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Gastritis

Gastritis
Peyman Adibi,MD.
Peyman Adibi,MD.
Defnition
Defnition

The term
The term
gastritis
gastritis
is used to denote
is used to denote
inflammation associated with mucosal
inflammation associated with mucosal
injury
injury

Gastritis is mostly a histological term that


Gastritis is mostly a histological term that
needs biopsy to be confirmed
needs biopsy to be confirmed

Gastritis is usually due to infectious agents


Gastritis is usually due to infectious agents
(such as Helicobacter pylori) and
(such as Helicobacter pylori) and
autoimmune and hypersensitivity
autoimmune and hypersensitivity
reactions.
reactions.
Defnition
Defnition

Epithelial cell damage and regeneration without


Epithelial cell damage and regeneration without
associated inflammation is properly referred to
associated inflammation is properly referred to
as "
as "
gastropathy
gastropathy
.
.

Gastropathy may be referred without histological


Gastropathy may be referred without histological
evidence and just according to gross
evidence and just according to gross
appearance in endoscopy or radiology
appearance in endoscopy or radiology

Gastropathy is usually caused by irritants such


Gastropathy is usually caused by irritants such
as drugs (eg! nonsteroidal antiinflammatory
as drugs (eg! nonsteroidal antiinflammatory
agents and alcohol)! bile reflu"! hypovolemia!
agents and alcohol)! bile reflu"! hypovolemia!
and chronic congestion
and chronic congestion
.
.
Grosshistologic
Grosshistologic
correlation?
correlation?
Research evidence
Research evidence

#mong $% patients with endoscopic


#mong $% patients with endoscopic
mucosal changes attributed to gastritis! &'
mucosal changes attributed to gastritis! &'
percent had a normal endoscopic biopsy
percent had a normal endoscopic biopsy
specimen( i.e.
specimen( i.e.
PPV of 73 percent
PPV of 73 percent
or at
or at
least ) in four false positive diagnosis
least ) in four false positive diagnosis
Research evidence
Research evidence

among *$ patients with a normal


among *$ patients with a normal
endoscopic appearance! *+ percent had
endoscopic appearance! *+ percent had
histological evidence of gastritis.
histological evidence of gastritis.
NPV
NPV
equals to 27 percent
equals to 27 percent

Classifcation
Classifcation

#cute vs. chronic


#cute vs. chronic

#cute refers to short term inflammation


#cute refers to short term inflammation

#cute refering to neurophilic infiltrate


#cute refering to neurophilic infiltrate

,hronic referring to long standing forms


,hronic referring to long standing forms

,hronic referring to mononuclear cell infiltrate


,hronic referring to mononuclear cell infiltrate
especially lymphocyte and maccrophages
especially lymphocyte and maccrophages
Anatomical site
Anatomical site
ANTRUM
CARDIA
BODY
MUCOUS
SECRETING
ENDOCRINE
SPECIALISED SECRETORY
PARIETAL - ACID
CHIEF -
PEPSINOGEN ENDOCRINE
HIST,
SOMASTATIN
MUCOUS SECRETING
ENDOCRINE
GASTRIN, 5HT
). ,hemical gastritis (acute
). ,hemical gastritis (acute
chronic)
chronic)
#lcoholic gastritis
#lcoholic gastritis
-rug induced gastritis (e.g.! ./#0-)
-rug induced gastritis (e.g.! ./#0-)
1eflu" ( due to duodenal juice or bile) gastritis
1eflu" ( due to duodenal juice or bile) gastritis
2ther chemical gastritis
2ther chemical gastritis
&. 1adiation gastritis
&. 1adiation gastritis
+. #llergic gastritis
+. #llergic gastritis
3. #utoimmune gastritis
3. #utoimmune gastritis
4. /pecial forms of gastritis
4. /pecial forms of gastritis
*. Gastritis
*. Gastritis
.2/
.2/
'. -uodenitis
'. -uodenitis
Non HP gastritis (
Non HP gastritis (
ICD10
ICD10

C!A""I#ICA$I%N
C!A""I#ICA$I%N
GASTRITIS
#,5TE ,2662. ,H12.0,
E6#G
#6#G
708E H9
/T1E//
./#0-
C!A""I#ICA$I%N
C!A""I#ICA$I%N
GASTRITIS
ACUTE ,2662. ,H12.0,
E6#G
#6#G
708E H9
/T1E//
NSAID
Ac&te hemorrhagic
Ac&te hemorrhagic
erosive
erosive

hemorrhagic and erosive lesions


hemorrhagic and erosive lesions
shortly after e"posure of the
shortly after e"posure of the
gastric mucosa to various
gastric mucosa to various
injurious substances or a
injurious substances or a
substantial reduction in mucosal
substantial reduction in mucosal
blood flow
blood flow
6ucosal congestion!
oedema! inflammation :
ulceration
AC'$( GA"$RI$I" )
AC'$( GA"$RI$I" )
*%RPH%!%G+
*%RPH%!%G+
Ac&te hemorrhagic
Ac&te hemorrhagic
erosive
erosive

nonsteroidal antiinflammatory drugs ;./#0-s<!


