ANATOMY OF THE STOMACH

The stomach lies between the oesophagus and the duodenum (the fi st pa t of the small intestine!" #t is on the left uppe pa t of theabdominal ca$it%" The top of the stomach lies against the diaph agm" &%ing behind the stomach is the panc eas" The g eate omentumhangs down f om the greater curvature" Two sphincte s' (eep the contents of the stomach contained" The% a e the oesophageal sphincte (found in the ca diac egion' not an anatomical sphincte ! di$iding the t act abo$e' and the )%lo ic sphincte di$iding the stomach f om the small intestine" The stomach is su ounded b% pa as%mpathetic (stimulant! and o thos%mpathetic (inhibito ! ple*uses (netwo (s of blood $essels and ne $es in the ante io gast ic' poste io ' supe io and infe io ' celiac and m%ente ic!' which egulate both the sec etions acti$it% and the moto (motion! acti$it% of its muscles" #n humans' the stomach has a ela*ed' nea empt% $olume of about +, ml" #t is a distensible o gan" #t no mall% e*pands to hold about - lit e of food' but will hold as much as ./0 lit es (whe eas a newbo n bab% will onl% be able to etain 01ml!"

Sections The stomach is di$ided into + sections' each of which has diffe ent cells and functions" The sections a e2 Ca dia Fundus 4od% o Co pus )%lo us 3he e the contents of the oesophagus empt% into the stomach" Fo med b% the uppe cu $atu e of the o gan" The main' cent al egion"

The lowe section of the o gan that facilitates empt%ing the contents into the small intestine" The lesse cu $atu e of the stomach is supplied b% the ight gast ic a te % infe io l%' and the left gast ic a te % supe io l%' which also supplies the ca diac egion" The g eate cu $atu e is supplied b% the ight gast oepiploic a te % infe io l% and the left gast oepiploic a te % supe io l%" The fundus of the stomach' and also the uppe po tion of the g eate cu $atu e' a e supplied b% the sho t gast ic a te %" &i(e the othe pa ts of the gast ointestinal t act' the stomach walls a e made of the following la%e s' f om inside to outside2 mucosa submucosa The fi st main la%e " This consists of an epithelium' the lamina p op ia composed of loose connecti$e tissue and which has gast ic glands in it unde neath' and a thin la%e of smooth muscle called the muscula is mucosae" This la%e lies o$e the mucosa and consists of fib ous connecti$e tissue' sepa ating the mucosa f om the ne*t la%e " TheMeissne 5s ple*us is in this la%e " O$e the submucosa' the muscula is e*te na in the stomach diffe s f om that of othe 6# o gans in that it has th ee la%e s ofsmooth muscle instead of two" inner oblique layer: This la%e is esponsible fo c eating the motion that chu ns and ph%sicall% b ea(s down the food" #t is the onl% la%e of the th ee which is not seen in othe pa ts of the digesti$e s%stem" The ant um has thic(e s(in cells in its walls and pe fo ms mo e fo ceful cont actions than the fundus" middle circular layer: At this la%e ' the p%lo us is su ounded b% a thic( ci cula muscula wall which is no mall% tonicall% const icted fo ming a functional (if not anatomicall% disc ete! p%lo ic sphincte ' which cont ols the mo$ement of ch%me into theduodenum" This la%e is concent ic to the longitudinal a*is of the stomach" outer longitudinal layer: Aue bach5s ple*us is found between this la%e and the middle ci cula la%e " This la%e is o$e the muscula is e*te na' consisting of la%e s of connecti$e tissue continuous with the pe itoneum"

muscula is e*te na

se osa

H#STO&6Y The epithelium of the stomach fo ms deep pits" The glands at these locations a e named fo the co esponding pa t of the stomach2 Cardiac glands Pyloric glands Fundic glands (at ca dia! (at p%lo us! (at fundus!

