2. STOMACH and DUODENAL GUT
INSPECTION
Patients with diseases of a stomach and a duode
nal gut show complaints to pains in epigastric ar
ea, a nausea, an eructation, vomiting, appetite
change that are often observed at a pathology o
f other organs. However some details in their ch
aracteristic, as well as the data of physical insp
ection of patients (survey, palpation of abdomen
) usually allow to orientate in a situation and to
use a number of additional methods of investiga
tion, first of all radiological and endoscopical.

3. Complaints
To the basic manifestation of stomach dise
ases and the duodenal gut are in mach de
fining complaints of patients, the following.
• Pains.
• Dispeptic phenomenas.
• Gastrointestinal bleeding.
• decreasing of body weight.

4. PAINS
Abdominal pains caused by pathology of a stom
ach and duodenal gut, are usually localised in e
pigastric areas and have constant or paroxysm
al character. Most typical paroxysmal pains con
nected with food intake, appearing periodical. D
istinguish early and late pains.
• Early pains are usually connected with stomach
pathology. They arise soon after meal (usually t
hrough 30-60 minutes), keep on 1-1, 5 h and de
crease in process of evacuation of contents fro
m a stomach.

5. • Late pains are caused by pathology of a duode
nal gut. They appear through 1,5 - 3 hours after
food use.
• The hungry pains are weakening after food intak
e, and night pains are possible also. Patients ca
n show complaints to a painful pressure sense
or weights in the epigastric area, connected wit
h stomach overflow. Complaints to a stomach s
welling (flatulence) because of strengthened ga
sification mainly in intestines are possible also.

6. DISPEPTIC SYNDROME
Dyspepsia - group concept for a designation
of the syndrome connected with disturban
ce of digestion of any aetiology. Dyspepsi
a can be gastric (a heartburn, an eructatio
n, a nausea, vomiting, weight and pains in
epigastric areas) and intestinal.

7. The reasons
Determine the organic and functional reaso
ns of dyspepsia.

8. The organic reasons of dyspepsia:
• Reflux- esophagitis;
• Stomach ulcer;
• Gastritis;
• Chronic pancreatitis;
• Cholelithiasis;
• Stomach cancer.

9. Nevertheless the list of diseases and the conditio
ns causing dyspepsia leaves far for frameworks
of a pathology of a digestive tract. To dyspepsy
also can result many other pathological conditio
ns.
• Infectious diseases.
• Intoxications (including a uraemic intoxication).
• using various medication (thus dyspepsia can a
rise as a by-effect or as an overdose sign).

10. • Diseases of nervous system (a meningitis and s
o forth).
• Heart diseases (at cardiac insufficiency as mani
festation of the marked developments of stagna
tion, including in GIS with development of a hyp
ostasis of mucous membranes; at a myocardiu
m heart attack – it an abdominal variant - as a r
esult irradiation of the painful impulses through
a solar plexus).
• Some pathological conditions from gynecologic
sphere (for example, ovary tumour the big sizes
), etc.

11. Functional dyspepsia
According to the international criteria the f
unctional dyspepsia is a condition answeri
ng to following criteria.
• Presence of constant or relapsing dyspeps
ia.
• Absence of organic disease (including at u
se EGDS) as which it would be possible to
count as the reason arisen dyspepsia.

12. • Expressiveness of displays dyspepsy doe
s not decrease after defecation and does
not depend on frequency of a stool or a fa
eces consistence (an exception of a syndr
ome of an irritable gut).
• The patient’s dyspepsy keeps on many we
eks for current year (not necessarily conse
cutive).

13. Thus, the diagnosis of functional dyspepsy -
the diagnosis of exception, i.e. it is necess
ary for doctor to have all bases to consider
that the organic pathology which can mani
fests itself by dyspepsy, really is absent.

14. Functional dyspepsia can proceed in the for
m of three variants:
• ulcerous,
• dyskinetic,
• nonspecific.

15. • Ulcerous dyspepsy is characterised by a painful
syndrome with primary localisation in epigastric
area.
• Dyskinetic dyspepsia is characterised by a com
bination of following signs: sensation of fast fillin
g of a stomach, feeling of discomfort in the epig
astric area, not accompanied by a painful syndr
ome, a nausea, disgust for some products, tran
sient signs of a syndrome of an irritable thick gu
t (seldom).