nonsteroidal antiinflammatory drugs ;./#0-s<!
alcohol! or bile acids) or to mucosal hypo"ia
alcohol! or bile acids) or to mucosal hypo"ia
(such as in trauma! burns ;,urling=s ulcers< or
(such as in trauma! burns ;,urling=s ulcers< or
sepsis) or to a combination of factors such as
sepsis) or to a combination of factors such as
with antineoplastic chemotherapy
with antineoplastic chemotherapy

Gastric and duodenal ulceroinflammatory


Gastric and duodenal ulceroinflammatory
ulcers occurring during severe damage to the
ulcers occurring during severe damage to the
central nervous system (,ushing=s ulcers) are
central nervous system (,ushing=s ulcers) are
often considered in this group
often considered in this group
Ac&te hemorrhagic
Ac&te hemorrhagic
erosive
erosive

Gastric and duodenal


Gastric and duodenal
ulceroinflammatory ulcers
ulceroinflammatory ulcers
occurring during severe damage
occurring during severe damage
to the central nervous system
to the central nervous system
(,ushing=s ulcers) are often
(,ushing=s ulcers) are often
considered in this group
considered in this group
Ac&te hemorrhagic
Ac&te hemorrhagic
erosive
erosive

specific pathogenetic factor in ./#0->


specific pathogenetic factor in ./#0->
induced acute hemorrhagic and erosive
induced acute hemorrhagic and erosive
gastropathy is the
gastropathy is the
inhibition of
inhibition of
prostaglandin production
prostaglandin production
. 9rostaglandins!
. 9rostaglandins!
especially those of the E class! protect
especially those of the E class! protect
against acute mucosal injury due to
against acute mucosal injury due to
./#0-s and other injurious substances by
./#0-s and other injurious substances by
several mechanisms! including the
several mechanisms! including the
stimulation of mucus and bicarbonate
stimulation of mucus and bicarbonate
secretion! and maintenance of mucosal
secretion! and maintenance of mucosal
blood flow
blood flow
N"AID GI to,icit- ris.
N"AID GI to,icit- ris.
/actor
/actor

9rior history of an adverse G0 event (ulcer!


9rior history of an adverse G0 event (ulcer!
hemorrhage) increases ris? four to fivefold
hemorrhage) increases ris? four to fivefold

#ge @*A increases ris? five to si"fold


#ge @*A increases ris? five to si"fold

High (more than twice normal) dosage of a


High (more than twice normal) dosage of a
./#0- increases ris? )A>fold
./#0- increases ris? )A>fold

,oncurrent use of glucocorticoids


,oncurrent use of glucocorticoids
increases ris? four to fivefold
increases ris? four to fivefold

,oncurrent use of anticoagulants


,oncurrent use of anticoagulants
increases ris? )A> to )4>fold
increases ris? )A> to )4>fold
HP and N"AID
HP and N"AID

9atients with a history of uncomplicated


9atients with a history of uncomplicated
or complicated peptic ulcers (gastric!
or complicated peptic ulcers (gastric!
duodenal)
duodenal)
should be
should be
tested for H. pylori
tested for H. pylori
prior to beginning a ./#0- or low dose
prior to beginning a ./#0- or low dose
aspirin
aspirin
. 0f present! H. pylori should be
. 0f present! H. pylori should be
treated with appropriate therapy! even if it
treated with appropriate therapy! even if it
is believed that the prior ulcer was due to
is believed that the prior ulcer was due to
./#0-s
./#0-s
Ac&te hemorrhagic
Ac&te hemorrhagic
erosive
erosive

Hemorrhagic or erosive
Hemorrhagic or erosive
gastropathy may be associated
gastropathy may be associated
with the development of gastric or
with the development of gastric or
duodenal ulcers. #cute ulceration
duodenal ulcers. #cute ulceration
is most li?ely to occur in relation to
is most li?ely to occur in relation to
shoc?>induced hemodynamic
shoc?>induced hemodynamic
instability (ie! the stress ulcer
instability (ie! the stress ulcer
syndrome).
syndrome).
NSAID prophylaxis
NSAID prophylaxis

