Diseases of gastro-Diseases of gastro-intestinal tractintestinal tract

Assistant of professorAssistant of professor

Nechiporenko G.V.Nechiporenko G.V.

Acute tonsillitis• Catarrhal • Fibrinous • Purulent • Follicular • Cryptous • Necrotic

• Complications: retropharyngeal abscess, peritonsillar abscess and cellulitis, sepsis.

Classification of Gastritis.Classification of Gastritis.ACUTE GASTRITISACUTE GASTRITIS

Acute Acute H. pylori H. pylori gastritisgastritis Other acute infective gastritis (bacteria, viruses, fungi, Other acute infective gastritis (bacteria, viruses, fungi,

parasites)parasites) Acute non-infective gastritisAcute non-infective gastritis

CHRONIC GASTRITISCHRONIC GASTRITIS

Type A (autoimmune)Type A (autoimmune) : Body-fundic predominant : Body-fundic predominant Type Type ВВ (H. (H. pylori-related)pylori-related) : Antral-predominant: Antral-predominant

gastritisgastritis Type AB (environmental)Type AB (environmental) : : Antral-body gastritisAntral-body gastritis Chemical (reflux) gastritisChemical (reflux) gastritis : Antral-body predominant: Antral-body predominant Uncommon forms of gastritisUncommon forms of gastritis

Morphologic classification of acute gastritis

1.Catarrhal gastritis 2.Fibrinous gastritis 3.Phlegmonous gastritis 4.Necrotic (or Corrosive) 5.Hemorrhagic gastritis 6.Pseudomembranous

gastritis

This is a more typical acute gastritis with a This is a more typical acute gastritis with a diffusely hyperemic gastric mucosa. diffusely hyperemic gastric mucosa.

At high power, gastric mucosa demonstrates infiltration by neutrophils. This is acute

gastritis.

Acute Acute catarrhal catarrhal gastritisgastritis

CHRONIC GASTRITISCHRONIC GASTRITIS

Chronic gastritis is the commonest histological Chronic gastritis is the commonest histological change observed in biopsies from the stomach. change observed in biopsies from the stomach.

ETIOPATHOGENESIS. ETIOPATHOGENESIS. All the causative factors of acute gastritis described All the causative factors of acute gastritis described

above may result in chronic gastritis too. Recurrent above may result in chronic gastritis too. Recurrent attacks of acute gastritis may result in chronic attacks of acute gastritis may result in chronic gastritis. Some other causes are as under:gastritis. Some other causes are as under:

Reflux of duodenal contents into the stomach.Reflux of duodenal contents into the stomach. Associated disease of stomach and duodenum, such Associated disease of stomach and duodenum, such

as gastric or duodenal ulcer, gastric carcinoma.as gastric or duodenal ulcer, gastric carcinoma. Chronic hypochromic anemia, especially associated Chronic hypochromic anemia, especially associated

with atrophic gastritis.with atrophic gastritis. Immunological factors such as autoantibodies to Immunological factors such as autoantibodies to

gastric parietal cells.gastric parietal cells.

CLASSIFICATIONCLASSIFICATION

Based on the type of mucosa affected a Based on the type of mucosa affected a clinicopathologic classification has been clinicopathologic classification has been proposed.proposed.

Type AType A Gastritis (Autoimmune Gastritis (Autoimmune gastritis).gastritis). Type A gastritis involves mainly Type A gastritis involves mainly the body-fundic mucosa. It is also called the body-fundic mucosa. It is also called autoimmune gastritis due to the presence of autoimmune gastritis due to the presence of circulating antibodies and is sometimes circulating antibodies and is sometimes associated with other autoimmune diseases associated with other autoimmune diseases such as Hashimoto's thyroiditis and such as Hashimoto's thyroiditis and Addison's disease. Due to depletion of Addison's disease. Due to depletion of gastric acid-producing mucosal area, there is gastric acid-producing mucosal area, there is hypo- or achlorhydria, and hyperplasia of hypo- or achlorhydria, and hyperplasia of gastrin-producing G-cells in the antrum gastrin-producing G-cells in the antrum resulting in hypergastrinemia.resulting in hypergastrinemia.

Type Type ВВ Gastritis (H. pylori-related). Gastritis (H. pylori-related). Type Type ВВ gastritis mainly involves the region gastritis mainly involves the region of antral mucosa and is more common. It of antral mucosa and is more common. It is also called hypersecretory gastritis due is also called hypersecretory gastritis due to excessive secretion of acid, commonly to excessive secretion of acid, commonly due to infection with due to infection with H. pylori. H. pylori. These These patients may have associated duodenal or patients may have associated duodenal or gastric ulcer.gastric ulcer.

