granulomatous ‫ال‬
granuloma of �‫ ﻏ‬stomach ‫ ﻣﻴﺠﻴﺶ ﻓﺎل‬،‫؟ ﻻ‬foreign body ‫ﻃﺐ ﻳﻨﻔﻊ ﻳﻴﺠﻰ‬
.crohn disease ‫ اﻰﻟ ﻫﻰ اﺳﻤﻬﺎ‬unknown origin
.acidity ‫؟ﻋﺸﺎن ال‬stomach TB ‫ﻟﻴﻪ ﻣﻴﺠﻴﺶ ﻓﺎل‬
.‫ﺑﺲ‬H. pylori ‫ﻳﺒﻘﻲ ﺳﺒﺒﻬﺎ‬chronic gastritis ‫ ﻋﻤﻠﺖ‬bacterial infection ‫ﻟﻮ ﻓﻴﻪ‬
:radiation ‫ ﺟﺪا ﺍﻟـ‬rare ‫اﺧﺮ ﺣﺎﺟﻪ وده‬
amyloidosis ‫ وﻟﻮ اﻧﺴﺎن ﻋﻨﺪه‬،endarteritis obliterans ‫ﺑﻴﻌﻤﻞ‬radiation ‫ﻻن ال‬
‫اﻰﻟ‬blood supply ‫ وﻓﻰ ده او ﻓﻰ ده ﻛﻤﻴﻪ ال‬wall of BVs ‫ ﻳﺮﺘﺳﺐ ﻓﺎل‬amyloid ‫ال‬
‫ ﻃﺐ ﻫﻮ ال‬،‫ﻋﺎﻟﻴﻪ وﻻ واﻃﻴﻪ ؟ﻋﺎﻟﻴﻪ وﻻ واﻃﻴﻪ ؟واﻃﻴﻪ ﺟﺪا‬stomach ‫واﺻﻠﻪ ﻟﻞ‬
‫ ﻋﺎوزاه ﻋﺸﺎن ﺗﻌﻤﻞ‬،secretion ‫ﻋﺎوزه دم ﻋﺸﺎن ﺗﻌﻤﻞ اﻳﻪ ؟ﻻ ﻣﺶ ﻋﺸﺎن ال‬stomach
chronic ‫ ﻳﺤﺼﻞ‬mucus & bicarbonate ‫ ﻓﻠﻮ ﻣﻔﻴﺶ‬،mucus & bicarbonate
.inflammation
‫؟‬chronic gastritis ‫ اﻳﻪ اﺷﻬﺮ ﺳﺒﺐ ل‬،to summarize
infection by H. pylori ‫ال‬
‫ﻣﻔﻬﻮم ؟‬chemical irritation ‫؟‬acute gastritis ‫ﻃﺐ اﻳﻪ اﺷﻬﺮ ﺳﺒﺐ ل‬
Pathogenesis
:‫وﻋﺎﻳﺰﻛﻢ ﺗﺮﻛﺰوا ﻓﻴﻬﺎ ﻻﻧﻬﺎ ﺳﻄﻤﺒﺔ ﻫﻜﺮرﻫﺎ ﻛﺬا ﻣﺮه‬
‫؟‬chronic gastritis ‫ﻫﻮ اﻳﻪ اﺷﻬﺮ ﺳﺒﺐ ل‬
.H. pylori ‫ال‬
‫ ﻻن اﺣﻨﺎ ﻛﻨﺎ‬،‫ ﺟﻪ واﺣﺪ ﺳﻮ�ﺪى اﺧﺪ ﺟﺎﻳﺰه ﻧﻮﺑﻞ ﻻﻧﻪ ﺷﺮﺣﻠﻬﻢ ﻫﺬا اﳌﻴﻜﺎﻧﻴﺰم‬2008 ‫ف‬
H. pylori ‫ ﻫﻮ ال‬peptic ulcer‫ و‬chronic gastritis ‫ﺑﻨﻘﻮل زﻣﺎن اﺷﻬﺮ ﺳﺒﺐ ﻳﻌﻤﻞ‬
‫ ﺟﻪ‬،predisposing factor ‫ ﻛﻨﺎ ﺑﻨﻘﻮل اﻧﻬﺎ‬،exact etiology ‫وﻟﻜﻦ ﻣﻜﻨﺎش ﺑﻨﻘﻮل ال‬
‫ﻣﻦ ﻏ� ال‬chronic gastritis ‫ او‬peptic ulcer ‫اﻟﺮاﺟﻞ ده وﻗﺎل ﻣﻔﻴﺶ ﺣﺎﺟﻪ اﺳﻤﻬﺎ‬
.‫ وﺑﺎﻟﺘﺎﻰﻟ اﺳﺘﺤﻖ ﺟﺎﻳﺰه ﻧﻮﺑﻞ‬H. pylori
‫ﻟﻮ ﺣﺪ‬،H. pylori ‫اﻰﻟ ﺑﺘﻌﻤﻠﻪ ال‬pathogenesis ‫ ال‬،‫ﺑﺼﻮا ﻣﻌﺎﻳﺎ ﻋ� ﻫﺬا اﻟﻔﻴﺪﻳﻮ‬
‫؟ ﺷﺎﻳﻔ� اﻟﺒﻜﺘ��ﺎ‬lumen ‫ ﺣﺪ ﺷﺎﻳﻒ ال‬،lumen ‫ﺷﺎﻳﻒ ﻣﻌﺎﻧﺎ ﻳﺎ دﻛﺎﺗﺮه ﻫﻨﺎ ﻧﺎﺣﻴﻪ ال‬
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‫‪Flash Notes in Pathoogy | From chronic gastritis to dysentery‬‬
‫اﻟﺤﻠﺰوﻧﻴﻪ دى؟ ﻻﻧﻪ اﺳﻤﻬﺎ ‪ pylori‬ﻳﻌﻨﻰ ‪ pylorus‬و ‪ helicobacter‬ﻳﻌﻨﻰ ﺣﻠﺰوﻧﻴﻪ‪،‬‬
‫ﻫﺬه ال ‪ H. pylori‬ﺑﺘﻌﻴﺶ ﻓ� ؟ﺑﺘﻌﻴﺶ ﻋﺎﻟـ ‪ ،surface of gastric glands‬ﻳﻌﻨﻰ ﻋ�‬
‫ال ‪ gastric glands‬ﻧﺎﺣﻴﻪ ال ‪ surface‬ﻟﻴﻬﺎ‪ ،‬ﻓﺸﻜﻠﻬﺎ ﻳﻤﻜﻦ ﻣﻴﺒﻘﺎش واﺿﺢ ﻓﻠﻴﻬﺎ‬
‫‪ ،special stain‬ال ‪ special stain‬ﻫﺮﺟﻌﻠﻬﺎ‪ ،‬ﺣﺪ ﺷﺎﻳﻒ ﻫﻨﺎ ﺣﺎﺟﺎت ﻣﻠﻮﻧﻪ ؟ ال ‪stain‬‬
‫دى اﺳﻤﻬﺎ ‪ Giemsa stain‬اﺳﻤﻬﺎ اﻳﻪ ؟‪.Giemsa stain‬‬
‫ال ‪H. pylori‬ﺑﺘﺒﻘﻲ ﻣﻮﺟﻮده ﻋ� ال ‪mucosal glands‬ﻋﻨﺪ ال ‪ surface‬وﻟﻬﺎ ‪special‬‬
‫‪ ،stain‬ﻫﻰ ال ‪.Giemsa stain‬‬
‫ﳌﺎ ﻧﻴﺠﻰ ﻧﺮﺟﻊ ﺗﺎ� ﻟﻠﻔﻴﺪﻳﻮ‪ ،‬ﻫﻰ اﺳﻤﻬﺎ ‪ H‬اﻳﻪ ؟‬
‫اﻧﺎ ﻫﺴﺘﺨﺪم ﺑﻌﺾ اﳌﺮادﻓﺎت اﻰﻟ اﺳﺘﺨﺪﻣﻬﺎ اﻟﺮاﺟﻞ اﻟ� اﺧﺪ ﺟﺎﻳﺰه ﻧﻮﺑﻞ‪ ،‬اﺳﻤﻬﺎ ‪ H‬اﻳﻪ؟ ‪H.‬‬
‫‪ pylori‬ﻳﻌﻨﻰ ﺑﺘﻌﻴﺶ ﻓ�؟ ﺑﺎل ‪ ،pylorus‬ﻫﻮ ﻛﺎن ﻋﺎوز ﻳﻌﺮف ازاى ﺑﺘﻌﻤﻞ ﻣﺸﺎﻛﻞ ﻓﺎل‬
‫‪.stomach‬‬
‫ﻫﻰ اﺳﻤﻬﺎ ‪H‬اﻳﻪ ؟ ‪ ،pylori‬وال ‪ pylorus‬دى ﺣﺘﻪ ﻓ�؟‬
‫ﻓﺎل ‪ ،stomach‬وال ‪acid‬ﺟﻮا ال ‪ stomach‬اﺧﺒﺎره اﻳﻪ ؟ﻋﺎﻰﻟ‪ ،‬ﺑﻴﺒﻘﻰ ‪one hundred‬‬
‫‪ times‬اﻛﺮﺘ ﻣﻦ اﻟ� ﻣﻮﺟﻮده ﻓﺎل ‪.blood‬‬
‫ﻃﻴﺐ ﻳﻨﻔﻊ ﺗﻌﻴﺶ ﺑﻜﺘﻴﺮﻳﺎ ﻓﻰ ﻫﺬﺍ ﺍﻟﻮﺳﻂ ﺍﻟﺤﺎﻣﻀﻰ ﻣﻦ ﻏﻴﺮ ‪protective‬‬
‫‪mechanism‬ﻟﻬﺎ ؟‬
‫ﻻ‪ number 1 ،‬اﻫﻢ ﺣﺎﺟﻪ ال ‪ H. pylori‬ﺑﺖ ‪ secrete‬ﺣﺎﺟﻪ اﺳﻤﻬﺎ ‪ ،urease‬اﺳﻤﻬﺎ‬
‫اﻳﻪ ؟ ‪.urease‬‬
‫ﻣﻦ اﺳﻤﻬﺎ ﻫﺘﺸﺘﻐﻞ ﻋ� اﻳﻪ ؟ ﻋ� ال ‪ ،urea‬وﻫﺘﺤﻮﻟﻬﺎ ﻻﻳﻪ ؟ ل ‪ ،ammonia‬ال‬
‫‪ ammonia‬دى ‪ alkaline PH‬وﻻ ‪acidic‬؟ ‪،alkaline‬ﻓﻌﻤﻠﺖ ‪ capsule‬ﺣﻮاﻟ�‬
‫اﻟﺒﻜﺘ��ﺎ ﻓﺤﻤﺘﻬﺎ‪ ،‬ﺑﺲ ﻫﻰ ﻟﻬﺎ ‪toxic effect‬ﻋ� ال ‪ ،stomach cells‬ﻓﺘﻌﻤﻞ اﻳﻪ‬
‫؟‪ ،stomach peptic ulcer‬وﺗﻌﻤﻞ‪chronic gastritis‬‬
‫اﻋﻴﺪ ﺗﺎ�‪ ،‬اول ﺣﺎﺟﻪ ﺑﺘﻄﻠﻌﻬﺎ ال ‪H. pylori‬ﻫﻰ ال ‪ urease‬اﻰﻟ ﺑﻴﺸﺘﻐﻞ ﻋ� ال ‪urea‬‬
‫ﻳﺤﻮﻟﻬﺎ اﻰﻟ ‪ ،ammonia‬ال ‪ ammonia alkaline‬ﻓﺒﺘﺒﻘﻰ ‪protective‬ﻟﻠﺒﻜﺘ��ﺎ ﻟﻜﻨﻬﺎ‬
‫‪toxic‬ﻟﻠﻤﻌﺪه وﺗﻌﻤﻞ ‪ chronic gastritis‬وﺑﻌﺪ ﻛﺪه ‪ peptic ulcer‬ﻻن دى ﻟﻴﻬﺎ‬
‫‪.toxic effect‬‬
‫‪:number2‬‬
‫اﻟﺒﻜﺘ��ﺎ دى ﺑﺘﻄﻠﻊ اﻧﺰ�ﻤﺎت ﻛﺘﻴ�ه اوى اﺣﻨﺎ ﻫﻨﺨﺘﺼﺮﻫﺎ وﻧﺴﻤﻴﻬﺎ ‪ ،proteases‬ﻣﻦ اﺳﻤﻬﺎ‬
‫ﺗﻜﺴﺮ ﻣ� ؟اﻟﺮﺒوﺗ�‪ ،‬ﻣ� اﻫﻢ ﺑﺮوﺗ� ﻓﺎل ‪stomach‬؟ ﻻ ﻣﺶ اﻟﺒﺒﺴ� ده ﺑﻴﻜﺴﺮ اﻟﺮﺒوﺗ�‬
‫اﺻﻼ‪ ،‬اﻫﻢ ﺑﺮوﺗ� ﻓﺎﳌﻌﺪه ال ‪ ،mucous layer‬وﺻﻠﺖ ؟ ﻳﻜﺴﺮ ال ‪،mucous layer‬ﻓﻴﻪ‬
‫ﺣﺎﺟﻪ ﺗﺤﻤﻰ ال ‪stomach‬ﻣﻦ ‪ HCl‬ﺑﺘﺎﻋﻬﺎ ؟ﻻ‪ ،‬ﻓﻴﺤﺼﻞ & ‪chronic gastritis‬‬
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‫‪Flash Notes in Pathoogy | From chronic gastritis to dysentery‬‬
‫‪gastric peptic ulcer.‬‬
‫ﻟﺤﺪ ﺩﻟﻮﻗﺘﻰ ﺍﻝ ‪H. pylori‬ﻋﺎﻣﻠﻪ ‪chronic gastritis &chronic peptic‬‬
‫‪ulcer‬ﺑﻜﺎﻡ ﻣﻴﻜﺎﻧﻴﺰﻡ؟‬
‫‪.2‬‬
‫* ال ‪ ammonia‬اﻟ� ﻃﺎﻟﻌﻪ ﻣﻦ ‪.urease‬‬
‫* وﺗﻜﺴ� ال ‪ mucous bicarbonate‬اﻟ� ﻫﻮ اﻟﺮﺒوﺗ� ﺑﺴﺒﺐ ال ‪.protease‬‬
‫* ﺣﺎﺟﻪ ﻛﻤﺎن‪ ،‬ﻫﻰ اﻟﺒﻜﺘ��ﺎ ﻋﺎﻳﺸﻪ ﻓﺎل ‪ stomach‬ﺑﺸﻜﻞ ‪ acute‬وﻻ‬
‫‪chronic‬؟ ‪ ،chronic‬ﻓﻤﻊ ال ‪ chronicity‬ﻳﺤﺼﻞ ‪ ،endarteritis obliterans‬ﻓﻬﻞ‬
‫ﻓﻴﻪ ‪healing‬؟ ﻻ‪ ،‬ﻳﺒﻘﻲ ﻳﺤﺼﻞ ‪ chronic destruction‬ﺑﻔﻌﻞ ﻛﺎم ﻃﺮ�ﻘﻪ ؟‪ : 3‬ال‬
‫‪proteases, urease, chronicity‬‬
‫ﺍﺧﺮ ﻣﻴﻜﺎﻧﻴﺰﻡ ﻭﻫﻰ ﺍﻟﻠﻰ ﺍﺧﺪ ﻋﻠﻴﻬﺎ ﺟﺎﻳﺰﻩ ﻧﻮﺑﻞ‪:‬‬
‫ﻣﺸﺮوح ﻋﻨﺪﻛﻢ ﺑﺸﻜﻞ واﺿﺢ‪ ،‬ﻫﺬه اﻟﺒﻜﺘ��ﺎ اﺳﻤﻬﺎ اﻳﻪ ؟ ‪ ،H. pylori‬ﻳﻌﻨﻰ ﻋﺎﻳﺸﻪ ﻓ� ؟‬
‫ﻲﻓ ال ‪ ،pylorus‬ودى ﺟﺰء ﻣﻦ اﻳﻪ ؟ اﳌﻌﺪه‪ ،‬وﻋﺸﺎن ﺗﺤﻤﻰ ﻧﻔﺴﻬﺎ ﻣﻦ اﻟﺤﻤﻮﺿﻪ اﻟ� ﺟﻮا‬
‫ﺗﻌﻤﻞ اﻳﻪ ؟ ‪.ammonia‬‬
‫ﻫﻮ ‪mainly‬ﻣ� ﺑﻴﻘﻴﺲ ال ‪ PH‬ﺟﻮا ال ‪stomach‬؟ ‪،receptors‬‬
‫ال ‪ chemoreceptors‬اﻟ� ﻣﻮﺟﻮده ﻓﺎل ‪ pylorus‬اﻟ� ﻣ� ﻗﺎﻋﺪ ﻋﻠﻴﻬﺎ ؟ ال اﻟ�‬
‫ﺣﻮاﻟﻴﻬﺎ ‪ ،ammonia‬ﻓﺒﺎﻟﺘﺎﻰﻟ دى ﺣﺎﺟﻪ ‪ alkaline‬ﻗﺎﻋﺪه ﻋ� ﻣﻘﻴﺎس ال‪ PH‬ﻓﺒﺘﻘﻴﺴﻬﺎ‬
‫‪ ،alkaline‬ﳌﺎ ﺗﻘﻴﺴﻬﺎ ‪ alkaline‬ﺗﻌﻤﻞ اﻳﻪ ؟ ﺗﺰود ﻛﻤﻴﻪ ال ‪ gastrin‬ﻓﻴﻄﻠﻊ ‪more HCl‬‬
‫‪ ،‬ال ‪ more HCl‬ﻣﺒﻴﺎﺛﺮش ﻋ� ال ‪ stomach‬ﻻن ‪ already‬رﺑﻨﺎ ﺧﺎﻟﻘﻬﺎ ﻋﺸﺎن ﺗﺴﺘﺤﻤﻞ‬
‫ال ‪.HCL‬‬
‫ﻟﻜﻦ اول ﻣﺎﻳﻮﺻﻞ ال ‪ duodenum‬ﻫﻞ ﻫﺘﺘﺤﻤﻞ ‪HCL‬ﻋﺎﻰﻟ ؟ ﻻ‪ ،‬ﻓﺘﻌﻤ� ‪duodenal‬‬
‫‪ ،peptic ulcer‬ال ‪ duodenal peptic ulcer‬ﺑﺎل ‪.H. pylori‬‬
