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THE STOMACH, UNDER NORMAL
PERFORMS THREE MAIN FUNCTIONS.
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CONDITIONS,
Firstly, it acts as a place of STORAGE, so that 2 or 3
meals a day can provide all our energy needs.
Secondly, it also aids the digestive process, as it is
here that food is turned into a semi-liquid substance
so that the nutrients can be absorbed from it.
A third very important function of the stomach is the
destruction of contaminants that the food may
contain – bacteria and other micro-organisms. Very
little is absorbed into the bloodstream straight
through the stomach walls – aspirin and alcohol
being exceptions to this rule.
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The main functions of the stomach is to break
down & digest food to extract nutrients from what
you have eaten.
It is necessary that the stomach, the digestive
glands and the intestines must produce various
enzymes, including pepsin, and acid.
These acids and enzymes need to change the food
into a semi-liquid form.
The starch, fat and protein need to be broken down
into smaller chemical units that can be absorbed
into the bloodstream through the wall of the
intestine.
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The process of digestion starts in the mouth, where food is
chewed and broken into smaller pieces.
Saliva is mixed with the food, which makes it easier to move
around in the Mouth.
SALIVARY AMYLASE also starts to digest carbohydrates like
sugar and starches.
Once the food has been chewed, it is pushed by the tongue to
the back of the mouth. From here, muscles move it further
down the oesophagus and from there past a ONE-WAY VALVE,
which is called the OESOPHAGEAL SPHINCTER. The muscles of
the oesophagus are STRONG AND GRAVITY-DEFYING – one can
swallow even if you are standing on your head or lying down.
Once the food is in stomach, it is not supposed to move back
up again, even lying down, or if the stomach contracts.
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The amount of acid in stomach varies – it increases
with food intake.
The stomach itself is made of protein, and if not
protected, will be consumed by the acid.
The stomach and the duodenum are protected
from the acid by a layer of mucus that stops the
acid from consuming the stomach lining.
Several factors, can lead to the malfunctioning of
this protective layer of mucus,stomach and
duodenal ulcers can result.
The oesophagus does not have this protective
layer, hence the feeling of heartburn if food pushes
back up past the oesophageal sphincter.
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After a few hours in the stomach, the liquidized
food is pushed downward through another
valve, called the PYLORUS, into the small
intestine, so called because it is narrow and not
short – it could be up to six metres long.
Here chemicals are added to neutralise stomach
acid:
◦ Enzymes from the pancreas
◦ bile from the liver
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are secreted to further the digestive process and
to break down fats, carbohydrates and proteins.
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Refers to erosion of the mucosa lining any portion of the G.I. tract.
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It is defined as :
“A circumscribed ulceration of the gastrointestinal mucosa occurring in areas
exposed to acid and pepsin and most often caused by Helicobacter pylori
infection. (Uphold & Graham, 2003)”
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GASTRIC ULCER : the ulcer that occurs in the stomach lining ,some
of them may be malignant
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DUODENAL ULCER : most often seen in first portion of duodenum
(>95%)
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 Protective
factors vs. hostile factors
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A) Normal
B) Increased Attack
*Hyperacidity
*Pepsin.
*NSAIDs.
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C) Weak defense
*Helicobacter pylori
*Stress,
*drugs
*smoking
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The causes of peptic ulcer disease include the following:
Infection with the bacteria Helicobacter pylori occurs in 80 to 95% of
patients with peptic ulcer disease. H. pylori infection impairs the
protective mechanisms of the G.I. tract against low pH and digestive
enzymes and leads to ulceration of the mucosa.
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Stress — Emotional, trauma, surgical.
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Injury or death of mucus-producing cells.
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Excess acid production in the stomach. The hormone gastrin stimulates
the production of acid in the stomach; therefore, any factors that
increase gastrin production will in turn increase the production of
stomach acid.
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Drugs: Chronic use of aspirins and NSAIDs, or Corticosteroids
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Most common infection in the world (20%)
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10% of men, 4% women develop PUD
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Positive in 70-100% of PUD patients.
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H.pylori related disorders:
 Chronic gastritis – 90%
 Peptic ulcer disease – 95-100%
 Gastric carcinoma – 70%
 Gastric lymphoma
 Reflux Oesophagitis.