Bor patients who are at high ris? for


Bor patients who are at high ris? for
./#0->related gastroduodenal
./#0->related gastroduodenal
to"icity! primary therapy with a ,2C>&
to"icity! primary therapy with a ,2C>&
selective inhibitor such as
selective inhibitor such as
rofeco"ib
rofeco"ib
is
is
a reasonable option.
a reasonable option.
NSAID prophylaxis
NSAID prophylaxis

Bor high>ris? patients ta?ing


Bor high>ris? patients ta?ing
nonselective ./#0-s!
nonselective ./#0-s!
misoprostol
misoprostol

(at a dose of &AA Dg four times
(at a dose of &AA Dg four times
daily) and
daily) and
lansopraEole
lansopraEole
()4 or +A
()4 or +A
mg daily) have received B-#
mg daily) have received B-#
approval for prophyla"is against
approval for prophyla"is against
./#0->induced ulcer disease and
./#0->induced ulcer disease and
its complications.
its complications.
"tress &lcer
"tress &lcer
0atho0h-siolog-
0atho0h-siolog-

Hypersecretion
Hypersecretion
of acid Fhead trauma.
of acid Fhead trauma.

-efects in gastric glycoprotein mucus


-efects in gastric glycoprotein mucus
F0n
F0n
critically ill patients! increased
critically ill patients! increased
concentrations of reflu"ed bile salts or the
concentrations of reflu"ed bile salts or the
presence of uremic to"ins can denude the
presence of uremic to"ins can denude the
glycoprotein mucous barrier
glycoprotein mucous barrier

0schemia
0schemia
F /hoc?! sepsis! and trauma can
F /hoc?! sepsis! and trauma can
lead to impaired perfusion of the gut
lead to impaired perfusion of the gut
1
1
"tress &lcer ris. /actors
"tress &lcer ris. /actors

1is? factors Ftwo major ris? factors for


1is? factors Ftwo major ris? factors for
clinically significant bleeding due to
clinically significant bleeding due to
stress ulcers areG
stress ulcers areG
mechanical
mechanical
ventilation
ventilation
for more than 3% hours
for more than 3% hours
(odds ratio )4.*)( and
(odds ratio )4.*)( and
coagulopathy
coagulopathy
(odds ratio 3.+) . The ris? of clinically
(odds ratio 3.+) . The ris? of clinically
important bleeding in patients without
important bleeding in patients without
either of these ris? factors was only
either of these ris? factors was only
A.) percent.
A.) percent.
"tress &lcer ris. /actors
"tress &lcer ris. /actors

H H
/hoc?
/hoc?
H /epsis
H /epsis
H Hepatic failure
H Hepatic failure
H 1enal failure
H 1enal failure
H 6ultiple trauma
H 6ultiple trauma
H 7urns over +4 percent of total body surface area
H 7urns over +4 percent of total body surface area
H 2rgan transplant recipients
H 2rgan transplant recipients
H Head or spinal trauma
H Head or spinal trauma
H 9rior history of peptic ulcer disease or upper G0
H 9rior history of peptic ulcer disease or upper G0
bleeding
bleeding
Common t-0e o/
Common t-0e o/
gastritides
gastritides
C!A""I#ICA$I%N
C!A""I#ICA$I%N
GASTRITIS
ACUTE COON ,H12.0,
E6#G
#6#G
708E H9
/T1E//
./#0-

Helicobacter pylori
Helicobacter pylori
is a spiral shaped!
is a spiral shaped!
microaerophilic!
microaerophilic!
gram negative
gram negative
bacterium
bacterium
measuring
measuring
appro"imately +.4
appro"imately +.4
microns in length
microns in length
and A.4 microns in
and A.4 microns in
width
width

urease for!s
urease for!s
a!!on"a an#
a!!on"a an#
$"car$onate t%at
$"car$onate t%at
neutral"&e
neutral"&e
'astr"c ac"# an#
'astr"c ac"# an#
for! a protect"(e
for! a protect"(e
clou# aroun# t%e
clou# aroun# t%e
or'an"s!
or'an"s!

5rease appears to
5rease appears to
be vital for its
be vital for its
survival and
survival and
coloniEation( it is
coloniEation( it is
produced in
produced in
abundance! ma?ing
abundance! ma?ing
up more than 4
up more than 4
percent of the
percent of the
organism=s total
organism=s total
protein weight.
protein weight.

spiral shape!
spiral shape!
flagella
flagella


facilitate its
facilitate its
passage
passage
through the
through the
mucus layer
mucus layer

H. pylori then
H. pylori then
attaches to
attaches to
gastric epithelial
gastric epithelial
cells by means of
cells by means of
specific receptor>
specific receptor>
mediated
mediated
adhesion
adhesion

Helicobacter
Helicobacter
pylori is the most
pylori is the most
common chronic
common chronic
bacterial infection
bacterial infection
in humans (4A
in humans (4A
percent of the
percent of the
world=s
world=s
population is
population is
affected.
affected.