‫اﺳﻤﻬﺎ ‪ H. Pylori‬ﻳﻌﻨﻰ ‪ pylorus‬وﻣﻊ ذﻟﻚ ﻫﻞ ﺗﻌﻤﻠﻨﺎ ‪duodenal peptic ulcer‬؟‬
‫اه ازاى ؟ ‪ ،secondary to hyperacidity‬ازاى ﺑﻴﻌﻤﻞ ‪hyperacidity‬؟‬
‫اﻧﺎ ﺑﻌﻴﺪ اﻟﻜﻼم ﻋﺸﺎن ﺗﻔﻬﻤﻮا؛ ﻻﻧﻬﺎ ﺑﺘﺨﺪع ال ‪ chemoreceptors‬ﺑﺘﺎﻋﺔ ال ‪stomach‬‬
‫اﳌﺆﻟﻒ ﻛﺎﺗﺒﻬﺎ ﻓﻰ اﻟﻜﺘﺎب ﺑﺲ ﺑﺸﻜﻞ ﻣﺶ واﺿﺢ‪.‬‬
‫ﺑﻌﺪ ﺷﻮ�ﻪ ﻓﻰ اﻟﻜﺘﺎب اﻧﻪ ال ‪parietal cells‬ﺑﻘﺖ ‪ ،less sensitive to gastrin‬ﻳﻌﻨﻰ‬
‫اﻳﻪ ؟ﻫﻢ ﻗﺎﻳﻠ� زﻣﺎن اﳌﻴﻜﺎﻧﻴﺰم ده ﻗﺒﻞ ﺟﺎﻳﺰه ﻧﻮﺑﻞ‪ ،‬ده ﻣﻴﻜﺎﻧﻴﺰم ﻣﻌﺮوف‪ ،‬ﺑﺲ اﻣﺎ ﻳﻴﺠﻮا‬
‫ﻳﻘﻴﺴﻮا ﻓﻰ اﻟﻌﻴﺎﻧ� ﻧﺴﺒﻪ ال ‪ gastrin‬ﻳﻼﻗﻮﻫﺎ ﻋﺎﻟﻴﻪ وﻻ واﻃﻴﻪ؟ ﻋﺎﻟﻴﻪ اه‪ ،‬ﻓﻬﻮ ﻛﺎن زﻣﺎن‬
‫ﻳﻘﻮﻟﻚ ال ‪ gastrin‬ﻧﺴﺒﺘﻪ ﻋﺎﻟﻴﻪ ﻳﺒﻘﻲ اﻛﻴﺪ ﻓﻴﻪ ﺣﺎﺟﻪ ﻓﻰ ال ‪parietal cells‬ﻣﺨﻠﻴﺎﻫﺎ‬
‫ﻣﺘﺴﺘﺠﻴﺒﺶ ﻟﻴﻪ ﻋﺸﺎن ﻛﺪه ﻧﺴﺒﺘﻪ ﻋﺎﻟﻴﻪ‪.‬‬
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‫‪Flash Notes in Pathoogy | From chronic gastritis to dysentery‬‬
‫ﻫﻮ ﺻﺢ وﻟﻜﻦ ﻟﻴﻪ ال ‪gastrin‬زاد ؟ﻋﺸﺎن ﻗﺼﺔ ال ‪ chemoreceptors‬ﻓﺎﻫﻤ� اﻟﻜﻼم ؟‬
‫‪To summarize:‬‬
‫ال ‪ chronic gastritis‬او ال ‪ chronic peptic ulcer‬ﺗﺘﻌﻤﻞ ازاى ﺑﺎل ‪H. pylori‬‬
‫؟ﺑﻜﺎم ﻣﻴﻜﺎﻧﻴﺰم ؟ ﺗﻼﺗﺔ‪.‬‬
‫ﻫﻞ ﻛﺎن ﻓﻴﻬﻢ ‪hyperacidity‬؟ ﻻ؛ ﻻن ﻓﺎل ‪ stomach‬ده اﻟ� ﻛﺎن ﻣﺠﻨﻨﻬﻢ ﻟﻜﻦ ﻓﺎل‬
‫‪ duodenal peptic ulcer‬ﻛﺎن ﻻزم ﻳﺒﻘﻲ ﻣﻌﺎﻫﺎ ‪hyperacidity‬؛ ﻻن رﺑﻨﺎ ﻣﺨﻠﻘﺶ ال‬
‫‪duodenum‬ﺗﺴﺘﺤﻤﻞ اﻟﺤﻤﺾ ﻟﻜﻨﻪ ﺧﻠﻖ ال ‪ stomach‬ﺗﺘﺤﻤﻠﻪ‪.‬‬
‫ﻳﺒﻘﻲ ﺍﻝ ‪ peptic ulcer‬ﻓﻰ ﺍﻝ ‪stomach‬ﻋﻴﺐ ﺣﺎﻣﺾ؟‬
‫ﻻ ال ‪H. pylori‬ﺑﺘﺎذى ال ‪stomach‬ﺑﻜﺎم ﻣﻴﻜﺎﻧﻴﺰم ؟ ‪:3‬‬
‫* ﺑﺘﻄﻠﻊ ‪ ،urease‬اﻻﻣﻮﻧﻴﺎ ﺗﻔﻴﺪ ال ‪ organism‬وده ﻣﻴﻬﻤﻨﺎش‪ ،‬اﻟ� ﻳﻬﻤﻨﺎ ال ‪toxic‬‬
‫‪ effect‬ﻋ� ال ‪mucosa‬ﻓﺘﻀﻌﻔﻬﺎ‪.‬‬
‫* ال ‪H. pylori‬ﺑﺘﻄﻠﻊ ‪ protease‬اﻟ� ﺑﻴﻜﺴﺮ ال ‪ mucous layer‬ﻓﺒﺎﻟﺘﺎﻰﻟ ﺑﺘﻀﻌﻔﻪ‪.‬‬
‫* ﺗﺎﻟﺖ ﻣﻴﻜﺎﻧﻴﺰم ‪ toxic effect :‬ﺑﺴﺒﺐ ﻧﻘﺺ ال ‪ blood supply‬واﳌﻮاد اﻰﻟ ﻃﺎﻟﻌﻪ‬
‫ﻓﻴﺤﺼﻞ ‪.gastric peptic ulcer‬‬
‫ﺍﻟـ ‪H. pylori‬ﺗﻌﻤﻞ ‪peptic ulcer‬ﻓﺎﻝ ‪duodenum‬ﺑﻜﺎﻡ ﻣﻴﻜﺎﻧﻴﺰﻡ ؟‬
‫واﺣﺪ‪ ،‬اﻻ وﻫﻮ ال ‪ ،hyperacidity‬اﻟﻜﻼم ده ﻣﻜﺘﻮب ﺑﻌﺪ ﺷﻮ�ﻪ ﻓﺎل ‪peptic ulcer‬اﻫﻢ‬
‫ﻣﻦ ﻫﻨﺎ‪.‬‬
‫ﻓﻴﻪ ﺣﺎﺟﻪ ﺗﺎﻧﻰ ﻳﺎ ﺩﻛﺎﺗﺮﻩ ﻓﺎﻝ ‪pathogenesis‬ﻣﺶ ﻣﻬﻤﻪ ﺍﺳﻤﻬﺎ‬
‫‪:autoimmune gastritis‬‬
‫اﻟ� ﻗﺪاﻣﻜﻮا ده ‪diagram‬ﻟﻞ ‪ ،stomach‬واﻧﺎ ﻋﺎرف اﻧﻜﻢ ﻣﺘﻌﺮﻓﻮش ﺣﺎﺟﻪ ﻋﻦ ال‬
‫‪ ،stomach‬ﻓﻴﻪ ﺣﺎﺟﻪ اﺳﻤﻬﺎ ‪ parietal cells‬ﺑﺘﻄﻠﻊ اﻳﻪ ؟‪HCl‬ﻋﻦ ﻃﺮ�ﻖ اﻳﻪ ؟ ‪vagal‬‬
‫‪ stimulation‬اﻟ� ﺑﻴﻄﻠﻊ ‪ ،gastrin‬ﻳﻌﻨﻰ ‪ vagus‬وﻓﻴﻪ ‪ gastrin‬ﺑﻴﺸﺘﻐﻞ ﻋ� ال‬
‫‪ parietal cells‬ﻳﺨﻠﻮﻫﺎ ﺗﻄﻠﻊ ‪.HCL‬‬
‫ال ‪parietal cells‬ﻣﻮﺟﻮده ﻓ� ﻓﺎل ‪stomach‬؟ ﺑﺴﻬﻮﻟﻪ ﺟﺪا ﻣﻮﺟﻮده ﻓﺎل ‪fundus‬‬
‫وال )‪ body(corpus‬ﻟﻴﻪ ؟‬
‫ﺑﺎﻟﻌﻘﻞ ﻟﻮ رﺑﻨﺎ ﺧﻠﻖ ‪parietal cells‬ﻓﺎل ‪pylorus‬ﻛﺎن ﻳﻨﻔﻊ ﻳﺒﻘﻲ‬
‫ﻓﻴﻬﺎ ‪chemoreceptors‬؟ وﺑﺎﻟﺘﺎﻰﻟ ﻣﻴﻨﻔﻌﺶ ﻳﺒﻘﻲ ﻓﻴﻪ ‪chemoreceptors‬ﻏ� ﻓﺎل‬
‫‪.pylorus‬‬
‫ﺍﻟﻨﺎﺱ ﺍﻟﻰ ﻋﻨﺪﻫﺎ ‪autoimmune gastritis‬ﻟﻘﻮ ﺍﻥ ﻋﻨﺪﻫﻢ ‪:‬‬
‫* ‪ autoantibodies‬ﺿﺪ ال ‪ parietal cells‬اﻟ� ﻓﺎل ‪ fundus‬وال ‪ body‬اﻟ� اﻛﺮﺘ‬
‫ﻣﻮﺟﻮده ﻓ� ؟ال ‪corpus‬؛ ﻻن ﻟﻬﺎ ‪ surface area‬ﻛﺒﻴ�ه ﻓﻬﻰ ﻣﻮﺟﻮده ﻓﺎل ‪fundus‬‬
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Flash Notes in Pathoogy | From chronic gastritis to dysentery
fundus ‫ ﺑﺲ ﻫﻰ ﻓﺎل‬body ‫ اﻟﻜﺘﺎب اﺗﻜﻠﻢ اﻧﻬﺎ ﻓﺎل‬،corpus ‫ﺑﺲ اﻛﺮﺘ ال‬corpus ‫وال‬
‫ وﺿﺪ ال‬parietal cells ‫ ﺿﺪ ال‬autoimmune antibodies ‫ ﻓﻴﻪ‬،body ‫وال‬
extrinsic �‫ اﻣﺎل ﻣ‬،�‫ اﻟ� ﻫﻮ ﺑﺮوﺗ‬intrinsic factor ‫ ﺑﺘﺎﻋﻬﺎ اﻟ� ﻫﻮ‬secretion
.vit B12 ‫؟‬factor
‫ اﻟﻌﻴﺎن ﻫﻴﺸﺘﻰﻜ ﻣﻦ‬parietal cells ‫ ﺿﺮﺑﺖ ال‬autoantibodies ‫دﻟﻮﻗﺘﻰ ﻟﻮ ﻓﻴﻪ‬
intrinsic ‫ وﺿﺮﺑﻨﺎ ﻛﻤﺎن ال‬،hypoacidity ‫ اﻟ� اﳌﺆﻟﻒ ﻛﺘﺒﻬﺎ‬hypochlorhydria
‫ﺑﺲ ﻣﺶ‬anemia ‫ اﺳﻤﻬﺎ‬anemia ‫ ﻓﻤﺶ ﻫﻴﻌﺮف ﻳﻤﺘﺺ اﻟﻔﻴﺘﺎﻣ� ﻓﻴﺤﺼﻞ‬factor
‫ او‬macrocytic anemia ‫ ﻋﺎوز ﺗﺴﻤﻴﻬﺎ ﺳﻤﻴﻬﺎ‬،pernicious anemia
macrocytic ‫ و‬chronic gastritis ‫ اﻣﺎ ﻳﻜﻮن ﻓﻴﻪ‬،megaloblastic anemia
.pernicious anemia ‫ ﺳﺎﻋﺘﻬﺎ ﺑﺲ ﺑﺴﻤﻴﻬﺎ‬anemia
‫ ﻳﺘﻤﻴﺰ‬stomach ‫ ﻋ� ﻣﺴﺘﻮى ال‬syndrome ‫ ده‬pernicious anemia ‫ال‬
.macrocytic anemia ‫ و‬hypoacidity ‫ و‬gastritis :�‫ﺑﺤﺎﺟﺘ‬
‫ وﻟﻜﻦ اﻫﻢ ﺣﺎﺟﻪ ﻋﺸﺎن‬،so common ‫ﻣﺶ‬immunological ‫ﻫﺬا اﳌﻴﻜﺎﻧﻴﺰم ال‬
more ‫ﻫﻴﺒﻘﻲ‬part ‫ اﻧﻬﻰ‬autoimmune gastritis ‫ ﻓﻰ ال‬:‫ﺟﺎﺑﻮﻫﺎ ﻣﺮه ﻓﺎﻻم ﻰﺳ ﻛﻴﻮ‬
.pylorus ‫ال‬affect ‫ وﻣﺴﺘﺤﻴﻞ ﻳـ‬fundus ‫ ﻳﻠﻴﻪ ال‬corpus ‫؟ ال‬affected
H. ‫ ﻻن ال‬pylorus ‫ اﻳﻪ اﻛﺮﺘ ﺣﺘﻪ ﻓﻰ اﻟﺠﺴﻢ ﻫﺘﺘﺎﺛﺮ ؟ ال‬H. pylori ‫ﻟﻜﻦ ﻓﻰ ﺣﺎﻻت ال‬
‫ ﻫﺎ وﺻﻠﺖ اﻟﺤﺘﻪ دى ؟‬،‫ﻋﺎﻳﺸﻪ ﻓﻴﻬﺎ‬pylori
fundus ‫ وﻟﻮ ﻗﺎﻟﻚ‬corpus ‫اﻛﺮﺘ ﻣﻜﺎن ﻳﺘﺎﺛﺮ ال‬autoimmune gastritis ‫ﻳﺒﻘﻲ ﻓﺎل‬
‫ﻟﻜﻦ ﻟﻮ ﻗﺎﻟﻚ‬parietal cells ‫؛ ﻻن دول ﻓﻴﻬﻢ‬most common site �‫ﺗﻤﺎم ﻛﺘﺎ‬
.parietal cells ‫ ﻫﻞ ﻫﺘﺘﺎﺛﺮ ؟ ﻻ ﻻن ﻣﻔﻴﻬﺎش‬pylorus
‫؟‬affected ‫ اﻳﻪ اﻛﺮﺘ ﺣﺘﻪ‬H. pylori ‫ﻓﻰ ﺣﺎﻟﺔ ال‬
‫ ﻣﺘﻔﻘ� ﻋ� ﻫﺬا اﻟﻜﻼم‬،fundus ‫ واﻗﻞ ﻣﺎ ﻳﻜﻮن ال‬body ‫ ﻳﻠﻴﻬﺎ ال‬pylorus ‫ال‬
.‫؟ﻫﺘﺸﻮﻓﻮا دﻟﻮﻗﺘﻰ اﻫﻤﻴﺘﻬﺎ ﺑﻌﺪ ﺷﻮ�ﻪ‬
Pathology
‫ ﺑﻴﻘﺴﻤﻬﻮﻫﻢ ﻣﻦ‬H. pylori ‫ اﻟ� ﻫﻮ ﺑﺴﺒﺐ ال‬chronic gastritis ‫ﻧﺘﻜﻠﻢ ﻋ� اﺷﻬﺮ ﻧﻮع‬
: ‫ﻧﺎﺣﻴﻪ اﻟﺒﺎﺛﻮﻟﻮﺟﻰ ﳌﺠﻤﻮﻋﺘ� ﻛﺒﺎر ﻻزم ﺗﻌﺮﻓﻮﻫﻢ وده ﺳﺆال ﻧﻈﺮى ﻣﻬﻢ‬
1. Chronic superficial gastritis
‫؟‬superficial ‫ ﻟﻴﻪ ﺳﻤﻮﻫﺎ‬،stomach ‫ اﻟ� ﻗﺪاﻣﻜﻢ دى ال‬،this is an early stage
lamina propria ‫ اﻟ� ﺑﻨﺴﻤﻴﻬﺎ‬superficial part of mucosa ‫ﻻن اوﻻ ﺑﻨﻼﻗﻴﻬﺎ ﻓﺎل‬
chronic ‫ ﺷﺎﻳﻔﻴﻨﻬﻢ ؟ ﻣ� ﻫﻢ ال‬chronic inflammatory ells ‫وﻓﻴﻪ‬
plasma cells, macrophages & lymphocytes ‫؟ ال‬inflammatory cells
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Flash Notes in Pathoogy | From chronic gastritis to dysentery
�‫ ﻫﻞ اﻧﺘﻮ ﺷﺎﻳﻔ‬،endarteritis ‫ ﻓﻠﺴﻪ ﻣﻔﻴﺶ‬early stage ‫اﻟﺤﺎﺟﻪ اﻟﺘﺎﻧﻴﻪ ﻫﻰ ﻟﺴﻪ‬
no atrophy of mucosal ‫؟‬atrophied ‫او‬destroyed ‫ ﻫﻨﺎ‬mucosa ‫ﻗﺪاﻣﻜﻢ ال‬
.early ‫ ﻻﻧﻬﺎ ﻟﺴﻪ‬glands