16. • For nonspecific dyspepsia the repeating er
uctation which is not bringing alleviation, a
n abdominal swelling, a nausea are chara
cteristic. Displays are aggravated at stress
ful situations.

17. Separate components of a syndrome
Nausea – is original unpleasant sensation i
n epigastric area, connected with irritation
of a vagus nerve. At diseases of a stomac
h the nausea is usually combined with pai
ns, and also often arises before vomiting o
ccurrence. The nausea is possible at man
y other conditions, however at pathology
GIT it is preceded usually by food intake.

18. Vomiting – is attack-like emission of a cont
ained stomach in an esophagus and furth
er in an oral cavity as a result of reduction
s of an abdominal tension, movements of r
espiratory muscles at the closed gatekeep
er; it is often combined with a nausea, bell
y-aches, hypersalivation. At patients with d
iseases of a stomach after vomiting the pa
in usually abates.

19. It is especially important to find out time of occurr
ence of vomiting, communication with food intak
e, painful sensations from patients. Vomiting on
an empty stomach with a slime considerable qu
antity is characteristic in the morning for a chron
ic gastritis (especially at alcoholics). Vomiting o
n an empty stomach sour gastric content is char
acteristic in the morning for night hypersecretio
n. Vomiting through 10-15 mines after meal is ty
pical for an ulcer or a cancer of forestomach, an
d also for a chronic gastritis.

20. At an ulcer or a cancer of a body of a stomach vo
miting arises through 2-3 hours after meal. The
ulcer of pyloric part of a stomach or a duodenal
gut is characterised by vomiting occurrence thro
ugh 4-6 hours after food intake. Vomiting by the
food eaten 1-2 days ago is extremely characteri
stic for a stenosis of the gatekeeper with stagna
tion of food in a stomach.
Special value has character of vomit masses.

21. Vomit masses can contain blood that testifies to a
gastroenteric bleeding; thus often vomit masses
take a form of "coffee grounds». Vomiting with a
putrefactive smell is characteristic for stagnatio
n of food in a stomach at a stenosis pylorus part
of stomach. At impassability of intestines vomit
masses can get fecal odor that is caused antipe
ristaltic contraction of intestines with receipt in a
stomach of contained intestines.

22. Besides usually gastric and esophageal vomitings
, is possible vomiting central genesis, not conne
cted with pathology GIS. For it following feature
s are characteristic: arises suddenly, without a p
revious nausea and others dyspeptic phenome
nas, after it, unlike usual vomiting, the alleviatio
n does not come in general or it is short. Vomiti
ng central genesis can arise at increase of intra
cranial pressure, irritation of brain covers, hyste
ria and other conditions connected with disturba
nce of functions CNS.

23. Eructation – is sudden involuntary eliminati
on from a stomach in an oral cavity of gas
es (an air eructation) or a small amount of
gastric contents (regurgitation).

24. • Air eructation is more characteristic for aeropha
gy (swallowing superfluous quantity of air with t
he subsequent it belches at the disturbance foo
d intake, some diseases GIT, neurosises).
• At stagnation of food in a stomach there is its fer
mentation and rotting with increase gas-formati
on. At fermentation an eructation is odourless, o
r with a smell of oil rancidity. At rotting patients c
omplain of foul-smelling eructation (for the acco
unt of formation of hydrogen sulphide).

25. • Eructation by sour is typical for hypersecretory
conditions.
• Bitter eructation (bile) arises at a reflux of conte
nts of a duodenal gut in a stomach. Sometimes
such eructation arises imperceptibly for the pati
ent, and it shows complaints to bitterness in a
mouth. The eructation is quite often accompani
ed by aspiration vomit masses, i.e. their hit in re
spiratory tracts and occurrence choking and co
ugh. Most often aspiration by vomit masses wit
h pneumonia development arises at sick of alco
holism.