 Non ulcer dyspepsia
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Gram negative, Spiral bacilli
Spirochetes
Do not invade cells – only mucous
 Gram negative, Spiral bacilli
Breakdown urea - ammonia
Break
Spirochetes
down mucosal defense
Superficial
inflammation
Chronic
Do not
invade
cells – only mucous
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Breakdown urea - ammonia
Break down mucosal defense
Chronic Superficial inflammation
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 duodenal sites are 4x as common common in late middle age.
as gastric sites
incidence increases with age.
 most common in middle age with Male to female ratio—2:1
peak 30-50 years
 Male to female ratio—4:1
More common with bl. group A
Use of NSAIDs: associated with a
 Genetic link: 3x more common in three- to four-fold increase in risk of
1st degree relatives
 more common with blood group O
gastric ulcer
Less
related
to
H.
pylori
than
 associated with increased serum duodenal ulcers : about 80%
pepsinogen
10 - 20% of patients with a gastric
 H. pylori infection common,up to ulcer have a concomitant duodenal
95%
ulcer
 smoking is twice as common
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Manifestations of peptic ulcer disease:
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• Episodes of remission and exacerbation
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• Pain that for duodenal ulcers is often relieved
by eating or antacids
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• G.I. bleeding and possible hemorrhage (20 to
25% of patients)
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• Perforation of ulcers with significant mortality
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• Obstruction of G.I. tract
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Endoscopy
Barium meal – contrast x-ray
Biopsy – bacteria & malignancy
H.Pylori:
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Endoscopy cytology
Biopsy – Special stains
Culture - difficult
Urease Breath test.
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1-Avoid spicy food.
2-Avoid xanthin containing beverges.
3-Avoid Alcohol.
4-Avoid Smoking.
5-Avoid heavy meals.
6-Encourage small frequent low caloric meals.
7-Avoid
ulcerating
drugs
e.g.
NSAIDs,
corticosteroids,
xanthines
and
parasympathomimetics
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◦ Proton Pump Inhibitor + clarithromycin and amoxicillin
 Omeprazole (Prilosec): 20 mg PO bid for 14 d or
Lansoprazole (Prevacid): 30 mg PO bid for 14 d or
Rabeprazole (Aciphex): 20 mg PO bid for 14 d or
Esomeprazole (Nexium): 40 mg PO qd for 14 d plus
Clarithromycin (Biaxin): 500 mg PO bid for 14 and
Amoxicillin (Amoxil): 1 g PO bid for 14 d
 Can substitute Flagyl 500 mg PO bid for 14 d if allergic to Penicillin.
◦ In the setting of an active ulcer, continue on proton pump inhibitor
therapy for additional 2 weeks.
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Goal: complete elimination of H. Pylori. Once achieved
reinfection rates are low.
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SURGICAL REMOVAL OF ALL OR PART OF THE
STOMACH
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There are THREE MAIN TYPES of gastrectomy:
◦ PARTIAL GASTRECTOMY, removal of the lower half of the
stomach
◦ FULL GASTRECTOMY, removal of the entire stomach
◦ SLEEVE GASTRECTOMY, removal of the left side of the
stomach
Removing the stomach doesn’t remove the body’s
ability to digest liquids and foods. However, a few
lifestyle changes after the procedure may be needed.
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GASTRECTOMY IS PERFORMED MOST COMMONLY
TO TREAT THE FOLLOWING CONDITIONS:
◦ STOMACH CANCER
◦ BLEEDING GASTRIC ULCER
◦ PERFORATION OF THE STOMACH WALL
◦ NONCANCEROUS POLYPS
 In severe duodenal ulcers it may be necessary to
remove the lower portion of the stomach called
the pylorus and the upper portion of the small
intestine called the duodenum.
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Bill Roth Procedure
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If there is a sufficient portion of the upper
duodenum remaining a Bill Roth I procedure is
performed, where the remaining portion of the
stomach is reattached to the duodenum before
the bile duct and the duct of the pancreas.
If the stomach cannot be reattached to the
duodenum a Bill Roth II is performed, where the
remaining portion of the duodenum is sealed off,
a hole is cut into the next section of the small
intestine called the jejunum and the stomach is
reattached at this hole.
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The pylorus is used to grind food and slowly
release the food into the small intestine,
removal of the pylorus can cause food to
move into the small intestine faster than
normal, leading to gastric dumping
syndrome.