Therefore! the
Therefore! the
freIuency of H.
freIuency of H.
pylori infection for
pylori infection for
any age group in
any age group in
any locality reflects
any locality reflects
that particular
that particular
cohort=s rate of
cohort=s rate of
bacterial
bacterial
acIuisition during
acIuisition during
childhood years
childhood years

Factors such as density of housing,


Factors such as density of housing,
oercro!ding, number of siblings,
oercro!ding, number of siblings,
sharing a bed, and lac" of running
sharing a bed, and lac" of running
!ater hae all been lin"ed to a
!ater hae all been lin"ed to a
higher ac#uisition of $. pylori
higher ac#uisition of $. pylori
infection
infection

The route by which


The route by which
infection occurs
infection occurs
remains un?nown
remains un?nown
9erson>to>person
9erson>to>person
transmission of H. pylori
transmission of H. pylori
through either fecalJoral
through either fecalJoral
or oralJoral e"posure
or oralJoral e"posure
seems most li?ely
seems most li?ely

Humans appear to be
Humans appear to be
the major reservoir of
the major reservoir of
infection( however!
infection( however!
bacteria have been
bacteria have been
isolated from primates
isolated from primates
in and from domestic
in and from domestic
cats and in mil? and
cats and in mil? and
gastric tissue of sheep
gastric tissue of sheep
Non GI associated
Non GI associated
disorders
disorders

%oronary heart disease


%oronary heart disease

&osacea
&osacea

Iron de'ciency
Iron de'ciency

Anorexia in aging
Anorexia in aging

9latelet aggregation
9latelet aggregation
mediated by an
mediated by an
H. pylori interaction with von
H. pylori interaction with von
Killebrand factor is speculated to
Killebrand factor is speculated to
contribute to infection related ulcer
contribute to infection related ulcer
disease but also possibly non>G0
disease but also possibly non>G0
manifestations of infection such as
manifestations of infection such as
cardiovascular disease and idiopathic
cardiovascular disease and idiopathic
thrombocytopenia
thrombocytopenia

# 7 cell response to H. pylori (with


# 7 cell response to H. pylori (with
production of 0gG and 0g# antibodies)
production of 0gG and 0g# antibodies)
occurs locally in the gastroduodenal
occurs locally in the gastroduodenal
mucosa and systemically. The role of local
mucosa and systemically. The role of local
antibodies in producing tissue injury or
antibodies in producing tissue injury or
modulating inflammation in H. pylori
modulating inflammation in H. pylori
infection remains controversial .
infection remains controversial .
9rolonged
9rolonged
stimulation of gastric 7 cells by activated T
stimulation of gastric 7 cells by activated T
cells can lead to 6#8T lymphoma in rare
cells can lead to 6#8T lymphoma in rare
cases
cases
2ac A 3 Cag A
2ac A 3 Cag A

vacuolating cytoto"in (Lac#) which causes


vacuolating cytoto"in (Lac#) which causes
cell injury in vitro and gastric tissue damage
cell injury in vitro and gastric tissue damage
in vivo . #ll H. pylori contain the gene coding
in vivo . #ll H. pylori contain the gene coding
for Lac#( however! only those strains with
for Lac#( however! only those strains with
the cytoto"in>associated gene # (cag#)
the cytoto"in>associated gene # (cag#)

/trains producing Lac# and ,ag# cause


/trains producing Lac# and ,ag# cause
more intense tissue inflammation and
more intense tissue inflammation and
induce cyto?ine production
induce cyto?ine production

#ppro"imately %4 to )AA percent of


#ppro"imately %4 to )AA percent of
patients with duodenal ulcers have
patients with duodenal ulcers have
,ag#M strains! compared to +A to *A
,ag#M strains! compared to +A to *A
percent of infected patients who do
percent of infected patients who do
not develop ulcers
not develop ulcers

,ag# strains may be associated with


,ag# strains may be associated with
a higher freIuency of precancerous
a higher freIuency of precancerous
lesions.
lesions.

