Seminar OnGASTRITIS, PEPTIC ULCER AND

DUMPING SYNDROME

GASTRITIS

INTRODUCTION • Gastritis is an inflammation of the

lining of the stomach, and has many possible causes. The main acute causes are excessive alcohol consumption or prolonged use of nonsteroidal anti-inflammatory drugs (also known as NSAIDs) such as aspirin or ibuprofen. Sometimes gastritis develops after major surgery, traumatic injury, burns, or severe infections. Gastritis may also occur in those who have had weight loss surgery resulting in the banding or reconstruction of the digestive tract.

DEFINITION

• Gastritis, an inflammation or

irritation of the lining of the stomach,

is not a single disease. Rather,

gastritis is a condition that has many

causes. Common to all people with

gastritis is pain or discomfort in the

upper part of the belly (abdomen),

also called dyspepsia.

GASTRITIS CAUSESMedications (only the most common medications are listed)• Aspirin (more than 300 drug products contain some form of aspirin)• Nonsteroidal anti-inflammatory drugs (NSAIDs, such as ibuprofen or

naproxen)• Prescription steroids (for example, prednisone• Potassium supplements• Iron tablets• Cancer chemotherapy medications• Swallowing chemicals or objects• Corrosives (acid or lye)• Swallowed foreign bodies (paper clips or pins)

Medical and surgical conditions• People who are critically ill or injured develop gastritis.• After medical procedures (such as endoscopy, in which a specialist looks

into the stomach with a small lighted tube)• After an operation to remove a part of the stomach• After radiation treatment for cancer• Autoimmune diseases• Pernicious anemia• Chronic vomiting

Infections• Tuberculosis• Syphilis• Bacterial infections: H pylori infection is the most common. Many other

bacteria-even those that usually cause pneumonia or bladder infection can cause gastritis.

• Viral infections• Fungal (yeast) infections• Parasites and worms

Other Causes• Stress• Alcohol consumption• Smoking

TYPES OF GASTRITIS Acute Gastritis• Acute gastritis refers" to a transient inflammation of the gastric mucosa. It is most commonly

associated with local irritants such as bacterial endotoxins, caffeine, alcohol, and aspirin.• Depending on the severity of the disorder, the mucosal re sponse may vary from moderate

edema and hyperemia to he morrhagic erosion of the gastric mucosa.• The complaints of persons with acute gastritis vary. • Persons with aspirin-related gastritis can be totally unaware of the con dition or may report

only heartburn or sour stomach. • Gastritis associated with excessive alcohol consumption is a different sit uation; it often

causes transient gastric distress, which may lead to vomiting-and, in more severe situations, to bleeding and hematemesis.

• Gastritis caused by the toxins of infectious or ganisms, such as the staphylococcal enterotoxins, usually has an abrupt and violent onset, with gastric distress and vomiting ensuing approximately 5 hours after the ingestion of a contam inated food source.

• Acute gastritis usually is a self-limiting dis order; complete regeneration and healing usually occur within several days.

Chronic Gastritis • Chronic gastritis is a separate entity from acute gastritis. It is characterized

by the absence of grossly visible erosions and the presence of .chronic inflammatory changes leading eventually to atrophy of the glandular epithelium of the stomach.

• The changes may become dysplastic and possibly transform into carcinoma. Factors such as chronic alcohol abuse, cigarette smoking, and chronic use of NSAIDs may contribute to the development of the disease.

• There are four major types of chronic gastritis: (1) auto immune gastritis, (2) multifocal atrophic gastritis, (3) Helicobac-terpylori gastritis, and (4) chemical gastropathy.

• Autoimmune gastritis is the least common form of chronic gastritis. Most per sons with the disorder have circulating antibodies to parietal cells and intrinsic factor, so this form of chronic gastritis is con sidered to be of autoimmune origin.

• Autoimmune destruction of the parietal cells leads to hypochlorhydria or achlorhydria, a high intragastric pH, and hypergastrinemia. Pernicious ane mia is a megaloblastic anemia that is caused by malabsorption of vitamin B12 caused by a deficiency of intrinsic factor. This type of chronic gastritis frequently is associ ated with other autoimmune disorders, such as Hashimoto's thyroiditis and Addison's disease.

These are the some other types of Gastritis

• Phlegmonous gastritis is an uncommon form of gastritis caused by numerous bacterial agents, including streptococci, staphylococci, Proteus species, Clostridium species, and Escherichia coli. Phlegmonous gastritis usually occurs in individuals who are debilitated.

• Ulcero-hemorrhagic gastritis is most commonly seen in patients who are critically ill. Ulcero-hemorrhagic gastritis is believed to be secondary to ischemia related to hypotension and shock or to the release of vasoconstrictive substances, but the etiology is often unknown.

• Eosinophilic gastritis is often seen in conjunction with eosinophilic gastroenteritis but can be associated with various disorders, including food allergies (eg, cow milk, soy protein), collagen vascular diseases, parasitic infections, gastric cancer, lymphoma, Crohn disease, vasculitis, drug allergies, and H pylori infections.