Type AB Gastritis (Environmental Type AB Gastritis (Environmental gastritis, Chronic atrophic gastritis).gastritis, Chronic atrophic gastritis).Type AB gastritis affects the mucosalType AB gastritis affects the mucosal region of A as well as region of A as well as ВВ types (body- types (body- fundic and antral mucosa). This is the fundic and antral mucosa). This is the most common type of gastritis in all age most common type of gastritis in all age groups, it is also called environmental groups, it is also called environmental gastritis because a number of gastritis because a number of environmental factors have been environmental factors have been implicated in its etiopathogenesis.implicated in its etiopathogenesis.

Reflux-gastritis (formerly known as Type C gastritis).

• Associated with reflux of duodenal contents in stomach.

• May occur after gastric surgery, or with weakened pyloric sphincter tone.

• Localization is antrum.

• Achlorhydria and hypergastrinemia is absent.

Based on: a) the extent of inflammatory Based on: a) the extent of inflammatory changes in the mucosa (superficial or changes in the mucosa (superficial or deep), b) the activity of inflammation deep), b) the activity of inflammation (quiscent or active; acute or chronic), c) (quiscent or active; acute or chronic), c) the presence of type of metaplasia the presence of type of metaplasia (intestinal or pseudo-pyloric), the following (intestinal or pseudo-pyloric), the following simple classification has emerged:simple classification has emerged:

Chronic superficial gastritisChronic superficial gastritis Chronic atrophic gastritisChronic atrophic gastritis Gastric atrophyGastric atrophy Chronic hypertrophic gastritis (Menetrier's Chronic hypertrophic gastritis (Menetrier's

disease)disease) Uncommon forms of chronic gastritisUncommon forms of chronic gastritis

Chronic Superficial Non-Chronic Superficial Non-atrophic Gastritisatrophic Gastritis".".

11– – desquamation of desquamation of mucosal mucosal epitheliumepithelium;;

22– – lymphocytes and lymphocytes and neutrophilsneutrophils;;

33 - - non-changed non-changed fundal glandsfundal glands..

Gastritis is often accompanied by infection with Helicobacter pylori. This small curved to spiral rod-shaped bacterium is found in the surface epithelial mucus of most patients with active gastritis. The rods are seen here with a methylene blue stain.

Chronic Atrophic GastritisChronic Atrophic Gastritis

1-1- atrophy of mucosa atrophy of mucosa

2– 2– moderate atrophy moderate atrophy of glandsof glands;;

3– 3– decreased parietal decreased parietal cellscells;;

4– 4– intestinal intestinal metaplasiametaplasia;;

5 - 5 - moderate moderate lymphohistiocytic lymphohistiocytic infiltrate in lamina infiltrate in lamina propria of mucosapropria of mucosa

Distinguishing Features of Distinguishing Features of Two Major Forms of Peptic Two Major Forms of Peptic

Ulcers.Ulcers.FEATUREFEATURE DUODENAL ULCERDUODENAL ULCER GASTRIC ULCERGASTRIC ULCER

IncidenceIncidence Four times more Four times more common than common than gastric ulcers Usual gastric ulcers Usual age 25-50 age 25-50 yearsyears..More More common in males common in males than in females than in females (4:1)(4:1)

Less common than Less common than duodenal ulcers duodenal ulcers Usually beyond 6th Usually beyond 6th decadedecade. . More More common in males common in males than in females than in females (3.5:1)(3.5:1)

EtiologyEtiology Most commonly as Most commonly as a result of a result of H. pylori H. pylori infection. Other infection. Other factors—factors—

hypersecretion of hypersecretion of acid-pepsin, acid-pepsin, association with association with alcoholic cirrhosis,alcoholic cirrhosis,

Gastric colonisation Gastric colonisation with with H. pylori H. pylori asymptomatic but asymptomatic but higherhigher

chances of chances of development of development of duodenal ulcer. duodenal ulcer.

tobacco, tobacco, hyperparathyroidism, hyperparathyroidism, chronic pancreatitis,chronic pancreatitis,

blood group 0, genetic blood group 0, genetic factorsfactors

Disruption of mucusDisruption of mucus

barrier most important barrier most important factor. Association with factor. Association with gastritis,gastritis,

bile reflux, drugs, bile reflux, drugs, alcohol, tobaccoalcohol, tobacco

PathogenePathogenesissis

Mucosal digestion from Mucosal digestion from hyperacidity most hyperacidity most significant factorsignificant factor

Protective gastric mucus Protective gastric mucus barrier may be damagedbarrier may be damaged

Usually normal-to-low Usually normal-to-low acid levels; acid levels; hyperacidity if present hyperacidity if present is due tois due to

high serum gastrin high serum gastrin Damage to mucus Damage to mucus barrier significant barrier significant factorfactor

Most common along Most common along the lesser curvature the lesser curvature and pyloric antrumand pyloric antrum

