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Let’s go back a bit. You swallowed this Swedish meatball and now it’s been pulverized and the stomach secretes acid. Now, believe it or not, the strength that the potency of the acid is secreted by the stomach is actually probably more potent than the acid you’d find in a battery, and so it’ll help break down this food. The meatball obviously contains different substances, fat and protein in particular. There’s a certain enzyme called Pepsin, which will be released into the stomach and will help break down this meatball further.
So today I’d like to talk to you about disorders of the stomach. But first I think it might be of importance to examine, so what is the function of the stomach? What’s the purpose? Well, as you probably can imagine, the stomach is a J-shaped organ, and it has three primary functions. Naturally, when you swallow a morsel of food, let’s say it’s Swedish meatball, okay? It has to go from your mouth down your Esophagus, which is your swallowing tube, and then into your stomach. Stomach has three main functions, one of which is to undergo muscular contractions to transform that bolus or ball of food into smaller particles.
If a patient presents with bleeding and let’s say more active bleeding. In other words, the patient either vomits blood or what we call coffee grounds, which is actually digested blood, but it looks like dark coffee grounds. That’s a symptom that you should be very concerned about. Or let’s say if a patient feels kind of weak or woozy, when that happens, person is probably lost about at least 15% of their blood volume. And if they were to stand up and they actually fainted, then that means they’ve lost at least a third of their blood volume. So those are just rough rule of thumb. But patient, let’s say, who presents with a bleeding ulcer, they may present with either a black bowel movement because that represents digested blood. It’s passed from the stomach through the GI tract, or in cases where the blood is, excuse me, where the bleeding is very vigorous, you may see actually frank red blood. That’s a very serious condition, which requires immediate therapy.
In reference to ulcers, the actual number of surgical procedures performed for ulcers in this country has, I would think dramatically decreased. Okay for garden variety else’s compared to 20, 30 years ago, simply because of the advent of these very potent antacid medications and the recognition that the majority of ulcers are triggered by a bacterial infection, so you give antibiotics, you give the potent and acids. Usually these ulcers heal, they don’t perforate and they don’t bleed. In the case of the bleeding ulcer, sometimes when we do these endoscopic therapies where we actually visualize the ulcer with the scope pass through the mouth nonsurgical and we can either try to control the bleeding with injections or placing clips or burning the a bleeding vessel, if that doesn’t work, then sometimes surgery is necessary to either oversew the ulcer. Or if there’s a complication related to the presence of a chronic ulcer. In other words, the outlet from the stomach becomes very narrowed. Sometimes you have to relieve that outlet obstruction. Surgery may be necessary to do that. Or let’s say if the ulcer that cut a sore in the lining of the stomach has perforated, so now there’s a hole in the stomach, you need to seal that. And so surgery may be indicated for those types of reasons.
There is a family form of having ulcers. This is not necessarily the most common cause of ulcers. There are other conditions by which patients can have multiple ulcers, and these are more difficult to treat. Sometimes it also runs in families, but on average, two thirds of all ulcers are caused by that bacterium H. Pylori. The other third related to the NSAIDs those aspirin, Motrin, Aleve, Ibuprofen type medications. The other causes of ulcers, 1% or less.
So in reference to stomach ulcers, they’re relatively rare in today’s world compared to previous times, and especially in reference to gastritis. But perhaps 10% of folks in the US populations may have some form of, of a stomach ulcer, and this could be from a very small or shallow, ulcer to a larger, more frank ulceration. Part of the reason why gastric ulcers may appear to have receded in their appearance in the u s population is because of the types of medications that we use which are very potent to treat them. And we give folks these medications to help prevent ulcers and to cure them more effectively.
In reference to stomach ulcers, the most common symptom is pain. In fact, about 85% of the time patients will experience pain. It may be a sharp pain. A dull pain. Could be gnawing, aching. It may radiate to the, you know, from just below your chest bone and your belly button may go straight back. It may induce a feeling of nausea. Appetite may decrease, and naturally, if your appetite drops off, then patient may lose weight. So these are some of the telltale signs of patient having a stomach ulcer. Now, what becomes worrisome is if the patient vomits blood, if the patient loses on average more than 10% of their body weight, then these may be signs, let’s say, of a more severe ulcer or a complicated ulcer. When we talk about complicated ulcers, we’re talking about ulcers, which may have perforated and either become walled off or they’re free perforations, and that may require surgical correction. Or another complication of an ulcer aside from bleeding could be that ulcer is related to a cancer.
