Gastro Intestinal Tract – II (Gastritis & Peptic ulcer)

Introduction to Gastritis & Peptic ulcer

Inflammatory Lisions

The two important inflammatory conditions of stomach are :-

  • Gastritis
  • Peptic ulcer

Gastritis

  • Gastritis is a mucosal inflammatory process.
  • Clinically upper abdominal discomfort like indigestion or dyspepsia
  • When neutrophils are present, the lesion is referred to as acute Gastritis.

ETIOPATHOGENESS

  1. Diet and personal habits:
    i) Highly spiced food
    ii) Excessive alcohol consumption
    iii) Malnutrition
    iv) Heavy smoking.
  2. Infections:
    i) Bacterial infections e.g. Helicobacter pylori, diphtheria,
    salmonellosis,
    ii) Viral infections e.g. viral hepatitis, influenza
  3. Drugs :Intake of drugs like non-steroidal anti-inflammatory drugs (NSAIDs),
    aspirin, cortisone, phenyl butazone, chemo
    therapeutic agents.
  4. Chemical and physical agents:
    i) Intake of corrosive chemicals such as caustic soda,
    phenol, lysol
    ii) Gastric irradiation
    iii) Freezing.
  5. Severe stress:
    i) Emotional factors like shock, anger, resentment etc.
    ii) Extensive burns
    iii) Trauma
    iv) Surgery.

Morphological features

  • Grossly: the gastric mucosa is oedematous with
    abundant mucus and haemorrhagic spots.
    Microscopically,
    – variable amount of oedema and
    – infiltration by neutrophils in the lamina propria
    – presence of neutrophils above basement membrane
    in direct contact with epithelial cell signify – active
    inflammation ( present in both acute \chronic states)

Chronic Gastritis

  • H.pylori gastritis
  • Autoimmune gastritis

Helicobacter pylori gastritis

  • H. pylori infection most often presents as a
    predominantly antral gastritis with normal or
    increased acid production.
  • H pyloriis a spiral shaped or curved bacilli
  • Associated with poverty ,jhousehold crowding
  • Mode of transmission : feco-oral

Pathogenesis

  • Virulence of H pylori is linked to following factors :
  • Flagella — motile in viscous mucus
  • Urease — generate ammonia -— elevate local
  • gastric pH — increase bacterial survival
  • Adhesions— enhance bacterial adhesion to
  • surface foveolar cells
  • Toxins — Cag A

Morphology

  • Endoscopically :H. pylori-infected antral mucosa
    is usually erythematous and has a coarse or
    even nodular appearance
    Biopsy : Antral biopsy is preferred for H. pylori
    evaluation

Microscopy

  • The organism is concentrated within the superficial
    mucus overlying epithelial cells in the surface and neck
    regions
  • extreme cases, the organisms carpet the luminal
    surfaces of foveolar and mucous neck cells, and can
    even extend into the gastric pits.
  • Organisms are most easily demonstrated with special
    stains- giemsa , warthin starry silver stain .
  • Intraepithelial neutrophils and subepithelial plasma
    cells are characteristic of H. pylori gastritis
  • Warthin-Starry silver
    stain
  • Intraepithelial and
    lamina propria
    neutrophils are
    prominent
  • Lymphoid aggregates
    with germinal centers
    and abundant
    subepithelial plasma
    cells within the
    superficial lamina
    propria

Other diagnostic tests for H pylori

Noninvasive serologic test :

  • for antibodies to H. pylori,
  • fecal bacterial detection, and
  • urea breath test based on the generation of ammonia by
    the bacterial urease.

Gastric biopsy:

  • can also be analyzed by
    • the rapid urease test,
    • bacterial culture, or bacterial DNA detection by PCR.

Autoimmune gastritis

  • It accounts for less than 10% of case
  • It typically spares the antrum and is associated with hypergastrinemia
  • Autoimmune gastritis is characterized by:
    • Antibodies to parietal cells and intrinsic factor that can be detected in serum and gastric secretions
    • Reduced serum pepsinogen | concentration
    • Endocrine cell hyperplasia
    • Vitamin B12 deficiency
    • Defective gastric acid secretion (achlorhydria)

Morphology

  • Diffuse mucosal
    damage of oxyntic (acid
    producing ) mucosa
    within the body &
    fundus
  • Inflammatory infiltrate
    consist of: lymphocyte, plasma cell & macrophages
  • Intestinal metaplasia: goblet cell

Peptic ulcer Disease

  • Itrefers to chronic mucosal ulceration affecting the
    duodenum or stomach
  • The most common form of peptic ulcer disease (PUD)
    occurs within:
    the gastric antrum
    duodenum
    Epidemiology :
    — Common in middle age ( 5th decade DU, 6″ decade GU)
    — More in males compared to females

Risk factors for Peptic Ulcer Disease

  • H. pylori infection
  • Cigarette use (synergizes with H. pylori for gastric PUD)
  • Chronic obstructive pulmonary disease
  • Illicit drugs, e.g. cocaine, that reduce mucosal blood flow
  • NSAIDs (potentiated by corticosteroids)
  • Alcoholic cirrhosis (primarily duodenal PUD)
  • Psychological stress (can increase gastric acid secretion)
  • Endocrine cell hyperplasia (can stimulate parietal cell
    growth and gastric acid secretion)
  • Zollinger-Ellison Syndrome (PUD of stomach, duodenum,
    and jejunum)
  • Viral infection (CMV, herpes simplex virus)