PATHOPHSIOLOGY• Acute gastritis has a number of causes, including certain drugs; alcohol; bile;

ischemia; bacterial, viral, and fungal infections; acute stress (shock); radiation; allergy and food poisoning; and direct trauma.

• The common mechanism of injury is an imbalance between the aggressive and the

defensive factors that maintain the integrity of the gastric lining (mucosa).

• Acute erosive gastritis can result from the exposure to a variety of agents or factors. This is referred to as reactive gastritis.

• These agents/factors include nonsteroidal anti-inflammatory medications (NSAIDs), alcohol, cocaine, stress, radiation, bile reflux, and ischemia. The gastric

mucosa exhibits hemorrhages, erosions, and ulcers.

• NSAIDs, such as aspirin, ibuprofen, and naproxen, are the most common agents associated with acute erosive gastritis.

• This results from oral or systemic administration of these agents either in therapeutic doses or in

supratherapeutic doses.

• Because of gravity, the inciting agents lie on the greater curvature of the stomach. This partly explains the development of acute gastritis distally on or near the greater curvature of the

stomach in the case of orally administered NSAIDs

• However, the major mechanism of injury is the reduction in prostaglandin synthesis. Prostaglandins are chemicals responsible for maintaining mechanisms that result in the

protection of the mucosa from the injurious effects of the gastric acid.

• Long-term effects of such ingestions can include fibrosis and stricture.

• Bacterial infection is another cause of acute gastritis. The corkscrew-shaped bacterium called H pylori is the most common cause of gastritis. Complications result from a chronic infection rather

than from an acute infection.

• The prevalence of H pylori in otherwise healthy individuals varies depending on age, socioeconomic class, and country of origin. The infection is usually acquired in childhood.

• Antigen-presenting cells activate lymphocytes and other mononuclear cells that lead to chronic

superficial gastritis.

• • The infection is established within a few weeks after the primary

exposure to H pylori. It produces inflammation via the production of a number of toxins and enzymes.

• • The intense inflammation can result in the loss of gastric glands responsible for the production of acid. This is referred to as atrophic

gastritis. Consequently, gastric acid production drops. •

• The virulence genotype of the microbe is an important determinant for the severity of the gastritis and the formation of intestinal

metaplasia, the transformation of gastric epithelium. This transformation can lead to gastric cancer.

GASTRITIS SYMPTOMS• The pain is usually in the upper central portion of the abdomen (the "pit" of the

stomach). • Sometimes gastritis pain occurs in the left upper portion of the abdomen and in

the back. The pain seems to "go right straight through." • People often use the terms burning, aching, gnawing, or soreness to describe the

pain. Usually, a vague sense of discomfort is present, but the pain may be sharp, stabbing, or cutting.

Other symptoms of gastritis include the following: • Belching: Belching usually either does not relieve the pain or relieves it only briefly. • Nausea and vomiting: The vomit may be clear, green or yellow, blood-streaked, or

completely bloody, depending on the severity of the stomach inflammation. • Bloating • Feeling of fullness or burning in the upper part of the belly

In more severe gastritis, bleeding may occur inside the stomach. Any

of the following symptoms can be seen as well as those already

mentioned.

• Pallor, sweating, and rapid (or "racing") heart beat.

• Feeling faint or short of breath

• Chest pain or severe stomach pain

• Vomiting large amounts of blood

• Bloody bowel movements or dark, sticky, very foul-smelling bowel

movements

• Any or all of these symptoms can occur suddenly. This is

particularly true in adults older than 65 years of age.

•

GASTRITIS DIAGNOSISThe diagnosis of gastritis can be established by a complete history and physical or in

some cases may include blood tests and other tests (endoscopy) or consultation with a specialist (usually a gastroenterologist).

• The health care practitioner first interviews you about your symptoms, medical history, habits and lifestyle, and the medications you take.

• This information is enough to make the diagnosis in many people.• Be sure to tell the doctor about all the medications the patient takes, including

nonprescription drugs, herbal and botanical preparations, and supplements such as vitamins.

• Also report any measures the patient has taken to relieve the symptoms and how well those measures worked.

Laboratory testing: No laboratory tests can pinpoint a diagnosis of gastritis.• Often, no tests are necessary.• If the health care practitioner orders tests, it is probably to rule out certain medical

conditions.• If all other possibilities are ruled out, that leaves gastritis as the most likely cause

of the patient's symptoms.

The following tests are most likely to be ordered:• H. Pylori test• Blood cell counts (looking mostly for anemia, a low blood count)• Liver and kidney functions• Urinalysis• Gallbladder and pancreas functions• Pregnancy test• Stool test to check for bloodX-rays films or other diagnostic images may be ordered, although they are usually not

necessary.An electrocardiogram (ECG, EKG) might be ordered if the patient's heartbeat is rapid or they

are having chest pain.• The patient may be referred to a gastroenterologist, a doctor who specializes in diseases of

the digestive system.• The gastroenterologist may in turn recommend an endoscopy.• During the endoscopy, a thin, flexible probe with a tiny camera on the end is sent into the

stomach for a direct look.• At the same time, samples of the stomach lining can be taken to test for a wide variety of

conditions.