26. Appetite change is often enough observed
at diseases of a stomach and a duodenal
gut.

27. • Appetite decrease usually note at patients with a
chronic gastritis with diminished secretory functi
on.
• Anorexia - absence of appetite - is often combin
ed with selective occurrence of disgust for certa
in products (for example, to meat) that the symp
tom of a cancer of a stomach is frequent.
• Appetite increase is characteristic for a stomac
h ulcer, especially at ulcer localisation in a duod
enal gut.

28. • Dysorexia (distortion of appetite) with the o
nset of predilection for certain inedible sub
stances. The dysorexia with predilection fo
r a chalk is especially frequent arises at pr
egnancy, anemias (chlorosis) and specifie
s in deficiency of iron.

29. GASTRO-INTESTINAL BLEEDING
This symptom always arises as a sign of a
serious pathology at which urgent medical
aid is usually necessary. Assign following r
easons of a gastroenteric bleeding.
• Stomach ulcer.
• Gastritis or stomach erosion.

30. • Esophagitis or esophagus ulcer.
• Duodenit.
• Ruptures varix dilatation of an esophagus (it is
especially frequent at a portal hypertensia).
• Tumours of a stomach and a duodenal gut (disi
ntegrating or destroying blood vessels).
• Ruptures of mucous membrane pars cardiaca v
entriculi at a syndrome Mellori - Veissa.

31. The most often gastroenteric bleeding is shown b
y vomiting with a blood impurity, and also melen
a. Colour of vomit masses depends on quantity
of blood and duration of its stay in a stomach. If
blood it is long contacts to sour gastric contents
, vomit masses take a form of "coffee grounds»
(brown colour with clots of blood and not digest
ed food), as at interaction with hydrochloric acid
blood haemoglobin will be transformed in muriat
ic haematin. At a considerable bleeding owing t
o damage of a large vessel to vomiting the cons
iderable quantity of scarlet blood contains.

32. DECREASE of BODY WEIGHT
The weight loss – is the frequent complaint of p
atients with diseases of a stomach and duoden
um. With similar complaints it is necessary for p
atients to ask following questions.
• How appetite has changed - it is increased or d
ecreased?
• What time the weight of a body has decreased f
or?
• Whether the patient receives pleasure from me
al?
• What the patient eats for a breakfast, a dinner a
nd a supper?

33. • Whether there are complaints to pains, nausea,
vomiting, and an eructation (besides decrease i
n weight of a body)?
• Whether always dejection has usual colour and
a consistence?
• Whether the patient noticed body rise in temper
ature?
The received answers will help the doctor to orie
nt concerning localisation of disease process, it
s duration and essence.

34. Medical history and history of life.
At anamnesis studying it is necessary to estimate
character of a food of the patient. The question
of a regularity of food intake, as absence of a c
ertain diet - one of the primary factors, predispo
sing to diseases GIT (first of all a stomach) is e
specially important. Also the information on is i
mportant what food is preferred by the patient (f
at, fried, spicy, salty, farinaceous food), what qu
antity of food eaten for once, whether well is foo
d chewed.

35. Besides, it is necessary to find out, whether the p
atient smokes, in what quantity accepts alcohol,
whether is exposed to influence of any occupati
onal hazards. The estimation of psychological s
phere of the patient and its susceptibility to stre
sses can become useful.
The onset of the illness can be acute (gastritis aft
er an error in a diet). At a chronic current often
observe the aggravations of disease also quite
often provoked by disturbance in a diet, alcohol
using. The remission periods (for example, at a
stomach ulcer) can be long.

36. At a cancer of a stomach illness usually progress
es quickly. It is always important to specify com
munication of a stomach disease with using MD
(for example, NSAID). Has certain value specifi
cation of features of the hereditary anamnesis (
a stomach ulcer, tumours).

37. Physical methods of exam
The general survey of the patient allows to r
eveal a weight loss (up to cachexia), the p
allor of integuments usually connected wit
h an anaemia (characteristic for gastric atr
ophy, the developed picture of a stomach
cancer). At survey of a mouth pay attentio
n on furred tongue.

38. At superficial palpation a stomach quite ofte
n find out painless in epigastric area and s
mall pressure of abdomen muscles, usuall
y connected with a stomach ulcer or gastri
tis. Deep sliding palpation only sometimes
allows palpate small and big curvature an
d pyloric part of stomach, is more rare - a
stomach tumour at its big sizes.

