Sindromul dispeptic

Simptome dispepticeMai specificePlenitudine postprandiala = senzatie neplacuta perceputa ca persistenta prelungita a alimentelor in stomacSatietate precoce = resimte stomac supraplin imediat dupa inceperea mesei, disproportionat fata de volumul cat a mancat, nu poate termina masa. (disparitia senzatiei de foame in timpul ingestiei alimentelor).

Simptome dispepticeMai specificeDurerea epigastrica se refera la regiunea dintre ombilic si stern, intre liniile medioclaviculare. Durerea se refera la o senzatie subiectiva neplacuta. Durerea epigastrica poate sau nu sa aiba caracter de arsura. Alte simptome pot fi extrem de suparatoare fara ca pacientul sa le interpreteze ca durere.Arsura epigastrica Arsura se refera la o senzatie subiectiva neplacuta de caldura.

Simptome dispepticeMai putin specificeBalonare in abdomenul superior = senzatie neplacuta de presiune localizata in epigastru; trebuie diferentiata de distensia abdominalaGreata = presimtirea ca are necesitatea de a varsaVarsatura = expulzia orala fortata a continutului gastric asociata cu contractia muschilor abdominali si ai peretelui toracic.Varsatura este precedata de obicei de eructatii, contractii repetitive ale peretelui abdominal fara expulzia continutului gastric.Eructatia = golirea aerului din stomac sau esofag

Cauzele dispepsieiTractul gastrointestinal luminalVolvus gastric cronicIschemia gastrica sau intestinala cronica Intoleranta alimentaraDispepsia functionalaBRGENeoplasm gastric sau esofagianInfectii gastrice ( cytomegalovirus, fungi, tbc, sifilis)Gastropareza (DZ, postvagotomie, sclerodermie, pseudo-obstructia intestinala cronica, postvirala, idiopatica)Afectiuni gastrice infiltrative si inflamatorii (boala Crohn, gastroenterita eozinofilica, sarcoidoza, amiloidoza)Sindromul de colon iritabilBoala MntrierUlcerul pepticParaziti (Giardia lamblia, Strongyloides stercoralis)

Cauzele dispepsiei MedicatiiAcarbozaAspirina, alte AINS, inclusiv anti-COX-2ColchicinaPreparate digitaliceEstrogeniEtanolGemfibrozilGlucocorticoiziFierLevodopaNiacinaNarcoticeNitratiOrlistatKClQuinidinaSildenafilTeofiline

Cauzele dispepsieiAfectiuni pancreatico-biliareDurere de tip biliar - colelitiaza, coledocolitiaza, disfunctia sfincter Oddi Pancreatita cronicaCancerul pancreatic

Cauzele dispepsieiAfectiuni sistemiceInsuficienta CSRICCDiabetul zaharatHiperparatiroidismNeoplasme non-digestive intra-abdominaleIschemia miocardicaSarcina Insuficienta renalaBoli tiroidiene

Cauzele frecvente ale dispepsieiBRGEInfectia cu H. pyloriBoala ulceroasaCancerul si alte tumori gastrice ColelitiazaBoala celiacaMedicatii (AINS)Gastropareza

Clasificarea si criteriile de diagnostic ale dispepsiei functionale, sindrom distress postprandial si sindrom dureros epigastricDispepsia functionalaInclude una sau mai multe dintre urmatoarele:1. Plenitudine postprandiala suparatoare2. Satietate precoce3. Durere epigastrica4. Arsura epigastricasiAbsenta bolii structurale (inclusiv la EDS) care este evident sa explice simptomeleCriterii indeplinite cu 3 luni inainte cu debut al simptom de cel putin 6 luni inaintea diagnosticului

Clasificarea si criteriile de diagnostic ale dispepsiei functionale, sindrom distress postprandial si sindrom dureros epigastricSindromul de distress postprandialTrebuie sa includa unul sau ambele din urmatoarele:Plenitudine postprandiala suparatoare care apare dupa mese de marime ordinara, cel putin de mai multeori/saptatamana 2. Satietate precoce care previne terminarea unei mese regulate, de mai multe ori/saptamanaCriterii suportive Balonare epigastrica sau greata sau eructatii excesive postprandial pot fi prezente2. Sindrom dureros epigastric poate coexistaCriterii indeplinite cu 3 luni inainte cu debut al simptom de cel putin 6 luni inaintea diagnosticului