WHEN TO SEEK MEDICAL CARESee your health care practitioner if your symptoms are new, long-lasting, or

worsen despite self-care. Seek immediate medical attention if you have any of the following symptoms. • Vomiting that does not allow the affected person to take food, fluids, and

medications• Fever with abdominal pain• Fainting or feeling faint• Rapid heartbeat• Unexplained sweating• Pallor• Repeated vomiting of green or yellow material• Vomiting any amount of blood• Shortness of breath• Chest pain

GASTRITIS TREATMENT

Gastritis Self-Care at Home• If a person knows what causes their gastritis, the simplest approach is to

avoid the cause.• Aspirin and alcohol are two widely used substances that cause gastritis.• If the patient develops an upset stomach and nausea after drinking alcohol

or using aspirin, then avoid these substances.• Sometimes a person cannot avoid certain substances that cause gastritis. • The health care practitioner may have a good reason to recommend

aspirin, iron, potassium, or some other medication that causes gastritis. • If the patient develops minor gastritis symptoms, it may be best to

continue the recommended medication and treat the gastritis symptoms. • Consult a health care practitioner before stopping any medication.• In the case of aspirin, coated aspirin may not cause the same symptoms

because: • Coated aspirin does not dissolve in the stomach. • Check the contents of any other over-the-counter medication the patient

is taking because more than 300 medications contain aspirin in some form.

Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (Advil,

Motrin, Nuprin) also cause gastritis.

• The health care practitioner may recommend that these medications be

taken with food or with antacids.

• Doing this may lessen the chance of developing gastritis symptoms.

Switching from aspirin or NSAIDs to another pain reliever may help as well.

Acetaminophen (Liquiprin, Tylenol, Panadol) is not known to cause

gastritis.

• Talk with a health care practitioner before switching to acetaminophen.

• He or she may have recommended aspirin or an NSAID for a specific

purpose.

If gastritis symptoms continue, antacids are sometimes recommended.

Three main types of antacids are available. All three are about equal

in effectiveness.

• Magnesium-containing antacids may cause diarrhea. People with

certain kidney problems should use these cautiously or not at all.

• Aluminum-containing antacids can cause constipation.

• Calcium-containing antacids have received a great deal of attention

for their ability to control stomach acid and also supplement body

calcium. Calcium supplementation is most important for

postmenopausal women. Calcium-based antacids can also lead to

constipation.

Antacids may also change the body's ability to absorb certain other medications. Only take medications with antacids after checking with a pharmacist or physician.

• If the patient requires an antacid more than occasionally, consult a health care practitioner as they can decide which one is best for the patient.

• Histamine (H2) blockers have received a lot of attention for stomach problems.

• Some of these medications, for example, cimetidine (Tagamet) and ranitidine (Zantac), are available without a prescription.

• Histamine blockers work by reducing acid secretion in the stomach. • This reduces gastritis pain and other symptoms. • If a person needs one of these medications regularly, should consult a

health care practitioner for a recommendation.• Stronger medications that protect the stomach's lining or lessen acid

production in the stomach are available by prescription. Talk to a health care practitioner if the nonprescription medications do not work.

GASTRITIS MEDICAL TREATMENTThe safest treatment is to avoid substances that trigger gastritis symptoms. • Almost all health care practitioners would recommend this as the first step

in preventing gastritis.• First, the patient has to identify the triggers of gastritis.• Most people are aware of their triggers before seeking medical care.• If a person does not know what triggers their gastritis, a health care

practitioner can assist them in determining the triggers.Common avoidable triggers of gastritis symptoms include the following. See

the "Causes" for a more complete list.• Certain medications and chemicals• Cigarette smoking• Alcohol• Coffee and other beverages that contain caffeine, such as cola and tea•

GASTRITIS MEDICATIONS

Histamine (H2) blockers: Four histamine blockers are available in the United States. Some are available without a prescription (see above); others require a prescription.

• H2 blockers work by blocking the release of acid from specialized glands in the stomach.

• The theory is that producing less acid allows the stomach to heal.

• Once healed, the previously inflamed stomach then causes no further symptoms.

• Commonly prescribed H2-blockers include cimetidine (Tagamet), famotidine (Pepcid), nizatidine (Axid), and ranitidine (Zantac).

• Proton pump inhibitors (PPIs): These medications are very powerful blockers of the stomach's ability to secrete acid.

• A health care provider who prescribes one of these medications to treat the patient's gastritis may be doing so in consultation with a gastroenterologist.

• Examples of PPIs include lansoprazole (Prevacid) and omeprazole (Prilosec, Losec).

