Stomach Disorders

Summary of Disorders of the Stomach

The stomach is a vital organ in the digestive system, responsible for storing food, breaking it down through muscular contractions and gastric secretions, and gradually releasing it into the small intestine. Disorders of the stomach can significantly impair these functions, leading to a variety of health issues. This summary provides an overview of common stomach disorders, including gastritis, peptic ulcer disease, pyloric stenosis, and gastric cancer, detailing their causes, pathophysiology, clinical manifestations, diagnostic approaches, and management strategies.

Gastritis

• Gastritis is characterized by the inflammation of the gastric mucosa, which can be either acute or chronic.
• Pathophysiology: The gastric mucosa is normally protected from acid auto-digestion by prostaglandins. Injury occurs when there is a break in this protective barrier, compounded by histamine release and vagal nerve stimulation, leading to hydrochloric acid diffusion into the mucosa and injury to small vessels. This results in edema, hemorrhage, and erosion of the stomach's lining.
• Types:
  • Acute Gastritis: An acute inflammation of the gastric mucosa or submucosa with destruction of superficial epithelial cells, lasting from a few hours to a few days. Causes include thermal injuries (very hot fluids or food), chemical irritants, irritating foods (spiced food, alcohol), and drugs like aspirin.
  • Chronic Gastritis: A chronic degeneration of the mucosa membranes of the stomach, often following prolonged dietary indiscretion or alcohol abuse. Causes include Helicobacter pylori infection, alcohol abuse, thyroid disease, diabetes mellitus, radiation therapy, repeated acute gastritis, autoimmune conditions, and smoking.
• Signs and Symptoms:
  • Acute Gastritis: Anorexia, nausea, vomiting, dyspepsia, epigastric pains, hematemesis, melena, water brush syndrome, signs of pernicious anemia, colic, diarrhea, and fever.
  • Chronic Gastritis: Anorexia leading to weight loss, nausea, vomiting (haematemesis), dyspepsia, flatulence, epigastric pain, abdominal pain, melena, and constipation followed by diarrhea.
• Diagnosis:
  • Acute Gastritis: Endoscopy/gastroscopy, FBC (revealing low hemoglobin), elevated ESR, histological examination of biopsy specimens, serologic testing for H. pylori, and gastric acid analysis.
  • Chronic Gastritis: Patient history, barium meal, endoscopy/gastroscopy, stool test for occult blood, FBC, and gastric acid analysis.
• Treatment:
  • Acute Gastritis: Antiemetics (e.g., Metochlopromide), anticholinergics (e.g., atropine), and Cimetidine.
  • Chronic Gastritis: Modifying the patient's diet, promoting rest, advising thorough chewing, triple therapy (Amoxicillin, Metronidazole, and Omeprazole) to eradicate H. pylori, and antiemetics.
• Nursing Management: Includes environmental management, positioning, rest, observation, psychological care, hygiene, exercises, nutrition, elimination management, medication administration, and discharge advice.
• Patient Education (IEC): Importance of rest, explaining the disease process, avoiding irritants, ensuring drug compliance, emphasizing review dates, teaching signs of complications, and lifestyle changes.
• Complications: Gastric ulcers, hemorrhage, anemia, obstruction, perforation, peritonitis, and stomach cancer.