39. Additional methods of investigation.
RADIOLOGICAL INVESTIGATION
For stomach exam carries out both radiographic
and roentgenoscopic investigations. The last is
more preferable, as allows estimating gastric m
otility. For the purpose of preparation of the pati
ent for investigation overnight and in the mornin
g to day of investigation carry out purgation of i
ntestines by enemas; at intractable constipation
appoint a depletive. Investigation carries out on
an empty stomach, in vertical position of the pat
ient. As contrast use a suspension of sulphate o
f barium.

40. Investigation begin with definition of a relief of a
mucous membrane of the stomach which folds
have the big variations and often vary dependin
g on a stage of process of digestion (relief or fla
tness). If their course breaks, assume presence
in this place of pathological process. The import
ant component of investigation - studying of a st
omach contours. Proof outpocketing its shades
in a certain place designate the term "niche" a t
ypical sign of a stomach ulcer. Absence of filling
is by contrast weight of a site of a stomach nam
e defect of filling (the important symptom of a n
eoplasm).

41. Fiber-optic endoscopy
With application of fiber optics gastroduoden
oscopy has had intensive development, now
it is the most informative and fast method of
diagnostics of diseases of a stomach and a
duodenal gut. The given method allows to c
arry out simultaneously and biopsy with mo
rphological studying of the received fragme
nt of a tissue. Among indications for are car
rying out GDS one of the base - a bleeding fr
om the top parts of GIT and a pain in epigast
ric area.

42. Gastroscopy procedure

43. As advantages of this method considers possibilit
y of application of local treatment in case of a pr
oceeding bleeding, and also detection of superfi
cial changes of the mucous membranes which
are not revealed by a radiological method. In th
e presence of the stomach ulcer which has bee
n found out at radiological investigation, endosc
opic investigation is necessary for visual and hi
stologic acknowledgement of absence an ulcer
ated tumour.

44. At any suspicion on a stomach tumour (including i
n the presence of such symptoms as decrease i
n weight of a body, an anaemia) it is necessary
endoscopic investigation though in certain case
s endoscopy, unlike a radiological method of inv
estigation, does not allow to reveal a stomach t
umour that first of all concerns to infiltrating gro
wth of tumour when it extend in a stomach wall,
leaving a mucous membrane practically intact

45. Biopsy of stomach mucous membrane HISTO
LOGIC STUDY

46. This method applies to an exception or ackn
owledgement of presence of a tumour. Th
us a tissue for study takes in several point
s. Accuracy of the diagnosis in this case st
udies 80-90 %. It is necessary to consider
that are possible both false-positive, and f
alse-negative results. Recently biopsy of s
tomach mucous membrane is use for reve
aling Helicobacter pylori.

47. Study biopsy material of mucous membrane
allows not only to reveal in due time this m
icroorganism, but also to specify morpholo
gical changes (for example, presence of a
n inflammation, an atrophy, metaplasia).

48. Investigation of GASTRIC JUICE
Investigation carries out by means of a thin probe
which enters into a stomach of the patient (thus
it should make swallowing movements). A portio
n of gastric contents receive on an empty stoma
ch and then each 15 mines after introduction of
a stimulator of gastric secretion. Basal secretion
of acid - total of hydrochloric acid, secreted in a
stomach for four 15-minutes intervals of time an
d marked in mmol/ch. This indicator fluctuates i
n norm from 0 to 12 mmol/ch, on the average m
akes 2-3 mmol/h.

49. Stimulated secretion of acid define after introducti
on of stimulators. The strongest stimulators of g
astric secretion – are histamine and pentagastri
n. As last has less marked side effect, now it us
e even more often. Basal and the maximal secr
etion of hydrochloric acid are more at patients w
ith ulcer localisation in a duodenal gut. At an ulc
er location in a stomach secretion of hydrochlori
c acid at patients is less, than at the healthy. Th
e stomach ulcer seldom arises at patients with
gastric anacidity.