Host polymorphism of 08>) beta


Host polymorphism of 08>) beta

(and possibly 08>)A) appears to
(and possibly 08>)A) appears to
determine the degree of
determine the degree of
inflammatory response to
inflammatory response to
infection! resulting alteration in
infection! resulting alteration in
acid secretion (hyper or hypo
acid secretion (hyper or hypo
secretion)! and ris? for
secretion)! and ris? for
subseIuent gastric cancer
subseIuent gastric cancer

0g#
0g#
antibodies may
antibodies may
modulate
modulate
mucosal injury by
mucosal injury by
inhibiting antigen upta?e!
inhibiting antigen upta?e!
disrupting bacterial
disrupting bacterial
adherence and motility! and
adherence and motility! and
neutraliEing various to"ins.
neutraliEing various to"ins.
0gG
0gG
presumably
presumably
au'!ents
au'!ents

inflammatory injury by
inflammatory injury by
activating complement and
activating complement and
facilitating neutrophil
facilitating neutrophil
activation.
activation.
)"le reflu* 'astropat%+
)"le reflu* 'astropat%+

7ile reflu" gastropathy typically


7ile reflu" gastropathy typically
results from the regurgitation of bile
results from the regurgitation of bile
into the stomach because of an
into the stomach because of an
operative stoma! an incompetent
operative stoma! an incompetent
pyloric sphincter! or abnormal
pyloric sphincter! or abnormal
duodenal motility
duodenal motility
)"le reflu* 'astropat%+
)"le reflu* 'astropat%+

The effect of bile salts on gastric


The effect of bile salts on gastric
mucosa is comparable to that seen
mucosa is comparable to that seen
after chronic ./#0- use
after chronic ./#0- use
,hronic
,hronic
metaplastic
metaplastic
gastritides
gastritides
C!A""I#ICA$I%N
C!A""I#ICA$I%N
GASTRITIS
#,5TE
,2662.
C,RONIC
E6#G
AAG
708E H9
/T1E//
./#0-
meta0lastic atro0hic
meta0lastic atro0hic
gastritis
gastritis

6etaplasia! especially of the intestinal


6etaplasia! especially of the intestinal
type! is virtually a universal feature of
type! is virtually a universal feature of
atrophic gastritis and is often the most
atrophic gastritis and is often the most
dependable defining morphologic
dependable defining morphologic
feature.
feature.

H
H
6etaplasia is highly relevant to the
6etaplasia is highly relevant to the
pathogenesis of atrophic gastritis and to
pathogenesis of atrophic gastritis and to
its complications (eg! pernicious
its complications (eg! pernicious
anemia! gastric ulcer! and gastric
anemia! gastric ulcer! and gastric
cancer).
cancer).
meta0lastic atro0hic
meta0lastic atro0hic
gastritis
gastritis

The term metaplastic atrophic gastritis ma?es a


The term metaplastic atrophic gastritis ma?es a
sharp distinction between metaplastic and
sharp distinction between metaplastic and
nonmetaplastic forms of gastric atrophy!
nonmetaplastic forms of gastric atrophy!
especially the atrophic change (gastrinopenic
especially the atrophic change (gastrinopenic
type) often noted in the o"yntic mucosa (ie!
type) often noted in the o"yntic mucosa (ie!
mucosa of the body and fundus)! which remains
mucosa of the body and fundus)! which remains
in place after antrectomy for peptic ulcer.
in place after antrectomy for peptic ulcer.
meta0lastic atro0hic
meta0lastic atro0hic
gastritis
gastritis

Endoscopic surveillance in patients from


Endoscopic surveillance in patients from
developed countries who do not have
developed countries who do not have
dysplasia is probably unnecessary
dysplasia is probably unnecessary

meta0lastic atro0hic
meta0lastic atro0hic
gastritis
gastritis

AUTOIUNE ETAP-ASTIC
AUTOIUNE ETAP-ASTIC
ATROP,IC GASTRITIS
ATROP,IC GASTRITIS
(#6#G) is
(#6#G) is
an inherited form that is associated
an inherited form that is associated
with an immune response in the
with an immune response in the
o"yntic mucosa directed against
o"yntic mucosa directed against
parietal cells and intrinsic factor.
parietal cells and intrinsic factor.
#6#G is inherited as an autosomal
#6#G is inherited as an autosomal
dominant disorder
dominant disorder
"+N%N+*" %# A*AG
"+N%N+*" %# A*AG

TN9E # G#/T10T0/
TN9E # G#/T10T0/

#5T20665.E G#/T10T0/
#5T20665.E G#/T10T0/

-0BB5/E ,21921#8 G#/T10T0/


-0BB5/E ,21921#8 G#/T10T0/
meta0lastic atro0hic
meta0lastic atro0hic
gastritis
gastritis