this is chronic ،‫؟ ﻻ‬blood supply ‫ ﻋﺸﺎن ﻳﻤﻨﻊ ال‬fibrosis ‫ﻃﺐ ﻫﻞ ﻓﻴﻪ‬
chronic ‫ ﻛﻞ اﳌﺸﻜﻠﻪ اﻟ� ﻧﻌﺮﻓﻬﺎ اﻧﻨﺎ ﻟﻘﻴﻨﺎ‬،early ‫ ودى‬superficial gastritis
.‫ ﺑﺲ‬inflammatory cells
acute inflammatory ‫ ﻻن ﺳﺎﻋﺎت ﺑﻴﺒﻘﻲ ﻓﻴﻪ ﻫﻨﺎ‬،‫واﻧﺎ ﻗﻠﺖ ﻛﺪه ﺳﺒﺒﻬﺎ ﻣﻘﻠﺘﺶ ﺳﺮﻋﺘﻬﺎ‬
‫ ﻫﻮ ﻣ� اﺻﻼ اﻰﻟ ﺑﻴﻀﺮﺑﻠﻨﺎ‬chronic gastritis ‫ ازاى ؟ ﻫﻮ اﳌﻮﺿﻮع اﺳﻤﻪ اﻳﻪ ؟‬cells
‫ ﻳﺎ‬immunological ‫ ﻳﺎ اﻣﺎ‬stomach ‫ دى؟ اﻟ� ﺑﻴﻀﺮﺑﻠﻨﺎ ال‬stomach ‫اﻟﺨﻼﻳﺎ ﺑﺘﺎﻋﻪ ال‬
inflammatory exudate ‫ اﻟﺨﻼﻳﺎ ﳌﺎ ﺑﺘﻔﺮﻗﻊ ﺑﻴﻄﻠﻌﻠﻨﺎ ﻣﻨﻬﺎ ال‬،H. pylori ‫اﻣﺎ ال‬
‫؟ اه‬neutrophil ‫ ﻓﺒﺎﻟﺘﺎﻰﻟ ﻫﻞ ﺑﺘﻼﻗﻰ‬،acute inflammatory cells ‫ﻳﻤﺘﺜﻠﻨﺎ ﻣﻨﻬﺎ ال‬
‫ ﻋﺎﻟﻴﻪ وﻻ واﻃﻴﻪ‬destruction ‫ ﺗﺰ�ﺪ ده ﻣﻌﻨﺎه ان ﺳﺮﻋﻪ ال‬neutrophil ‫وﻛﻞ ﻣﺎ ال‬
.‫؟ﻋﺎﻟﻴﻪ‬
:‫ﻫﻌﻴﺪ ﺗﺎﻧﻰ‬
chronic inflammatory ‫ ﻛﻞ اﻟ� ﻓﻴﻬﺎ ﺑﻨﻼﻗﻰ‬chronic superficial gastritis ‫ال‬
rate of ‫ اﻟ� ﳌﺎ ﺗﺰ�ﺪ ﻳﺒﻘﻰ‬neutrophil ‫ وﺑﻨﻼﻗﻲ ﻓﻴﻪ‬submucosa ‫ ﻓﻰ ال‬cells
submucosa ‫وال‬mucosa ‫ ﻓﺎﻫﻤ� دى ؟ ﺑﻨﻼﻗﻴﻬﻢ ﻓﻰ وﺳﻂ ال‬،‫ ﻋﺎﻰﻟ‬destruction
plasma cells, macrophages, lymphocytes & ‫ ﻫﻨﻼﻗﻰ‬lamina propria ‫وﻲﻓ ال‬
.neutrophils
‫؟‬mucosal glands ‫ﻓﺎل‬atrophy ‫ﻃﻴﺐ ﻫﻞ ﻓﻴﻪ‬
‫ او‬immunological ‫ ﻓﺒﺎﻟﺘﺎﻰﻟ ﻓﻰ ال‬،early ‫؟ ﻻن ﻫﻰ ﻟﺴﻪ‬atrophy ‫ ﻟﻴﻪ ﻣﺤﺼﻠﺶ‬،‫ﻻ‬
chemical ‫ ﺑﺎﻟـ‬neutrophils‫ﺗﻔﺮﻗﻊ وﳌﺎ ﺗﻔﺮﻗﻊ ﺗﺠﺘﺬب اﻟـ‬cells ‫ ﻫﺘﻴﺠﻰ ال‬h. pylori ‫ال‬
.mediators
‫ اﻟ� ﻛﻤﻴﺘﻬﺎ ﺑﺘﻌﺮﻓﻨﺎ‬،‫؟ اه‬neutrophils ‫ أو‬acute inflammatory cells ‫ﻫﻞ ﻫﻨﻼﻗﻰ‬
‫ ﻫﺎ‬،destruction ‫ أو ﺳﺮﻋﻪ ال‬inflammation ‫ ﺑﺘﺎﻋﻪ ال‬severity ‫ اوال‬activity ‫ال‬
‫ﻓﻰ اى ﺻﻌﻮﺑﻪ ؟‬
2. Chronic atrophic gastritis
.‫ﻃﻴﺐ ﺑﻌﺪ ﻛﺪه اﻟﻌﻴﺎﻧ� ﺑﻴﺨﺸﻮا ﻓﻰ ﻫﺬه اﳌﺮﺣﻠﺔ‬
‫ ﻃﻮﻟﻬﺎ اد اﻳﻪ ؟ اد ﻛﺪه )ﺻﻐﺮت( ﻓﺎﻛﺮ�ﻦ ﻗﺒﻞ ﻛﺪه اﻟﺼﻮر اﻰﻟ ﻛﻨﺖ‬stomach ‫ﺷﺎﻳﻔ� ﻫﻨﺎ ال‬
‫ﺑﺠﻴﺒﻬﺎ؟‬
.chronic atrophic gastritis ‫ﻫﺬا اﳌﻨﻈﺮ ﺑﻴﺴﻤﻮه‬
advanced ‫ وﻻ‬early stage ‫ ﻧﻘﻮل ان ﻫﻰ‬chronic atrophic gastritis ‫ﻻزم ﻓﻰ ال‬
‫ وﻣﺎزاﻟﺖ ال‬،atrophy ‫ ﻫﻴﺒﻘﻲ اﻫﻢ ﺣﺎﺟﻪ ﺗﻤﻴﺰﻫﺎ وﺟﻮد اﻳﻪ؟ ال‬،advanced ‫؟‬stage
.chronic inflammatory cells ‫ ﺟﻮاﻫﺎ‬lamina propria
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Flash Notes in Pathoogy | From chronic gastritis to dysentery
macrophages, ‫؟ اﻟ� ﻫﻢ اﻳﻪ ؟‬chronic inflammatory cells ‫ﺣﺪ ﺷﺎﻳﻒ ال‬
‫ اﻟ� ﺣﺼﻞ ﻓﻤﻨﻊ ال‬fibrosis ‫ واﻟ� زاد ﻋﻠﻴﻬﺎ ال‬،lymphocytes & plasma cells
mucosa ‫ ﻳﻌﻨﻰ ال‬mucosal rugae atrophy ‫ ﻓﻼزم ﻧﺸﻮف‬،blood supply
.blood supply ‫؛ ﻻن ﺑﻘﺎﻟﻬﺎ ﻓﺮﺘه ﻛﺒ�ه وده ﻳﻤﻨﻊ ال‬atrophied
‫ ﺗﺘﺤﺪد إزاي؟‬severity ‫ﻫﻨﺎ ﺑﺌﺎ ال‬
immunological ‫ ﻳﺎ اﻣﺎ ﺑﺎل‬chronic inflammatory cells ‫ﻣ� اﻰﻟ ﺑﻴﻤﻮت اﻟﺨﻼﻳﺎ ؟‬
‫ ﻓﺎﻳﻪ‬،‫ دﻟﻮﻗﺘﻰ اﻟﺨﻼﻳﺎ ﻛﻠﻬﺎ ﻣﺎﺗﺖ‬،secondary to H. pylori ‫ ﻳﺎ اﻣﺎ‬mechanism
‫ ﻫﺘﺰ�ﺪ وﻻ ﻫﺘﻘﻞ ؟ ﻓﻰ اﻟﻨﻬﺎﻳﻪ ﺧﺎﻟﺺ‬inflammatory cells ‫ ال‬severity ‫راﻳﻜﻮا ﻣﻊ ال‬
.‫ ﺗﺰ�ﺪ وﻻ ﺗﻘﻞ؟ ﺗﻘﻞ‬inflammatory cells ‫ﺑﻌﺪ ﻣﺎ اﻟﺨﻼﻳﺎ ﻛﻠﻬﺎ ﻣﺎﺗﺖ ال‬
‫ ﺳﺮﻋﻪ ال‬chronic superficial gastritis ‫أو ﻓﻰ ال‬destruction ‫ﻲﻓ أول ال‬
‫ ﻟﻜﻦ‬،‫ اﻟﺨﻼﻳﺎ ﻋﻤﺎﻟﻪ ﺗﺘﻜﺴﺮ‬،neutrophils ‫ ﻣﻌﺘﻤﺪه ﻋ� اﻳﻪ ؟ ﻋ� ال‬destruction
‫ ﻻﻧﻬﺎ ﺑﺘﻘﻞ ﻷن ﺧﻼص ﻣﻔﻴﺶ‬chronic cells ‫ ﻳﺘﻌﺘﻤﺪ ﻋ� ال‬severity ‫ ال‬later on
‫ وده ﻃﺒﻌﺎ ﻣﺒﻴﺘﺴﺎﻟﺶ ﻟﻴﻜﻢ اﻧﺘﻮ ده ﻟﻞ‬،�‫ وده ﻋﻜﺲ اﳌﻴﻜﺎﻧﻴﺰم اﻻوﻻ‬،‫ﺣﺎﺟﻪ ﺗﻜﺴﺮﻫﺎ‬
.master
‫ﺑﻴﺰ�ﺪ وﻻ ﻳﻘﻞ ﻣﻊ‬inflammatory cells ‫ ﻋﺪد ال‬chronic atrophic gastritis ‫ﻓﻰ ال‬
‫ ﻧﺤﺪد ال‬chronic superficial gastritis ‫ ﻟﻜﻦ ﻓﻰ ﺣﺎﻟﻪ ال‬،‫؟ﺑﻴﻘﻞ‬stage ‫ز�ﺎده ال‬
‫ ﺗﺠﺘﺬب‬mediators ‫ﻟﻴﻪ؟ ﻻن اﻟﺨﻼﻳﺎ ﻛﻞ ﻣﺎ ﺗﻔﺮﻗﻊ ﻫﺘﻄﻠﻊ‬neutrophils ‫ ﺑﺎل‬severity
‫ ﺑﺎل‬severity ‫ ﻫﻨﻘﻴﺲ ال‬chronic atrophic gastritis ‫ ﻟﻜﻦ ﻓﻰ ال‬،neutrophils
‫ وﺻﻠﺖ اﳌﻌﻠﻮﻣﻪ دى ؟‬،stage ‫ ﻣﻊ ز�ﺎده ال‬chronic inflammatory cells
atrophied ‫ﺑﺘﺒﻘﻰ‬mucosal glands ‫ ال‬chronic atrophic gastritis ‫دﻟﻮﻗﺘﻰ ال‬
‫ وﻣﺶ ﻋﺎرف اﻳﻪ واﻟﻜﻼم‬acidity ‫ اﻟ� ﻛﺎﻧﺖ ﺑﺘﺰود ال‬H. pylori ‫ﺑﺎﺷﻬﺮ ﺣﺎﺟﻪ وﻫﻰ ال‬
‫ ﺗﺴﺘﺤﻤﻞ اﻟﻜﻼم ده وﻋﺸﺎن ﺗﺴﺘﺤﻤﻠﻪ ﻳﺤﺼﻠﻬﺎ‬stomach ‫ ﻣﻔﺮوض ان ال‬،‫ده‬
‫ ﺑﺪاﻧﺎ ﻧﺸﻮف ال‬chronic atrophy ‫ ﺧﻠﻮ ﺑﺎﻟﻜﻢ ﺑﺌﺎ ﻓﻰ ال‬،intestinal metaplasia
metaplasia ‫ ودى ﻣﺼﻴﺒﻪ ﻻن ال‬،intestinal metaplasia ‫ ﳌﺎ ﺣﺼﻞ‬goblet cells
‫ وﺑﻌﺪﻫﺎ ﺑﺘﻠﺖ‬dysplasia ‫ ﺗﻌﻤﻞ‬metaplasia ‫ ﺑﻌﺪﻫﺎ ﻳﺸﻮ�ﻪ ال‬،precancerous ‫دى‬
‫ ﻃﺒﻌﺎ اﻣﺎ ﻳﺘﻘﺎل اﻟﻜﻼم ﻛﺪه ورا ﺑﻌﻀﻪ ﻣﺘﻔﻬﻤﺶ‬،carcinoma in situ ‫ﺷﻮ�ﺎت ﻳﺤﺼﻞ‬
.‫ﺣﺎﺟﻪ‬
‫ﻣﻄﻠﻮﺏ ﺍﻛﻮﻣﻨﺖ ﻋﻠﻰ ﻛﺎﻡ‬chronic atrophic gastritis ‫ﺍﻧﺎ ﻟﻮ ﻗﺪﺍﻣﻰ ﻋﻴﻨﻪ‬
‫ﺣﺎﺟﻪ ؟‬
‫ ﻟﻮ‬،Giemsa ‫ ازاى اﻋﺮﻓﻬﺎ ؟ﺑﺎل‬،non ‫ وﻻ‬H. pylori associated ‫ ﻫﻞ ﻫﻰ‬:1 ‫رﻗﻢ‬
.‫ﻳﺒﻘﻲ ﺧﻼص ﻣﻔﻴﺶ‬negative for Giemsa ‫ﻃﻠﻌﺖ‬
‫ ﻳﺒﻘﻲ ﻣﺤﺘﺎج اﻋﻠﻖ ع‬early ‫؟ ﻟﻮ‬atrophic ‫ وﻻ‬early ‫ اﻗﻮل ﻫﻰ ﻓﻰ ﻣﺮﺣﻠﻪ‬:2 ‫رﻗﻢ‬
‫؟ اﺑﻘﻰ‬intestinal metaplasia ‫ ﻳﻨﻔﻊ اﻗﻮﻟﻪ اﺻﻞ ﻓﻴﻬﺎ‬early ‫ ﻫﻞ ﻓﻰ ال‬،severity
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‫‪Flash Notes in Pathoogy | From chronic gastritis to dysentery‬‬
‫ﻋﺒﻴﻂ‪ ،‬ازاى ‪early‬ﻳﺒﻘﻰ ﻓﻴﻪ ‪ ،metaplasia‬اﻧﻤﺎ ﻟﻮ ﻫﻰ ‪ atrophic‬اﺣﺪدﻟﻪ ال ‪severity‬‬
‫ﺑﺎﻳﻪ ؟ ﻟﻮ ‪ more inflammatory cells‬ﻳﺒﻘﻰ ‪ less severity‬ﻻن ﻓﺎﻟﻨﻬﺎﻳﻪ ﺧﺎﻟﺺ ﺑﻌﺪ‬
‫اﻟﺨﻼﻳﺎ ﻣﺎ ﺗﻤﻮت ﻋﺪد ال ‪ inflammatory cells‬ﺑﻴﻘﻞ ﻟﻮ ﻣﻠﻘﺘﺶ ﺣﺎﺟﻪ ﺗﻤﻮﺗﻬﺎ‪ ،‬ﺑﺲ ﻻزم‬
‫اﻋﻠﻖ ﻋﺎل ‪ ،complications‬ﻓﻴﻬﺎ ‪intestinal metaplasia‬وﻻ ﻣﻔﻴﻬﺎش؟ ﻣﻔﻬﻮم اﻟ�‬
‫ﺑﻘﻮﻟﻪ؟ ‪.this is chronic atrophic gastritis‬‬
‫ال ‪ chronic gastritis‬اﺷﻬﺮ ﻧﻮع ﻫﻮ ال ‪ ،H. pylori associated‬اﻷﻧﻮاع اﻟﺘﺎﻧﻴﻪ ﻛﻠﻬﺎ‬
‫‪ ،10%‬ال ‪ immunological‬ﺷﺮﺣﻮﻫﻮﻟﻜﻢ ﻋﺸﺎن ﺣﺎﺟﻪ واﺣﺪه‪ ،‬ﻋﺸﺎن ال ‪H. pylori‬‬
‫‪ associated‬ﺑﻴﻀﺮب ﺣﺎﺟﻪ واﺣﺪه اﻟ� ﻫﻰ ال ‪ ،pylorus‬ﻟﻜﻦ ال ‪immunological‬‬
‫ﺑﻴﻀﺮب ال ‪ corpus‬أﻛﺮﺘ ﺣﺎﺟﺔ وﺑﻌﺪﻳﻬﺎ ال ‪.fundus‬‬