50. Investigation of gastrin in blood serum
Definition gastrins in the blood serum, carred out
by a radio immune method, at diseases of a sto
mach and a duodenal gut can have diagnostic v
alue. Normal values of this indicator on an empt
y stomach make 100-200 ng/l. Increase more th
an 600 ng/l (marked gypergastrinemy) observe
at Zollinger-Ellison’s syndrome and pernicious a
nemia.

51. DETECTION OF HELICОВACTER PYLORI
For revealing Helicobacter pylori; use the tests based
on research of a material, received with the help of sto
mach biopsy (usually during carrying out FEGDS). It is
convenient the urease test at which a material of a mu
cous membrane biopsy place in the gel containing ure
a (a bacterium produces urease). In the presence of H
elicobacter pylori; in an investigated material observe
change of colour within several minutes. Cultivation of
Helicobacter pylori; Rather inconveniently, and use ser
ological methods for dynamic research is impossible.

52. The SPECIAL PATHOLOGY

53. Gastritises
The gastritis – is affection of a mucous membran
e of a stomach mainly with inflammatory chang
es at acute development of process and the ph
enomena of its morphological and functional re
organisation with a progressing atrophy at a chr
onic current. Representations about gastritises
with clinical, endoscopical and morphological p
oints of view often do not coincide, but all the sa
me on the basis clinicopathologic datas it is acc
epted to allocate acute and chronic gastritises.

54. The ACUTE GASTRITIS
Disease can develop as for no apparent reason, and at
using rough and not quite good-quality food infected w
ith various microorganisms (staphylococcus, salmonell
as), using MD, first of all acetylsalicinic acids and othe
rs NSAID. Action AID is connected with inhibition by th
em prostaglandins, thus arises acute erosive gastritis
more often; last can be caused also alcohol using, an
allergy to some foodstuff, stress in connection with a b
urn, a trauma, operation. Occurrence an erosive gastri
tis is probably at respiratory, nephritic, hepatic insuffici
ency and accompanying disturbance of blood circulati
on in a stomach mucous membrane (congestive heart
failure).

55. Clinical features
Acute catarrhal gastritis is characterised by
pains in epigastric area, dyspepsy syndro
me (a nausea, vomiting by food with a sli
me and bile impurity), sometimes - low gra
de fever. Symptoms usually appear throug
h 6-8 hours after influence on a mucous m
embrane of a stomach of the pathogenic f
actor. At FEGDS usually reveal a diffuse h
yperaemy of the stomach mucous membr
ane.

56. Acute erosive gastritis can become complicated a
bleeding of various expressiveness and duratio
n (therefore it consider as the most dangerous f
orm of an acute gastritis). Patients note an easy
pain or discomfort and painless at palpation in e
pigastric area, nausea. Radiological investigatio
n spuriously. The diagnosis confirms by means
of FEGDS at which define the multiple erosion
of a mucous membrane and it hyperaemia.

57. CHRONIC GASTRITIS
The chronic gastritis - is chronic inflammation of a stoma
ch mucous membrane with reorganisation of its struct
ure and a progressing atrophy, motility disturbance, se
cretory and other functions. This diagnosis often finalis
e only at endoscopic and that especially informatively,
histologic study of biopsy material. At initial stages of d
isease there is a superficial lesion with infiltration a mu
cous membrane by lymphocyte and plasmocytes, at la
ter stages glands of mucous membrane are affected,
at last, at process progressing there is gastritis with m
ucous membrane atrophy, reduction of its foldings.

58. Among aetiological factors it is necessary to
name first of all Helicobacter pylori infectio
n, and also a number of not microbic facto
rs (alcohol, NSAID, influence of chemical
agents - a reflux of bile, a medicine) and d
evelopment autoantibody.

59. Clinical features
The chronic gastritis can proceed asymptomatic
ally. For a clinical picture of disease following si
gns are characteristic.
• Pain in the epigastric area marked slightly and i
ndistinctly localised.
• The dispeptic phenomenas: fill of spreading in th
e epigastric area, connected with food intake; a
n eructation, nausea, vomiting, appetite disturb
ance, a stomach swelling, rumbling, meteorism,
unstable stool.