7iffe ent t%pes of cells a e found at the diffe ent la%e s of these glands2 Layer of stomach Name Secretion mucus gel la%e Region of stomach Fundic' ca diac' p%lo ic Fundic' ca diac' p%lo ic Staining Clea

#sthmus of Mucous nec( cells gland 4od% of gland 4ase of gland 4ase of gland pa ietal (o*%ntic! cells chief (8%mogenic! cells ente oendoc ine (A)97! cells

gast ic acid and int insic facto pepsinogen ho mones gast in' histamine' endo phins' se otonin' cholec%sto(inin and somatostatin

Acidophilic

Fundic onl% 4asophilic Fundic' ca diac' p%lo ic /

Mic oscopic c oss section of the p%lo ic pa t of the stomach wall"

Cont ol of sec etion and motilit% The mo$ement and the flow of chemicals into the stomach a e cont olled b% both the autonomic ne $ous s%stem and b% the $a ious digesti$e s%stem ho mones2 The ho mone gastrin causes an inc ease in the sec etion of HCl f om the pa ietal cells' and pepsinogen f om chief cells in the stomach" #t also causes inc eased motilit% in the stomach" 6ast in is eleased b% 6/cells in the stomach in esponse 6ast in to distenstion of the ant um' and digesti$e p oducts(especiall% la ge :uantities of incompletel% digested p oteins!" #t is inhibited b% a pH no mall% less than + (high acid!' as well as the ho mone somatostatin" Cholecystokinin (CC;! has most effect on the gall bladde ' causing gall bladde Cholec%sto(inin cont actions' but it also dec eases gast ic empt%ing and inc eases elease of panc eatic <uice which is al(aline and neut ali8es the ch%me" #n a diffe ent and a e manne ' secretin' p oduced in the small intestine' has most Sec etin effects on the panc eas' but will also diminish acid sec etion in the stomach" 6ast ic inhibito % Gastric inhibitory peptide (6#)! dec eases both gast ic acid elease and motilit%" peptide Ente oglucagon enteroglucagon dec eases both gast ic acid and motilit%" Othe than gast in' these ho mones all act to tu n off the stomach action" This is in esponse to food p oducts in the li$e and gall bladde ' which ha$e not %et been abso bed" The stomach needs onl% to push food into the small intestine when the intestine is not bus%" 3hile the intestine is full and still digesting food' the stomach acts as sto age fo food"

)E)T#C 9&CE= 7#SEAESE Classification By Region/Location Stomach (called gastric ulcer! 7uodenum (called duodenal ulcer! Esophagus (called Esophageal ulcer! Mec(el5s 7i$e ticulum (called Meckel s !i"erticulum ulcer!

Modified #ohnson Classification of peptic ulcers$

 T%pe #2 9lce along the bod% of the stomach' most often along the lesse cu $e at incisu a angula is along the locus mino is esistentiae" T%pe ##2 9lce in the bod% in combination with duodenal ulce s" Associated with acid o$e sec etion" T%pe ###2 #n the p%lo ic channel within 0 cm of p%lo us" Associated with acid o$e sec etion" T%pe #>2 ) o*imal gast oesophageal ulce T%pe >2 Can occu th oughout the stomach" Associated with ch onic NSA#7 and ASA use" )athogenesis" H. pylori and NSA#7s dis upt no mal mucosal defense and epai ' ma(ing the mucosa mo e susceptible to acid" H. pylori infection is p esent in ,1 to ?1@ of patients with duodenal ulce s and 01 to ,1@ of patients with gast ic ulce s" #f H. pylori is e adicated' onl% -1@ of patients ha$e ecu ence of peptic ulce disease' compa ed with ?1@ ecu ence in patients t eated with acid supp ession alone" NSA#7s now account fo A ,1@ of peptic ulce s" Ciga ette smo(ing is a is( facto fo the de$elopment of ulce s and thei complications" Also' smo(ing impai s ulce healing and inc eases the incidence of ecu ence" =is( co elates with the numbe of ciga ettes smo(ed pe da%" Although alcohol is a st ong p omote of acid sec etion' no definiti$e data lin( mode ate amounts of alcohol to the de$elopment o dela%ed healing of ulce s" >e % few patients ha$e h%pe sec etion of gast in (Bollinge /Ellison s%nd ome