‫‪Another classification of gastritis:‬‬
‫اﻛﺘﺸﻒ ﺳﻨﻪ ‪ ،1967‬وﻛﺎﻧﻮ ﺑﻴﺴﻤﻮه ﻋ� اﺳﻢ ﻋﺎﻟﻢ ﻓﺮﻧﺴﺎوى اﻧﺎ ﻣﺶ ﻋﺎرف اﻗﻮﻟﻪ ﺑﺲ ﻫﻮ‬
‫اﻻﺳﻢ اﻻﺧ� ﺑﺘﺎﻋﻪ ﻓﻴﻪ ﻣﻨﺮﺘ�ﺮ‪ ،‬ﻫﻮ ﻓﺮﻧﺴﺎوى‪ ،‬ﻓﻰ ﻧﻔﺲ اﻟﻌﺎم ال ‪classification‬ده‬
‫اﺗﺸﻄﺐ ﻣﻦ اﻟﻄﺐ‪ ،‬ﻫﻮ ﻣﻜﺘﻮب ﻓﺎﻟﻜﺘﺎب ﺑﺨﻂ ﺻﻐ�‪.‬‬
‫ﻛﺎن ﻣﻘﺴﻤﻬﺎ ﻟﻨﻮﻋ� ﻛﺒﺎر‪ ،‬ﻫﻮ ﻣﺶ ﻋﻠﻴﻜﻢ ﺑﺲ ﻫﻘﻮﻟﻪ ﻋﺸﺎن ﺗﻔﻬﻤﻮ ﻛﺎن ﺑﻴﺤﺴﺒﻬﺎ إزاي‪،‬‬
‫اﺻﻠﻪ ﺑﻴﻘﻮﻟﻚ ﺑﺘﻮع اﻟﺒﺎﺛﻮﻟﻮﺟﻰ ﻛﺪه ﻟﻮ ﺟﺎﻰﻟ ﺣﺎﻟﻪ ‪ chronic gastritis‬اﻗﻮﻟﻪ اﻳﻪ؟‬
‫ﻟﻮ ‪ H. pylori associated‬ال ‪activity‬وال ‪severity‬ﺑﺘﺎﻋﺘﻬﺎ ﺑﺎل ‪chronic‬‬
‫‪ inflammatory cells‬وﻻزم ﺗﻘﻮل ﻓﻴﻪ ‪metaplasia‬وﻻ ﻣﻔﻴﺶ وﻓﻴﻪ ‪ dysplasia‬وﻻ‬
‫ﻣﻔﻴﺶ ﻫﻮ ﻻزم ﺗﻘﻮل ﻛﺪه ﻓﺎﳌﻮﺿﻮع ﻛﺪه ﺳﻬﻞ‪.‬‬
‫ﻛﺎن ﺑﻴﻘﻮل ﻓﻴﻪ ﻧﻮﻋ� ﻣﻦ ال ‪ ،chronic gastritis‬ﻧﻮع ‪ A‬وﻧﻮع ‪ ،B‬ال ‪ A‬ال‬
‫‪ ،autoimmune‬ﺷﺎﻳﻒ اﻟﻐﺒﺎوه؟ ﺣﻂ ال ‪ autoimmune‬اﻟ� اﻗﻞ ﻣﻦ ‪ %1‬اﻧﻬﺎ ‪ A‬ﻻﻧﻪ‬
‫‪ autoimmune‬ﺑﺤﺮف ال ‪!!A‬‬
‫ﻋﺸﺎن ﻛﺪه ﻓﺎﻟﻜﺘﺎب ﻣﻌﺪﻳﻴﻨﻪ‪ ،‬وﻓﻴﻪ ﺣﺎﺟﻪ ﺗﺎﻧﻴﻪ اﺳﻤﻪ ‪ ،B‬ال ‪B‬ﻳﺮﺟﻊ ﻳﻘﺴﻤﻬﺎ ﻳﺎ اﻣﺎ ‪ BA‬ﻳﺎ‬
‫اﻣﺎ ‪ ،BB‬اﻟ� ﺳﻤﺎﻫﺎ ﺑﻌﺪ ﻛﺪه ﻏ�ﻫﺎ ﻳﺎ اﻣﺎ ‪ AB‬او ‪.BB‬‬
‫ال ‪ A‬دى ﻫﻰ ﻟﻮ ﻓﻴﻬﺎ ال ‪ H. pylori‬ﻋﺎﻣﻠﻪ ‪ peptic ulcer‬ﻓﺎل ‪ stomach‬وال‬
‫‪ duodenum‬وده اﻰﻟ ﻳﻬﻤﻨﺎ وﻓﻴﻪ ‪ ،hyperacidity‬ال ‪ B‬ﺳﻤﺎﻫﺎ ‪environmental‬‬
‫وﻣﻴﻔﻬﺎش ‪ ،hyperacidity‬اﻟﺘﻘﺴﻴﻤﻪ دى وﻻ ﻟﻴﻬﺎ ﻻزﻣﺔ‪.‬‬
‫ﻓﻴﻪ ﻧﺎس ﻗﺪام ﺑﻴﺴﺎﻟﻮﻫﺎ‪ ،‬ﻫﻮ ده اﻟﺴﺆال ﺑﺘﺎﻋﻬﻢ‪ ،‬ﻳﻘﻮﻟﻚ ﺗﻌﺮف ‪type A gastritis‬؟ ﺗﻘﻮﻟﻪ‬
‫‪ ،autoimmune‬ﻳﻘﻮﻟﻚ و ‪ ،type B‬ﻗﻮﻟﻪ ‪.non immunological‬‬
‫‪Hypertrophic gastropathy‬‬
‫ﻋﻨﺪﻧﺎ ﺣﺘﻪ ‪ oral‬اﺳﻤﻬﺎ ‪ ،hypertrophic gastropathy‬ﻟﻮ ﺟﻴﺘﻮا ﺑﺼﻴﺘﻮا ﻣﻌﺎﻳﺎ ﻋ� ﻫﺬه‬
‫اﻟﺼﻮره‪ ،‬ده ﻣﻨﻈﺮ ال ‪ ،hypertrophic gastropathy‬ده ‪ ،uncommon‬اﺗﻮﺻﻒ‬
‫ﻣﻨﻬﻢ ﻋﺪد ﺣﺎﻻت ﻧﺴﺒﺘﻬﺎ ‪ ،%15‬ده ‪.uncommon‬‬
‫‪‬‬
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Flash Notes in Pathoogy | From chronic gastritis to dysentery
uncommon non ‫ ده‬hypertrophic gastropathy ‫اول ﻛﻠﻤﻪ ﻻزم ﺗﻘﻮﻟﻬﺎ إن ال‬
‫ ﻣﺮه ﻻﻧﻪ ﻋﺸﺎن ﻛﺪه ﺳﻤﺎﻫﺎ‬700non inflammatory �‫ و رﻛﺰ ﻋ‬inflammatory
.gastritis ‫ﻣﺶ‬gastropathy
hypertrophic ‫ ﻣﻨﺮﺘ�ﺮ اول ﻣﺎ ﺳﻤﺎﻫﺎ ﺳﻤﺎﻫﺎ‬hypertrophic gastropathy ‫ال‬
‫ ﻫﻮ‬3 ‫ رﻗﻢ‬،non inflammatory ‫ ﻫﻰ‬2 ‫ رﻗﻢ‬،uncommon ‫ ﻓﺪى ﻫﻰ‬gastropathy
‫ ﻓﻰ ال‬same thickness ‫ ﻛﺎﻧﺖ ﻳﺎ اﻣﺎ‬chronic gastritis ‫ ﻓﺎﻟـ‬،hypertrophic ‫ﺳﻤﺎﻫﺎ‬
‫ ﺗﺒﻘﻰ زى‬stomach ‫ إن ال‬very rare ‫ ﻟﻜﻦ‬،atrophic ‫ ﻳﺎ اﻣﺎ‬chronic superficial
acid ‫ وﺑﺎﻟﺘﺎل ال‬hypertrophy of mucosal rugae ‫ ﻳﻌﻨﻰ ﻓﻴﻪ‬hypertrophied ‫ﻫﻨﺎ‬
.multiple peptic ulcers ‫ ﺑﻴﺒﻘﻰ ﻋﺎﻰﻟ وﺑﺎﻟﺘﺎﻰﻟ ﻓﻴﻪ‬secreted
‫ ودى ﻋﺪد اﻟﺤﺎﻻت اﻰﻟ اﺗﻮﺻﻔﺖ ﻓﻴﻬﺎ ﻗﻠﻴﻞ‬hypertrophic gastropathy ‫ودى ﺑﻨﺴﻤﻴﻬﺎ‬
‫ اﻧﺎ ﺑﺸﺮﺣﻬﺎ ﺑﺲ‬،‫؟ ﻻ ﻃﺒﻌﺎ‬chronic gastritis ‫اوى ﻟﻜﻦ اﻫﻢ ﺣﺎﺟﻪ ﻫﻞ ﻫﻰ ﻧﻮع ﻣﻦ اﻧﻮاع‬
.‫ﻫﻰ ﺑﺎﻟﻨﺴﺒﺎﻟﻜﻢ ﻗﺮاءه‬
�‫ اﻟ‬،Menterier disease ‫ ﻫﻮ اﺷﻬﺮ ﺣﺎﻟﻪ ﻓﻴﻬﺎ ﺑﻴﺴﻤﻮﻫﺎ‬،‫ ﺑﺼﻮا ﻛﺪه‬،‫ﻓﻴﻪ ﺣﺎﺟﻪ اﻫﻢ‬
. ‫ ﻓﺴﻤﻮﻫﺎ ﻋ� اﺳﻤﻪ‬menterier ‫ﺷﺎﻓﻬﺎ ﺳﻤﺎﻫﺎ‬
Ulcers of stomach & duodenum
.peptic ulcer ‫اﻟﺼﻮره اﻰﻟ ﻗﺪاﻣﻜﻢ دى ﻫﺸﺮح ﻓﻴﻬﺎ ال‬
‫؟‬duodenum ‫ﻭﺍﻝ‬stomach ‫ ﺍﻟﻰ ﺗﻄﻠﻊ ﻑ‬ulcers ‫ﺑﺲ ﻗﺒﻞ ﻛﺪﻩ ﺍﻳﻪ ﺍﻝ‬
‫ اﻟ� ﺑﺘﺤﺼﻞ ﻓﺤﺎﻻت‬ulcer ‫؟ ال‬acute ulcer ‫ ﺣﺪ ﻋﺎرف ﻳﻌﻨﻰ اﻳﻪ‬،acute ulcer ‫* ال‬
.acute gastritis
.chronic ulcer ‫* ال‬
.malignant ulcer *
Acute ulcers of stomach & duodenum
‫ ﻋﺎرف اﻣﺘﻰ ﺣﻀﺮﺗﻚ ؟‬،‫ اﺣﻨﺎ ﻗﻠﻨﺎﻫﺎ‬acute ulcer ‫ال‬
acute gastritis ‫ ﻣﺎ ﻫﻰ ﻫﻰ ال‬،‫ اﻳﻪ ﻗﺼﺘﻬﺎ ؟ ﻳﺎ ﺟﺪﻋﺎن ﻣﺎﻧﺘﻮ اﺷﻔﺘﻮﻫﺎ‬acute ulcer ‫ال‬
‫ ﻣﺒﺘﺠﻴﺶ‬،A ‫ دى ﻛﺎﺗﻴﺠﻮرى‬acute ulcer ‫ ال‬،MCQ ‫اﻧﺎ ﺑﻘﻮﻟﻬﺎ ﻋﺸﺎن اﻫﻤﻴﺘﻬﺎ ﻓﻰ ال‬
multiple superficial small ulcers ‫ ﻫﻰ‬acute ulcer ‫ ال‬،‫ ﺑﺘﻴﺠﻰ ام ﻰﺳ ﻛﻴﻮ‬،‫ﻛﺪه‬
‫ ﺑﻴﻘﻮﻟﻮا اﻧﻬﺎ اﻗﻞ ﻣﻦ‬gastroenterology ‫ ﻟﻜﻦ ﺑﺘﻮع ال‬،‫ﻫﻨﺎ ﻫﻤﺎ ﺑﻴﻘﻮﻟﻮﻫﺎ ﻋ� اﺳﺘﻌﺠﺎل‬
‫ اﻟ� اﺧﺪﻧﺎﻫﺎ ﻗﺒﻞ ﻛﺪه‬،‫ﺳﻢ‬1 ‫ اﻗﻞ ﻣﻦ‬،superficial ulcer ‫ ﺳﻢ؛ ﻋﺸﺎن ﻛﺪه اﺳﻤﻬﺎ‬1
‫ دى‬ulcer ‫ ﺑﻴﻘﻮﻟﻮا ﻻ دى ﻣﺶ‬gastroenterology ‫ ﺑﺘﻮع ال‬acute gastritis ‫ﻓﻰ ال‬
.‫ ﺳﻢ‬1 ‫ اﻗﻞ ﻣﻦ‬small multiple ‫ ﻓﻴﺒﻘﻮا‬،‫ دول اﻳﻪ ﻳﺎ دﻛﺎﺗﺮه؟ دول اﺧﺮام‬،erosion
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‫‪Flash Notes in Pathoogy | From chronic gastritis to dysentery‬‬
‫ﻳﺒﻘﻰ ال ‪ acute ulcers‬دى ‪.multiple tiny superficial ulcers‬‬
‫ﺑﺘﺤﺼﻞ ﺑﺴﺒﺐ ﺍﻳﻪ؟‬
‫اﻟﺤﺎﻻت اﻟ� ﻓﻴﻬﺎ ‪ ،acute gastritis‬ﻫﻞ ال ‪ acute gastritis‬ﻣﻌﻤﻮﻟﻪ ﺑﺴﺒﺐ ﺑﻜﺘ��ﺎ ؟‬
‫ﻻ اﻣﺎل ﺑﺎﻳﻪ؟‬
‫ال ‪ ،irritation‬اﻳﻪ اﺳﺒﺎب ال ‪irritation‬؟‬
‫اﻟﺤﺎﺟﺎت اﻰﻟ ﻗﻠﻨﺎﻫﺎ ﻗﺒﻞ ﻛﺪه‪ ،‬ال ‪ steroids‬وال ‪ NSAIDs‬وال ‪ spicy food‬وال‬
‫‪.smoking‬‬
‫ﻟﻜﻦ اﻧﺎ ﻗﻠﺘﻠﻜﻢ ان ﻛﻞ اﻟﺤﺎﺟﺎت دى اﻻﻫﻢ ﻣﻨﻬﺎ واﻟ� ﺑﻴﺤﻤﻰ اﳌﻌﺪه ال ‪mucosal‬‬
‫‪ bicarbonate‬اﻟ� ﺑﺘﻌﻤﻠﻪ ‪ ،PGs‬ﻓﻌﺸﺎن ﻛﺪه ﻣﻤﻜﻦ ﺳﺒﺒﻬﺎ ﻳﺒﻘﻰ ‪ ،stress‬اﻟﻜﻮرﺗﻴﺰون‬
‫ﻓﻰ ال ‪ stress‬ﻧﺴﺒﺘﻪ ﺑﺘﺰ�ﺪ ﻓﺎل ‪mucous‬ﻳﻘﻞ‪ ،‬ﻻزم ﺗﻌﺮﻓﻮ اﳌﻌﻠﻮﻣﻪ دى‪.‬‬
‫اﻳﻪ اﺷﻬﺮ اﻟﺤﺎﻻت اﻟ� ﻳﺤﺼﻞ ﻓﻴﻬﺎ ‪stress‬؟ ال ‪ ،cerebrovascular accidents‬ﻳﻌﻨﻰ‬
‫واﺣﺪ ﻋﻨﺪه ﻧﺰ�ﻒ ﻓﺎﳌﺦ ‪ ،‬وراح ﻋﻨﺪ ﻧﺎﻳﺐ ﻣﻴﻌﺮﻓﺶ ﺣﺎﺟﻪ‪ ،‬دى اﺳﻤﻬﺎ ‪ ،acute ulcers‬اى‬
‫ﻋﻴﺎن ﻋﻨﺪه ‪ cerebral hemorrhage‬ﻻزم أدﻳﻪ ‪ ،zantac‬اﻟ� ﺑﻴﻘﻔﻞ ال ‪proton pump‬‬
‫ﻃﻴﺐ ﻟﻮ ﻧﺎﻳﺐ ﻣﻴﻌﺮﻓﺶ اﻟﻜﻼم ده؟؟ ﻛﻞ ال ‪ capillaries‬ﻓﻰ ﺟﺴﻤﻪ ﻫﻴﺤﺼﻠﻬﺎ ‪VC‬ﻋﺪا‬
‫اﻟﺮﺋﻪ واﻟﻘﻠﺐ واﳌﺦ‪ ،‬ال ‪ mucous membrane of stomach‬ﻫﻴﺤﺼﻞ ﻓﻴﻬﺎ ‪VC‬‬
‫ﻓﻬﻴﻄﻠﻊ ‪mucous‬؟ ﻻ‪ ،‬ﺑﺲ ﻟﺤﺪ دﻟﻮﻗﺘﻰ ﻣﻌﻨﺪوش ﻣﺸﻜﻠﻪ ﻻن ال ‪ HCl‬ﻗﻠﻴﻞ‪ ،‬ﻟﻮ اﻟﻌﻴﺎن‬
‫ده ﺷﺮق اﻳﻪ اﻰﻟ ﻳﺤﺼﻞ؟ ﻋﺎوز ﻳﻄﻠﻊ اﻟـ ‪ secretion‬ﺑﺘﺎع ال ‪ HCl‬وﻫﻮ اﺳﺎﺳﺎ ﻣﻔﻴﺶ‬
‫‪ ،mucus & bicarbonate‬ﻓﺎﻟﻌﻴﺎن ﻳﻘﻮم ﻣﺮﺟﻊ دم ﻣﻦ ﺑﻘﻪ‪.‬‬
‫اى ﻋﻴﺎن ﻋﻨﺪه ‪ acute stress ulcer‬اول ﺣﺎﺟﻪ ﺗﺴﺒﺒﻬﺎ ال ‪،cerebral hemorrhage‬‬
‫ﺗﺎ� ﺣﺎﺟﻪ ﻟﻮ واﺣﺪ اﺗﺤﺮق ﺑﻨﺴﺒﻪ ‪ %20‬ﻣﻦ ال ‪ ،surface area‬ﺗﻤ� ﺑﺪﻳﻠﻪ ﻧﺺ اﻣﺒﻮل‬