60. Clinical presentations of gastritis with raised or n
ormal secretory function essentially differ from p
resentations of gastritis with insufficient produci
ng of acid and pepsin.
• For a gastritis with raised and normal secretory f
unction most typical a heartburn, an eructation
sour, weight and stupid aching pains in epigstric
area after meal (sometimes pains "hungry" or ni
ght), propensity to constipation.

61. • For a gastritis with secretory insufficiency are m
ore characteristic: spreading and dull aches in e
pigastric area, a nausea, the appetite decrease,
unpleasant taste in a mouth, an eructation rotte
n, rumbling, propensity to diarrheas. Besides th
ere are hypovitaminosis signs (dryness of a ski
n, « angular cheilosis», changes of nails) and s
ometimes a dumping-syndrome (after meal ther
e is a weakness, hyperhidrosis, dizziness and p
alpitation)

62. Tool methods of research.
The definitive diagnosis often establish only at FEG
DS or even histologic studying of biopsy material.
Revealing Helicobacter pylori (carrying out eradica
te therapy can lead to recovery) is the extremely i
mportant. Research of secretory stomach function
carries out by a method of fractional gastric intuba
tion with application of stimulators of gastric secr
etion (histamine, pentagastrin). In blood serum def
ine reduction of gastrin level, especially at lesion a
ntral’s stomach part. Carrying out of contrast radio
logical research is inexpedient, as it does not reve
al characteristic changes.

63. Acute gastritis with superficial ero
sions.

64. Mucosal erythema and edema co
nsistent with acute gastritis.

65. Ulcer of stomach and duodenal gut.
Disease is characterised by formation peptic ulcer
s in a mucous membrane of a stomach or a duo
denal gut, thus disturbance of mucous membra
ne integrity occurs under the influence of the ga
stric juice containing hydrochloric acid and peps
in. The stomach ulcer - is principal cause of dys
peptic syndrome and long belly-aches. Disease
current – is cyclic, with alternation of the period
s of an aggravation and remission. For a diseas
e aggravation seasonal prevalence (spring, aut
umn) is characteristic.

66. Aetiology and pathogenesis
Stomach ulcer development, on modern representation
s, is caused by disturbance of balance between influe
nce of aggressive factors and the mechanisms of prot
ection keeping integrity of a stomach mucous membra
ne.
• To aggressive factors relate: hydrochloric acid, pepsin,
bilious acids, infection Helicobacter pylori, NSAID, alc
ohol.
• Protective mechanisms include: mucous-bicarbonate b
arrier, prostaglandins, constant regeneration of a muc
ous membrane cells, presence of the branched out mi
crovascular network.

67. Peptic ul
cer and
H-pylori

68. • Immune disturbance, chronic inflammatory infiltration a
mucous membrane, gastrin hypersecretion, accompan
ying infection Helicobacter pylori has certain value als
o.
For occurrence of a stomach ulcer great value, undoubt
edly, hereditary predisposition has. A number of the ge
netic defects realised in those or other links pathogene
sis of this disease is established.
To the important factors of formation of an ulcer also rel
ate adverse influence of environment: stresses, diet di
sturbance, smoking and so forth.

69. Hydrochloric acid, pepsin and bilious acids
At a stomach ulcer the level of a stomach secreti
on of hydrochloric acid is close to norm or even
is lowered. In the pathogenesis of disease great
er value has decrease in resistance of a mucou
s membrane, and also bile reflux in a cavity of a
stomach owing to insufficiency sphincter muscl
e of pylorus. In development of a stomach ulcer
of a duodenal gut a leading role, most likely, pla
ys acid – peptical factor.

70. Gastrin and parasympathetic nervous sy
stem
The special role in stomach ulcer developm
ent is appropriate to gastrin and cholinergi
c postganglionic nervous fiber of nervus v
agus, participating in regulation of gastric
secretion.

71. Histamine
There is an assumption that in realization of
stimulating action of gastrin and cholinergi
c mediators on acid-forming function of pa
rietal cells participate histamine, which pro
ves to be true therapeutic effect of antago
nist’s Н2-receptor’s histamine (cimetidine,
ranitidine and so forth).