The chronic inflammation! gland


The chronic inflammation! gland
atrophy! and epithelial metaplasia of
atrophy! and epithelial metaplasia of
#6#G are closely paralleled by
#6#G are closely paralleled by
elevated serum antibodies to parietal
elevated serum antibodies to parietal
cells and to intrinsic factor! reflecting
cells and to intrinsic factor! reflecting
its autoimmune origin.
its autoimmune origin.
meta0lastic atro0hic
meta0lastic atro0hic
gastritis
gastritis

The loss of parietal cell mass leads to


The loss of parietal cell mass leads to
profound hypochlorhydria! while the
profound hypochlorhydria! while the
inadeIuate production of intrinsic
inadeIuate production of intrinsic
factor leads to
factor leads to
vitamin 7)&
vitamin 7)&

malabsorption and pernicious
malabsorption and pernicious
anemia
anemia
.
.
meta0lastic atro0hic
meta0lastic atro0hic
gastritis
gastritis

9atients with #6#G are at increased


9atients with #6#G are at increased
ris? for the development of gastric
ris? for the development of gastric
carcinoid tumors and
carcinoid tumors and
adenocarcinoma
adenocarcinoma
.
.
CANCER
meta0lastic atro0hic
meta0lastic atro0hic
gastritis
gastritis
surveillance strategy for patients diagnosed with
surveillance strategy for patients diagnosed with
pernicious anemia
pernicious anemia
H
H
5pper endoscopy soon after diagnosis
5pper endoscopy soon after diagnosis
H
H
1emoval of gastric polyps if possible( most of
1emoval of gastric polyps if possible( most of
these polyps will be benign
these polyps will be benign
H
H
BreIuent reinvestigation in patients whose
BreIuent reinvestigation in patients whose
polyps are not removed or who have severe
polyps are not removed or who have severe
mucosal dysplasia( in the remaining patients
mucosal dysplasia( in the remaining patients
follow>up endoscopies should be performed at
follow>up endoscopies should be performed at
appro"imately five>year intervals.
appro"imately five>year intervals.
meta0lastic atro0hic
meta0lastic atro0hic
gastritis
gastritis

9atients with #6#G are


9atients with #6#G are
less l".el+
less l".el+
to
to
be infected by H. pylori
be infected by H. pylori
than aged>
than aged>
matched controls . Two possible
matched controls . Two possible
e"planations are that the metaplastic
e"planations are that the metaplastic
epithelium is unsuitable for H. pylori
epithelium is unsuitable for H. pylori
coloniEation! and that the associated
coloniEation! and that the associated
hypochlorhydria encourages
hypochlorhydria encourages
overgrowth by other bacterial species
overgrowth by other bacterial species
meta0lastic atro0hic
meta0lastic atro0hic
gastritis
gastritis

Environmental metaplastic atrophic


Environmental metaplastic atrophic
gastritis (E6#G) is due to
gastritis (E6#G) is due to
environmental factors! such as diet
environmental factors! such as diet
and H. pylori infection! on the gastric
and H. pylori infection! on the gastric
mucosa
mucosa
.
.
meta0lastic atro0hic
meta0lastic atro0hic
gastritis
gastritis

5nli?e #6#G! mucosal changes


5nli?e #6#G! mucosal changes
in patients with E6#G affect both
in patients with E6#G affect both
the corpus and antrum in a
the corpus and antrum in a
multifocal distribution! but
multifocal distribution! but
with
with
heaviest involvement of the
heaviest involvement of the
antrum.
antrum.
meta0lastic atro0hic
meta0lastic atro0hic
gastritis
gastritis

EMAG vs AMAG
EMAG vs AMAG

H
H
Gastric acid production
Gastric acid production
does not
does not

disappear entirely
disappear entirely
H /erum gastrin
H /erum gastrin
is not
is not
elevated
elevated
H 9arietal cell and intrinsic factor
H 9arietal cell and intrinsic factor
autoantibodies and pernicious anemia
autoantibodies and pernicious anemia
are
are
absent
absent


meta0lastic atro0hic
meta0lastic atro0hic
gastritis
gastritis

There is an increased ris? for gastric


There is an increased ris? for gastric
ulcer compared to #6#G!
ulcer compared to #6#G!
presumably due to the accompanying
presumably due to the accompanying
hypochlorhydria the latter disorder
hypochlorhydria the latter disorder
CANCER
meta0lastic atro0hic
meta0lastic atro0hic
gastritis
gastritis

diagnosis of E6#G should


diagnosis of E6#G should
not
not
be
be
made from biopsy specimens
made from biopsy specimens
unless
unless
at least &A percent
at least &A percent
of the
of the
available antral or transitional
available antral or transitional
mucosa is replaced by
mucosa is replaced by
metaplastic glands! or there is
metaplastic glands! or there is
uneIuivocal atrophy
uneIuivocal atrophy
.
.
meta0lastic atro0hic
meta0lastic atro0hic
gastritis
gastritis

