ERRI PRATAMA

405140008
1st Learning Objective
A. Anatomy
B. Physiology
C. Histology
D. Biochemistry
2nd Learning Objective
Dyspepsia & Gerd
Dyspepsia
 Peptic Ulcer

Peptic ulcer disease refers to

painful sores or ulcers in the lining of
the stomach or first part of the small
intestine, called the duodenum.

http://www.webmd.com/digestive-disorders/tc/dyspepsia-topic-overview
 Figure 1. Photograph of a peptic ulcer taken during an
upper endoscopy. This ulcer is a “gastric ulcer” because it is
located in the stomach.

http://www.webmd.com/digestive-disorders/tc/dyspepsia-topic-overview
 What Causes Ulcers?
No single cause has been found for ulcers. However, it is now clear that an ulcer is the end result of an
imbalance between digestive fluids in the stomach and duodenum. Most ulcers are caused by an infection
with a type of bacteria called Helicobacter pylori (H. pylori).

Factors that can increase your risk for ulcers include:

• Use of painkillers called nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin, naproxen (Aleve,
Anaprox, Naprosyn, and others), ibuprofen (Motrin, Advil, some types of Midol, and others), and many
others available by prescription; even safety-coated aspirin and aspirin in powered form can frequently
cause ulcers.
• Excess acid production from gastrinomas, tumors of the acid producing cells of the stomach that increases
acid output (seen in Zollinger-Ellison syndrome)
• Excessive drinking of alcohol
• Smoking or chewing tobacco
• Serious illness
• Radiation treatment to the area

http://www.webmd.com/digestive-disorders/tc/dyspepsia-topic-overview
 What Are the Symptoms of an Ulcer?
An ulcer may or may not have symptoms. When symptoms occur, they may include:

• A gnawing or burning pain in the middle or upper stomach between meals or at night
• Bloating
• Heartburn
• Nausea or vomiting

In severe cases, symptoms can include:

• Dark or black stool (due to bleeding)

• Vomiting blood (that can look like "coffee-grounds")
• Weight loss
• Severe pain in the mid to upper abdomen

http://www.webmd.com/digestive-disorders/tc/dyspepsia-topic-overview
 How Serious Is an Ulcer?
Though ulcers often heal on their own, you shouldn't ignore their warning signs. If not
properly treated, ulcers can lead to serious health problems, including:

• Bleeding
• Perforation (a hole through the wall of the stomach)
• Gastric outlet obstruction from swelling or scarring that blocks the passageway leading from the stomach to the
small intestine

Taking NSAIDs can lead to an ulcer without any warning. The risk is especially concerning for the elderly and for those
with a prior history of having peptic ulcer disease.

http://www.webmd.com/digestive-disorders/tc/dyspepsia-topic-overview
 Who Is More Likely to Get Ulcers?
You may be more likely to develop ulcers if you:

• Are infected with the H. pylori bacterium

• Take NSAIDs such as aspirin, ibuprofen, or naproxen
• Have a family history of ulcers
• Have another illness such as liver, kidney, or lung disease
• Drink alcohol regularly
• Are age 50 or older

http://www.webmd.com/digestive-disorders/tc/dyspepsia-topic-overview
 How Are Ulcers Diagnosed?

Your doctor may suspect you have an ulcer just by talking with you about your
symptoms. However, to confirm the diagnosis one of several tests should be taken.
First, your doctor may ask you to take an acid-blocking medication, such as those
used to treat heartburn, for a short period of time to see if symptoms improve.

If needed, your doctor may recommend a procedure called an upper endoscopy. It

involves inserting a small, lighted tube (endoscope) through the throat and into the
stomach to look for abnormalities. This procedure is usually given if you are having
severe or recurring symptoms of ulcers.