‫‪ ،zantac‬ﻳﻌﻨﻰ ﺑﺪﻳﻪ ‪ zantac IV‬ﻷن ﻟﻮ اﻟﻌﻴﺎن ﺷﺮق ال ‪ HCl‬ﻫﻴﺰ�ﺪ وع اﻟﺤﺮ�ﻖ وﻣﻔﻴﺶ‬
‫‪mucous‬واﻟﻌﻴﺎن ﻳﻘﻮم ﻣﺮﺟﻊ دم ﻣﻦ ﺑﻘﻪ و�ﺨﺶ ﻓﻰ ‪ acute ulcer‬ودى ‪.fatal‬‬
‫ﺳﺆﺍﻝ‪ :‬ﺍﺯﺍﻯ ﺗﻌﺮﻑ ﺍﻧﻪ ﻋﻴﺎﻧﻚ ﻋﻨﺪﻩ ‪acute ulcer‬ﻣﺶ ﺍﻯ ‪ulcer‬ﺗﺎﻧﻴﻪ ﺳﻮﺍء‬
‫‪chronic‬ﺍﻭ ‪whatever‬؟‬
‫ﺑﺤﺎﺟﻪ واﺣﺪه ؟ ﻫﺎ ؟ﺑﺎل ‪ ،size‬ال ‪ ،acute ulcer small‬ﻳﻌﻨﻰ اﻳﻪ ‪ small‬دى؟ ﻳﻌﻨﻰ‬
‫ﻣﺘﺰ�ﺪش ﻋﻦ ‪ 1 cm‬وﻣﺘﻮﺻﻠﺶ اﺑﺪا ﻻﻛﺮﺘ ﻣﻦ ﻛﺪه‪.‬‬
‫ﻻزم ﻋﺸﺎن اﻋﺮف ال ‪ stress ulcer‬اﻗﻮل اﻧﻬﺎ ‪ ،multiple superficial‬ﺑﺲ اﻫﻢ ﺣﺎﺟﻪ‬
‫اﻧﻬﺎ اﻗﻞ ﻣﻦ ‪ ،1 cm‬اﻛﺘﺒﻮ ﻋﻠﻴﻬﺎ ﻛﺎﺗﻴﺠﻮرى ‪ ،A‬ﻫﻰ ﻣﻬﻤﻪ ﺟﺪا ‪.clinically‬‬
‫‪Peptic ulcer‬‬
‫اﻛﺘﺒﻮ ﻋﻠﻴﻬﺎ ﻛﺎﺗﻴﺠﻮرى ‪ ،A‬ده اﳌﻮﺿﻮع اﻻﺳﺎﻰﺳ ﺑﺘﺎﻋﻨﺎ‪ ،‬ﻧﻈﺮى و ﺟﺎر و ‪ case‬و ‪،class A‬‬
‫دى ﺗﺎ� ﺣﺎﺟﻪ اﻟﻨﻬﺎرده ﻛﺎﺗﻴﺠﻮرى ‪ A‬ﺑﻌﺪ ال ‪.chronic gastritis‬‬
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‫‪Flash Notes in Pathoogy | From chronic gastritis to dysentery‬‬
‫ال ‪peptic ulcer‬ﻧﻈﺮى وﺟﺎر ﻋﻨﺪﻛﻢ ﻣﻨﻬﺎ ‪ 3‬ﺟﺎرات ﺑﻴﺸﻄﺒﻮ واﺣﺪ وﻋﻠﻴﻜﻢ ﻣﻬﻢ ‪.2‬‬
‫‪ literally‬ﻳﻌﻨﻰ ﺍﻳﻪ ‪peptic‬؟‬
‫ﻟﻴﻪ ﺳﻤﻮا ال ‪pepsin pepsin‬؟ ال ‪ peptic‬ﻳﻌﻨﻰ اﻟﻬﻀﻤﻰ‪ ،‬ال ‪ peptic ulcer‬ﻣﻌﻨﺎﻫﺎ‬
‫اﻟﻘﺮﺣﻪ اﻟﻬﻀﻤﻴﻪ ده ﺑﺎﻟﻌﺮﺑﻲ‪ ،‬ال ‪ pepsin‬ﺗﺴﻤﻴﻪ ﺧﺎﻃﺌﻪ ﻻن اﳌﻌﺪه ﻣﺶ ‪site for‬‬
‫‪.digestion‬‬
‫ﺍﻝ ‪ peptic ulcer‬ﺩﻯ ‪acute‬ﻭﻻ ‪chronic‬؟‬
‫‪ ،chronic‬ﻃﺐ دى ‪ disease‬وﻻ ﺣﺎﺟﻪ ﻓﻜﻠﻴﻪ زراﻋﻪ ؟ ‪disease‬ﻳﺒﻘﻰ ﻻزم ﺗﺒﺪا ب‬
‫‪.definition‬‬
‫‪Definition‬‬
‫ال ‪ peptic ulcer‬ﻣﻦ ﺣﻴﺖ اﻟﺘﻌﺮ�ﻒ وﺗﺤﻴﻪ ﻟﻠﻤﺆﻟﻒ ﻻﻧﻪ ﻛﺎﺗﺐ اﻟـ‪ site‬ﻣﻌﺎه ﻻن ال‬
‫‪ definition‬ﺑﻴﻌﺮﻓﻨﻰ ال ‪.site‬‬
‫‪ simply‬ده ‪ ،defect‬ﻣﺶ ال ‪ ulcers‬ﻋﻤﻮﻣﺎ ‪defects‬؟‬
‫ﻳﺒﻘﻰ ‪ simply‬ده ‪ defect‬ﻓﻰ اى ‪portion‬ﻓﺎل ‪ GIT‬ﺑﺴﺒﺐ ‪ combined action‬ﺑﺎل‬
‫‪HCl‬وال ‪.pepsin‬‬
‫ﻳﺒﻘﻰ ﻫﻰ ‪ defect‬ﻓﻰ ال ‪ GIT‬ﻓﻰ اى ﻣﻜﺎن ﺑﺲ ﻳﻜﻮن ﺑﺴﺒﺐ ز�ﺎده اﻟﻬﻀﻢ ﺑﻔﻌﻞ ال‬
‫‪pepsin & HCl‬ﻋﺸﺎن ﻛﺪه ﺳﻤﻮﻫﺎ اﻟﻘﺮﺣﻪ اﻟﻬﻀﻤﻴﻪ‪.‬‬
‫‪Site‬‬
‫ﻻزم ﺑﻌﺪﻫﺎ ﻋ� ﻃﻮل ﺗﻘﻮل ال ‪site‬؛ ﻻن اﻟﻄﻠﺒﻪ اﻏﻠﺒﻬﻢ ﻣﺶ ﻓﺎﻫﻤ�‪ normally ،‬ﻳﺎ‬
‫دﻛﺎﺗﺮه ال ‪peptic ulcer‬ﺑﺘﺤﺼﻞ ﻓﻰ ﺧﻤﺲ ﺣﺘﺖ ﻣﻠﻬﻤﺶ ﺳﺎدس‪.‬‬
‫ﻓﻰ راﻳﻚ‪ ،‬اﻳﻪ اﺷﻬﺮ ﺣﺘﻪ ﺗﺤﺼﻞ ﻓﻴﻬﺎ ‪peptic ulcer‬؟‬
‫ال ‪ stomach‬وﻻ ال ‪duodenum‬؟‬
‫ال ‪ ،duodenum‬ﳌﺎذا؟ ﻟﻮ ﻛﺎن ال ‪ peptic ulcer‬ﻻزم ﻳﻜﻮن ﻣﻌﺎﻫﺎ اﺳﻴﺪ ﻋﺎﻰﻟ ﻓﺎﺷﻬﺮ ﺣﺘﻪ‬
‫ﺗﻄﻠﻊ ﻓﻴﻬﺎ ﻫﻰ ال ‪ ،duodenum‬اﺷﻤﻌﻨﻰ؟ ﻟﻢ ﻳﺨﻠﻖ اﻧﻪ ﻳﺴﺘﺤﻤﻞ ‪hyper acidity‬‬
‫ﻓﻬﻤﺘﻮ ﺣﺎﺟﻪ؟‬
‫اوﺿﺤﻬﺎ اﻛﺮﺘ‪ :‬اﻟـ ‪ peptic ulcer by definition‬ﻫﻰ ﻋﺒﺎره ﻋﻦ ‪ defect‬ﻓﻰ اى ‪portion‬‬
‫ﻓﻰ ال ‪GIT‬ﺑﺴﺒﺐ ز�ﺎده اﻟﻬﻀﻢ ﺑﺎل ‪HCL‬وال ‪.pepsin‬‬
‫اﻟـ ‪site‬ﻋﺸﺎن ﺗﻌﺮﻓﻮه ﺑﺼﻮا ﻣﻌﺎﻳﺎ ﻋ� ﻫﺬا اﻟﺪﻳﺎﺟﺮام‪ ،‬ﻫﺬا اﻟﻔﻴﺪﻳﻮ ﻓﻴﻪ ‪oesophagus‬‬
‫و ‪ stomach‬و ‪ duodenum‬و ‪ ،small intestine‬اﺷﻬﺮﺣﺘﻪ ﺗﻄﻠﻊ ﻓﻴﻬﺎ ال ‪peptic‬‬
‫‪ ulcer‬ﻫﻰ ال ‪ ،duodenum‬ال ‪ duodenum‬ﻛﺎم ‪part‬؟‪ ، 4‬اول ‪ part‬ﻛﺎم ‪inch‬؟ ‪2‬‬
‫واﻟﺘﺎ� ‪ 3‬واﻟﺘﺎﻟﺖ ؟‪ 4‬واﻟﺮاﺑﻊ ؟‪.1 inch‬‬
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‫‪Flash Notes in Pathoogy | From chronic gastritis to dysentery‬‬
‫ﻳﺒﻘﻲ ﻛﻠﻬﺎ ﻋ� ﺑﻌﻀﻬﺎ ﻛﺎم ‪inch‬؟‪ ،10‬اﻣﺎل ﺑﻴﺴﻤﻮه اﻻﺛﻨﻰ ﻋﺸﺮ ﻟﻴﻪ ؟ ﻷﻧﻪ ‪ 12‬ﺻﺒﺎع‪،‬‬
‫ﻣﺎﻧﺘﻮا ﺷﺎﻃﺮ�ﻦ اﻫﻮ‪ ،‬ﺣﺪ ﻣﺶ ﻋﺎرف اﻰﻟ ﺑﻘﻮل ده ؟ ﻛﻠﻜﻢ ﻋﺎرﻓﻴﻨﻪ ؟ اﻻﺛﻨﻰ ﻋﺸﺮ ﻟﻴﺲ ﺑﺎﺛﻨﻰ‬
‫ﻋﺸﺮ‪.‬‬
‫اﺷﻬﺮ ﺣﺘﻪ ﺗﻄﻠﻊ ﻓﻴﻬﺎ ‪ peptic ulcer‬ﻫﻮ ال ‪ 1st inch‬ﻣﻦ ال ‪ ،1ST part‬اﺷﻤﻌﻨﻰ ؟ ال ‪1st‬‬
‫‪part‬ﻟﻪ ﻛﺎم ‪inch‬؟ ‪ ،2‬ﺗﻄﻠﻊ ﻓﻰ اﻧﻬﻰ ﻣﻨﻬﻢ ؟ اﻟﺘﺎ�‪ ،‬اﺷﻤﻌﻨﻰ ؟ ﻻن دى اول ﺣﺘﻪ ﻫﻴﺪﺧﻞ‬
‫ﻓﻴﻬﺎ ال ‪HCL‬ﺑﺎل ‪ concentration‬ﺑﺘﺎﻋﻪ‪ ،‬ﻛﻞ ﻣﺎﻧﻨﺰل ﻛﻞ ﻣﺎ ال ‪ conc.‬ﻳﻘﻞ‪ ،‬ﺑﺘﺤﺼﻞ‬
‫ﻫﻨﺎ ﺑﻨﺴﺒﻪ ‪%80‬‬
‫‪st‬‬
‫‪st‬‬
‫‪ %80‬ﻣﻦ اﻟﻘﺮﺣﻪ اﻟﻬﺎﺿﻤﻪ ﺑﺘﺤﺼﻞ ﻓﻰ ال ‪ 1 inch‬ﻣﻦ ال ‪.1 part of duodenum‬‬
‫ﻳﻠﻴﻬﺎ ﻓﻴﻦ ؟‬
‫ﻫﻨﺎ ﻓﻰ ال ‪ ،stomach‬ﻓ�؟ ﻓﻰ ال ‪ antrum‬او ال ‪ cardia‬ﻓﻮق ﺑﻨﺴﺒﻪ ‪ %18‬ﻫﻨﺎ‪،‬‬
‫اﺷﻤﻌﻨﻰ ؟ﻫﻞ اﻟـ ‪ stomach‬ﻳﻴﺠﻰ ﻓﻴﻬﺎ ‪ ulcer‬ﻋﺸﺎن ز�ﺎده ال ‪ HCL‬وﻻ ﻧﻘﺺ اﻟﺤﻤﺎﻳﻪ‬
‫ﻣﻨﻬﻢ؟‬
‫ﻧﻘﺺ اﻟﺤﻤﺎﻳﻪ ﻣﻨﻬﻢ‪ ،‬ﻃﺐ اﺷﻤﻌﻨﻰ ﻓﻰ اﻟﺤﺘﻪ دى ﺑﺎﻟﺬات ؟‬
‫دى ﺑﺮدو ﺣﺎﺟﻪ ‪ ،anatomy‬ﻟﻮ اﻧﺎ ﻛﻠﺖ اﻛﻞ ‪ normally‬اﻻﻛﻞ ده ﻳﻘﻊ ﻛﺪه ؟ اﻣﺎل ﻳﻠﻒ‬
‫ﻛﺪه ؟ اه اﻻﻛﻞ ﻳﻠﻒ ﻛﺪه و�ﺘﺠﻤﻊ ﻟﺤﺪ ﻣﺎ ﻳﻤ� ال ‪stomach‬ﻛﻠﻬﺎ؛ ﻻن ﻓﻴﻪ ‪mucosal‬‬
‫‪fold‬ﻋﻨﺪ ال ‪lesser curvature‬ﺑﻴﺴﻤﻮﻫﺎ ‪ ،trans magnum‬ﻓﺎﻛﺮ�ﻦ ال ‪trans‬‬
‫‪magnum‬؟ ﻓﺎﻛﺮ�ﻨﻪ؟ ده ‪mucosal fold‬ﻛﺒ� اﻟ� ﻛﺎﻧﻮ ﺑﻴﺴﻤﻮه ﺷﺎرع اﳌﻌﺪه‪،‬‬
‫ﻣﺨﺪﺗﻮﻫﻮش؟‬
‫اﳌﻬﻢ‪ ،‬اﻛﺮﺘ ﺣﺘﻪ ال ‪ ،antrum‬ﺑﻴﻴﺠﻰ ﻋﻠﻴﻬﺎ اﻻﻛﻞ وﺗﻴﺠﻰ ﻓﻴﻬﺎ ال ‪ulcer‬ﺑﻨﺴﺒﻪ ‪%18‬‬
‫وﺑﻴﺠﻴﺒﻮﻫﺎ ﻛﻞ ﻣﺮه ﻓﻰ اﻻﻣﺘﺤﺎن‪ ،‬اﻳﻪ اﻛﺮﺘ ﺣﺘﻪ ﺗﺤﺼﻞ ﻓﻴﻬﺎ ‪peptic ulcer‬؟‬
‫‪st‬‬
‫ال ‪ stomach‬وﻻ ال ‪duodenum‬؟ ال ‪ duodenum‬ﻓ� ﺑﺎﻟﻈﺒﻂ ؟ ال ‪1 inch of‬‬
‫‪ the 1st part‬وﻋﺸﺎن ﻛﺪه ﺷﺮﺣﺖ اﻻﻧﺎﺗﻮﻣﻰ ﺑﺘﺎﻋﻪ‪.‬‬
‫ﺗﺎ� ﻣﻜﺎن ﻓﻰ ال ‪ ،stomach‬ﻓ� ؟ ال ‪ antrum‬وال ‪ ،cardia‬ﻓ� ؟ﻋﻨﺪ ال ‪lesser‬‬
‫‪.curvature‬‬
‫ﻳﻠﻴﻬﺎ ﺑﻌﺪ ﻛﺪﻩ ﺗﺎﻟﺖ ﻣﻜﺎﻥ‪:‬‬
‫اﻟـ ‪ lower end of the oesophagus‬ﳌﺎ ﻳﺼﻠﻬﺎ ‪ ،HCl & pepsin‬اﻣﺘﻰ ﻳﻮﺻﻠﻮﻟﻬﺎ ؟ﻓﻰ‬
‫ﺣﺎﻻت ال ‪Barret oesophagus‬ـ‪ ،‬ده رﻗﻢ ‪3‬‬
‫ﺑﻌﺪ ﻛﺪﻩ ﻳﻴﺠﻰ ﻓﻴﻦ ؟‬
‫ﻓﻰ ال ‪ ،jejunum‬ﻳﺎ ﻧﻬﺎر اﺑﻴﺾ؟؟؟ اﻟـ ‪ jejunum‬ﻛﻤﺎن ﺑﻴﻮﺻﻠﻪ ‪HCl & pepsin‬؟؟ اه‪،‬‬
‫ﻓﻴﻪ ﻧﺎس ﺑﻴﺠﻴﻠﻬﺎ ﺳﺎﻋﺎت ‪ cancer head of pancreas‬وده ‪ ،very common‬اﻟﻌﻴﺎن‬
‫ﻛﺪه ﻳﻘﺪر ﻳﺎﻛﻞ ﻻ ؟ ﻫﻴﻤﻮت ﻣﻦ اﻟﺠﻮع ﻓﻴﻘﻮﻣﻮا ﻳﻌﻤﻠﻮ ﻋﻤﻠﻴﻪ ﻛﺒ�ه ﺟﺪا ﻣﺶ ﻟﻠﻌﻼج وﻟﻜﻦ‬
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‫‪Flash Notes in Pathoogy | From chronic gastritis to dysentery‬‬
‫ﻛﻤﺤﺎوﻟﻪ ﻟﺘﺤﺴ� اﳌﻮﻗﻒ‪ ،‬اﻟﻌﻤﻠﻴﻪ اﺳﻤﻬﺎ ‪ gastrojejunostomy‬ﻳﻌﻨﻰ إﻳﻪ ؟وﺻﻠﻮا‬
‫اﳌﻌﺪه ﺑﺎل ‪ jejunum‬ﺑﻌﺪ ﻣﺎ ﺷﺎﻟﻮا اﻟـ‪.duodenum‬‬
‫دى ﻋﻤﻠﻴﻪ ﺑﻴﺴﻤﻮﻫﺎ ‪ ،bypass‬ﻋﻤﻠﻴﺎت اﻟﺴﺒﺎﻛﻪ‪ ،‬واﻟﺘﺴﻤﻴﻪ ﻛﺎﻟﺘﺎﻰﻟ ‪from proximal to‬‬
‫‪ distal‬وﻧﺤﻂ ال ‪ suffix -ostomy‬ﻟﻴﻪ ؟ ﻻن ﻟﻮ ﻋﻤﻠﻨﺎ ال ‪ suffix otomy‬ﻳﻌﻨﻰ ﺧﺮم‬
‫‪ otomy‬ﻳﻌﻨﻰ ﺧﺮﻣﻨﺎ‪ ،‬وﻟﻮ ﺣﻄﻴﻨﺎ ‪ ectomy‬ﻳﻌﻨﻰ ﺷﻠﻨﺎ‪ ،‬اﻣﺎ ‪ ostomy‬ﻳﻌﻨﻰ ﻓﺘﺤﻨﺎ ده ﻋ�‬