Pathogenesis

  • PUD results from imbalances between defense mechanisms and damaging factors that cause chronic gastritis

Gastric ulcer

  • Hyperacidity may occur in gastric ulcer due to increased
    serum gastrin levels in response to ingested food in an
    atonic stomach
  • patients of gastric ulcer have low-to-normal gastric acid
    levels. Ulcerogenesis in such patients is explained on the
    basis of damaging influence of other factors such as
    gastritis, bile reflux, cigarette smoke etc
  • Thenormally protective gastric mucus ‘barrier’ against
    acid-pepsin is deranged in gastric ulcer.
  • colonisation of the gastric mucosa by H. pylori seen in 75-
    80% patients of gastric ulcer.

Duodenal ulcer

  • hypersecretion of gastric acid into the fasting
    stomach at night under vagal stimulation
  • Helicobacter gastritis caused by H. pylori is seen in 95-100% cases of duodenal ulcers
  • rapid emptying of the stomach so that the food
    which normally buffers and neutralises the gastric
    acid, passes down into the small intestine, leaving
    the duodenal mucosa exposed to the aggressive
    action of gastric acid

Morphology

  • Duodenal ulcer : proximal
    duodenum & involve the
    anterior duodenal wall
  • Gastric peptic ulcers:
    located along the lesser
    curvature near the
    interface of the body and
    antrum

Grossly

  • Peptic ulcers are solitary
    in more than 80% of
    patients
  • The classic peptic ulcer
    is a round to oval,
    sharply punched-out
    defect

Microscopically

4 histological zones:

  1. Necrotic zone —lies in the floor of the
    ulcer and is composed of fibrinous
    exudate containing necrotic debris anda
    few leucocytes
  2. Superficial exudative zone—lies
    underneath the necrotic zone. show
    coagu lative necrosis giving eosinophilic,
    smudgy appea rance with nuclear debris
  3. Granulation tissue zone: is composed of
    non specific inflammatory infiltrate and
    proliferating capillaries
  4. Zone of cicatrization: is composed of
    dense fibro collagenic scar tissue

Difference Between DU & GU

Gastric polyp

Gastric Adenocarcinoma

  • Adenocarcinoma is the most common
    malignancy of the stomach, comprising more
    than 90% of all gastric cancers.
  • Morphologically
    • Intestinal type
    • Diffuse type

Etiology

  • H. pylori infection: seropositivity with H. pylori is associated with 3 to 6
    times higher risk of development of gastric cancer
  • Dietary factors :
    • i) Occurrence of gastric cancer in the region of gastric canal (i.e. along the lesser curvature and the pyloric ant rum) where irritating foods exert their maximum effect
    • ii) ingestion of smoked foods, high intake of salt, pickled raw vegetables, high intake of carcinogens as nitrates in foods and drinking water, nitrites as preservatives for certain meats
    • iii) Tobacco smoke, tobacco juice and consumption of alcohol have all been shown to have carcinogenic effect on gastric mucosa.
  • Geographical factors: Japan, Chile and Italy have the highest recorded death rate from gastric cancer
  • Racial factors :incidence is higher in Blacks, American Indians
  • Genetic factors: Individuals with blood group A have higher tendency to develop gastric cancer .

Morphology

  • Location : gastric antrum, lesser curvature is more frequently involved.

Gastric tumors morphology

  • 1 Intestinal type
    • Bulky tumors
    • Glandular structures
    • Neoplastic cells contain apical mucin vacuoles & abundant micin in gland lumina
  • 2 Diffuse type
    • Infiltrative growth
    • Signet ring cells
    • Discohesive cells
    • Large mucin vacuoles that push nucleus to periphery
    • Extracellular mucin as mucin lakes
    • Desmoplastic reaction (lintus plastica)

CLINICAL FEATURES

i) Persistent abdominal pain

ii) Gastric distension and vomiting
iii) Loss of weight (cachexia)

iv) Loss of appetite (anorexia)

v) Anaemia, weakness, malaise

Spread

  • Metastases are often detected at time of diagnosis
  • Sites most commonly involved include:
    • supraclavicular sentinel lymph node (Virchow node),
    • periumbilical lymph nodes (Sister Mary Joseph
      nodule),
    • the left axillary lymph node (Irish node),
    • the ovary (Krukenberg tumor), or the pouch of Douglas (Blumer shelf)

Prognosis

  • With surgical resection, the 5-year survival
    rate of early gastric cancer can exceed 90%,
    even if lymph node metastases are present
  • In contrast, the 5-year survival rate for
    advanced gastric cancer remains less than
    20%

Other tumors

  • Lymphoma
  • Carcinoid tumor
  • Gastrointestinal stromal tumor (GIST)

Other Pathology Notes

Pathophysiology of Renal Disease: Renal Failure

Leukemia : (Acute Lymphoblastic leukemia)

Chronic Myeloid Leukemia

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