• Coating agents: These medications protect the stomach's lining. • Sucralfate (Carafate) - Coats and protects the stomach lining • Misoprostol (Cytotec) - Also protects the stomach lining, used as a

preventive measure for people taking NSAIDs who are at high risk of developing stomach damage

• Antibiotics: An antibiotic may be prescribed if H pylori is demonstrated to

be the cause of the patient's gastritis.

• Antiemetics: Antiemetic medications help control nausea and vomiting. A

number of different antiemetics can be used in the emergency

department to control gastritis symptoms. Some of these medications are

available by prescription for home use as well. Note that these

medications do not improve the gastritis, but rather only decrease the

symptoms of gastritis.

GASTRITIS FOLLOW-UP

• Avoid those things that irritate the stomach or cause symptoms to flare up.

• Take all medications as prescribed by the health care provider.

• Return for medical attention if symptoms worsen or persist.

• Report any new symptoms to a health care provider.

GASTRITIS PREVENTION

• The mainstay of gastritis prevention is to avoid those things that irritate or inflame the stomach's lining.

• Aspirin (use coated aspirin if the person must take aspirin) • NSAIDs such as ibuprofen (Motrin, Advil) or naproxen

(Naprosyn) • Smoking • Caffeine and other caffeine-like substances • Alcohol

PROGNOSIS

• Most people recover from gastritis. Depending on the many factors that affect the stomach lining, gastritis symptoms may flare-up from time to time.

• Overall, gastritis is generally a common, mildly troubling ailment that responds well to simple treatments.

• On occasion, rare forms of gastritis can be serious or even life-threatening. Severe, ongoing symptoms or internal bleeding should alert a health care practitioner to search for a more serious underlying cause.

COMPLICATIONS OF GASTRITIS• Most forms of chronic nonspecific gastritis do not

cause symptoms. • However, chronic gastritis is a risk factor for peptic

ulcer disease, gastric polyps, and benign and malignant gastric tumors.

• Some people with chronic H. pylori gastritis or autoimmune gastritis develop atrophic gastritis. Atrophic gastritis destroys the cells in the stomach lining that produce digestive acids and enzymes.

• Atrophic gastritis can lead to two types of cancer: gastric cancer and gastric mucosa-associated lymphoid tissue (MALT) lymphoma.

PEPTIC ULCER

INTRODUCTION

• Peptic ulcer is very common, millions of Americans being diagnosed

with different forms of the disorder each year. The advance of

modern medicine has allowed scientists to find out more valuable

information about these disorders, enabling them to develop new

medical treatments. Although in the past peptic ulcer was known to

affect mostly male persons, more and more women suffer from

forms of peptic ulcer nowadays. Statistics indicate that the

predominance of smoking among women has determined an

increase of peptic ulcer incidence with the female gender.

DEFINITION• A peptic ulcer is a sore in the lining of your

stomach or duodenum. The duodenum is the first part of your small intestine. A peptic ulcer in the stomach is called a gastric ulcer. One that is in the duodenum is called a duodenal ulcer. A peptic ulcer also may develop just above your stomach in the esophagus, the tube that connects the mouth to the stomach. But most peptic ulcers develop in the stomach or duodenum.

• Many people have peptic ulcers. You can have both gastric and duodenal ulcers at the same time.

• Peptic ulcers can be treated successfully. Seeing your doctor is the first step.

INCIDENCE• Since the early 1980s, there has been a radical

shift in think ing regarding the cause of peptic ulcer. No longer is peptic ulcer thought to result from a genetic predisposition, stress, or di etary indiscretions. Most cases of peptic ulcer are caused by H. pylori infection. The second most common cause of peptic ulcer is NSAID and aspirin use.18 It has been reported that vir tually all persons with duodenal ulcer and 70% of persons with gastric ulcer have H. pylori infection." Aspirin and NSAIDs ac count for 1.0% to 20% of gastric ulcers and 2% to 5% of duo denal ulcers.

CAUSES OF PEPTIC ULCER

Most peptic ulcers are caused by• Helicobacter pyloricus (H. pylori) a germ that causes infection• nonsteroidal anti-inflammatory drugs NSAIDs), such as aspirin

and ibuprofen• H. pylori is the most common cause of peptic ulcers. Use of NSAIDs is the second most common cause of peptic

ulcers. But not everyone who takes NSAIDs gets a peptic ulcer. Ulcers caused by NSAIDs are more often found in people who

• are age 60 or older• are female• have taken NSAIDs for a long time• have had an ulcer before

OTHER CAUSES OF PEPTIC ULCER

• Other causes of peptic ulcers are rare. One rare cause is Zollinger-Ellison syndrome - a disease that makes the body produce too much stomach acid, which harms the lining of the stomach or duodenum.

• Stress or spicy food does not cause peptic ulcers, but either can make ulcer symptoms worse.