72. Prostaglandin
Prostaglandins play the central role in protection
of stomach mucous membrane epithelium from
action of aggressive factors. Key enzyme of syn
thesis prostaglandins – is ciklooxigenaz, presen
t at an organism in forms COG- l and COG-2.
• COG- l it is found out in a stomach, kidneys, plat
elets, and endothelium.
• Induction COG-2 occurs under the influence of a
n inflammation; the expression of this enzyme i
s carried out mainly by inflammatory cells.

73. Clinical effect of NSAID is connected basically wit
h oppression COG-2, and their side effects dep
end on oppression COG-1 and disturbance of p
rotective function of stomach mucous membran
e with development gastropathy, very close to
many characteristics to a stomach ulcer. High h
opes assign application at inflammatory disease
s selective inhibitors COG-2, effective and safer
.

74. Other factors reducing resistance of a m
ucous membrane
To decrease of a mucous membrane resist
ance also result of deficiency IgA, change
in it microcirculation with the tendency to a
n ischemia.

75. Clinical features
Characteristic signs - belly-aches and dispeptical
phenomenas, it is connected with food intake.
• Pains are localised in epigastric area, is frequen
t irradiation in a back, a backbone (its lumbar re
gion) that is more peculiar for an ulcer localised
on a back wall of a stomach. Pains arise soon a
fter food intake - early (through 30-40 minutes t
hat is characteristic for a stomach ulcer), late (t
hrough 3-4 hours after food intaking that is char
acteristic for the piloric channel ulcer and a duo
denal gut). The painful syndrome stops food int
ake (for example, milk) and the means reducing
acidity of gastric juice.

77. • At height an attack of pains is possible vomiting by sour
contents of a stomach after which the pain quickly aba
tes.
• The stomach ulcer aggravation (especially duodenal g
ut) often proceeds with constipations, i.e. with disturba
nce of motor function of a large intestine (at 5 % of pat
ients these symptoms can be leaders).
• The heartburn and an eructation are possible.
At survey usually reveal furred tongue. At palpation of a
bdomen it is possible to find out painless in epigastric
area or in a point of duodenal cap projection.

78. TOOL METHODS of INVESTIGATION

79. Fibroesophagogastroduodenoscopy (FEGDS)
- the basic method of diagnostics of peptic ulcer
disease. It allows not only specifying localisatio
n and the sizes of an ulcer, but also at carrying
out biopsy to estimate degree of ulcer high quali
ty (the ulcers localised in a stomach and repres
enting sometimes in a radiological picture good-
quality formations usually on the big curvature o
f a stomach, can appear malignant). Besides, d
uring carrying out FEGDS make sampling for re
search on Helicobacter pylori.

81. Gastric ulcer (lesser curvature) with punched
-out ulcer base with whitish exudate.

82. Gastric ulcer with punched-out ulcer
base with whitish fibrinoid exudates.

83. Investigation of a stomach acid-forming function
Usually apply fractional intubation of a stomach for defin
ition of secretion level. Secretional function of a stoma
ch happens is raised:
• After a resection part of a small intestine (number secr
etion the intestinals factors oppressing secretional fun
ction of a stomach) as a result stops;
• At hypercalc(in)emia any origin;
• After damage of the brain which has led to increase of
activity of vagus;
• At a pancreatitis or glandular obstruction of a pancreas
.

84. The most marked hypersecretion observe at pan
creas tumours, secretioning gastrin (gastrinoma
hypercalc(in)emia), i.e. a syndrome of Zollinger
a-Ellisona for which high acidity of gastric juice i
s characteristic, and also frequent relapses the
peptic ulcers, progressing deterioration of a con
dition, a belly-ache, dyspepsia, high level of gas
trin in blood that estimate a radio immune meth
od. The pancreas tumour can be revealed by
means of computed tomography, ultrasonic of a
belly cavity.

85. Radiological investigation
At radiological investigation (with contrasting of a
barium sulphate suspension) is in the field of an
ulcer found out "a niche" symptom. Nevertheles
s the radiological method does not allow to diffe
rentiate a good-quality ulcer from malignant, to
estimate degree of healing of an ulcer, especiall
y when sclerous process deforming a mucous
membrane is marked.

86. COMPLICATIONS
Carry the following to stomach ulcer compli
cations (develop at 20 % of patients).
• Ulcer perforation.
• Bleeding.
• Pyloric stenosis.
• Penetration in adjacent organ.
• Malignization of an ulcer.