Doctors sometimes treat for ulcers without confirming the diagnosis using
endoscopy.

http://www.webmd.com/digestive-disorders/tc/dyspepsia-topic-overview
 How Are Ulcers Treated?
If not properly treated, ulcers can lead to serious health problems.
There are several ways in which ulcers can be treated, including making
lifestyle changes, taking medication, and/or undergoing surgery.
Lifestyle Changes to Treat an Ulcer
To treat an ulcer, first eliminate substances that can be causing the
ulcers. If you smoke or drink alcohol, stop. If the ulcer is believed to be
caused by the use of NSAIDs, they need to be stopped.

http://www.webmd.com/digestive-disorders/tc/dyspepsia-topic-overview
 Ulcer Medications
Ulcer medications can include:
• Proton pump inhibitors (PPI). Proton pump medications reduce acid levels and allow the
ulcer to heal. They include dexlansoprazole (Dexilant), esomeprazole (Nexium),
lansoprazole (Prevacid), omeprazole (Prilosec), pantoprazole (Protonix), rabeprazole
(Aciphex), and omeprazole/sodium bicarbonate (Zegerid).
• Antibiotics. If you have H. pylori infection, then antibiotics are also used. There are
multiple combinations of antibiotics that are taken for one to two weeks along with a PPI.
Bismuth is also part of some treatment regimens.
• Upper endoscopy. Some bleeding ulcers can be treated through an endoscope.
• Surgery. Sometimes an operation is needed if the ulcer has created a hole in the wall of
the stomach, or if there is serious bleeding that can't be controlled with an endoscope.

http://www.webmd.com/digestive-disorders/tc/dyspepsia-topic-overview
 How Can I Prevent Ulcers?
To reduce the risk of developing ulcers:
• Don't smoke.
• Avoid alcohol.
• Don't overuse aspirin and/or NSAIDs

http://www.webmd.com/digestive-disorders/tc/dyspepsia-topic-overview
GERD (Gastro Esophageal Reflux Disease)
Gastritis
Gastritis is an inflammation, irritation, or erosion of the lining of the
stomach. It can occur suddenly (acute) or gradually (chronic).
What Causes Gastritis?
Gastritis can be caused by irritation due to excessive alcohol use, chronic vomiting, stress, or the use
of certain medications such as aspirin or other anti-inflammatory drugs. It may also be caused by
any of the following:

• Helicobacter pylori (H. pylori): A bacteria that lives in the mucous lining of the stomach; without
treatment, the infection can lead to ulcers, and in some people, stomach cancer.
• Pernicious anemia: A form of anemia that occurs when the stomach lacks a naturally occurring
substance needed to properly absorb and digest vitamin B12
• Bile reflux: A backflow of bile into the stomach from the bile tract (that connects to the liver and
gallbladder)
• Infections caused by bacteria and viruses

If gastritis is left untreated, it can lead to a severe loss of blood and may increase the risk of
developing stomach cancer.
What Are the Symptoms of Gastritis?
Symptoms of gastritis vary among individuals, and in many people there are no symptoms.
However, the most common symptoms include:

• Nausea or recurrent upset stomach

• Abdominal bloating
• Abdominal pain
• Vomiting
• Indigestion
• Burning or gnawing feeling in the stomach between meals or at night
• Hiccups
• Loss of appetite
• Vomiting blood or coffee ground-like material
• Black, tarry stools
How Is Gastritis Diagnosed?
To diagnose gastritis, your doctor will review your personal and family medical history, perform a
thorough physical evaluation, and may recommend any of the following tests:

• Upper endoscopy. An endoscope, a thin tube containing a tiny camera, is inserted through your
mouth and down into your stomach to look at the stomach lining. The doctor will check for
inflammation and may perform a biopsy, a procedure in which a tiny sample of tissue is removed
and then sent to a laboratory for analysis.
• Blood tests. The doctor may perform various blood tests, such as checking your red blood cell
count to determine whether you have anemia, which means that you do not have enough red
blood cells. He or she can also screen for H. pylori infection and pernicious anemia with blood
tests.
• Fecal occult blood test (stool test). This test checks for the presence of blood in your stool, a
possible sign of gastritis.
What Is the Treatment for Gastritis?

Treatment for gastritis usually involves:

• Taking antacids and other drugs (such as proton pump inhibitors or H-2 blockers) to
reduce stomach acid
• Avoiding hot and spicy foods
• For gastritis caused by H. pylori infection, your doctor will prescribe a regimen of
several antibiotics plus an acid blocking drug (used for heartburn)
• If the gastritis is caused by pernicious anemia, B12 vitamin shots will be given.
• Eliminating irritating foods from your diet such as lactose from dairy or gluten from
wheat

Once the underlying problem disappears, the gastritis usually does, too.