Clasificarea si criteriile de diagnostic ale dispepsiei functionale, sindrom distress postprandial si sindrom dureros epigastricSindrom dureros epigastricTrebuie sa includa toate dintre urmatoarele:1. Durere sau arsura localizata in epigastru cu severitate cel putin moderata, minim 1/sapt2. Durerea este intermitenta3. Nu este generalizata sau localizata in alte regiuni din abdomen sau torace4. Neameliorata de defecatie sau flatulenta5. Nu indeplineste criteriile pentru disfunctia vezicii biliare sau pentru afectiuni ale sfincterului Oddi.Criterii indeplinite cu 3 luni inainte cu debut al simptom de cel putin 6 luni inaintea diagnosticului

Clasificarea si criteriile de diagnostic ale dispepsiei functionale, sindrom distress postprandial si sindrom dureros epigastricSindrom dureros epigastricCriterii suportive 1. Durerea poate avea caracter de arsura, dar fara componenta retrosternala2. Durerea este frecvent indusa sau ameliorata de ingestia unei mese, dar poate apare si intre mese3. Sindromul de distress postprandial poate coexista

Simptome si semne de alarmaVarsta> 55 ani cu simptome nou aparuteIstoric familial de cancer gastricScadere ponderala neintentionataHemoragie gastrointestinalaDisfagie progresiva OdinofagiaAnemie feripriva neexplicataVarsaturi persistente Tumora palpabila sau limfadenopatie(i)IcterLimfadenopatii Tumora abdominala palpabila

Studii diagnostice la pacientul cu suspiciune de dispepsie functionalaUtileAnamneza atenta si examen fizic minutiosEndoscopie digestiva superioara in perioada simptomatica fara supresia aciditatiiTestarea pentru Helicobacter pylori

Studii diagnostice la pacientul cu suspiciune de dispepsie functionalaOptionaleTeste hematologice si biochimice (HLG, VSH sau PCR, glicemie, teste functionale hepatice, electroliti si creatinina, Ca, functia tiroidiana)US vezicii biliare, ficat si pancreasTestarea pH esofagian pentru 24-h sau 48-h

Studii diagnostice la pacientul cu suspiciune de dispepsie functionalaValoare clinica incertaStudiul golirii gastriceRelaxarea fornix gastric postprandial (prin SPECT, US, MRI)Testul incarcarii cu apa sau nutrientiElectrogastrografieManometrie gastroduodenala

Algoritm diagnostic pentru dispepsia simplaDispepsie Simptome alarma/ varsta>55 aniInfectie H pyloriTesteaza&trat inf H pyloriSucces?Urmarire clinicaIPP empiricEndoscopie Tratament adecvatMare Mica DaNuDaNu

Suprapunerea simptomelor gastrointestinaleDispepsie singura

Boala de reflux gastro-esofagian

Patogeneza BRGE Clearance esofagian scazutSalivatie scazutaRezistenta tisulara scazutaTonus de repaus scazut al SEIIntarzierea golirii stomaculuiReflux biliarHernia hiatalaSEIDuoden

Aciditatea are rol central in producerea simptomelor RGEAcidPepsina BicarbonatTerminatie nerv123Jonctiuni celulareJonctiuni largiteAtac acido-peptic (1) slabeste junctiunile celulare (2) ducand la largirea cell gaps si permite penetrarea crescuta a acidului (3)

Simptome tipice(Pirozis/regurgitatie)Simptome atipiceComplicatiiCu esofagitaFara esofagitaDurere toracica (hiperalgezia viscerala)Astm, tuse cronica, wheezingRaguseala(laringita de reflux)Eroziuni esofagiene si/sau ulcereStricturiEsofag BarrettAdenocarcinom esofagianEroziuni dentaleNathoo, Int J Clin Pract 2001;55:4659.Spectrul manifestarilor RGE

BRGE poate fi diagnosticata numai pe baza simptomelorSimptome suparatoarePirozis Regurgitatii Durere epigastricaDurere toracicaDisfagia - poate indica BRGESimptome extraesofagiene (raguseala, tuse cronica)

Toti bolnavii cu simptomele BRGE vor fi suferi endoscopie?