It comes down to whether these patients have symptoms and oftentimes, if they had some sort of inflammation or erosion of their stomach that was felt to be due to the H. Pylori. So a young person, we would probably give them the trial, they potent antacid first. That didn’t work. Then we may consider testing their blood for the presence of H. Pylori or we may get them to do a breath test where we can detect the presence of H. Pylori in their systems. If we noted that they didn’t quite respond or we thought that there may be something more serious going on, we might then go to endoscopy. An endoscopy is where you pass that lighted scope through the mouth, down the esophagus into the stomach, let’s say and you can look directly at the lining of the stomach and see if there’s an ulceration or inflammation. You can pass a small instrument obtained biopsies. We can send it to the lab and we can check to see if that H. Pylori bacteria is present or anything else. And we could make treatment recommendations based on that.
Now, in reference to financial issues, as one of the nice things about healthcare here in our country. A number of these products, these proton pump inhibitors such as prilosec or the H2 blockers, the less potent but still effective agents such as Tagamet, Pepcid and so on, can be purchase over the counter and used appropriately according to your healthcare provider’s instruction.
For further information, good sites would be the AGA, American Gastroenterological Association website. Also, UpToDate has an online source where they have a section for patient information. Another good outlet for information would be your own healthcare practitioner. They’ll probably have pamphlets, patient information and, or can direct you to sites and even local support groups depending upon your circumstance.
Sources online where you can get good information as to coupons to reduce the costs. GoodRx is a great source where you can compare the cost of certain of these medications at different pharmacies and receive a coupon to help with a copay or help reduce the pay. Certain other outlets such as Walmart pharmacies may have $4 generics, that type of thing. The cost has come down significantly from when these type of more potent antacid agents first hit the market. And that’s a good thing.
In the patient who has active upper GI bleed, upper gastrointestinal tract bleed from an ulcer, what we would do is stabilize a person, protect their airway, give them IV fluids and blood if necessary. Okay. Get them stabilized and then we would perform an endoscopy or use that fiberoptic scope, pass it down to the area of the ulceration, and then we’d probably either inject the chemical to constrict the blood vessels to slow down bleeding. We may pass clips through the scope to actually clip the vessel, or we could use the device and actually coagulate or burn the visible vessel to stop the bleeding. If that didn’t work, then surgical intervention may be necessary. And/or sending the patient to Interventional radiology.
One thing in particular I would want to mention that I think is very important in reference to ulcer disease is that you know, you have blood vessels in every portion of your body. That includes your stomach. And if you have an ulcer, which is like a cut or a sore and it erodes or if it hits a blood vessel, naturally the blood vessel can bleed. It could be a circumstance where the blood vessel is, there’s just a slight erosion and so person may lose blood. It’s very small amount and that can go on for an extended period of time resulting in anemia or low blood count. The patient may or may not complain of pain. And we actually see this more so let’s say in older individuals. And you may ask, well, why is that older person presents with an ulcer but yet they don’t really have the classic abdominal pain? Well, think about it. All right, What do we know? Older persons have a tendency to have arthritis or back pain. And so they take those NSAIDs, or anti-inflammatory medications or if they have to take aspirin for their heart. And we’ve mentioned that those medications can cause those ulcerations, but what else do we know about aspirin, Motrin, Aleve, et Cetera? They’re used to treat pain. Now it’s no wonder why a person could be consuming aspirin, Motrin, Aleve, et Cetera, developing ulcer, but yet they don’t complain of classic paid because you’re actually taking a medication that treats pain.
Now, sometimes patients will come in and they’ll say, well, gee, you know, my father had an ulcer, and his father had an ulcer. Are ulcers hereditary? And the answer is there can be a hereditary component and or form of ulcer disease in families. But not necessarily. I mean, the person may represent what we call an index case, they may be the only person. Or it may be because they’re taking certain types of NSAIDs or anti-inflammatory medications because they have issues with arthritis or back pain and this type of thing. And let’s say their parents or siblings didn’t have to take those kinds of medications, et cetera. And so they don’t develop ulcers.
Question arises in reference to gastritis is, is surgery necessary? And I would say the great majority of cases, surgery is not needed. In fact, it would probably be a very rare cause or circumstance for which surgery would be required.
There can be some complications, especially in reference to ulcers where patient’s appetite may decrease, their weight may decrease. If that ulcer erodes and hits a blood vessel, they can have significant bleeding, which may require endoscopic therapy, where scope is passed through the mouth to the stomach, let’s say, and the ulcer is treated locally with either a thermal heating device or a clip or chemical injection. In rare cases, surgery might be required. But the things to keep in mind is that you can do a lot by watching your diet. If you have certain dyspeptic symptoms, it may be appropriate to be on a trial of antacid medicines for short period of time, but if you notice that your symptoms are prolonged, especially if they’re in existence for two weeks, you should definitely let your healthcare provider know so that you can be appropriately evaluated and treated.