You should talk to your doctor before stopping any medicine or starting any gastritis
treatment on your own.
What Is the Prognosis for Gastritis?
Most people with gastritis improve quickly once treatment has begun.
 Functional Dyspepsia

Nonulcer stomach pain is a term used to describe signs and symptoms of

indigestion that have no obvious cause. Nonulcer stomach pain is also called
functional dyspepsia (dis-PEP-see-uh) or nonulcer dyspepsia.
Nonulcer stomach pain is common and can be long lasting. Nonulcer stomach
pain can cause signs and symptoms that resemble those of an ulcer, such as pain
or discomfort in your upper abdomen, often accompanied by bloating, belching
and nausea.

http://www.mayoclinic.org/diseases-conditions/stomach-pain/basics/treatment/con-20027306
 Signs and symptoms of nonulcer stomach pain may include:
• A burning sensation or discomfort in your upper abdomen or lower chest, sometimes
relieved by food or antacids
• Bloating
• Belching
• An early feeling of fullness when eating
• Nausea

When to see a doctor

Make an appointment with your doctor if you experience persistent signs and symptoms
that worry you.
• Seek immediate medical attention if you experience:
• Bloody vomit
• Dark, tarry stools
• Shortness of breath
• Pain that radiates to your jaw, neck or arm
http://www.mayoclinic.org/diseases-conditions/stomach-pain/basics/treatment/con-20027306
 Causes
Many times it's not clear what causes nonulcer stomach pain. Doctors consider it a
functional disorder, which means it's not necessarily caused by a specific disease.

http://www.mayoclinic.org/diseases-conditions/stomach-pain/basics/treatment/con-20027306
 Factors that can increase the risk of nonulcer stomach pain include:
• Drinking too much alcohol or too many caffeinated beverages
• Smoking
• Taking certain medications, especially certain over-the-counter pain relievers,
such as aspirin and ibuprofen (Advil, Motrin IB, others), which can cause
stomach problems

http://www.mayoclinic.org/diseases-conditions/stomach-pain/basics/treatment/con-20027306
 Your doctor will likely review your signs and symptoms and perform a physical
examination. A number of diagnostic tests may help your doctor determine the cause of
your discomfort. These may include:
• Blood tests. Blood tests may help rule out other diseases that can cause signs and
symptoms similar to those of nonulcer stomach pain.
• Tests for a bacterium. Your doctor may recommend a test to look for a bacterium called
Helicobacter pylori (H. pylori) that can cause stomach problems. H. pylori testing may
use your blood, stool or breath.
• Using a scope to examine your digestive system. A thin, flexible, lighted instrument
(endoscope) is passed down your throat so that your doctor can view your esophagus,
stomach and the first part of your small intestine (duodenum).

http://www.mayoclinic.org/diseases-conditions/stomach-pain/basics/treatment/con-20027306
 Nonulcer stomach pain that is long lasting and isn't controlled by lifestyle changes may require treatment.
What treatment you receive depends on your signs and symptoms. Treatment may combine medications with
behavior therapy.
Medications
Medications that may help in managing the signs and symptoms of nonulcer stomach pain include:
• Over-the-counter gas remedies. Drugs that contain the ingredient simethicone may provide some relief by
reducing gas. Examples of gas-relieving remedies include Mylanta and Gas-X.
• Medications to reduce acid production. Called H-2-receptor blockers, these medications are available over-
the-counter and include cimetidine (Tagamet HB), famotidine (Pepcid AC), nizatidine (Axid AR) and
ranitidine (Zantac 75). Stronger versions of these medications are available in prescription form.
• Medications that block acid 'pumps.' Proton pump inhibitors shut down the acid "pumps" within acid-
secreting stomach cells. Proton pump inhibitors reduce acid by blocking the action of these tiny pumps.
• Over-the-counter proton pump inhibitors include lansoprazole (Prevacid 24HR) and omeprazole (Prilosec
OTC). Stronger proton pump inhibitors also are available by prescription.

http://www.mayoclinic.org/diseases-conditions/stomach-pain/basics/treatment/con-20027306
 • Medication to strengthen the esophageal sphincter. Prokinetic agents help your
stomach empty more rapidly and may help tighten the valve between your stomach
and esophagus, reducing the likelihood of upper abdominal discomfort.
• Doctors may prescribe the medication metoclopramide (Reglan), but this drug
doesn't work for everyone and may have significant side effects.
• Low-dose antidepressants. Tricyclic antidepressants and drugs known as selective
serotonin reuptake inhibitors (SSRIs), taken in low doses, may help inhibit the
activity of neurons that control intestinal pain.
• Antibiotics. If tests indicate that a common ulcer-causing bacterium called H. pylori
is present in your stomach, your doctor may recommend antibiotics.