Urmand diagnosticului bazat pe simptom, aproape toti pacientii pot fi tratati in ambulatorDiagnostic bazat pe simptomEvaluarea risculuiNERDEsofagita dereflux~35%BRGEcomplicata~5%~60%EndoscopieSimptome de alarmaTratamentempiricEsec terapeutic~95% din pacientii din ambulator1Adapted from Labenz J et al. World J Gastroenterol 2005;11:429191DeVault KR, Castell DO. Am J Gastroenterol 2005;100:190200; Rao G. J Fam Pract 2005;54(12 Suppl):38

Laringita de refluxRaguseala; eritem bilateral al peretilor aritenoizi mediali, striuri rosii pe corzile vocale adevarate = laringita posterioara

Esofagita gradul A

Esofagita gradul BC

Esofagita gradul D

Strictura peptica esofagiana

Esofagul Barrett

Ulceratie esofagiana dupa tetraciclina

Strictura esofagiana dupa sonda naso-gastrica

Acalizie + infectie cu Candida

Tuse+disfagie

Carcinom scuamos avansat

Fistula esofagiana tratata cu stent

Endoscopie cu rezolutie inalta: Esofag Barrett

Sindromul ulcer pepticGastricDuodenal

Patogeneza ulcerelorFactorii de agresiuneAcid, pepsinaSaruri biliareMedicamente (AINS)H. pylori Factorii aparariiStrat mucus, bicarbonateFlux sanguin, turnover celularProstaglandineFosfolipideGunoierii radicalilor liberi

Aciditatea gastrica joaca rol central inlezarea GD asociata cu AINSMediuacidStrat bicarbonateGradient ionicAcid gastric AINSPepsinaSuprafata celulelor epitelialeStrat mucusMediuneutruAport sanguinmucosal Mediu alcalinProductieprostaglandineProductiebicarbonatProductiemucusNSAIDsEfect sistemic

Gastrita predominent antralaUlcer duodenal la varsta de 20-40 aniFactori bacterieni & ai organismuluiGastrita cronicaGastrita acutaGastrita atrofica multifocalaUlcer gastric la varsta de 40-70 aniCancer gastric dupa varsta de 70 aniInfectia cu Helicobacter pylori - evolutie

Sindromul ulceros Istoric de dispepsie prezent la 8090%.Simptomele ulcer caracterizate prin ritmicitate siperiodicitate.10- 20% din pacienti se prezinta cu complicatii ale ulcerului fara simptome in antecedente.Majoritatea ulcerelor induse de AINS sunt asimptomatice EDS cu biopsie gastrica pentru H pylori=procedura diagnostica Biopsia ulcer gastric sau documentarea vindecarii complete este necesara pentru excluderea cancerului gastric.

Indicatiile testarii si tratamentuluiinfectiei cu Helicobacter pyloriSuportate de doveziBoala ulceroasa activa (ulcerul gastric sau duodenal)Ulcerul peptic confirmat de anamneza (netratat anterior pentru infectia cu H. pylori)Limfomul MALT gastric (de grad mic)Dupa rezectia endoscopica a cancer gastric precoceDispepsia neinvestigata (daca H. pylori are prevalenta mare in populatie)

Indicatiile testarii si tratamentuluiinfectiei cu Helicobacter pyloriControversateDispepsia functionala BRGEPersoane care folosesc AINS, in special la initierea tratamentuluiAnemia feripriva neexplicata sau purpura trombocitopenica imunaPopulatiile cu risc mai mare de cancer gastric (Asiatici, Est-europeni, America Latina)

EDS: Sediile biopsiei gastrice Biopsiile din antru si genunchiul stomac sunt utile pentru diagnosticul infectiei cu H pyloriBiopsiile din corp stomac sunt utile pentru diagnosticul gastritei atrofice metaplazice autoimune

Gastrita cronica nespecificaGastrita antrala difuza Gastrita atrofica difuza a corp Gastrita atrofica multifocala

Cauzele ulcerului pepticInfectie H pyloriAINSNecunoscuta Sdr Z-E, etcUlcer duodenalInfectie H pyloriAINSNecunoscuta Sdr Z-E, etcUlcer gastric