CLASSIFICATIONBy Region/Location• Duodenum (called duodenal ulcer)• Oesophagus (called esophageal ulcer)• Stomach (called gastric ulcer)• Meckel's diverticulum (called Meckel's diverticulum ulcer; is very tender

with palpation)Modified Johnson Classification of peptic ulcers:• Type I: Ulcer along the body of the stomach, most often along the lesser

curve at incisura angularis along the locus minoris resistantiae.• Type II: Ulcer in the body in combination with duodenal ulcers. Associated

with acid oversecretion.• Type III: In the pyloric channel within 3 cm of pylorus. Associated with acid

oversecretion.• Type IV: Proximal gastroesophageal ulcer• Type V: Can occur throughout the stomach. Associated with chronic NSAID

use (such as aspirin).

PATHOPHYSIOLOGY • Peptic ulcer is basically a lesion located at the level of the stomach, duodenum

or esophagus. •

• Ulcer tends to affect the entire gastrointestinal tract, starting from the lining of the mouth and ending with the rectal region.

• • Peptic ulcer suggests the involvement of hydrochloric acid and pepsin in the

development of the disorder. •

• When gastric acid is produced in excess, the mucosal membrane that protects the stomach and internal organs from danger is damaged, enabling the bacteria

Helicobacter pylori to penetrate the barrier and cause internal infections. •

• Therefore, in the case of peptic ulcer, both gastric acid and bacteria are responsible for the development of the disorder.

SIGNS AND SYMPTOMS OF PEPTIC ULCERS

A dull or burning pain in your stomach is the most common symptom of peptic ulcers. You may feel the pain anywhere between your belly button and breastbone. The pain often

• starts between meals or during the night• briefly stops if you eat or take antacids• lasts for minutes to hours• comes and goes for several days or weeks.Other symptoms of peptic ulcers may include• weight loss• poor appetite• bloating• burping• vomiting• feeling sick to your stomach

Even if your symptoms are mild, you may have peptic ulcers. You should see your doctor to talk about your symptoms. Peptic ulcers can get worse if they aren't treated.

Call your doctor right away if you have• sudden or sharp pain that doesn't go away• black or bloody stools• bloody vomit or vomit that looks like coffee groundsThese symptoms could be signs that an ulcer has• broken a blood vessel• gone through, or perforated, your stomach or duodenal wall• stopped food from moving from you stomach into the duodenumThese symptoms must be treated quickly. You may need surgery.

DIAGNOSTIC EVALUATION

• Esophagogastroduodenoscopy (EGD or upper endoscopy) is a special test performed by a gastroenterologist. A thin tube with a camera on the end is inserted through your mouth into the GI tract to see your stomach and small intestine.

• Your doctor may also order these tests:• Hemoglobin blood test to check for anemia• Stool occult blood test to test for blood in your stool• Your doctor also may want to look inside your stomach and

duodenum by doing an endoscopy or an upper gastrointestinal (GI) series - a type of X-ray. Both procedures are painless.

DIAGNOSTIC EVALUATION

• For an endoscopy, you will be given medicine to relax you. Then the doctor will pass an endoscope - a thin, lighted tube with a tiny camera - through your mouth to your stomach and duodenum. Your doctor also may take a small piece of tissue - no bigger than a match head-to look at through a microscope. This process is called a biopsy.

• For an upper GI series, you will drink a liquid called barium. The barium will make your stomach and duodenum show up clearly on the X-rays.

RISK FACTORSThe following also raise your risk for peptic ulcers:• Drinking too much alcohol• Regular use of aspirin, ibuprofen, naproxen, or other nonsteroidal anti-

inflammatory drugs (NSAIDs). Taking aspirin or NSAIDs once in a while is safe for most people.

• Smoking cigarettes or chewing tobacco• Being very ill, such as being on a breathing machine• Having radiation treatments• A rare condition called Zollinger-Ellison syndrome causes stomach and

duodenal ulcers. Persons with this disease have a tumor in the pancreas. This tumor releases high levels of a hormone that increases stomach acid.

• Many people believe that stress causes ulcers. It is not clear if this is true, at least for everyday stress at home.

TREATMENT FOR PEPTIC ULCERS

• If you have peptic ulcers, they can be cured. Depending on what caused your ulcers, your doctor may prescribe one or more of the following medicines:

• a proton pump inhibitor (PPI) or histamine receptor blocker (H2 blocker) to reduce stomach acid and protect the lining of your stomach and duodenum

• one or more antibiotics to kill an H. pylori infection • a medicine that contains bismuth subsalicylate, such as Pepto-

Bismol, to coat the ulcers and protect them from stomach acid

• These medicines will stop the pain and help heal the ulcers.