Signs and s%mptoms S%mptoms of a peptic ulce can be abdominal pain' classicall% epigast ic with se$e it% elating to mealtimes' afte a ound 0 hou s of ta(ing a meal (duodenal ulce s a e classicall% elie$ed b% food' while gast ic ulce s a e e*ace bated b% it!C bloating and abdominal fullnessC wate b ash ( ush of sali$a afte an episode of egu gitation to dilute the acid in esophagus!C nausea' and copious $omitingC loss of appetite and weight lossC hematemesis ($omiting of blood!C this can occu due to bleeding di ectl% f om a gast ic ulce ' o f om damage to the esophagus f om se$e eDcontinuing $omiting" melena (ta %' foul/smelling feces due to o*idi8ed i on f om hemoglobin!C a el%' an ulce can lead to a gast ic o duodenal pe fo ation' which leads to acute pe itonitis" This is e*t emel% painful and e:ui es immediate su ge %"

Complications %astrointestinal &leeding is the most common complication" Sudden la ge bleeding can be life/th eatening" #t occu s when the ulce e odes one of the blood $essels" Perforation (a hole in the wall! often leads to catast ophic conse:uences" E osion of the gast o/intestinal wall b% the ulce leads to spillage of stomach o intestinal content into the abdominal ca$it%" )e fo ation at the ante io su face of the stomach leads to acute pe itonitis'

initiall% chemical and late bacte ial pe itonitis" The fi st sign is often sudden intense abdominal pain" )oste io wall pe fo ation leads to panc eatitisC pain in this situation often adiates to the bac(" Penetration is when the ulce continues into ad<acent o gans such as the li$e and panc eas" Sca ing and swelling due to ulce s causes na owing in the duodenum and gastric outlet o&struction" )atient often p esents with se$e e $omiting" Cancer is included in the diffe ential diagnosis (elucidated b% biops%!' Helicobacte p%lo i as the etiological facto ma(ing it 0 to E times mo e li(el% to de$elop stomach cance f om the ulce " 7iagnosis" An esophagogast oduodenoscop% (E67!' a fo m of endoscop%' also (nown as a gast oscop%' is ca ied out on patients in whom a peptic ulce is suspected" 4% di ect $isual identification' the location and se$e it% of an ulce can be desc ibed" Mo eo$e ' if no ulce is p esent' E67 can often p o$ide an alte nati$e diagnosis" The diagnosis of Helicobacter pylori can be made b%2

9 ea b eath test (nonin$asi$e and does not e:ui e E67!C 7i ect cultu e f om an E67 biops% specimenC this is difficult to do' and can be e*pensi$e" Most labs a e not set up to pe fo m H. pylori cultu esC 7i ect detection of u ease acti$it% in a biops% specimen b% apid u ease testC Measu ement of antibod% le$els in blood (does not e:ui e E67!" #t is still somewhat cont o$e sial whethe a positi$e antibod% without E67 is enough to wa ant e adication the ap%C Stool antigen testC Histological e*amination and staining of an E67 biops%"

!ifferential diagnosis of epigastric pain )eptic ulce 6ast itis Stomach cance 6ast oesophageal eflu* disease )anc eatitis Hepatic congestion Cholec%stitis 4ilia % colic #nfe io m%oca dial infa ction