Manifestarile de alarma la pacientii cu suspiciune de boala ulceroasaVarsta> 55 ani cu dispepsie nou aparutaAHC de cancer gastrointestinal Hemoragie gastrointestinala, acuta sau cronica, inclusiv anemia feripriva neexplicataIcterAdenopatie supraclaviculara stanga (ggl Virchow)Tumora abdominala palpabilaVarsaturi persistenteDisfagia progresivaScadere ponderala neintentionata

Sindromul ulcer pepticUlcer duodenal indus de H pyloriUlcer antral AINS+,Hpylori-

Ulcer gastric benign

Adenocarcinom gastric ulcerat

Cromoendoscopie: Cancer gastric superficial

Gastrite & GastropatiiGastropatie denota conditii in care exista lezare epiteliala sau endoteliala fara inflamatieGastrita termen folosit in conditiile in care exista dovada histologica de inflamatieIn practica clinica, termenul gastrita este aplicat la 3 categorii:(1) gastrita eroziva si hemoragica (gastropatie); (2) gastrita ne-eroziva, nonspecific (histologic); (3) tipuri specifice de gastrita caracterizate prin trasaturi distincte histologic si endoscopic.

Gastrita eroziva & hemoragica (Gastropatie)Cel mai frecvent intalnita la alcoolici sau pacienti critici, sau cei cu tratament cu AINSFrecvent asimptomatica; poate produce durere epigastrica, greata, varsaturi.Poate produce hematemeza; de obicei nu este sangerare semnificativaEndoscopic: hemoragii subepiteliale, petesii, eroziuni.

Gastrita eroziva & hemoragica Cauze specificeGastrita de stress Gastrita indusa de AINSGastrita alcoolicaGastropatia portal-hipertensiva (congestia capilarelor si venulelor din submucosa, care se coreleaza cu severitatea HTPo si a bolii hepatice subiacente)

Gastrita ne-eroziva, nespecificaDiagnosticul se bazeaza pe ex histologic Endoscopic: semne normale care nu prezic prezenta inflamatiei histologic Principale tipuri:Gastrita ne-eroziva indusa de H pyloriGastrita asociata anemiei pernicioase (Histo fundica: atrofia glandulara severa si metaplazie intestinala produse de distructia autoimuna a mucoasei gastrice fundice).Gastrita limfocitica.

Boala Mntrier (Gastropatia hipertrofica)Afectiune idiopatica caracterizata prin falduri gastrice ingrosate, gigantice, care incrimineaza predominant corpul stomacului.Pacientii se plang de: greata, durere epigastrica, pierdere ponderala, diaree Din cauza pierderii cronice de proteine, pot apare hipoproteinemie severa si anasarca. Cauza este necunoscutaRezolutia simptome si ameliorarea histologica dupa eradicarea H pylori.

Cancerul gastricCancer precoce Coloratie indigocarmin Aspiratia Rezectie endoscopica .

Tratamentul RGE IstoricChina antica: extract de lichid seminal si urina de copilCaius Plinus sec I: pulbere de coral + laptePaul de Aegina: caolinParacelsus sec XVI: pulbere de perleAlte terapii: lipitori si cataplasme, administrare de arsenic, nitrat de argint, acid carbonic, canabis, cocainaSecolul XIX Abercrombie (Edinburgh): regim alimentar Secolul XX: lapte si antiacide