http://www.mayoclinic.org/diseases-conditions/stomach-pain/basics/treatment/con-20027306
Helicobacter Pylori

In 1983, Warren (a biologist) and Marshall (a clinician) described

Helicobacter pylori (HP). At first, they named the bacterium
Campylobacter pyloridis. Later, it was named Campylobacter pylori.
Since then, a large number of reports have been produced on H pylori
and its pathogenetic potential.
In fact, although peptic ulcer disease is the most studied disease related to H
pylori infection, this bacterium is seemingly involved in the pathogenesis of
several extragastric diseases, such as mucosa-associated lymphoid tissue
lymphomas (MALTomas), coronaritis (inflammation of coronary arteries),
gastroesophageal reflux disease (GERD), iron deficiency anemia, skin disease,
and rheumatologic conditions. However, at present, many of these
associations remain largely uncertain, and the debate to confirm or refute
causality related to these associations is still open.
PATOPHYSIOLOGY
The most common route of H pylori infection is either oral-to-oral (stomach contents are
transmitted from mouth to mouth) or fecal-to-oral (from stool to mouth) contact.
Parents and siblings seem to play a primary role in transmission.

In a susceptible host, H pylori results in chronic active gastritis that may lead, in turn, to
duodenal and gastric ulcer disease, gastric cancer, and MALTomas. H pylori infection
causes chronic active gastritis, which is characterized by a striking infiltrate of the gastric
epithelium and the underlying lamina propria by neutrophils, T and B lymphocytes,
macrophages, and mast cells. Mast cells, usually responsible for the immune response
balance, may be important effector cells in the pathogenesis of gastritis. However, H
pylori does not seem to invade the gastric mucosa, although evidence suggests that the
mucus layer provides a niche wherein the germ is protected from gastric secretions.

The release of host cytokines after direct contact of H pylori with the epithelial cells of
the gastric lining could recall the inflammatory cells in the infected area.
Etiology
Note the following:

• H pylori infection causes atrophic and even metaplastic changes in the stomach.
• The bacterial adhesion appears to result in tyrosine phosphorylation and is specific for gastric cells.
• The adhesion of H pylori to the gastric cells causes a direct decrease in mucosal levels of glutathione, a
fundamental molecule in the maintenance of the cellular redox status and in the molecular regulation of host
immune responses. However, the LPS of H pylori may induce the production of autoantibodies that are able to
worsen the atrophy in the corpus mucosa and cause a concomitant increase in parietal cell antibodies. Such events
are accompanied by a decrease in anti- H pylori immunoglobulin titers. This process leads to a scenario of severe
atrophy without bacterial colonization combined with high levels of autoantibodies against gastric parietal cells.
• A number of reports show the close association between H pylori infection and low-grade gastric MALTomas.
• Giannakis and colleagues demonstrated that H pylori may adapt to gastric stem cells, influencing their biology and
contributing to tumorigenesis of the stomach.
Epidemiology
United States statistics
The frequency of H pylori infection may be linked to race. White persons account for 29% of cases, and Hispanic
persons account for 60% of cases.

International statistics
H pylori is a ubiquitous organism. At least 50% of all people are infected, but an exact determination is not
available, mostly because exact data are not available from developing countries. H pylori may be detected in
approximately 90% of individuals with peptic ulcer disease; however, less than 15% of infected persons may have
this disease.

Race-, sex-, and age-related statistics

The pathogenetic role of H pylori may differ depending on the geography and race. White persons are infected
with H pylori less frequently than persons of other racial groups. The prevalence rate is approximately 20% in
white persons, 54% in African American persons, and 60% in Hispanic persons.

No sex predilection is known; however, females have a higher incidence of reinfection (5-8%) than males.
H pylori infection may be acquired at any age. According to some epidemiologic studies, this infection is acquired
most frequently during childhood. Children and females have a higher incidence of reinfection (5-8%) than adult
males.
PROGNOSIS
The prognosis is usually excellent, even in patients with complications, such as gastric
MALToma. However, the prognosis becomes poor for patients who develop squamous
cell esophageal cancer or gastric carcinoma.
The rate of reinfection is very low (1-2%); however, children and females have a
higher incidence of reinfection (5-8%)