Peptic Ulcer Disease

• Peptic ulcer disease (PUD) involves excavation (erosion) in the mucosal wall of the stomach, pylorus, duodenum, or esophagus, characterized by epigastric pain and heartburn. It results from an erosion or break in the mucus or tissues of the digestive tract that comes into contact with gastric juices, potentially penetrating the muscle layer and causing bleeding or perforation.
• Epidemiology: The greatest frequency is seen between 40 and 60 years of age. Peak age in duodenal ulcers is 30-60, while in gastric ulcers, it is 50 and above.
• Types:
  • According to Degree: Acute ulcers (stress-related, superficial) and chronic ulcers (single lesion with thickened margins).
  • According to Location: Esophageal, gastric, and duodenal ulcers.
• Causes: Helicobacter pylori is attributed to more than 90% of all peptic ulcers. Predisposing factors include emotional factors, inflammation, Zollinger-Ellison syndrome, hereditary factors, trauma, serious illness, and conditions like severe burns.
• Pathophysiology: The gastric mucosa is protected by various factors including a balance between acid secretion and mucosal defenses. Ulceration occurs due to decreased resistance of the gastric mucosa to pepsin and acid injury.
• Clinical Manifestations: Epigastric pain (burning, occurring 1-3 hours after meals, relieved by food or antacids), heartburn, dyspepsia, nausea, and excessive salivation. Other symptoms include vomiting, weight loss, anorexia, hematemesis or melena, and constipation.
• Comparison between Duodenal and Gastric Ulcers:
  • Gastric Ulcers: Predominantly in the antrum, normal to decreased gastric secretion, higher incidence in women, burning or gaseous pressure in the high left epigastric region, pain aggravated by food, weight loss, and higher risk of developing cancer.
  • Duodenal Ulcers: Predominantly in the first 2cm of the duodenum, increased gastric secretion, higher incidence in men, burning and crampy pain across the mid-epigastrium, pain relieved by food, normal or weight gain, and less common to develop cancer.
• Investigations: History taking, physical assessment, H. pylori test, endoscopy, barium swallow, stool test for occult blood, biopsy, and exfoliative cytology.
• Treatment:
  • First-line therapy: Omeprazole (20mg PO BD) and Amoxicillin (500mg TDS P.O.).
  • Second-line therapy: Proton pump inhibitor, bismuth, metronidazole, and tetracycline.
  • Other Drugs: Antacids, histamine receptor antagonists (e.g., Cimetidine), mucosal barrier fortifiers (e.g., sucralfate), and anticholinergic drugs.
• Nursing Management: Similar to gastritis, focusing on environment, positioning, rest, observation, psychological care, hygiene, nutrition, elimination, medication, and discharge advice.
• Surgical Treatment: Vagotomy, antrectomy, pyloroplasty, gastroduodenostomy (Billroth I), gastrojejunostomy (Billroth II), subtotal gastrectomy, total gastrectomy, and oesophagojejunostomy.
• Pre-operative and Post-operative Care: Includes physical preparation, gastric preparation, bowel preparation, bladder preparation, psychological support, and patient education.
• Complications: Hemorrhage, perforation, peritonitis, pyloric obstruction, intractable ulcer, gastric outlet obstruction, malignancy, and penetration.

Gastric Cancer

• Gastric cancer is the malignancy of the cells of the stomach, characterized by blood in stool, indigestion, and heartburn.
• Risk Factors: Family history, Helicobacter pylori infection, large stomach polyps, chronic atrophic gastritis, pernicious anemia, and smoking.
• Clinical Stages:
  • Stage 0: Limited to the inner lining, treatable by endoscopic mucosal resection.
  • Stage I: Penetrates the muscle layer, treated by gastrectomy and lymphadenectomy.
  • Stage II: Spreads to deeper tissues and nearby lymph nodes, cure possible.
  • Stage III: Spreads to nearby organs, gastrectomy can be done.
  • Stage IV: Spreads to distant tissues, cure rarely possible.
• Clinical Manifestations: Early symptoms are often subtle, including loss of appetite and indigestion. Later symptoms include vomiting, hematemesis, cachexia, weakness, anemia, and pain.
• Diagnosis: History, physical examination, gastric content aspiration, biopsies, CT scan, and MRI.
• Surgical Treatment: Radical subtotal gastrectomy and total gastrectomy.
• Post-operative Complications: Hemorrhage, shock, pulmonary complications, steatorrhea, dumping syndrome, gastritis, oesophagitis, and vitamin B12 deficiency.

Congenital Pyloric Stenosis

• Pyloric stenosis is the narrowing of the pylorus, the opening from the stomach into the small intestine, leading to the partial or complete blockage.
• Types: Primary acquired hypertrophic pyloric stenosis (AHPS) and secondary AHPS.
• Causes: Prolonged pylorospasms, pyloric ulcer, hiatal hernia, gastritis, gallbladder disease, and stomach cancer.
• Pathophysiology: Thickening of the pyloric muscles interferes with stomach emptying.
• Signs and Symptoms: Vomiting (projectile), abdominal pain, belching, constant hunger, dehydration, and failure to gain weight.
• Diagnosis: History from the mother, physical examination (detecting an olive-shaped mass), ultrasound, and barium x-ray.
• Treatment: Pyloromyotomy or pyloroplasty.
• Complications: Failure to thrive, chronic constipation, anemia, and dehydration.

Conclusion:

This summary has covered several key disorders affecting the stomach, including gastritis, peptic ulcer disease, and gastric cancer. Each condition presents unique challenges in terms of etiology, pathophysiology, diagnosis, and management. Understanding these disorders is crucial for healthcare professionals to provide effective care and improve patient outcomes.