The overlap of gastrointestinal (GI) symptoms among femalesubjects (n = 777). About 18% of patients were excluded for reasonsunrelated to GI symptoms. Pure dyspepsia represents subjects withoutpredominant gastroesophageal reflux disease (GERD) symptoms orsymptoms of irritable bowel syndrome (IBS).Anatomy of the gastroesophageal junction illustrating the major elements of the antireflux barrierSchematic diagram showing the effect of a hiatal hernia onthe antireflux barrier*The main culprit in GERD is the movement of reflux, which is a mix of bile acid, pepsin, trypsin, and food, from the stomach back into the esophagus. In GERD, the antireflux barrier located at the gastroesophageal junction is no longer preventing reflux because of any of 3 reasons:Transient relaxation of the LES (predominant in milder disease)Hiatal hernia (predominant in more severe disease)Hypotension of the LES (predominant in more severe disease)Reflux involves a 2- to 3-fold increase in esophageal acid clearance time (time the esophageal mucosa is acidified to a pH of 5 mm confined to folds but not continuous between tops of mucosal foldsClassic peptic stricture demonstrated by barium esophagogram (A) and endoscopy (B). The film shows a large hiatal hernia (HH) common to all GERDstrictures. Dark arrow points to short thick fibrous stricture with multiple pseudodiverticula (white arrows). Although not seen on barium examination, the endoscopic view also demonstrates circumferential esophagitis (Los Angeles grade D). GERD, gastroesophageal reflux disease Endoscopic photograph of Barretts esophagus. The arrows mark the gastroesophageal junction (GEJ), which is identified endoscopically as the most proximal extent of the gastric folds. The reddish color and velvet-like texture of the Barretts epithelium contrast sharply with the pale and glossy appearance of the esophageal squamous epithelium. Note that Barretts columnar epithelium extends well above the GEJ to line the distal esophagus.A, Esophageal ulceration secondary to tetracycline, with arrow pointing to area of ulcerations demonstrated by barium esophagography.B, Endoscopic image of tetracycline-induced esophageal burnNasogastric tubeinduced stricturedemonstrated by barium esophagography. B, Endoscopicappearance of a tight nasogastric tubeinducedstricture.A, Achalasia with candidal infectiondemonstrated by barium esophagography. B,Endoscopic photograph of a dilated esophaguswith debris and Candida plaques (arrow) in apatient with achalasiaThis barium esophagogram in a patient complaining of cough and dysphagia demonstrates complete esophageal obstruction and a tracheoesophageal fistula. Note the presence of ingested barium in the airways.Advanced squamous cell carcinoma of the esophagusthat is nearly completely occluding the lumen.Stent therapy of an esophageal fistula.A, This patient with a circumferential esophageal carcinoma,previously treated with chemoradiotherapy,developed an esophagomediastinal fistula, seen inferiorly.B, Placement of a covered self-expanding metallicstent achieved long-term symptomatic palliation.Images of nondysplastic Barretts esophagus using a high-resolution endoscope without (A) and with (B) narrow band imaging. In the lower panels (C, D) anarea of early intramucosal cancer in the background of high-grade dysplasia associated with Barretts esophagus is shown. Note the irregular and distorted pit and vascular pattern in the area of high-grade dysplasia or intramucosal cancer compared with the nondysplastic Barretts esophagus (A, B), which has a regular pit and vascular pattern. 10. Gastric acid plays a central role in NSAID-associated gastroduodenal damageThe net effect of the systemic and topical effects of NSAIDs on the GI system is to impair the mucosal barrier to gastric acid, which, together with the corrosive action of pepsin, exacerbates the initial damage, potentially resulting in deeper erosions and peptic ulceration. Moreover, gastric acid can enhance the direct absorption of some NSAIDs into the gastric mucosal cells, where they may interfere with cell metabolism, have a toxic effect on the mitochondria and cause cell disruption. Gastric acid thus plays a central role in the NSAID-associated gastroduodenal damage that can lead to upper GI symptoms and peptic ulcers, with the concomitant potential for complications such as bleeding and perforation.

Gastric biopsy protocol. Blue and black symbols represent sites from which gastric mucosal biopsies should be obtained. Biopsies from the antrum (greater and lesser curvature) and from the incisura are useful for diagnosing Helicobacter pylori infection. Biopsies from the gastric body (greater and lesser curvature) are useful for diagnosing autoimmune metaplastic atrophic gastritis. Biopsies from the antrum and body in combination are useful for diagnosing environmental metaplastic atrophic gastritis.Topographic patterns of chronic, nonspecific gastritis. The darkest areas in the schematics of autoimmune metaplastic atrophic gastritis and environmental metaplastic atrophic gastritis represent areas of focal atrophy and intestinal metaplasia.Endoscopic view of a clean based antral gastric ulcer in a patient taking a nonsteroidal anti-inflammatory drug. Tests for infection with Helicobacter pylori were negative.Radiograph from an upper gastrointestinal series showing abenign gastric ulcer. Note the smooth, symmetrical folds radiating to theulcer crater, which appears to project outside the lumen of the stomach.Endoscopic examples of gastric cancer. A, Ulcerated gastric adenocarcinoma mass lesion.Chromoendoscopic view of a superficial depressed gastric cancer, highlighted with indigo carmine (arrow).