TREATMENT FOR PEPTIC ULCERS• If an NSAID caused your peptic ulcers, your doctor may tell you to • stop taking the NSAID • reduce how much of the NSAID you take • take a PPI or H2 blocker with the NSAID • switch to another medicine that won't cause ulcers • You should take only the medicines your doctor tells you to take all

medicines exactly as your doctor tells you to, even if your pain stops • Tell your doctor if the medicines make you feel sick or dizzy or cause

diarrhea or headaches. Your doctor can change your medicines. • And if you smoke, quit. You also should avoid alcohol. Smoking and

drinking alcohol slow the healing of ulcers and can make them worse.

HOW IS A PERFORATED ULCER TREATED?

• A perforated ulcer is a serious condition that requires

emergency attention. To make a diagnosis, an X-ray

of the stomach area is required (to check whether air

has escaped through the perforation and then risen

to underneath the diaphragm). A perforated ulcer

requires emergency surgery.

HOW IS SCARRING OF THE DUODENUM TREATED?

• A chronic ulcer can cause scarring of the stomach outlet (the pylorus and the duodenum), causing restricted emptying of the stomach.

• The symptoms may include vomiting and weight loss. • This condition is often treated surgically by creating a

shortcut around the scarred or narrowed duodenum to facilitate gastric emptying ('gastro-enteric-anastomosis').

WHEN IS A CHRONIC ULCER TREATED SURGICALLY?

Treating a chronic ulcer with surgery is rarely necessary. An exception is surgery for bleeding or perforated ulcers and in cases where

the stomach outlet or the duodenum has become deformed and restricted by scar tissue.

It was quite common some years ago to treat chronic ulcers surgically (because effective acid-suppressing medicine did not exist, and Helicobacter pylori had not yet been discovered). The surgical procedure depended on the ulcer's position.

• Generally, three different types of surgery were used.• The nerves to the stomach were cut (vagotomy).• A part of the stomach was removed (partial gastrectomy).• Combinations of these two operations with adjustment to the

duodenum's attachment to the stomach.

• Side-effects were frequent and included stomach upsets, reflux and abdominal pain, fatigue, diarrhoea, and weight loss. The operations used at the time must be seen from the perspective that no other treatment options were available then. In rare cases, it's possible today to require one of these surgical procedures – but only when medication has failed.

• Yes. If you smoke or take NSAIDs, your ulcers

may come back. If you need to take an NSAID,

your doctor may switch you to a different

medicine or add medicines to help prevent

ulcers.

CAN PEPTIC ULCERS COME BACK?

To help prevent ulcers caused by H. pylori, • wash your hands with soap and water after using the bathroom and

before eating• eat food that has been washed well and cooked properly• drink water from a clean, safe source To help prevent ulcers caused by NSAIDs,• stop using NSAIDs, if possible• take NSAIDs with a meal, if you still need NSAIDs• use a lower dose of NSAIDs• ask your doctor about medicines to protect your stomach and duodenum

while taking NSAIDs• ask your doctor about switching to a medicine that won't cause ulcers

WHAT CAN I DO TO PREVENT PEPTIC ULCERS?

• Gastrointestinal bleeding is the most common complication. Sudden large bleeding can be life-threatening. It occurs when the ulcer erodes one of the blood vessels, such as the gastroduodenal artery.

• Perforation (a hole in the wall) often leads to catastrophic consequences. Erosion of the gastro-intestinal wall by the ulcer leads to spillage of stomach or intestinal content into the abdominal cavity. Perforation at the anterior surface of the stomach leads to acute peritonitis, initially chemical and later bacterial peritonitis. The first sign is often sudden intense abdominal pain. Posterior wall perforation leads to bleeding due to involvement of gastroduodenal artery that lies posterior to the 1st part of duodenum.

COMPLICATIONS

• Penetration is when the ulcer continues into adjacent organs such as the liver and pancreas.

• Scarring and swelling due to ulcers causes narrowing in the duodenum and gastric outlet obstruction. Patient often presents with severe vomiting.

• Cancer is included in the differential diagnosis (elucidated by biopsy), Helicobacter pylori as the etiological factor making it 3 to 6 times more likely to develop stomach cancer from the ulcer.

COMPLICATIONS

DUMPING SYNDROME

DUMPING SYNDROME

DEFINITION• Dumping syndrome is a group of symptoms most

likely to develop if you've had surgery to remove all or part of your stomach, or if your stomach has been surgically bypassed to help lose weight. Also called rapid gastric emptying, dumping syndrome occurs when the undigested contents of your stomach are transported or "dumped" into your small intestine too rapidly.

INCIDENCE• Incidence and severity of symptoms in dumping syndrome

are related directly to the extent of gastric surgery. An estimated 25-50% of all patients who have undergone gastric surgery have some symptoms of dumping. However, only 1-5% are reported to have severe disabling symptoms.

• Incidence of significant dumping has been reported to be 6-14% in patients after truncal vagotomy and drainage and from 14-20% after partial gastrectomy. Incidence of dumping syndrome after proximal gastric vagotomy without any drainage procedure is less than 2%. Newer gastric operations, such as proximal gastric vagotomy (which produces minimal disturbance of gastric emptying mechanisms), are associated with a much lower incidence of postgastrectomy syndromes.