 =efe ed pain (pleu is%' pe ica ditis! Supe io mesente ic a te % s%nd ome T eatment Once H. pylori is detected in patients with a peptic ulce ' the no mal p ocedu e is to e adicate it and allow the ulce to heal" The standa d fi st/line the ap% is a one wee( Ft iple the ap%F consisting of p oton pump inhibito s such as omep a8ole' lansop a8ole and the antibiotics cla ith om%cin and amo*icillin">a iations of the t iple the ap% ha$e been de$eloped o$e the %ea s' such as using a diffe ent p oton pump inhibito ' as with pantop a8ole o abep a8ole' o eplacing amo*icillin with met onida8ole fo people who a e alle gic to penicillin"Such a the ap% has e$olutioni8ed the t eatment of peptic ulce s' and has made a cu e to the disease possibleC p e$iousl%' the onl% option was s%mptom cont ol using antacids' H./antagonistso p oton pump inhibito s alone" An inc easing numbe of infected indi$iduals a e found to ha bou antibiotic/ esistant bacte ia" This esults in initial t eatment failu e and e:ui es additional ounds of antibiotic the ap% o alte nati$e st ategies' such as a :uad uple the ap%' which adds a bismuth colloid' such as bismuth subsalic%late"Fo the t eatment of cla ith om%cin/ esistant st ains of H. pylori' the use of le$oflo*acin as pa t of the the ap% has been suggested" H. pylori coloni8es the stomach and induces ch onic gast itis' a long/lasting inflammation of the stomach" The bacte ium pe sists in the stomach fo decades in most people" Most indi$iduals infected b% H. pylori will ne$e e*pe ience clinical s%mptoms despite ha$ing ch onic gast itis" App o*imatel% -1/.1@ of those coloni8ed b% H. pylori will ultimatel% de$elop gast ic and duodenal ulce s" H. pylori infection is also associated with a -/.@ lifetime is( of stomach cance and a less than -@ is( of gast ic MA&T l%mphoma" #t is widel% belie$ed that in the absence of t eatment' H. pylori infectionGonce established in its gast ic nicheGpe sists fo life" #n the elde l%' howe$e ' it is li(el% infection can disappea as the stomach5s mucosa becomes inc easingl% at ophic and inhospitable to coloni8ation" The p opo tion of acute infections that pe sist is not (nown' but se$e al studies that followed the natu al histo % in populations ha$e epo ted appa ent spontaneous elimination" The incidence of acid eflu* disease' 4a ett5s esophagus' and esophageal cance ha$e been ising d amaticall%"

) ima % gast ic l%mphoma Clinical presentation Most of the people p ima % gast ic l%mphoma affects a e o$e E1 %ea s old" S%mptoms include epigast ic pain' ea l% satiet%' fatigue and weight loss" !iagnosis These l%mphomas a e difficult to diffe entiate f om gast ic adenoca cinoma" The lesions a e usuall% ulce s with a agged' thic(ened mucosal patte n on cont ast adiog aphs" The diagnosis is t%picall% made b% biops% at the time of endoscop%" Se$e al endoscopic findings ha$e been epo ted' including solita % ulce s' thic(ened gast ic folds' mass lesions and nodules" As the e ma% be infilt ation of the submucosa' la ge biops% fo ceps' endoscopic ult asound guided biops%' endoscopic submucosal esection' o lapa otom% ma% be e:ui ed to obtain tissue" #maging in$estigations including CT scans o endoscopic ult asound a e useful to stage disease" Hematological pa amete s a e usuall% chec(ed to assist with staging and to e*clude concomitant leu(emia" An ele$ated &7H le$el ma% be suggesti$e of l%mphom

