Lecture 9 Flashcards
parts of the stomac
top: Fundus
mid: Body
low: Antrum
Gastritis & Peptic Ulcer Disease (PUD)
Ulcerations of gut mucosa that penetrate
the submucosa
– Gastric (typically near antrum)
– Duodenal (first few cm)
• Areas of breakdown continuously
exposed to gastric acid & pepsin
– Erosion
– Perforation
Etiology of Peptic Ulcer Disease
H.pylori
infection
H.pylori
infection
Stress &
Severe Illness
Gastritis
Etiology: Helicobacter pylori
• Gram negative bacteria residing under mucosal layer
– Present in ~90% adults; 10-15% develop symptomatic ulcerations
• Most common cause of gastritis and PUD
– Confirmed by endoscopy
• Mechanisms
– Damages mucosal cells and causes inflammation
• Also implicated in
– Gastric carcinoma
– Atrophic gastritis
Etiology: Medications / Substance Use
Substances • Alcohol abuse – Excessive ethanol can damage gastric mucosa • Ingestion of erosive substances • Tobacco use – Decreases bicarbonate secretion & mucosal blood flow – Exacerbates inflammation • Poor diet – Delayed wound / tissue healing
Medications • NSAIDS and Aspirin – Corrosive – Inhibit prostaglandin synthesis • Prostaglandins: essential for maintaining mucous and bicarbonate barrier in the stomach • Corticosteroids
Symptomology
Chief complaint: Abdominal discomfort
– Dull, burning, transient pain; usually occurring on empty stomach
• Other symptoms:
– Bloating, burping, nausea, vomiting, anorexia
Can also be asymptomatic!
Nutritional Implications
• Impaired oral intake – Pain, N/V, anorexia, malaise etc. • Involuntary weight loss • Nutrient imbalances / deficiencies • Atrophic gastritis – Risk B12 deficiency d/t lack intrinsic factor à impaired absorption – Gastric acid enhances bioavailability à low acid states negatively influence absorption, particularly Fe, Ca
Nutritional Diagnoses
• Some commonly associated with PUD
• Some commonly associated with PUD – Inadequate food / oral beverage intake – Altered GI function – Involuntary weight loss – Food and nutrition-related knowledge deficit
Management of PUD: Pharmacotherapy
• Antacids – Neutralize acid, prevent formation of pepsin • Maalox, Tums, Gaviscon • Proton pump inhibitors (PPI’s) – Suppress acid production • Omeprazole, esomeprazole, lansoprazole, pantoprazole • H2-receptor agonists – Block histamine-stimulated gastric secretions • Cimetidine, ranitidine
Prostaglandin analogs – Reduce gastric acid and enhance mucosal resistance to injury • Misoprostol • Mucosal barrier fortifiers – Form a protective coating- bismuth - dark stool
H. pylori ”triple therapy”
7-14 day course 2 antibiotics + PPI
– Antibiotics
• Amoxicillin, tetracycline, metronidazole, clarithromycin
– Nelms Table 14.16
• 86-98% eradication rate
• Side effects: nausea, vomiting, abdominal pain
– May reduce compliance
Management of PUD: Nutrition
• Nutritional goals of care
– Support medical therapy & decrease symptoms
– Prevent weight loss & restore nutrient imbalances
• Nutrition therapy
– Trial restriction of foods that may increase acid secretion
• Black and red pepper, caffeine, coffee (inc. decaf), alcohol
– Avoid foods not tolerated (diet as tolerated or “DAT”)
• Meal considerations: timing & size
– Avoid lying down after eating
– Avoid larger meals close to bedt
Nutrition: Other Considerations
Historical dietary treatment: milk & cream
– Coat stomach
– Now know they increase gastrin and pepsin secretion
– Do NOT recommend
• pH of food prior to consumption has little effect after
consumption
– Restricting acidic juices/foods not warranted
Acute Symptomology
• Sharp, sudden, persistent, severe pain • Melena – Bloody/black stools • Hematemesis – Vomiting blood; “coffee ground emesis” Serious complications • Acute or chronic GI bleed • Perforation • Obstruction • i.e. gastric outlet obstruction
Surgical Treatment of PUD
• Surgical treatment significantly reduced post-1960
– Secondary to discovery of H. pylori
• Present day, indicated for:
– Severe cases, refractory to treatment
– Complications
• GI bleeds, perforation, obstruction of pyloric sphincter
• Types of surgery
– Vagotomy (with or w/o gastric resection)
– Gastroenterostomy
Vagotomy
• Interruption of the impulses (cholinergic stimulation of stomach) carried by the vagus nerve to parietal cells – ↓ acid production – ↓ response to gastrin • Truncal vagotomy with – Pyloroplasty, or – Antrectomy • Highly selective vagotomy