Now, we’ve also mentioned the effects of ulcers in the stomach. Ulcers, as you recall, our cuts or sores in the lining of the stomach. And two thirds of all ulcers are related to that bacterium, H Pylori. Okay. Another third of ulcers, or the remaining would be due to medications such NSAIDs, you know, aspirin, motrin, Ibuprofen. And so you’d have to treat the patient accordingly. If they had H. Pylori, you have to eradicate that organism with antibiotics as well as antacids.
The next, the stomach will secrete acid as well as certain other enzymes to help hydrolyze or break down the food particle into smaller particles. The stomach also has a reservoir capacity, so in other words, it could also store food for a certain period of time. In fact, believe it or not, your stomach and hold up four liters of fluid at maximum capacity. That’s like two large bottles of coke.
Most commonly and things that you should look out for would be medications such as aspirin, Ibuprofen, naproxen. Some of those types of agents can directly irritate the lining of the stomach. Granted those medications when used properly are wonderful, but you just have to be careful and be mindful of the fact that they can cause gastric irritation. Another substance that commonly can cause gastritis is alcohol. Okay. So if you’ve noticed that after I put him back, a few cocktails that your stomach feels a little queasy. Well, it may be because you’ve irritated your lighting. And there’s some other substances, perhaps caffeine, especially in increased doses, that can have that effect. But, it just depends.
In reference to gastritis, as we mentioned earlier, itis means inflammation. So inflammation can be due to a number of things. It could be secondary to a viral infection. So a person could have a viral gastritis, a viral gastroenteritis. It could be due to a bacteria in particular. There’s a certain bacteria call H. Pylori, which can cause a chronic type of inflammation in the lining of the stomach and bacterial cause of gastritis.
So, how do we confirm the diagnosis of H. Pylori? As I mentioned, it’s possible to obtain information from a blood test, H. Pylori serology. That’s one. We could also detect the presence of H. Pylori through a breath test. Okay. Hydrogen breath tests. And we can obtain information from stomach or intestinal biopsies where we can look under the microscope and actually see the organisms.
So, when a patient presents with a gastric upset, or indigestion, there can be several things going on. But the most common situation is called gastritis. Gastric refers to stomach. Itis refers to inflammation just as you can have, tonsillitis, inflammation of your tonsils. Gastritis is inflammation of the stomach lining. Gastritis is usually a self limiting condition, but when it becomes problematic and problematic situations are when it alters your daily activity may affect your asleep, your wellbeing. And especially if this has gone on for several days or definitely within two weeks period of time, you should definitely bring it to the attention of your health care practitioner.
So a word about home remedies. For mild, I would say mild dyspeptic symptoms, you could try some tums, antacid tablets, or liquid antacids, Maalox, Mylanta, that type of thing. Or nowadays you can get those H2 blockers, like the Tagamet or the Pepcid over the counter and use them as directed. Or you can even get omeprazole, prilosec, or nexium over the counter, use them as directed. But definitely if your symptoms are prolonged two weeks, and this is in the absence of having those severe symptoms of bleeding or you can’t eat or you’re drastically losing weight, you should be seen by your physician.
As far as a diet, again, things that trigger the symptoms such as excess alcohol or excess caffeine, nicotine and cigarette smoking, or certain other substances should be avoided because they’ll help reduce symptoms.
Gastritis is a fairly prevalent circumstance. In fact, most adults will experience gastritis related symptoms several times throughout the year. It becomes problematic when you notice this gastric upset perhaps two or three times in a given week on a fairly regular basis. That’s when it should get your attention. In reference to symptoms for gastritis, these can be somewhat variable. But oftentimes patients complain of abdominal bloating, fullness. They may actually feel some gnawing pain in the pit of their stomach, and in some instances, the discomfort may be such that the individual doesn’t want to consume food, and in some instances, patients may actually vomit.