‫ده ﻳﻌﻨﻰ ﻋﻤﻠﻨﺎ ﻛﺪه ‪ fistula‬ﺑﻠﻐﻪ اﻟﺒﺎﺛﻮﻟﻮﺟﻰ‪.‬‬
‫ﺑﺲ ﺑﺘﻮع اﻟﺠﺮاﺣﻪ ﻣﻴﻘﻮﻟﻮش ‪ ،fistula‬ﻳﻘﻮﻟﻮا ‪.ostomy‬‬
‫ﻟﻮ واﺣﺪ ﻋﻨﺪه ﻣﺼﻴﺒﻪ ورﺣﻨﺎ ﻣﻮﺻﻠﻴﻨﻠﻪ ال ‪ jejunum‬ﺑﺎل ‪ stomach‬ﺑﻬﺬا اﻟﺸﻜﻞ ﻳﺤﺼﻞ‬
‫ان ال ‪HCl‬ﺣﻴﺨﺒﻂ ﻓﻰ ال ‪ edge‬دى و�ﺤﺼﻞ ‪ ulcer‬ﻓﻰ ال ‪ ،jejunum‬اﻣﺘﻰ؟‬
‫ﻓﻰ ﺣﺎﻻت ال ‪ ،gastrojejunostomy‬ال ‪ulcer‬دى ﺑﺘﻮع اﻟﺠﺮاﺣﻪ ﻳﺴﻤﻮﻫﺎ ‪stomal‬‬
‫‪ ،ulcer‬ﻳﻌﻨﻰ اﻳﻪ ‪stomal‬؟ ﺧﺮم‪.‬‬
‫ﺍﻳﻪ ﻛﻤﺎﻥ ؟‬
‫ﻟﺤﺪ دﻟﻮﻗﺘﻰ اﺷﻬﺮ ﻣﻜﺎن ال ‪ duodenum‬وﺑﻌﺪﻳﻦ ال ‪ stomach‬وﺑﻌﺪﻳﻦ ال‬
‫‪ ،oesophagus on top of Barrett's oesophagus‬وﺑﻌﺪﻳﻦ ﺗﺤﺼﻞ ﻓﻰ ال‬
‫‪.jejunum on top of gastrojejunostomy‬‬
‫وﺑﻌﺪﻳﻦ ﻓﻴﻪ ﻣﻦ ‪ 1‬ل ‪%3‬ﻣﻦ اﻟﺒﺸﺮ ﺑﻴﺒﻘﻲ ﻋﻨﺪﻫﻢ ﺣﺎﺟﺔ اﺳﻤﻬﺎ ‪Meckel's‬‬
‫‪ diverticulum‬وده ‪ bulge in small intestine‬ﻓﻴﻪ ‪ectopic gastric tissue‬‬
‫و�ﺤﺼﻞ ‪.peptic ulcer‬‬
‫ﻳﺒﻘﻲ ‪:to summarize‬‬
‫* اول ﺣﺘﻪ اﻧﺎ ﻋﺎوزﻫﺎ ﺗﺘﻘﺎل ﺻﺢ‪ ،‬ﻣﺤﺪش ﻳﻘﻮﻰﻟ ال ‪ ،duodenum‬ﻗﻮل ال ‪1st inch of‬‬
‫‪1st part of duodenum‬‬
‫* ال ‪ stomach‬ﻓ� ؟ ‪ ،lesser curvature of antrum‬ﻳﺎ اﻣﺎ ﻳﺒﻘﻰ ﻣﻦ ﺗﺤﺖ ﻋﻨﺪ ال‬
‫‪ lesser curvature‬ﻓﻰ ال ‪ ،pylorus‬ﻳﺎ اﻣﺎ ﻳﺒﻘﻰ ﻋﻨﺪ ال ‪.cardia‬‬
‫* ﺑﻌﺪ ﻛﺪه اﳌﺮئ‪ ،‬ﻓ� ﻳﻌﻨﻰ ؟ ‪.Barret oesophagus‬‬
‫*ﻧﻤﺮه ‪ 4‬ﻓﻰ ال ‪ ،jejunum‬ﻟﻴﻪ ؟ ﻓﻰ ال ‪ stoma ulcer‬ﻓﻰ ﺣﺎﻻت‬
‫‪.gastrojejunostomy‬‬
‫*اﺧﺮ ﺣﺎﺟﻪ ال ‪ Meckel's diverticulum‬ﻻﻧﻪ ﻓﻴﻪ ‪ ،ectopic gastric tissue‬ﻣﻤﻜﻦ‬
‫واﺣﺪ ﻳﺘﻮﻟﺪ ﻋﻨﺪه ‪ Meckel‬ﻣﻦ ﻏ� ‪.ectopic gastric tissue‬‬
‫‪Etiology‬‬
‫ﻻن ﻫﻨﺎ ﻓﻴﻪ ﻣﺼﻴﺒﻪ ﺣﺎﺻﻠﻪ واﻧﺘﻮ ﻣﺶ واﺧﺪﻳﻦ ﺑﺎﻟﻜﻢ ﻣﻨﻬﺎ‪.‬‬
‫ﻣ� اﻫﻢ ﻣﻜﺎن ﺗﻄﻠﻊ ﻓﻴﻪ ‪peptic ulcer‬؟‬
‫اﺣﻨﺎ اﺗﻜﻠﻤﻨﺎ ﻋﻦ ‪ def.‬و ‪ ،site‬دﻟﻮﻗﺘﻰ اﻳﻪ ﺳﺒﺐ ال ‪peptic ulcer‬؟‬
‫ﻗﺒﻞ ‪ 2008‬ﻛﺎن ﻳﻘﻮﻟﻚ ال ‪ ،exact etiology is unknown‬اول ﻣﺎ اﳌﺆﻟﻒ ﻛﺘﺐ ﻛﺘﺐ ال‬
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Flash Notes in Pathoogy | From chronic gastritis to dysentery
‫ اﻧﺖ ﺗﺼﻠﺢ اﻟﻐﻠﻄﺔ‬،stress ‫ وﻣﻨﻬﻢ ال‬sex ‫ وال‬age ‫ ﺑﻌﺪ ال‬predisposing factors
.predisposing factors‫ ﻣﻊ اﻟـ‬age & sex‫دى ﺑﺎﻧﻚ ﺗﺤﻂ اﻟـ‬
Predisposing factors
‫؟‬stomach �‫اﻳﻪ اﻰﻟ ﻳﻐﻠﺲ ﻋ‬
.‫ ﺗﻨﻔﻊ ؟ اه‬spicy food ‫ وال‬stress ‫ال‬
.‫؟ اه‬spirits ‫ال‬
.‫؟اه‬smoking ‫ال‬
.‫؟ ﻷ ﻃﺒﻌﺎ‬sharp tooth ‫ ﻳﻨﻔﻊ‬،‫؟ ﻻ‬syphilis ‫ﻳﻨﻔﻊ‬
‫ ﻓﻬﻤﺘﻮا ؟‬،stress ‫ وال‬nonsteroidal ‫ ﺗﻨﻔﻊ وال‬steroids ‫ ﺗﺎﻧﻴﻪ زى ال‬S ‫ﻓﻴﻪ‬
.‫ﻣﺎ ﻫﻮ ده اﻰﻟ ﻣﻜﺘﻮب ﻋﻨﺪﻛﻢ‬
gastric ‫ و‬duodenal ‫ ال‬peptic ulcer ‫ ده اﺗﻠﻐﻰ؛ ﻻن اﻰﻟ ﻳﻬﻤﻨﺎ ﻓﻰ ال‬2008 ‫ﺑﻌﺪ‬
etiology of peptic ‫ اﳌﺆﻟﻒ ﻛﺘﺐ اﻟ� ﻛﻨﺎ ﺑﻨﻘﻮﻟﻪ زﻣﺎن وراح ﺣﻂ ﺑﻌﺪﻫﺎ ال‬،‫ﺑﺎﻟﺮﺘﺗﻴﺐ‬
duodenal ‫ وﻛﺘﺐ ال‬،pathogenesis ‫ ﻛﺎﺗﺒﻪ‬etiology ‫ ﺑﺲ ﻣﺶ ﻛﺎﺗﺒﻪ‬،ulcer
.‫ﻟﻮﺣﺪﻳﻬﺎ‬gastric peptic ulcer ‫ﻟﻮﺣﺪﻳﻬﺎ وال‬peptic ulcer
Duodenal peptic ulcer
:2H ‫ﺑﺘﺎﻋﺘﻬﺎ‬predisposing factor ‫ ال‬duodenal peptic ulcer ‫اﳌﺆﻟﻒ ﻗﺎﻟﻚ اﻟـ‬
:hyperacidity ‫ ﺍﻟـ‬H ‫ﺍﻭﻝ‬
.hyperacidity �‫ﻣﻦ ﻏ‬duodenal peptic ulcer ‫ﻣﻔﻴﺶ‬
... ‫اﻟﻌﺎﻰﻟ‬HCL ‫ ﺗﺴﺘﺤﻤﻞ ال‬duodenum ‫؟ ﻻن رﺑﻨﺎ ﻣﺨﻠﻘﺶ ال‬HCL ‫ﻟﻴﻪ ﻻزم‬
‫؟‬hyperacidity ‫ﺍﻳﻪ ﺍﺳﺒﺎﺏ ﺍﻝ‬
HCL formation ‫ اﳌﻴﻜﺎﻧﻴﺰم ﺑﺘﺎﻋﺔ‬،‫؛ ﻻن اﻧﺘﻮ اﻛﻴﺪ ﻣﺶ ﻓﺎﻛﺮ�ﻨﻪ‬physiology ‫ﻫﺮﺟﻊ ﻟﻞ‬
�‫ اﻟ‬gastrin cells ‫ ﺗﻴﺠﻰ ﻋ� ال‬،vagus ‫ﻗﺎﻟﻮ زﻣﺎن ﻓﻴﻪ اﺷﺎرات ﺑﺘﻨﺰل ﻣﻨ�؟ ﻣﻦ ال‬
�‫ ﻳﺸﺘﻐﻞ ﻋ‬gastrin ‫ اﻟ� ﺑﺘﻄﻠﻊ اﻳﻪ ؟‬،‫ﻣﻮﺟﻮده ﻓ� ؟ ﻓﻰ اﳌﻌﺪه ﺑﺲ اﻛﺮﺘ ﻣﻨﻬﺎ اﻟﺒﻨﻜﺮ�ﺎس‬
.‫ ﺻﻌﺒﻪ دى‬HCL ‫ وﺗﻄﻠﻊ‬parietal cells ‫ال‬
:H. pylori ‫ﺍﻝ‬number 1 ‫ ﻻﺯﻡ ﺗﺤﻂ ﻛﺪﻩ‬hyperacidity ‫ﻓﻲ ﺃﺳﺒﺎﺏ ﺍﻝ‬
‫ازاى ؟‬HCl ‫ ﺗﻄﻠﻊ ال‬H. pylori ‫ال‬
predisposing ‫ زﻣﺎن ﻳﻘﻮﻟﻚ ده‬،‫ ده اﺷﻬﺮ ﺳﺒﺐ‬،chemoreceptors ‫ ﻋ� ال‬effect
‫ ﺑﺲ‬Pylori ‫ ﻋﻨﺪﻫﻢ‬peptic ulcer ‫ ﻛﺎﻧﻮ ﻳﻘﻮﻟﻮا ان ﻣﻌﻈﻢ اﻟﻨﺎس اﻟ� ﻋﻨﺪﻫﻢ‬،factor
.‫ ﻣﻦ اﻟﺤﺎﻻت‬100% ‫ﻣﺒﺘﺤﺼﻠﺶ ﻓﻰ‬
Zollinger Ellison ‫ﺣﺎﺟﻪ ﺍﺳﻤﻬﺎ‬hyperacidity ‫ﺗﺎﻧﻰ ﺍﺷﻬﺮ ﺣﺎﺟﻪ ﻓﺎﻝ‬
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‫‪Flash Notes in Pathoogy | From chronic gastritis to dysentery‬‬
‫‪:syndrome‬‬
‫ﺧﺪﺗﻮﻫﺎ؟ اﻧﺘﻮا ﻣﺨﺪﺗﻮش ﺣﺎﺟﻪ؟؟!‬
‫ﻫﻘﻮﻟﻬﺎ‪ ،‬ال ‪ Zollinger Ellison syndrome‬ﻣﺎ ﻫﻮ اﻻ ‪pancreatic gastrinoma‬‬
‫ﻳﻌﻨﻰ ده ‪ benign tumor‬ﺑﻴﻴﺠﻰ ﻓﻰ ال ‪ ،pancreas‬ال ‪ gastrinoma‬ﻫﺘﻄﻠﻊ ‪gastrin‬‬
‫ﻛﺘﻴ� وﺑﺎﻟﺘﺎﻰﻟ ﻫﺘﺸﺘﻐﻞ ﻋ� ال ‪ ،parietal cells‬ﻓﺎذن ﻓﻴﻪ ‪hyperacidity‬ﻓﻴﻌﻤﻠﻨﺎ‬
‫‪.duodenal peptic ulcer‬‬
‫ﺍﺧﺮ ﺳﺒﺐ ‪:chronic stress‬‬
‫ﻫﻮ ﻋﻤﻮﻣﺎ ال ‪stress‬ﺑﻴـ ‪stimulate‬ال ‪ sympathetic‬وﻻ ال ‪para‬؟‬
‫ال ‪ aute stress‬ﺑﻴﺤﻔﺰ اﻟﺴﻴﻤﺒﺎﺛﻴﺘﻴﻚ‪ ،‬ﻟﻜﻦ ال ‪ chronic stress‬ﺑﻴﺤﻔﺰ اﻟﺒﺎرا‪ ،‬اﻳﺎم‬
‫اﻻﻣﺘﺤﺎﻧﺎت ﺑﺘﺒﻘﻰ داﺧﻞ ﺧﺎرج ﻋﺎﻟﺤﻤﺎم ﻟﻴﻪ ؟ده اﻧﺖ ﺑﺮﺘﺟﻊ ‪ 50‬ﻣﺮه‪ ،‬ال ‪acute stress‬‬
‫‪ stimulates sympathetic‬وال ‪ ،chronic stimulate parasympathetic‬ﻳﺒﻘﻰ‬
‫ﻓﻴﻪ ‪ increase‬ﻲﻓ اﻟـ ‪.vagal tone‬‬
‫ﻳﺒﻘﻲ ﺍﻟـ ‪ hyperacidity‬ﻟﻪ ‪ 3‬ﺍﺳﺒﺎﺏ‪:‬‬
‫* ‪.H. pylori infection‬‬
‫* ‪.Zollinger Ellison syndrome‬‬
‫* ‪.chronic stress‬‬
‫ﻛﺎﻧﻮا زﻣﺎن ﺣﺎﻃ� ال ‪ predisposing factors of duodenal peptic ulcer‬ﻛﺎﻟﺘﺎﻲﻟ‪:‬‬
‫اول ‪ H‬ال ‪ H. pylori‬وﺗﺎ� ‪ H‬ال ‪ ،hereditary‬ودى أي ﻛﻼم‪.‬‬
‫زﻣﺎن ﻛﺎن ﻳﻘﻮﻟﻚ ال ‪ duodenal peptic ulcer‬اﳌﺸﻜﻠﻪ ﻛﻠﻬﺎ ‪ ،hereditary‬ادﻳﻨﻰ دﻟﻴﻞ ع‬
‫ﻛﻼﻣﻚ؟ ﻗﺎﻟﻚ اﻟ� ﻋﻨﺪﻫﻢ ‪ peptic ulcer‬اﳌﺸﻜﻠﻪ ﺑﺘﺒﻘﻰ ‪ ،familial‬ﻳﻌﻨﻰ اﺑﻮه ﺑﺒﻘﻲ ﻋﻨﺪه‬
‫واﻣﻪ ﻋﻨﺪﻫﺎ وﻫﻜﺬا‪ ،‬ﻗﺎﻟﻮﻟﻪ ازاى ؟؟‬
‫ﻗﺎﻟﻬﻢ اﺻﻞ ال ‪ mucous bicarbonate‬اﻟ� ﺑﻴﺤﻤﻰ ﻓﻴﻪ ‪.genetic defect‬‬
‫ﻫﺎت ﺑﻘﻰ اﻟﺪﻟﻴﻞ اﻟﺘﺎ�؟ ﻗﺎﻟﻚ اﻧﺎ ﻋﻤﻠﺖ اﺣﺼﺎﺋﻴﻪ ﻟﻠﻨﺎس اﻟ� ﻋﻨﺪﻫﻢ ‪duodenal ulcer‬‬
‫ﻟﻘﻴﺖ ﻣﻌﻈﻤﻬﻢ ‪ blood group O‬ﻓﻰ ‪%30‬ﻣﻦ اﻟﻨﺎس‪ ،‬وال ‪ blood groups‬دى‬
‫‪ genetic‬ﻳﺒﻘﻰ ﻫﻰ ﻟﻮ ﻟﻬﺎ ﻋﻼﻗﻪ ﺑﺎل ‪ blood groups‬اذن اﳌﺮض ده ‪ ،genetic‬ﻓﻬﻤﺘﻮا؟‬