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The most obvious effect of the
removal of the stomach is the loss of a
storage place for food while it is being
digested.
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Since only a small amount of food can
be allowed into the small intestine at a
time, the patient will have to eat small
amounts of food regularly in order to
prevent gastric dumping syndrome.
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Another major effect is the LOSS OF THE INTRINSICFACTOR-SECRETING
PARIETAL
CELLS
IN
THE
STOMACH LINING.
Intrinsic factor is essential for the uptake of vitamin
B12 in the terminal ileum and without it the patient
will suffer from a vitamin B12 deficiency.
This leads to a type of anaemia known as megalo
blastic anaemia (can also be caused by folate
deficiency, or autoimmune disease where it is
specifically known as pernicious anaemia) which
severely reduces red-blood cell synthesis (known
as erythropoiesis, as well as other haematological cell
lineages if severe enough but the red cell is the first
to be affected).
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Intrinsic factor is a glycoprotein secreted by
parietal (humans) cells of the gastric mucosa.
In humans, it has an important role in the
absorption of vitamin B12 (cobalamin) in the
intestine, and failure to produce or utilize intrinsic
factor results in the condition Pernicious anaemia.
Dietary vitamin B12 is released from ingested
proteins in the stomach through the action of
pepsin and acid. It is rapidly bound by one of two
vitamin B12-binding proteins that are present in
gastric juice; at acid pH, these binding proteins
have a greater affinity for the vitamin than does
intrinsic factor.
In the small intestine, pancreatic proteases digest
the binding proteins, releasing vitamin B12 which
then becomes bound to intrinsic factor. Finally,
there are receptors for intrinsic factor on the ileal
mucosa which bind the complex, allowing vitamin
B12 to be absorbed into portal blood.
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Vitamin B12
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In all mammals, vitamin B12 is necessary for
maturation of erythrocytes, and a deficiency of
this vitamin leads to development of anaemia.
Since efficient absorption of vitamin B12 in
humans depends on intrinsic factor, diseases
which decrease the secretion of intrinsic factor
(e.g. atrophic gastritis), interfere with cleavage of
the binding proteins (e.g. pancreatic exocrine
insufficiency) or decrease binding and absorption
of the intrinsic factor-vitamin B12 complex (e.g.
ileal disease or resection) can result in this type
of anaemia.
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Gastric dumping syndrome, or rapid gastric
emptying is a condition:
◦ where ingested foods bypass the stomach too
rapidly and enter the small intestine largely
undigested.
◦ It happens when the small intestine expands too
quickly due to the presence of hyperosmolar (having
increased osmolarity) contents from the stomach.
◦ This causes symptoms due to the fluid shift into the
gut lumen with plasma volume contraction and acute
intestinal distension.
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"EARLY" dumping begins concurrently within
15 to 30 minutes from ingestion of a
meal. Symptoms of early dumping include
nausea,
vomiting,
bloating,
cramping,
diarrhoea, dizziness, and fatigue.
"Late" dumping happens one to three hours
after eating. Symptoms of late dumping
include weakness, sweating, and dizziness.
Many people have both types. The syndrome
is most often associated with gastric
bypass (Roux-en-Y) surgery.
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Nausea
Vomiting
Abdominal pain and cramping
Diarrhoea
Feeling uncomfortably full or bloated after a meal
Sweating
Weakness
Dizziness
flushing, or blushing of the face or skin
rapid or irregular heartbeat
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Hypo glycaemia
Sweating
Weakness
Rapid or irregular heartbeat
Flushing
Dizziness
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Dumping syndrome is caused by problems with
the storage of food particles in the stomach and
emptying of particles into the duodenum.
Early dumping syndrome results from rapid
movement of fluid into the intestine following a
sudden addition of a large amount of food from
the stomach.
Late dumping syndrome results from rapid
movement of sugar into the intestine, which
raises the body's blood glucose level and causes
the pancreas to increase its release of the
hormone insulin. The increased release of insulin
causes a rapid drop in blood glucose levels, a
condition known as hypoglycaemia, or low blood
sugar.
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People who have had surgery to remove or
bypass a significant part of the stomach are
more likely to develop dumping syndrome.