CAUSES• In dumping syndrome, food and

gastric juices from your stomach move to your small intestine in an unregulated, abnormally fast manner.

• This accelerated process is most often related to changes in your stomach associated with surgery. For example, when the opening (pylorus) between your stomach and the first portion of the small intestine (duodenum) has been damaged or removed during an operation, dumping syndrome may develop.

CAUSES• Dumping syndrome may occur at least mildly

in one-quarter to one-half of people who have had gastric bypass surgery. It develops most commonly within weeks after surgery, or as soon as you return to your normal diet.

• The more stomach removed or bypassed, the more likely that the condition will be severe. It sometimes becomes a chronic disorder.

TYPES OF DUMPING SYNDROME• Early dumping• Late dumping

Early dumping• Rapid emptying of gastric contents into the small intestine or colon may

result in high amplitude propagated contractions and increased propulsive motility, thereby contributing to the diarrhea seen in persons with the dumping syndrome.

• The emptying of liquids is fast relative to persons without distal gastrectomy with Billroth-I reconstruction.

• Symptoms of early dumping syndrome (30-60 min postprandial) are believed to result from accelerated gastric emptying of hyperosmolar contents into the small bowel.

• This leads to fluid shifts from the intravascular compartment into the bowel lumen, resulting in rapid small bowel distention and an increase in the frequency of bowel contractions. Rapid instillation of liquid meals into the small bowel has been shown to induce dumping symptoms in healthy individuals who have not had gastric surgery.

Early dumping• Bowel distention may be responsible for GI symptoms, such as

crampy abdominal pain, bloating, and diarrhea. Intravascular volume contraction due to osmotic fluid shifts is perhaps responsible for vasomotor symptoms, such as tachycardia and lightheadedness.

• This hypothesis has been questioned for several reasons. First, the severity of dumping is not reliably related to the volume of hypertonic solution ingested. Second, intravenous infusion sufficient to prevent the postprandial fall in plasma volume may not abolish the dumping symptoms. Furthermore, Kalser and Cohen measured intrajejunal osmolarity and glucose content using a continuous perfusion method. They found that the degree of dilution of the hyperosmolar glucose in patients postgastrectomy was similar in symptomatic and asymptomatic subjects.

Late dumping• Late dumping occurs 1-3 hours after a meal. The pathogenesis is

thought to be related to the early development of hyperinsulinemic (reactive) hypoglycemia.

• Rapid delivery of a meal to the small intestine results in an initial high concentration of carbohydrates in the proximal small bowel and rapid absorption of glucose.

• This is countered by a hyperinsulinemic response. The high insulin levels are responsible for the subsequent hypoglycemia. Intrajejunal glucose induces a higher insulin release than does the intravenous infusion of glucose.

• The serum glucose levels were the same in both experiments. This effect of enhanced insulin release after an enteral glucose load as compared to intravenous glucose administration is called the incretin effect.

Late dumping• Two hormones are thought to play a pivotal role in the incretin effect.

These are glucose-dependent insulinotropic peptide and GLP-1. • In human studies, an increase in GLP-1 response has been noted after an

oral glucose challenge. An increased GLP-1 response has been noted in patients after total gastrectomy, esophageal resection, and partial gastrectomy.

• Furthermore, a positive correlation was found between the rise in plasma GLP-1 and insulin release. Exaggerated GLP-1 response likely plays an important role in the hyperinsulinemia and hypoglycemia in patients with late dumping.

• The reason why some patients remain asymptomatic after gastric surgery whereas others develop severe symptoms remains elusive.

PATHOPHYSIOLOGY

SYMPTOMSWhen symptoms of dumping syndrome occur during a

meal or within 15 to 30 minutes following a meal, they may include:

• Nausea• Vomiting• Abdominal pain, cramps• Diarrhea• Dizziness, lightheadedness• Bloating, belching• Fatigue• Heart palpitations, rapid heart rate

When signs and symptoms develop later, usually one to three hours after eating, they may include:

• Sweating• Weakness, fatigue• Dizziness, lightheadedness• Shakiness• Feelings of anxiety, nervousness• Heart palpitations, rapid heart rate• Fainting• Mental confusion• Diarrhea• Low blood sugar (hypoglycemia)

RISK FACTORS

• Several types of stomach surgery increase your risk of dumping syndrome. These include:

• Gastrectomy, in which a portion or all of your stomach is removed. It typically includes removing the pylorus.

• Gastroenterostomy or gastrojejunostomy, in which your stomach is surgically connected directly to your small intestine beyond the pylorus, thus bypassing the pylorus. Doctors sometimes perform this operation in people with cancer of the stomach.

• Vagotomy, in which the nerves to your stomach are cut in order to lower the levels of acid produced by your stomach.