‫ﻃﺒﻌﺎ ده أي ﻛﻼم ﻣﻴﺘﺎﺧﺪش ﺑﻴﻪ دﻟﻮﻗﺘﻰ‪ ،‬اوﻋﻮا ﺗﻜﺘﺒﻮا اﻟﻜﻼم ده ﻓﻰ اﻻﻣﺘﺤﺎن‪،‬ﻃﻴﺐ أﻣﺎل‬
‫إﻳﻪ ﺣﻜﺎﻳﺔ ‪ blood group O‬اﻟ� ﺑﻴﻘﻮل ﻋﻠﻴﻬﺎ دى؟‬
‫ﻻﻧﻪ ﻋﻤﻞ اﻟﺮﺳﺎﻟﻪ ﻋ� اﻻوروﺑ� ﻳﻌﻨﻰ ﻋ� اﻟﺴﻼﻟﻪ اﻟﻘﻮﻗﺎز�ﻪ اﻟ� اﻏﻠﺒﻬﻢ ‪blood group‬‬
‫‪O‬؛ ﻻن ﻫﻮ ﻫﻮ ﻧﻔﺲ اﻟﺸﺨﺺ اﻟ� ﻋﻤﻞ ﻧﻔﺲ اﻟﺮﺳﺎﻟﻪ ﻋ� ال ‪cancer stomach‬ﺑﺲ ﻓﻰ‬
‫اﻟﻴﺎﺑﺎﻧﻴ� ﻻن ﻫﻤﺎ اﻰﻟ ﻋﻨﺪﻫﻢ ‪ cancer stomach‬وراح ﻣﻄﻠﻌﻬﺎ اﻧﻬﺎ ‪ common‬ﻓﻰ‬
‫‪ !!!blood group A‬أي ﻛﻼم‪.‬‬
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‫‪Flash Notes in Pathoogy | From chronic gastritis to dysentery‬‬
‫ﻧﺮﺟﻊ ﺗﺎﻧﻰ ﻟﻜﻼﻣﻨﺎ‪:‬‬
‫ﻗﺒﻞ ‪ 2008‬ﻗﺴﻤﻮا اﺳﺒﺎب ال ‪ duodenal peptic ulcer‬ﻟـ ‪:2H‬‬
‫ﻳﺎ ‪ hyperacidity‬ﻳﺎ ‪.hereditary‬‬
‫‪Gastric peptic ulcer:‬‬
‫زﻣﺎن ﻗﺎﻟﻚ ال ‪ gastric‬دى ﻣﻔﻬﺎش ‪H‬؛ ﻻن ﻟﻘﻮا اﻟﻨﺎس اﻟ� ﻋﻨﺪﻫﻢ اﻟـ ‪gastric peptic‬‬
‫‪ulcer‬ﻣﻌﻨﺪﻫﻤﺶ ‪ ،hyperacidity‬ﺑﻞ ﺑﺎﻟﻌﻜﺲ ﻣﻤﻜﻦ ﻳﺒﻘﻰ ﻋﻨﺪﻫﻢ ‪hypoacidity‬‬
‫ﻻن اﻰﻟ ﻫﻴﺎﺛﺮ ﻋ� ال ‪ mucous & bicarbonate‬ﻳﺎﺛﺮ ﻋ� ال ‪parietal cells‬و�ﻌﻤﻞ‬
‫‪ ،achlorhydra‬ﻳﺒﻘﻰ ﻫﻰ ‪.unassociated with hyperacidity‬‬
‫رﻗﻢ ‪ ،not associated with hereditary 2‬ﻣﺒﺘﺘﻮرﺛﺶ اﻣﺎل اﻳﻪ ؟ﻋﻼﻗﺘﻬﺎ ﺑﺎﻳﻪ ؟‬
‫ﻋﻼﻗﺘﻬﺎ ان ﻓﻴﻪ ‪ ،defective gastric protective mechanism‬اﻟﻌﻴﺐ ان اﻟـ‬
‫‪ stomach‬ﺿﻌﻴﻔﻪ‪ ،‬اﺷﻬﺮ ﺳﺒﺐ ﻳﻀﻌﻒ اﳌﻌﺪه ال ‪.H. pylori‬‬
‫ﻃﺐ ﻣﺎ ﺧﻼص ﺧﻠﺼﺖ ﻛﺪه‪ ،‬ﻟﻮ اول ﺳﺒﺐ ﻳﻀﻌﻒ اﳌﻌﺪه ال ‪ H. pylori‬ﻃﺐ ﻣﺎ ﺧﻠﺼﺖ‬
‫ﻛﺪه‪ ،‬ﺧﻼص ده ال ‪.exact etiology‬‬
‫ﻳﺒﻘﻰ اﳌﻔﺮوض ال ‪ H. pylori‬ﻫﻰ اﻟﺴﺒﺐ‪ ،‬ﺑﺲ ﻣﺤﺪش ﺧﺪ ﺑﺎﻟﻪ ﻣﻨﻬﺎ‪ ،‬ﻋﻤﻠﻮا‬
‫‪ investigation‬ﻋ� ﻣﺶ ﻋﺎرف ﻛﺎم واﺣﺪ ﻋﻨﺪﻫﻢ ‪ gastric peptic ulcer‬وﻃﻠﻊ‬
‫ﻣﻌﻈﻤﻬﻢ ﻋﻨﺪﻫﻢ ال ‪ H. pylori‬ﻫﻰ ال ‪.defect‬‬
‫ﻣﻤﻜﻦ ﻳﺒﻘﻰ ﻟﻪ اﺳﺒﺎب ﺗﺎﻧﻴﻪ‪:‬‬
‫* زى ال ‪ ،ischemia‬زى اﻟﻨﺎس اﻰﻟ ﻋﻨﺪﻫﻢ ‪ hypercoagulability‬ﻓﻴﺤﺼﻞ ‪،thrombi‬‬
‫ﻣﺶ ﻫﻴﻄﻠﻌﻮا ‪mucous‬ﺳﺎﻋﺘﻬﺎ و�ﺤﺼﻞ ‪ chronic gastritis‬ﺛﻢ ‪gastric peptic‬‬
‫‪.ulcer‬‬
‫* ﻛﻤﺎن اﻟﻨﺎس اﻟ� ﻋﻨﺪﻫﻢ ‪ ،bile reflux‬اﻟـ ‪ bil‬ﻳﺮﺟﻊ ﻳﻌﻤﻞ ‪.ulcer‬‬
‫* ﻛﻤﺎن اﻟﻨﺎس اﻟ� ﻋﻨﺪﻫﻢ ‪ ،delayed stomach emptying‬ﻓﻴﻪ ﻣﻌﻠﻮﻣﻪ ﻣﻌﺮﻓﺶ‬
‫اﺧﺪﺗﻮﻫﺎ ﻓﺎﻻﻧﺎﺗﻮﻣﻰ وﻻ ﻻ‪ ،‬ﻣ� اﻟ� ﻳﺘﺤﻜﻢ ﻓﻰ ﺷﻜﻞ ال ‪stomah‬؟‬
‫اﻛﻴﺪ ﺧﺪﺗﻮﻫﺎ‪ ،‬ﻣﺶ ﺧﺪﺗﻮا اﻧﺎﺗﻮﻣﻰ؟‬
‫ﻳﻌﻨﻰ ﻟﻮ رﺳﻤﺖ ال ‪ stomach‬ﺑﺘﺎﻋﺘﻰ ﻫﺘﺒﻘﻲ ﻛﺪه ‪ transverse line‬اﻣﺎ ﻟﻮ رﺳﻤﺖ ﺑﺘﺎع‬
‫اﻟﺪﻛﺘﻮره ﻫﺘﺒﻘﻲ ‪ ،vertical line‬ﻫﻞ اﻧﺎ ﻋﺸﺎن ﺗﺨ� ﻓﺪه ﺷﻜﻞ ‪ stomach‬ﺑﺘﺎﻋﺘﻰ ؟‬
‫وﻻ اﻧﺎ ﻋﺸﺎن ﻛﺪه ﺑﻘﻴﺖ ﺗﺨ� ؟ ﻋﺸﺎن ﻛﺪه ﺑﻘﻴﺖ ﺗﺨ�‪.‬‬
‫اﺳﺘﻨﻮا اﻛﻤﻞ‪ ،‬اﳌﻌﺪه ﳌﺎ ﺗﻜﻮن ‪ transverse line‬اﻻﻛﻞ ﻳﻘﻌﺪ ﻓﻴﻬﺎ ﻓﺮﺘه اﻛﺮﺒ‪ ،‬ﻟﻜﻦ اﻟﺪﻛﺘﻮره‬
‫اﻣﺎ ﺗﺎﻛﻞ اﳌﻌﺪه ‪ vertical line‬وال ‪ emptying‬ﺑﺘﺎﻋﻬﺎ ﺳﺮ�ﻊ‪ ،‬ﻓﺒﺎﻟﺘﺎﻰﻟ ﻳﻨﺰل وﻣﺘﻤﺘﺼﺶ‬
‫ﻛﻞ ال ‪ calories‬وﺻﻠﺖ ؟ اﻳﻪ اﻟﻘﺼﻪ؟‬
‫ﻟﻮ واﺣﺪ ﻋﻨﺪه ‪ delayed gastric emptying‬ﻫﻴﻘﻌﺪ اﻷﻛﻞ ﻓﺮﺘه ﻛﺒ�ه ﻓﺒﺎﻟﺘﺎﻰﻟ اﻟـ‬
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Flash Notes in Pathoogy | From chronic gastritis to dysentery
.protection ‫ ﺑﺘﺎع اﻷﻛﻞ ﻫﻴﺰ�ﺪ وﺑﺎﻟﺘﺎﻰﻟ ﻳﻘﻠﻞ ال‬traumatic effect
defect of protective mucosa ‫ اﺷﻬﺮ ﺳﺒﺐ ﻟﻴﻬﺎ ﻫﻮ‬gastric peptic ulcer ‫ﻳﺒﻘﻲ ال‬
:‫اﻟ� ﺑﺴﺒﺐ‬
H. Pylori ‫* ال‬
ischemia ‫* ال‬
duodeno-gastric reflux *
delayed gastric emptying *
mucous/ bicarbonate ‫* ﻧﻘﺺ ال‬
‫ اﻟﻨﺎس اﻟ� ﺑﺘﺎﻛﻞ اﻛﻞ ﻧﺎﺷﻒ زي اﻟﻌﻴﺶ‬،traumatic action of food ‫ﺗﺎ� ﺣﺎﺟﻪ ال‬
.gastric peptic ulcer ‫اﻟﻨﺎﺷﻒ وﻛﺪه ﻳﺠﻴﻠﻬﻢ‬
Pathology
Site:
1. First inch of first part of duodenum (Duodenal peptic ulcer).
2. Lesser curvature of stomach (Gastric peptic ulcer).
Size:
‫ ﻟﻮ‬،endoscope ‫ اﻷﺳﺎﻲﺳ ﻟﻠـ‬role‫ وده ﻣﻔﻴﺶ ﻓﻴﻪ ﻧﻘﺎش ﻋﺸﺎن ده ﻫﻮ اﻟـ‬،‫ ﺳﻢ‬3 ‫ اﻰﻟ‬1 ‫ﻣﻦ‬
.acute ulcer ‫ ﺳﻢ دى‬1 ‫ وأﻗﻞ ﻣﻦ‬،malignant ulcer ‫ ﺳﻢ ﻫﺘﺒﻘﻲ‬3 ‫زادت ﻋﻦ‬
Shape:
‫ ﻳﻌﻨﻰ اﻳﻪ؟‬saddle ‫ ﻣﻤﻜﻦ ﺗﺒﻘﻰ‬stomach ‫ وﻟﻜﻦ ﻓﻰ اﻟـ‬،Rounded or oval
‫ ﻳﻌﻨﻰ‬،‫ وﺗﻤﻰﺸ ﺑﺎﻟﻌﺮض‬lesser curvature ‫ ﻫﺘﺤﺼﻞ ﻓﻰ اﻟـ‬،‫ﻳﻌﻨﻰ زي ﺳﺮج اﻟﺤﺼﺎن‬
.posterior wall ‫ ﻋ� اﻟـ‬lip ‫ و‬anterior wall ‫ ﻋ� اﻟـ‬lip ‫ﻫﺘﺒﻘﻰ ﻟﻴﻬﺎ‬
Edge:
‫ وﺑﻌﺪ ﻛﺪه ﻳﺤﺼﻠﻬﺎ‬sharp ‫ ﻳﻌﻨﻰ ﻫﺘﺒﻘﻰ ف اﻻول‬،non specific ‫ ﻫﺘﺒﻘﻰ‬ulcer ‫ﻫﻨﺎ ال‬
‫ ﻳﻌﻨﻰ ﺑﺘﺒﺪأ‬traumatic ‫ ﺑﺘﺒﻘﻰ‬non specific ulcer ‫ اى‬،sloping ‫ وﺗﻘﻠﺐ‬healing
.sloping ‫ وﺑﻌﺪ ﻛﺪه ﺗﺒﻘﻰ‬sharp
Floor:
‫ وﳌﺎ‬pepsin ‫ وال‬acid ‫ ﻟﻴﻪ ؟ ﻫﻮ ﻣ� اﻟ� ﺑﻴﺎﻛﻞ ؟ ال‬smooth ‫ وﻫﻨﺎ ﺑﺘﺒﻘﻰ‬،‫دى ﻣﻬﻤﺔ‬
.smooth ‫ ﺗﺘﻌﺮﺿﻠﻬﻢ ﻫﺘﺘﺎﻛﻞ ﻫﻲ ﻛﻤﺎن ﻓﺘﺒﻘﻰ‬necrotic debris‫اﻟـ‬
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Flash Notes in Pathoogy | From chronic gastritis to dysentery
Base:
.fibrosis ‫ ﻋﺸﺎن ال‬firm
Under microscope:
superficial ‫ ﻫﺸﻮف ﻲﻓ اﻟـ‬،superficial part & deep part ‫ ﺑﺘﺒﻘﻰ ﻣﻜﻮﻧﺔ ﻣﻦ‬ulcer ‫اى‬
.fibrosis‫ و‬chronic inf. cells ‫ ﻓﻴﻪ‬deep part‫ وﻲﻓ اﻟـ‬necrotic debris ‫ ده‬part
Complications
‫؟‬peptic ulcer ‫ﺍﻳﻪ ﺍﻟﻤﺸﻜﻠﺔ ﻟﻤﺎ ﻭﺍﺣﺪ ﻳﺠﻴﻠﻪ‬
.hematemesis ‫ وﻫﻨﺎ اﺳﻤﻪ‬،(ulcer‫ )ﻓﻮق اﻟـ‬Hemorrhage and bleeding .a
‫ ﻳﻤﻮت اﻻﻧﺴﺎن ﻓﻰ‬duodenal ‫ ﻋ� ﺣﺴﺐ ﻟﻮ ﻫﻰ‬،(ulcer‫ )ﺗﺤﺖ اﻟـ‬Perforation .b
fibrosis‫ )ﻧﺘﻴﺠﺔ اﻟـ‬stenosis & peritonitis ‫ ﻫﻴﺤﺼﻞ‬gastric ‫ ﻟﻜﻦ ﻟﻮ‬,‫ﺳﺎﻋﺘﻬﺎ‬
.(ulcer‫ﻋ� ﻣﺴﺘﻮي اﻟـ‬
‫ ﻫﻴﻤﻮت ﻧﺘﻴﺠﺔ اﻟـ‬duodenum‫ ﻋ� ﺣﺴﺐ ﻟﻮ ﻫﻰ ﻲﻓ اﻟـ‬،�‫ ﻳﺒﻘﻰ ﺗﺎ‬,‫اﻟﺤﺘﺔ دى ﻣﻬﻤﺔ‬
‫ ﻓﻴﻪ‬gastric ‫ ﻟﻜﻦ اﻟـ‬،acute haemorrhagic pancreatitis ‫ واﻫﻢ ﻣﻦ ﻛﺪه‬stenosis
‫ ﻟﻜﻦ ﻟﻮ ﻛﺎﻧﺖ ال‬،peritonitis ‫ و‬stenosis ‫ ﻳﻌﻨﻰ ال‬،‫ﺧﻄﻮرة ﺑﺮﺿﻮ ﺑﺲ ﻫﺘﺒﻘﻰ اﻗﻞ‬
‫ واﻟﻜﺸﺔ اﻟ� ﻫﻴﻌﻤﻠﻬﺎ ﻫﺘﻌﻤﻞ ﺷﻜﻞ ﻫﻨﺴﻤﻴﻪ‬fibrosis ‫ ال‬saddle shape ‫ ﺷﻜﻠﻬﺎ‬ulcer
.‫ ﻳﻌﻨﻰ اﻟﺴﺎﻋﺔ اﻟﺮﻣﻠﻴﺔ‬hour glass shape
‫؟‬malignant ‫ ﻣﻤﻜﻦ ﺗﺘﺤﻮﻝ‬peptic ulcer ‫ﻫﻞ ﺍﻟـ‬
.‫ ﻷ‬duodenum‫ ﻟﻜﻦ اﻟـ‬،stomach ‫ ﻳﻘﻮﻟﻮا اﻳﻮه وﺑﺘﻜﻮن ﻓﻰ اﻟـ‬pathology ‫ﺑﺘﻮع ال‬
‫ ﺑﺲ‬stomach ‫ ﻓﻰ اﻟـ‬change malignant ‫ ﺑﻴﻘﻮﻟﻮا اﻧﻬﺎ ﺗـ‬,‫ﺑﺘﻮع اﻟﺠﺮاﺣﺔ ﻣﻴﻘﻮﻟﻮش ﻛﺪه‬