Patholo-Patholo-gic gic chan-chan-gesges

Most common in the first Most common in the first part of duodenumpart of duodenum

Often solitary, 1-2.5 cm in Often solitary, 1-2.5 cm in size, round to oval, size, round to oval, punched outpunched out

Histologically, composed of Histologically, composed of 4 layers—necrotic, 4 layers—necrotic, superficialsuperficial

exudative, granulation exudative, granulation tissue and cicatrisationtissue and cicatrisation

Most common along the Most common along the lesser curvature and lesser curvature and pyloric antrumpyloric antrum

Grossly similar to Grossly similar to duodena! ulcerduodena! ulcer

Histologicaily, Histologicaily, indistinguishable fromindistinguishable from

duodenal ulcerduodenal ulcer

ComplicaComplicationstions

Commonly hemorrhage, Commonly hemorrhage, perforation, sometimes perforation, sometimes obstruction;obstruction;

malignant transformation malignant transformation never occursnever occurs

Perforation, Perforation, hemorrhage and at hemorrhage and at times obstruction;times obstruction;

malignant malignant transformation in less transformation in less than 1% than 1% casescases

Clinical Clinical featurfeatureses

Pain-food-relief patternPain-food-relief pattern

Night pain commonNight pain common

No vomitingNo vomiting

Melena more common than Melena more common than hematemesishematemesis

No loss of weightNo loss of weight

Food-pain patternFood-pain pattern

No night painNo night pain

Vomiting commonVomiting common

Hematemesis more Hematemesis more commoncommon

Significant loss of Significant loss of weightweight

Acute ulcers:They are predominantly muptiple, circular and small, less than 1 cm in diameter, not deep.•Inflammatory reaction absent initially, develops secondarily.•Layers of the bed : 1) fibrinous exudate with fragments of leucocytes, 2) necrotic.•This type of ulcer usually heals without a visible scar.

A 1 cm acute gastric ulcer is shallow and sharply demarcated, with surrounding

hyperemia.

Here is a much larger 3 x 4 cm gastric ulcer that led to the resection of the stomach shown here. This ulcer is

much deeper with more irregular margins.

Microscopically, the ulcer here is sharply demarcated, with normal gastric mucosa on the left falling away into a deep

ulcer whose base contains infamed, necrotic debris. An arterial branch at the ulcer base is eroded and bleeding.

Seen here is a penetrating acute ulceration in the duodenum just beyond the pylorus.

Chronic peptic ulcers have 4 histological zonesChronic peptic ulcers have 4 histological zones

11. . Necrotic zoneNecrotic zone — lies in the floor of the ulcer and is — lies in the floor of the ulcer and is composed of fibrinous exudate containing necrotic debris composed of fibrinous exudate containing necrotic debris and a few leucocytes.and a few leucocytes.

2.2. Superficial exudative zoneSuperficial exudative zone —lies underneath the necrotic —lies underneath the necrotic zone. The tissue elements here show coagulative zone. The tissue elements here show coagulative necrosis giving eosinophilic, smudgy appearance with necrosis giving eosinophilic, smudgy appearance with nuclear debris.nuclear debris.

3.3. Granulation tissue zoneGranulation tissue zone —is seen merging into the —is seen merging into the necrotic zone. It is composed of nonspecific necrotic zone. It is composed of nonspecific inflammatory infiltrate and proliferating capillaries.inflammatory infiltrate and proliferating capillaries.

4.4. Zone of cicatrisationZone of cicatrisation —is seen merging into thick layer of —is seen merging into thick layer of granulation tissue.granulation tissue.It is composed of dense fibrocollagenic scar tissue over It is composed of dense fibrocollagenic scar tissue over which granulation tissue rests.which granulation tissue rests.

The principal complications of peptic ulcer.

I. Ulcerative-destructive:• Perforation.

• Penetration.

• Hemorrhage.

II. Ulcerative- cicatricial (obstruction or healing and scarring)

III. Malignization.

IV. Inflammatory (gastritis, perigastritis, duodenitis, periduodenitis).

V. Mixed.

AppendicitisAppendicitis Appendicitis is Appendicitis is inflammationinflammation of the appendix. of the appendix. It is thought that appendicitis begins when It is thought that appendicitis begins when

the opening from the appendix into the the opening from the appendix into the cecum becomes blocked. The blockage may cecum becomes blocked. The blockage may be due to a build-up of thick mucus within be due to a build-up of thick mucus within the appendix or to the appendix or to stool stool that enters the that enters the appendix from the cecum. The mucus or appendix from the cecum. The mucus or stool hardens, becomes rock-like, and blocks stool hardens, becomes rock-like, and blocks the opening. This rock is called a fecalith. At the opening. This rock is called a fecalith. At other times, the other times, the lymphatic tissuelymphatic tissue in the in the appendix may swell and block the appendix.appendix may swell and block the appendix.