• Fundoplication, which is an operation sometimes performed on people with gastroesophageal reflux disease. It involves wrapping the upper portion of your stomach around the lower esophagus to apply pressure that reduces the reflux of gastric contents into the esophagus. However, on rare occasions, certain nerves to the stomach are unintentionally damaged during surgery, leading to dumping syndrome.

• Gastric bypass surgery (Roux-en-Y operation), which is performed to treat morbid obesity. It surgically creates a stomach pouch that's smaller than the entire stomach, meaning you're no longer able to eat as much as you once did, resulting in weight loss.

TESTS AND DIAGNOSISYour doctor may use some of the following methods to determine if you have

dumping syndrome.

• Medical history and evaluation. Your doctor can often diagnose dumping

syndrome by taking a careful medical history and then evaluating your

signs and symptoms. If you have undergone stomach surgery, that may

help lead your doctor to a diagnosis of dumping syndrome.

• Gastric emptying test. A test that uses radioactive material mixed with

food measures how quickly the food moves through your stomach.

TESTS AND DIAGNOSIS• Blood sugar test. Because low blood sugar is sometimes associated with dumping

syndrome, your doctor may order a test to measure your blood sugar level at the

peak time of your symptoms to help confirm the diagnosis.

TREATMENTS AND DRUGS

• Most cases of dumping syndrome improve as people learn to

eat better for the condition and as the digestive system

adjusts. There's a good chance that changing your diet will

resolve your symptoms. But if it doesn't, your doctor may

advise medications or surgery to slow the emptying of your

stomach's contents.

MEDICATIONS Your doctor may prescribe certain medications to slow the

passage of food out of your stomach, and relieve the signs and symptoms associated with dumping syndrome. These drugs are most appropriate for people with severe signs and symptoms, and they don't work for everyone.

The medications that doctors most frequently prescribe are: • Acarbose (Precose). This medication delays the digestion of

carbohydrates. Doctors prescribe it most often for the management of type 2 diabetes, and it has also been found to be effective in people with late-onset dumping syndrome. Side effects may include sweating, headaches, sudden hunger and weakness.

MEDICATIONS • Octreotide (Sandostatin). This anti-diarrheal drug

can slow down the emptying of food into the intestine. You take this drug by injecting it under your skin (subcutaneously).

• Be sure to talk with your doctor about the proper way to self-administer the drug, including optimal choices for injection sites.

• Long-acting formulations of this medication are available. Because octreotide carries the risk of side effects (diarrhea, bulky stools, gallstones, flatulence, bloating) in some people, doctors recommend it only for people who haven't responded to other treatments.

SURGERY

• Doctors use a number of surgical procedures to

treat cases of dumping syndrome that are

resistant to more-conservative approaches. Most

of these operations are reconstructive

techniques, such as reconstructing the pylorus, or

they're intended to reverse gastric bypass

surgery.

LIFESTYLE AND HOME REMEDIESHere are some dietary treatment strategies that your doctor may

recommend and that you can do on your own: • Eat smaller meals. Try consuming about six small meals a day rather

than three larger ones.• Avoid fluids with meals. Drink liquids only between meals. Avoid

liquids for a half-hour before eating and a half-hour after eating.• Change your diet. Consume more low-carbohydrate foods. In

particular, concentrate on a diet low in simple carbohydrates, such as sugar (found in sweets like candy, cookies and cakes). Read labels on packaged foods, and avoid foods with sugar, including glucose, sucrose, fructose, dextrose, honey and corn syrup. Consume more protein. It may help to see a registered dietitian.

• Chew well. Chewing food thoroughly before you swallow can ease digestion.

• Increase fiber intake. Psyllium, guar gum and pectin in food or supplements can delay the absorption of carbohydrates in the small intestine. Pectin is found in many fruits, such as peaches, apples and plums.

• Avoid alcohol.• Stay away from acidic foods. Tomatoes and citrus fruits are

harder for some people to digest.• Use low-fat cooking methods. Prepare meat and other

foods by broiling, baking or grilling.• Consume adequate vitamins, iron and calcium. These can

sometimes become depleted following stomach surgery. Discuss this nutritional issue with a registered dietitian.

• Lie down after eating. This may slow down the movement of food into your intestines.

ALTERNATIVE MEDICINE

• Some people use supplements such as pectin,

guar gum, black psyllium and blond psyllium to

improve the symptoms associated with dumping

syndrome. If you decide to try a supplement,

discuss it with your doctor to learn about any

potential side effects or interactions with other

medications you're taking.

PREVENTION

• You can't prevent dumping syndrome.

However, measures such as dietary

adjustments may prevent recurrences of your

symptoms or minimize their severity.

COMPLICATIONS

• In people with severe cases of dumping syndrome, marked weight

loss and malnutrition may occur.

• Sometimes people who lose a lot of weight may also develop a fear

of eating, related to the discomfort associated with the rapid

dumping of undigested food.

• They may also avoid outdoor physical activity in order to stay close

to a toilet.

• Some have difficulty keeping a job because of their chronic

symptoms.