87. • Ulcer perforation is often characterised marke
d «knife-like pain» in abdomen with the subseq
uent development of an acute peritonitis.
• Bleeding most often observe at ulcer localisatio
n in a duodenal gut. Sometimes possible insign
ificant low simptomatic bleedings revealed only
at research feces on latent blood.

88. Ulcer emergencies

89. Stenosis of the gatekeeper arises more often at
patients with ulcer localisation in a duodenal gut
and is rarer at ulcer localisation in a stomach.
With increase of degree of a stenosis patients n
ote that food intake does not reduce painful and
their unpleasant sensations, and even strength
ens them. The most typical symptom of a gatek
eeper stenosis – is persistent vomiting which ca
n accompany pressure from an organism of con
siderable quantities of gastric juice and leads to
hypochloremia with development of nephritic in
sufficiency.

90. At palpation and a light tapotement in epig
astric area reveal "splash" noise. The sten
osis reason establish at FEGDS and biops
y with histologic study of a material (for an
exception of a stomach cancer and rare at
adults of a hypertrophy of the gatekeeper).

91. Ulcer’s penetration. As this term understan
d distribution of infiltrative-destructive proc
ess of a stomach or a duodenal gut to thic
kness of the next organ - a liver, a pancre
as, an epiploon that is accompanied by ris
e in temperature of a body to subfebrile va
lues, increase ESR.

92. Stomach cancer
Stomach cancer remains among malignant t
umours to the most widespread though its
frequency, especially in the developed cou
ntries, gradually decreases.

93. AETIOLOGY
Aetiology up to the end is not clear. To pretumor
al conditions relate atrophic gastritis with the lo
wered acidity, especially at patients with pernici
ous [Biermer's, Biermer-Ehrlich, B12- deficiency
] anemia (i.e. a chronic gastritis of type A), stom
ach polyps, gastrectomy in the anamnesis (con
cerning a stomach ulcer).
On morphology the stomach cancer is almost alw
ays presented by adenocarcinoma, usually loca
lised in a stomach body on small curvature.

94. Clinical features

95. Complaints
Characteristic complaints for decrease or abse
nce of appetite with the appearance of disgust f
or certain products (for example, to meat), a sm
all nausea, and discomfort after meal which at p
ersons of middle age can be first signs of disea
se. At 1/4 patients the clinical presentations simi
lar to a clinical picture of a stomach ulcer are po
ssible. At half of patients note fast decrease in b
ody weight, a progressing nausea and vomiting.

96. Sometimes the anaemia (partially as a resul
t of regular blood lossing) early develops.
Frequently first signs of disease are conne
cted with metastasis. Less often at patient
s with malignant process observe long low
grade fever, dermatomyositis, neuromyop
athy (i.e. manifestation of paraneoplastic s
yndrome).

97. Physical examination
Objective methods of inspection (survey, pal
pation, percussion) allow revealing a stom
ach cancer only at late stages of disease.

98. Metastasis
At early stages of disease a tumour metastas in r
egional lymph nodes of an abdomen cavity, at l
ate stages - in more remote lymph nodes (throu
gh a lymphatic channel), for example left suprac
lavicular lymph node (Virchow's metastasis) an
d various organs a liver, ovary and so forth.

99. TOOL METHODS of INVESTIGATION
In diagnostics of a stomach cancer is the most rel
iable method – FEGDS with target biopsy of tiss
ues and morphological study of biopsy material.
Radiological investigation of a stomach with do
uble contrasting allows revealing defect of filling
with rough contours. At laboratory examination i
n analyses of blood at 2/3 patients define asider
otic [iron-deficiency] anemia (as a result of freq
uent small bleedings) or pernicious anaemia, an
d also increase ESR. At investigation of gastric
secretion usually note its decrease up to achlor
hydria.

100. Gastric cancer. Note the irregul
ar heaped up overhanging margi
ns.

101. Gastric cancer with ulcerated ma
ss.

107. Gastric cancer with ulcerated ma
ss.

108. Transjugular liver biopsy

109. Ultrasound