Some types of gastric surgery, such as
bariatric surgery, reduce the size of the
stomach. As a result, dietary nutrients pass
quickly into the small intestine.
Other conditions that impair how the stomach
stores and empties itself of food, such as
nerve damage caused by oesophageal
surgery, can also cause dumping syndrome.
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A health care provider will diagnose dumping
syndrome primarily on the basis of
symptoms.
A scoring system helps differentiate dumping
syndrome from other GI problems. The
scoring system assigns points to each
symptom and the total points result in a
score. A person with a score above 7 likely
has dumping syndrome.
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A modified oral glucose tolerance test checks how well insulin
works with tissues to absorb glucose. A health care provider
performs the test during an office visit or in a commercial facility
and sends the blood samples to a lab for analysis. The person
should fast—eat or drink nothing except water—for at least 8
hours before the test. The health care provider will measure
blood glucose concentration, haematocrit—the amount of red
blood cells in the blood—pulse rate, and blood pressure before
the test begins. After the initial measurements, the person drinks
a glucose solution. The health care provider repeats the initial
measurements immediately and at 30-minute intervals for up to
180 minutes. A health care provider often confirms dumping
syndrome in people with
◦ LOW BLOOD SUGAR BETWEEN 120 AND 180 MINUTES AFTER
DRINKING THE SOLUTION
◦ AN INCREASE IN HEMATOCRIT OF MORE THAN 3 PERCENT AT 30
MINUTES
◦ A RISE IN PULSE RATE OF MORE THAN 10 BEATS PER MINUTE AFTER
30 MINUTES
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A gastric emptying scintigraphy test involves
eating a bland meal—such as eggs or an egg
substitute—that contains a small amount of
radioactive material. A specially trained
technician performs this test in a radiology center
or hospital, and a radiologist—a doctor who
specializes in medical imaging—interprets the
results. Anaesthesia is not needed. An external
camera scans the abdomen to locate the
radioactive material. The radiologist measures
the rate of gastric emptying at 1, 2, 3, and 4 hours
after the meal. The test can help confirm a
diagnosis of dumping syndrome.
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Upper GI endoscopy involves using an endoscope—a small,
flexible tube with a light—to see the upper GI tract. A
gastroenterologist——performs the test . A small camera
mounted on the endoscope transmits a video image to a
monitor, allowing close examination of the intestinal lining.
The test may show ulcers, swelling of the stomach lining, or
cancer.
An upper GI series examines the small intestine. An x-ray
technician performs the test at a hospital or an outpatient
center and a radiologist interprets the images. Anesthesia is
not needed. No eating or drinking is allowed before the
procedure. During the procedure, the person will stand or sit
in front of an x-ray machine and drink barium, a chalky liquid.
Barium coats the small intestine, making signs of a blockage
or other complications of gastric surgery show up more
clearly on x rays.
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Treatment for dumping syndrome includes changes in eating, diet,
and nutrition; medication; and, in some cases, surgery.
EATING, DIET, AND NUTRITION
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The first step to minimizing symptoms of dumping syndrome
involves changes in eating, diet, and nutrition, and may
include eating five or six small meals a day instead of three
larger meals delaying liquid intake until at least 30 minutes
after a meal increasing intake of protein, fiber, and complex
carbohydrates—found in starchy foods such as oatmeal and
rice avoiding simple sugars such as table sugar, which can
be found in candy, syrup, sodas, and juice beverages
increasing the thickness of food by adding pectin or guar
gum—plant extracts used as thickening agents .Some
people find that lying down for 30 minutes after meals also
helps reduce symptoms.
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Octreotide acetate (Sandostatin) to treat
dumping
syndrome
symptoms.
The
medication
works by
slowing
gastric
emptying and inhibiting the release of insulin
and other GI hormones. Octreotide comes in
short- and long-acting formulas. The shortacting formula is injected subcutaneously—
under the skin—or intravenously—into a
vein—two to four times a day.
Complications of octreotide treatment include
increased or decreased blood glucose levels,
pain at the injection site, gallstones, and
fatty, foul-smelling stools.
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A person may need surgery if dumping
syndrome is caused by previous gastric
surgery or if the condition is not responsive
to other treatments.
For most people, the type of surgery depends
on the type of gastric surgery performed
previously. However, surgery to correct
dumping syndrome often has unsuccessful
results.
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