Acute appendicitisAcute appendicitis

SimpleSimple SuperficialSuperficial Destructive types: Destructive types:

-phlegmonous, -phlegmonous,

-phlegmonous-ulcerative, -phlegmonous-ulcerative,

-apostematous, -apostematous,

-gangrenous.-gangrenous.

Seen here is acute appendicitis with yellow to tan exudate and hyperemia, including the

periappendiceal fat superiorly, rather than a smooth, glistening pale tan serosal surface.

The appendix has been sectioned in half. The serosal surface at the left shows a tan-yellow exudate. The cut surface at the right demonstrates yellowish-tan mucosal exudation with a

hyperemic border.

Acute phlegmonous-ulcerative appendicitis

Here, the mucosa shows ulceration and undermining by an extensive neutrophilic

exudate.

Complications of acute Complications of acute appendicitisappendicitis

Septic peritonitis, mostly localized due to Septic peritonitis, mostly localized due to perforation.perforation.

Appendicular abscess. It forms after mutilation of Appendicular abscess. It forms after mutilation of appendix. The abscess may rupture in the appendix. The abscess may rupture in the bladder, intestine or on the anterior abdominal bladder, intestine or on the anterior abdominal wall with fistula formation.wall with fistula formation.

Septic thrombophlebitis leading to portal pyemia, Septic thrombophlebitis leading to portal pyemia, abscesses in liver. Sepsis.abscesses in liver. Sepsis.

Fibrotic stricture leads to mucocele or empyema Fibrotic stricture leads to mucocele or empyema of the appendix.of the appendix.

Chronic appendicitis.Chronic appendicitis.

False appendicitis.False appendicitis. The diagnosis of appendicitis can be The diagnosis of appendicitis can be

difficult because other inflammatory difficult because other inflammatory problems may mimic appendicitis. problems may mimic appendicitis.

Meckel's diverticulitis.Meckel's diverticulitis. A Meckel's A Meckel's diverticulum is a small outpouching of diverticulum is a small outpouching of the small intestine which usually is the small intestine which usually is located in the right lower abdomen located in the right lower abdomen near the appendix. The diverticulum near the appendix. The diverticulum may become inflamed or even may become inflamed or even perforate (break open or rupture). If perforate (break open or rupture). If inflamed and/or perforated, it usually inflamed and/or perforated, it usually is removed surgically.is removed surgically.

Pelvic inflammatory disease.Pelvic inflammatory disease. The right The right fallopian tubefallopian tube and and ovaryovary lie near the appendix. Sexually active lie near the appendix. Sexually active women may contract infectious diseases that women may contract infectious diseases that involve the tube and ovary. Usually, antibiotic involve the tube and ovary. Usually, antibiotic therapy is sufficient treatment, and surgical removal therapy is sufficient treatment, and surgical removal of the tube and ovary are not necessary.of the tube and ovary are not necessary.

Inflammatory diseases of the right upper Inflammatory diseases of the right upper abdomen.abdomen. Fluids from the right upper abdomen Fluids from the right upper abdomen may drain into the lower abdomen where they may drain into the lower abdomen where they stimulate inflammation and mimic appendicitis. stimulate inflammation and mimic appendicitis. Such fluids may come from a perforated Such fluids may come from a perforated duodenal ulcer,duodenal ulcer, gallbladder disease,gallbladder disease, or or inflammatory diseases of the inflammatory diseases of the liverliver, e.g., a liver , e.g., a liver abscess.abscess.

Right-sided diverticulitisRight-sided diverticulitis.. Although most Although most diverticuli are located on the left side of the colon, diverticuli are located on the left side of the colon, they occasionally occur on the right side. When a they occasionally occur on the right side. When a right-sided diverticulum ruptures it can provoke right-sided diverticulum ruptures it can provoke inflammation they mimics appendicitis.inflammation they mimics appendicitis.

Kidney diseases.Kidney diseases. The right kidney is close enough The right kidney is close enough to the appendix that inflammatory problems in the to the appendix that inflammatory problems in the kidney-for example, an abscess-can mimic kidney-for example, an abscess-can mimic appendicitis.appendicitis.

Chronic appendicitis is characterized by sclerosis and atrophy, lipomatosis and diffuse infiltration by lymphocytes and hystiocytes.

•Obliteration of part or all of the appendiceal lumen by a mixture of fibrous tissue, lymphocytes, lymphoid follicles, and nerve bundles is common.

•In the fibrosis causes complete obstruction of the lumen, continued mucous secretion may result in cystic dilatation – mucocele.

•Such a cyst may rupture, giving rise to myxomatosis peritonei: the mucus-secreting epithelium is spilled into the peritoneal cavity and loculations of mucin and adhesions result.