9ossible e"ceptions are nitroso


9ossible e"ceptions are nitroso
compounds! which may be
compounds! which may be
important in E6#G and in the
important in E6#G and in the
development of gastric cancer .
development of gastric cancer .
.itroso compounds! which are
.itroso compounds! which are
?nown carcinogens ! are
?nown carcinogens ! are
generated in the gastric lumen by
generated in the gastric lumen by
bacterial metabolism of
bacterial metabolism of
nitrates
nitrates
.
.
meta0lastic atro0hic
meta0lastic atro0hic
gastritis
gastritis
chronic infection
chronic infection

cell injuryJ inflammation
cell injuryJ inflammation
susceptibility to
susceptibility to
mutagenic factors.
mutagenic factors.
H-0er0lastic
H-0er0lastic
gastro0athies
gastro0athies
proliferative!
inflammatory! and
infiltrative
conditions are
associated with
large folds due to
e"cessive number
of mucosal
epithelial cells
*4n4trier5s disease
*4n4trier5s disease

Epithelial
Epithelial
hyperplasia
hyperplasia
involving the
involving the
surface and
surface and
foveolar mucous
foveolar mucous
cells (ie! foveolar
cells (ie! foveolar
hyperplasia)( the
hyperplasia)( the
o"yntic glands can
o"yntic glands can
be normal or
be normal or
atrophic.
atrophic.
(ollinger)*llison syndrome
(ollinger)*llison syndrome
0ncreased numbers
0ncreased numbers
of parietal cells
of parietal cells
with no change in
with no change in
surface and
surface and
foveolar mucous
foveolar mucous
cells.
cells.
H-0er0lastic
H-0er0lastic
gastro0athies
gastro0athies


mi"ed>type in which
mi"ed>type in which
both mucous and
both mucous and
o"yntic glandular
o"yntic glandular
cells show
cells show
hyperplasia! may be
hyperplasia! may be
seen in as
seen in as
lymphocytic and H.
lymphocytic and H.
pylori gastritis.
pylori gastritis.
!arge gastric /olds 6 110 cm
!arge gastric /olds 6 110 cm

H H
,hronic gastritisJlymphoid
,hronic gastritisJlymphoid
hyperplasia F 3A
hyperplasia F 3A

H
H
7enign tumors F )*
7enign tumors F )*
H
H
Gastric malignancy F )&
Gastric malignancy F )&
H
H
Oollinger>Ellison
Oollinger>Ellison
syndrome F )A
syndrome F )A
H
H
6enetrier=s disease F %
6enetrier=s disease F %
*4n4trier5s
*4n4trier5s

Epigastric pain F *4 percent


Epigastric pain F *4 percent

#sthenia F *A percent
#sthenia F *A percent

#nore"ia F 34 percent
#nore"ia F 34 percent

Keight loss F 34 percent


Keight loss F 34 percent

Edema F +% percent
Edema F +% percent

Lomiting F +% percent
Lomiting F +% percent

80 percent of patients had


80 percent of patients had
hypoalbuminemia
hypoalbuminemia
*4n4trier5s
*4n4trier5s

/urgery has been


/urgery has been
advocated for patients
advocated for patients
with intractable pain!
with intractable pain!
hypoalbuminemia with
hypoalbuminemia with
edema! hemorrhage!
edema! hemorrhage!
pyloric obstruction! and
pyloric obstruction! and
for those in whom a
for those in whom a
malignancy cannot be
malignancy cannot be
e"cluded
e"cluded
*4n4trier5s
*4n4trier5s

Gastric
Gastric
atrophyP@
atrophyP@

Gastric
Gastric
cancerP@
cancerP@
(ollinger)*llison syndrome
(ollinger)*llison syndrome

A.) to ) percent of patients with peptic


A.) to ) percent of patients with peptic
ulcer disease .
ulcer disease .