Gastritis, how would you treat well, basic rules of thumb is you always try to get the patient to do something good for themselves. Okay. So we would ask that they avoid substances that naturally they feel triggered is. In particular, we would ask them to avoid alcoholic beverages and they may want to look out for caffeine. Okay. Because these types of agents can actually trigger increased secretion of gastric acid and it’s the gastric acid that irritates the lining of the stomach that produces some of the symptoms. So referencing gastritis, that’s one of the very first things we do. The next thing we would do is prescribe a form of antacid therapy. In the past we used to rely on medications such as liquid antacids, but we’ve developed more potent and more easily acceptable forms of medication for patients. And so there are certain types of antacids that block acid secretion in the stomach. One group called H2 blockers is a fairly useful group, but that would represent things such as Tagamet or Zantac or Pepcid. There is a newer category of medications called Proton pump inhibitors, very fancy term, but basically you can think of Proton pump inhibitors or PPIs as smart bombs. So they hit the main factory where acid is produced in the stomach lining. It knock it out. You’re not going to produce stomach acid if you hit that particular acid factory. And so those are the most potent types of antacid medications that we would recommend for patients who have, let’s say, gastritis, and usually that’ll take care of it.
Now, what about prevention? Well, prevention can probably get best achieved, let’s say for example, if you have to take medications such as you have to take aspirin, let’s say for your heart, or if you have to take certain NSAIDs, that’s aspirin, Motrin, Aleve, Ibuprofen, because you have arthritis or back pain. Then in conjunction with your healthcare provider, you may need to take a form of antacid to neutralize stomach acid and to help protect against the development of erosions and/or gastritis and/or stomach ulcers.
In reference to H. Pylori induced gastritis is that for the most part, this is a benign condition. It can be treated with antibiotics and antacids and totally eradicated. If left untreated patients who have chronic gastritis due to h pylori, these folks may develop ulcers that cut a sore in the lining of the stomach and in those individuals, and we’ll say a little bit more about that. You have to treat them a certain way. The last category of patients, and we’re talking about a very, very small number of patients with H. Pylori related gastritis may actually develop a form of cancer of the stomach. In fact, there’s two major types. One is a type called malt lymphoma involving the stomach where the stomach lining becomes hypertrophied or swollen. However, this type of a malt lymphoma of the stomach can be cured in many instances with antibiotics and those potent antacids that we talked about. There’s another category of patients, and again, this is a minority of patients, may develop a different type of cancer of the stomach called the Adenocarcinoma of the stomach. And so even though the great majority of patients who have H. Pylori related chronic gastritis, benign condition, easily treated in a very, very small number of cases, patients may develop a form of lymphoma or cancer of the stomach. And so therefore, it’s very important to try to make diagnoses and treat and manage patients with chronic H. Pylori induced gastritis appropriately.
One of the questions that frequently we’re asked as gastroenterologists, we have a patient comes into the office and they’re complaining of Halitosis or bad breath. They may feel bloated and they may have some gastric upset. This may or may not be related to H. pylori. It may be related to perhaps their diet. They may consume a lot of, let’s say certain types of vegetables or beans that tend to produce gaseousness. Perhaps the person’s have some issues with their teeth or oral hygiene and perhaps just good flossing brushing and maybe an occasional gargling or chewing sugarless gum could help. It may also be a side effect of some medications that they have to take that may cause dryness and that can have some effects on the bacteria counts in the mouth and the upper digestive tract. So there can be other reasons for that. May or may not be related to H. Pylori, but if it becomes problematic, then obviously I think it’s a good idea for the patients to raise these types of questions with their physicians as oppose to, you know, pursuing, you know, certain home remedies, which may or may not help them.
The main issue with H. Pylori is that it causes chronic inflammation of the lining of the stomach. So chronic gastritis is the most common issue. Beyond that, patients who have chronic inflammation may have some compromise of the blood flow to that tissue. And so patients who have chronic gastritis are predisposed to developing ulcerations, cuts of sore in the lining of the stomach. And then beyond that, if you have this inflammation over extended periods of time, this chronic irritant in a very small number of cases may cause the cells in the lining of the stomach to change. And in some very small cases, that change may become cancerous.
Hello. This is Dr. Eugene Trowers from the University of Arizona, department of Internal Medicine, division of gastroenterology. I am one of the full professors here in the division. My area of interest, concerns motility or swallowing disorders. I also perform general endoscopic procedures. Today I’d like to talk to you about disorders of the stomach in particular, peptic ulcer disease.
We’ve spoken about gastritis. Peptic ulcer disease is a related but different kettle of fish. Now ulcers, you can think of it as a cut or a sore in the lining of the stomach. All right, so imagine if you had a cut and now you’re sprinkling that cut or bathing that cut with acid. Okay. Ouch. That would hurt. All right, so when patients have an ulcer, especially in the stomach, then it’s being coded with acid on a fairly frequent basis. Now this acid serves as an irritant and it may also prevent the ulcer from healing. It can cause an extension of an ulcer. And ulcer symptoms are somewhat different then gastritis type symptoms.
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