‫ ﺑﻌﻜﺲ ﺑﺘﻮع اﻟﺒﺎﺛﻮﻟﻮﺟﻰ اﻟ� ﻋﻨﺪﻫﻢ اﻟﻨﺴﺒﺔ‬90% ‫وﺟﻪ اﻻﺧﺘﻼف اﻧﻬﻢ ﺑﻴﻘﻮﻟﻮا ده ﺑﻨﺴﺒﺔ‬
.duodenum ‫ ﻟﻜﻦ اﻻﺗﻨ� ﻣﺘﻔﻘ� اﻧﻬﺎ ﻣﺒﺘﺤﺼﻠﺶ ف‬،1% ‫دى‬
:‫ﺳﺆﺍﻝ ﺑﻴﺴﺄﻟﻮﻩ ﺍﻟﺪﻛﺎﺗﺮﺓ ﻓﻲ ﺍﻟﺸﻔﻮﻱ‬
‫؟‬diseases caused by H. Pylori‫ﺇﻳﻪ ﻫﻰ ﺍﻟـ‬
1. Chronic gastritis.
2. Chronic duodenitis.
3. Chronic duodenal peptic ulcer.
4. Chronic gastric peptic ulcer.
5. Gastric carcinoma & Lymphoma.
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Flash Notes in Pathoogy | From chronic gastritis to dysentery
TUMORS OF THE STOMACH
.‫اﺣﻨﺎ ﻣﻤﻜﻦ ﻧﻘﺴﻤﻬﺎ ﺑﺴﻬﻮﻟﺔ‬
benign tumor ‫ ﻳﺒﻘﻰ ال‬columnar ‫ ﺑﺘﺎﻋﻬﺎ‬epithelium ‫ ﺑﻴﺒﻘﻰ ال‬stomach ‫اﻟـ‬
‫ﻧﺴﻤﻴﻪ اﻳﻪ؟‬
‫( ﻋﺸﺎن ده‬adenopapilloma) adenomatous polyp ‫ ﺑﺲ ﻫﻨﺎ‬،Adenoma
.surface
capillary & cavernous ‫ ﻳﻌﻨﻰ ﻣﻤﻜﻦ ﻳﻄﻠﻊ ﻓﻴﻬﺎ‬BVs ‫ ﻓﻴﻬﺎ‬stomach ‫اﻟـ‬
. hemangioma
.neurofibroma ‫ ﻓﻴﻄﻠﻊ ﻣﻨﻬﺎ‬nerves ‫ ﻓﻴﻬﺎ‬stomach ‫اﻟـ‬
smooth muscles ‫ وﻓﻴﻬﺎ‬,lipoma ‫ ﻳﻌﻨﻰ ﻣﻤﻜﻦ ﺗﻌﻤﻞ‬fat cells ‫ ﻓﻴﻬﺎ‬stomach ‫اﻟـ‬
.leiomyoma ‫ﺗﻌﻤﻞ‬
‫ او‬lymphoma ‫ ﺑﺎﺧﺘﻼف اﻧﻮاﻋﻬﺎ او‬sarcoma & carcinoma ‫ ﺗﻌﻤﻞ‬malignant ‫اﻟـ‬
.GIST
‫(؟‬gastrointestinal stromal tumor) ‫ ﺩﻯ‬GIST ‫ﺍﻳﻪ ﺣﻜﺎﻳﺔ ﺍﻝ‬
Kajal ‫ ﻟﺤﺪ ﻣﺎ ﻓﻴﻪ واﺣﺪ اﺳﻤﻪ‬،leiomyoma ‫ ﻛﺎﻧﻮا ﻓﺎﻛﺮ�ﻨﻬﺎ‬1968 ‫دى ﻟﻐﺎﻳﺔ ﺳﻨﺔ‬
smooth muscles of stomach ‫ ﻣﺶ ﺑﻴﻄﻠﻊ ﻣﻦ‬tumor ‫اﻛﺘﺸﻒ ان اﻟﻨﻮع ده ﻣﻦ اﻟـ‬
.pacemaker cells of smooth muscles ‫ﻟﻜﻦ ﻗﺎل اﻧﻪ ﺑﻴﻄﻠﻊ ﻣﻦ‬
.GIT ‫ ف ال‬SM ‫ ؟؟ ﻋﺸﺎن ﻫﻲ اﻛﺮﺘ ﻣﻜﺎن ﻓﻴﻪ‬stomach ‫ﻃﺐ اﺷﻤﻌﻨﻰ ال‬
‫ ﻣﻤﻜﻦ ﻛﺪه‬,‫ ؟؟ اﻻﺟﺎﺑﺔ ﻣﺤﺪش ﻳﻘﺪر ﻳﺤﺪدﻫﺎ‬benign or malignant ‫ ده‬GIST ‫ﻃﺐ اﻟـ‬
.‫او ﻛﺪه‬
CARCINOMA OF STOMACH
.Category A
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Flash Notes in Pathoogy | From chronic gastritis to dysentery
Definition
1ry malignant neoplasm arising from gastric mucosa.
Commonest in Japan & Australia (Smoked food), but rare in Africa.
Etiology
Age & Sex
More common in males, above 40.
Predisposing factors:
Smoked & spicy food
Smokers
Chronic gastritis
Chronic gastric peptic ulcer
Adenomatous polyp (benign)
•
•
•
•
•
Pathology
Site
Pyloric antrum, lesser curvature & also in cardia.
Gross
:‫ ﺍﺷﻜﺎﻝ‬4 ‫ﻋﻨﺪﻧﺎ‬
‫ دى‬stomach‫ وﻧﻘﻮﻟﻪ أول ﺣﺎﺟﺔ ﻋﺸﺎن اﻟـ‬،‫ وده ﻣﻌﺮوف‬Polypoid fungating .1
.capacious organ
:‫ ﺧﺪﻧﺎﻫﺎ‬malignant ulcer ‫ زى اى‬ulcer ‫ وﻫﻨﺎ ﻫﻨﻮﺻﻒ ﺷﻜﻞ اﻟـ‬،Ulcerative type .2
raised everted edge, rough necrotic floor, indurated base.
:‫ﻋﻨﺪﻧﺎ ﺑﻘﻰ ﺍﻫﻢ ﺍﺗﻨﻴﻦ‬
:‫ وده ﻓﻴﻪ ﻧﻮﻋ� ﻣﻨﻪ‬،Deep infiltrative pattern .3
pyloric ‫ ﻣﻘﺘﺼﺮة ﻋ� اﻟـ‬malignant cells ‫ وده ﺑﻴﺒﻘﻰ اﻟـ‬:Localized infiltrative
pyloric stenosis ‫ وﺑﺘﻌﻤﻞ‬musculosa ‫ وﺑﻴﻨﺘﺸﺮ ﻓﻰ اﻟﺠﺰء ده ﺑﺲ ﻟﻐﺎﻳﺔ اﻟـ‬region
compensatory ‫ ﻛﻨﻮع ﻣﻦ ال‬stomach ‫ ﻓﻰ ﺑﺎﻗﻰ ال‬dilatation ‫وده ﺑﻴﺮﺘﺗﺐ ﻋﻠﻴﻪ‬
.mechanism
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Flash Notes in Pathoogy | From chronic gastritis to dysentery
‫ وﺑﺘﺘﺴﻤﻰ‬،pylorus‫ ﻣﺶ ﺑﺲ اﻟـ‬stomach ‫ وده ﺑﻴﺒﻘﻰ ﻓﻰ ﻛﻞ اﻟـ‬:Diffuse infiltrative
‫ ﻷﻧﻬﺎ ﺑﺘﺒﻘﻲ ﺷﺒﻪ‬،bottle ‫ ﻳﻌﻨﻰ‬linitis،linitis plastica ‫ أو‬leather bottle ‫ﺑﺮﺿﻮ‬
stomach of sheep ‫ﺣﺎﺟﺔ ﻛﺎﻧﺖ ﺑﺘﺘﺸﺮب ﻓﻴﻬﺎ اﳌﺎء اﺛﻨﺎء ﺣﻴﺎة اﻟﺒﺪو ﻣﺴﺘﺨﻠﺼﺔ ﻣﻦ ال‬
.(‫)اﻟﻘﺮﺑﺔ‬
:superficial spreading ‫ اﻣﺎ اﺧﺮ ﻧﻮع ﻓﻬﻮ ال‬.4
‫ ﻟﻜﻦ‬submucosa ‫ وال‬mucosa ‫ ﻓﻴﻪ ﺑﺘﻨﺘﺸﺮ ﻓﻰ ال‬malignant cells ‫وده ال‬
.musculosa ‫ﻣﺒﺘﻌﺪﻳﺶ ﻟﻠـ‬
Microscopy
A. Adenocarcinoma.
.acini ‫ ﻣﺮﺘﺗﺒﺔ ﻲﻓ ﺷﻜﻞ‬malignant cells‫ﻫﻨﺎ اﻟـ‬
B. Mucoid carcinoma.
.‫ ﻃﺎﻟﻊ ﺑﺮه‬mucin‫ﻫﻨﺎ اﻟـ‬
C. Signet cell carcinoma
‫ و ده اﺧﻄﺮ اﻷﻧﻮاع ـ‬،‫ ﺟﻮه‬mucin‫ﻫﻨﺎ اﻟـ‬
D. Undifferentiated carcinoma.
.‫ﻻ ده وﻻ ده‬
prognosis ‫ ﺑﺘﻔﺮق ﻲﻓ اﻟـ‬،microscopic extent of invasion ‫وﻓﻴﻪ ﺣﺎﺟﻪ اﺳﻤﻬﺎ‬
.carcinoma of stomach ‫ﺑﺘﺎع اﻟـ‬
invasion ‫ وده ﺳﺮﻃﺎن ﻣﺒﻴﺤﺼﻠﺶ ﻓﻴﻪ‬superficial spreading type ‫ﻓﻴﻪ ﻋﻨﺪﻧﺎ‬
‫ أو‬infiltrative ‫ وﻓﻴﻪ‬،good prognosis. ‫ﻳﻌﻨﻲ‬submucosa ‫ﺟﺎﻣﺪ ﻳﻌﻨﻲ اﺧﺮه‬
bad ‫ ﻳﻌﻨﻲ‬deeply invasive ‫ و اﻟﻨﻮع ده ﺑﻴﺒﻘﻰ‬advanced gastric carcinoma
prognosis.
Spread:
A. Direct: Pancreas, Colon, Liver and Spleen.
B. Lymphatic: gastric, celiac , paraaortic lymph nodes.
C. Blood: liver then lung, bone, …
D. Transcoelomic spread:
* Peritoneal metastasis & Hemorrhagic ascites.
* Krukenberg tumors.
Complications
HIDML (hemorrhage/infection/distal carcinoma ‫ ﺑﺘﺎﻋﺔ أي‬Effects‫زي اﻟـ‬
‫ ﻋﺸﺎن‬2ry infection ‫ ﺑﺲ ﻫﻨﺎ ﻣﺶ ﻫﻨﻘﻮل‬،metastasis/loss of function)
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Flash Notes in Pathoogy | From chronic gastritis to dysentery
.‫ أﺻﻼ ﻋﻴﺐ ﻳﺤﺼﻞ ﻓﻴﻬﺎ ﻛﺪه‬stomach‫اﻟـ‬
A. hematemesis and ‫و ﻋ� اﻟﺮﻏﻢ ﻣﻦ ان دي ﻏﺎﻟﺒﺎ ﻣﺒﺘﺤﺼﻠﺶ ﺑﺲ اﻛﺘﺒﻮﻫﺎ ﺑﺮده‬
melena
B. Pyloric stenosis.
C. Mucosal destruction leading to hypochlorhydria & intrinsic factor
deficiency.
D. Anemia due Intrinsic factor deficiency (macrocytic anemia).
LYMPHOMA OF STOMACH
:‫ﻭﺩﻱ ﻧﻮﻋﻴﻦ‬
1. MALT lymphoma.
2. Large B cell lymphoma.
.‫دى ﻗﺮاءة‬
GASTRIC POLYPS
adenomatous polyps ‫ وﻫﻰ‬neoplastic ‫ ﻓﻴﻪ ﻣﻨﻬﺎ‬،‫ اﺣﻨﺎ ﻗﻮﻟﻨﺎﻫﺎ‬polyps ‫اﻟـ‬
.highly precancerous ‫ودي ﺑﺘﻜﻮن‬
.hyperplastic polyps ‫وﻓﻴﻪ‬
DYSENTERY
‫؟‬Dysentery ‫ﻳﻌﻨﻲ ﺍﻳﻪ‬
.‫دي اﺣﻨﺎ ﻛﻌﺮب ﺗﺮﺟﻤﻨﺎﻫﺎ ﺗﺮﺟﻤﻪ ﻣﻮﺳﻴﻘﻴﻪ وﺳﻤﻴﻨﺎﻫﺎ اﻟﺪوﺳﻨﺘﺎر�ﺎ‬
.GIT ‫ ﻳﻌﻨﻰ‬entery‫ و‬،‫ ﻳﻌﻨﻰ ﺧﻠﻞ‬dys ‫وﺣﺮﻓﻴﺎ‬
inflammation of large ‫ ﻳﻌﻨﻲ‬dysentery ‫ اﻟـ‬pathology ‫ﻟﻜﻦ ﻋﻠﻤﻴﺎ ﺑﻘﻰ ﻲﻓ اﻟـ‬
.colonic mucosa‫ أو اﻟـ‬intestine
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Flash Notes in Pathoogy | From chronic gastritis to dysentery
‫ﻫﻲ ﺍﻳﻪ ﺍﻟﻮﻇﻴﻔﻪ ﺍﻻﺳﺎﺳﻴﻪ ﻟﻠﻘﻮﻟﻮﻥ ؟‬
.Absorption of excess water & electrolytes.
‫ و‬vasodilatation ‫ ﻫﻴﺤﺼﻞ ﻓﻴﻪ‬inflammation ‫ ﺣﺼﻞ ﻓﻴﻪ‬colon ‫ﻃﻴﺐ ﻟﻮ اﻟـ‬
water ‫ وﻧﺘﻴﺠﻪ اﻟـ‬diarrhea ‫ و ﺑﺎﻟﺘﺎﻲﻟ ﻫﺘﺤﺼﻞ‬water ‫ﺑﺎﻟﺘﺎﻲﻟ ﻫﺘﺰ�ﺪ ﻛﻤﻴﻪ اﻟـ‬
stretch ‫ و ﺑﺎﻟﺘﺎﻲﻟ ﻫﻴﺤﺼﻞ‬stretch ‫ ﻫﻴﺤﺼﻞ ﻓﻴﻪ‬wall of the colon ‫اﻟﺰ�ﺎده ﻲﻓ‬
(false desire of defecation due to stretch of ‫ وﺑﺎﻟﺘﺎﻲﻟ ﻫﻴﺤﺼﻞ‬reflex
‫ ﻛﻞ ده ﻧﺘﻴﺠﺔ‬.‫ اﻟ� ﺑﻴﺴﻤﻮﻫﺎ ﺑﺎﻟﻌﺮﺑﻲ ﺗﻌﻨﻴﺔ‬tenesmus mechanoreceptors)
.loss of function ‫إﻧﻪ ﺣﺼﻞ‬
.‫ ده داﺧﻞ ﺧﺎرج ﻣﻦ اﻟﺤﻤﺎم ﻣﻦ ﻏ� داﻋﻰ‬dysentery ‫ﺑﻴﻔﻀﻞ ﻋﻴﺎن اﻟـ‬
:‫ ﻧﻮﻋﻴﻦ‬Dysentery ‫ﺍﻟـ‬
.amoebic and bacillary Dysentery
compare ‫اﻟﺠﺪول ده ﺑﻴﻨﺰل‬
bilharzial ‫ ﻋﻨﺪﻧﺎ ﻲﻓ ﻣﺼﺮ ﻻزم ﻧﺤﻂ ﻣﻊ اﻟﻨﻮﻋ� دول اﻟـ‬،‫ﺑﺲ ﻗﺒﻞ ﻣﺎﻧﻘﻮل اﻟﺠﺪول‬
.dysentery
Amoebic Dysentery
Bacillary Dysentery
Etiology
Ingestion of food
contaminated with
Entamoeba histolytica
cysts.
Ingestion of food
contaminated with
shigella bacilli.
Pathology
Acidity prevents any
pathogenic effect of the
cyst. The cyst dissolves in
small intestine, divide and
invade mucosa.
Secrete exotoxins leading
to pseudomembranous
inflammation.
Site
Colon
Colon
Gross picture
- Amoebic ulcer:
* Multiple (Division of
ameba).
* Small or large.
- Parts of mucosal
necrotic false
membrane detach
leading to small
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Flash Notes in Pathoogy | From chronic gastritis to dysentery
superficial ulcers with
sharp edges, mucosa in
between is not healthy.
- Fibrosis may occur.
- The intestinal lumen
contains greenish
exudate and the
mesenteric nodes are
enlarged.
‫ ﻫﺘﺒﺎن ﻓﻴﻬﺎ‬floor ‫ و اﻟـ‬edges ‫ اﻟـ‬pseudomembrane :‫ﻫﺘﻼﻗﻲ‬
‫ﻣﺤﺎﻃﻪ ﺑﻤﻨﻄﻘﻪ‬amoebae ‫اﻟـ‬
PMNS , ‫ ﺑﻴﺘﻜﻮن ﻣﻦ‬,
fibrosis , macrophage &
‫ ﻲﻓ‬lysis ‫ ﻧﺎﺗﺠﻪ ﻋﻦ اﻟـ‬clear
bacteria.
amoebic ‫اﳌﻨﻄﻘﻪ دي ﻧﺘﻴﺠﻪ ال‬
Microscopic
feature
proteolytic enzyme.
rounded ‫ ﻫﺘﺒﺎن‬amoebae ‫واﻟـ‬
(25 micron) with eccentric
nuclei.
‫ اﺿﻌﺎف‬10 ‫ﺑﺘﻴﻘﻰ‬amoebae ‫اﻟـ‬
surface ‫ ﻣﻦ ﺣﻴﺚ اﻟـ‬RBCs ‫اﻟـ‬
area
Intestinal
complications
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* Deep undermined edges.
* Yellowish necrotic floor.
* Base is formed of
musculosa.
NB. Mucosa in between the
ulcers is normal.
‫ و دي ﻋﺒﺎرة ﻋﻦ‬،Amoeboma
.stool ‫ ﺑﺘﺒﺎن ﻲﻓ اﻟـ‬large mass
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Submucosa: dilated
capillaries, neutrophils
and macrophages.
Secondary infection.
Flash Notes in Pathoogy | From chronic gastritis to dysentery
bacillary & :�‫ ﺗﺎﻧﻴﺔ ﺑﺘﺤﺼﻞ ﻲﻓ اﻻﺗﻨ‬intestinal complications ‫ﻓﻴﻪ‬
:amebic dysentery
1. Hemorrhage: bleeding per rectum & not melena (above ulcer).
2. Perforation (below ulcer) leading to septic peritonitis.
3. Rectal prolapse
4 . Intussusception due to abnormal peristalsis.
5. Intestinal stricture & fibrosis (at level of ulcer).
6. Chronic carrier.
‫ ﻧﺘﻴﺠﺔ‬septicemia ‫ وﻟﻴﺲ‬toxemia ‫ ﻣﻤﻜﻦ ﻳﺤﺼﻞ ﻓﻴﻬﺎ‬bacillary dysentery‫واﻟـ‬
.spread ‫ ﻳﺤﺼﻞ ﻓﻴﻬﺎ‬amebic dysentery‫ إﻧﻤﺎ اﻟـ‬،exotoxins‫اﻟـ‬
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