5nderestimationQ
5nderestimationQ

symptoms similar to typical peptic ulcer .


symptoms similar to typical peptic ulcer .

symptoms may be controlled by


symptoms may be controlled by
standard doses of an antisecretory drug
standard doses of an antisecretory drug

patients may not be tested for


patients may not be tested for
hypergastrinemia
hypergastrinemia
7("
7("

6ost patients are diagnosed


6ost patients are diagnosed
between the ages of &A and 4A.
between the ages of &A and 4A.
The male to female ratio ranges
The male to female ratio ranges
between to &G) .
between to &G) .
/ES
/ES

Gastrinomas can be either


Gastrinomas can be either
sporadic (%A percent) or
sporadic (%A percent) or
associated with multiple
associated with multiple
endocrine neoplasia type
endocrine neoplasia type
0
0
D"arr%ea "n /ES
D"arr%ea "n /ES

H
H
The high rate of acid volume load that
The high rate of acid volume load that
cannot be
cannot be
absorbed by the intestine
absorbed by the intestine

H
H
The e"cess acid
The e"cess acid
e"ceeds the neutraliEing
e"ceeds the neutraliEing
capacity of pancreatic bicarbonate
capacity of pancreatic bicarbonate
. The
. The
e"ceptionally low pH of the intestinal contents
e"ceptionally low pH of the intestinal contents
inactivates pancreatic digestive enEymes!
inactivates pancreatic digestive enEymes!
interferes with the emulsification of fat by bile acids!
interferes with the emulsification of fat by bile acids!
and damages intestinal epithelial cells and villi.
and damages intestinal epithelial cells and villi.
H
H
The e"tremely high serum gastrin concentrations
The e"tremely high serum gastrin concentrations
may
may
inhibit absorption of sodium and water
inhibit absorption of sodium and water
by the
by the
small intestine!
small intestine!
"igns o/ 7("
"igns o/ 7("

6ultiple ulcers
6ultiple ulcers
diarrhea
diarrhea
ulcer in atypical site
ulcer in atypical site
resistant ulcer
resistant ulcer
enlarged folds
enlarged folds
severe esophagirtis
severe esophagirtis
BH of 6E.)
BH of 6E.)
7(" diagnosis
7(" diagnosis
E"clude hpoacidityQ
E"clude hpoacidityQ
,hec? gastrin! if
,hec? gastrin! if
@
@
)AAAROE/
)AAAROE/
.
.
S)AAA but abnormal
S)AAA but abnormal
secretin test to be
secretin test to be
performed
performed
!M&AA pgJml is
!M&AA pgJml is
OE/
OE/
!ocali8ation o/
!ocali8ation o/
gastrinoma
gastrinoma

/9E,T imaging with pentetreotide should


/9E,T imaging with pentetreotide should
be the
be the
f"rst test
f"rst test
because of its high
because of its high
sensitivity for both primary tumors and
sensitivity for both primary tumors and
hepatic metastases
hepatic metastases

0f no tumor or metastases are found but


0f no tumor or metastases are found but
clinical suspicion remains high! endoscopic
clinical suspicion remains high! endoscopic
ultrasonography (E5/) or dual phase
ultrasonography (E5/) or dual phase
helical ,T scan should be performed.
helical ,T scan should be performed.
7(" treatment
7(" treatment

2mepraEole
2mepraEole
effectively controlled
effectively controlled
acid output in
acid output in
all
all
patients.
patients.

.o patients e"perienced
.o patients e"perienced
tachyphyla"is! and no hematologic!
tachyphyla"is! and no hematologic!
metabolic! or gastric to"icity was
metabolic! or gastric to"icity was
noted
noted
.
.
7(" treatment
7(" treatment

any patient with a sporadic


any patient with a sporadic
gastrinoma and without evidence of
gastrinoma and without evidence of
metastatic spread of disease should
metastatic spread of disease should
be offered e"ploratory laparotomy
be offered e"ploratory laparotomy
with curative intent
with curative intent
/ES treat!ent
/ES treat!ent

laparotomy is not routinely


laparotomy is not routinely
recommended for patients with OE/
recommended for patients with OE/
as part of 6E. ) since the multifocal
as part of 6E. ) since the multifocal
nature of the tumors in this disorder
nature of the tumors in this disorder
almost uniformly precludes cure of
almost uniformly precludes cure of
gastrin hypersecretion
gastrin hypersecretion
Portal h-0ertensive
Portal h-0ertensive
gastro0ath-
gastro0ath-

9ortal hypertensive gastropathy


9ortal hypertensive gastropathy
characteristically appears as a fine
characteristically appears as a fine
white reticular pattern separating
white reticular pattern separating
areas of pin?ish mucosa on
areas of pin?ish mucosa on
endoscopy! giving the gastric mucosa
endoscopy! giving the gastric mucosa
a "
a "
sna?es?in
sna?es?in
" appearance
" appearance
Portal h-0ertensive
Portal h-0ertensive
gastro0ath-
gastro0ath-