'istopathology The ma<o it% of gast ic l%mphomas a e non/Hodg(in5s l%mphoma of 4/cell o igin" These tumo s ma% ange f om well/diffe entiated' supe ficial in$ol$ements (MA&T! to high/g ade' la ge/cell l%mphomas" Sometimes' it5s ha d to diffe entiate poo l% diffe entiated high g ade 4/cell gast ic l%mphoma f om gast ic adenoca cinoma clinicall% o adiologicall%' %et histopatholog% withimmunohistochemist % is ecommended to stain specific ma (e s on the malignant cell that fa$o the diagnosis of l%mphoma" #mmunohistochemist % stains specific cluste s of diffe entiation that a e p esent on 4/cells li(e C7.1" C%to(e atin is also a su face ma (e that is p esented on epithelial cells' is stained histochemicall% and fa$o s the diagnosis of epithelial tumo s li(e adenoca cinoma" 7iffe entiating poo gast ic l%mphoma f om adenoca cinoma is a must because the p ognosis and modalities of t eatment diffe significantl%" Othe l%mphomas in$ol$ing the stomach include mantle cell l%mphoma and T/cell l%mphomas which ma% be associated with ente opath%C the latte usuall% occu in the small bowel but ha$e been epo ted in the stomach"

Risk factors =is( facto s fo gast ic l%mphoma include the following2 Helicobacter pylori &ong/te m immunosupp essant d ug the ap% H#> infection T eatment 7iffuse la ge 4/cell l%mphomas of the stomach a e p ima il% t eated with chemothe ap% with CHO) with o without itu*imab being a usual fi st choice" Antibiotic t eatment to e adicate H" p%lo i is indicated as fi st line the ap% fo MA&T l%mphomas" About E1@ of MA&T l%mphomas completel% eg ess with e adication the ap% " Second line the ap% fo MA&T l%mphomas is usuall% chemothe ap% with a single agent' and complete esponse ates of g eate than ?1@ ha$e gain been epo ted Subtotal gast ectom%' with post/ope ati$e chemothe ap% is unde ta(en in ef acto % cases' o in the setting of complications' including gast ic outlet obst uction" STOMACH )O&Y)S Stomach pol%ps a e masses of cells that fo m on the inside lining of %ou stomach" Stomach pol%ps' also called gast ic pol%ps' a e a e" Stomach pol%ps usuall% don5t cause s%mptoms" Howe$e ' as a stomach pol%p enla ges' ulce s ma% de$elop on its su face' o a el%' the pol%p ma% bloc( the opening between %ou stomach and %ou small intestine" #f %ou ha$e stomach pol%ps' %ou ma% e*pe ience2 Abdominal pain o tende ness when %ou p ess %ou abdomen 4leeding Nausea and $omiting

Classification CT%pes of stomach pol%ps The most common t%pes of stomach pol%ps a e2

 H%pe plastic pol%ps" H%pe plastic pol%ps fo m as a eaction to ch onic inflammation in the cells that line the inside of the stomach" H%pe plastic pol%ps a e most common in people with stomach inflammation (gast itis!' which has man% causes" Most h%pe plastic pol%ps a e unli(el% to become stomach cance " 4ut la ge h%pe plastic pol%ps' such as those la ge than about 0D+ inch (. centimete s! in diamete ' ha$e a g eate is( of becoming cance ous" Fundic gland pol%ps" Fundic gland pol%ps fo m f om the glandula cells that a e found on the inside lining of the stomach" Fundic gland pol%ps occu in people with an inhe ited colon cance s%nd ome called familial adenomatous pol%posis (FA)!' but the% can also occu in people who don5t ha$e this inhe ited s%nd ome" Most fundic gland pol%ps a e unli(el% to become stomach cance ' e*cept fo those that occu in people with FA)" Adenomas" Adenomas fo m f om the glandula cells found on the inside lining of the stomach" 4ut when adenomas fo m' thei cells de$elop e o s in thei 7NA" These changes ma(e the cells $ulne able to becoming cance ous" Though adenomas a e the least common t%pe of stomach pol%p' the% a e the most li(el% t%pe to become stomach cance " Adenomas a e associated with stomach inflammation and FA)" =is( facto s #nc easing age" The is( of stomach pol%ps inc eases with age" Stomach pol%ps a e mo e common among people in thei ,1s o olde " 4acte ial stomach infection" Helicobacte p%lo i (H" p%lo i! bacte ia a e a common cause of the gast itis that cont ibutes to h%pe plastic pol%ps and adenomas" E*pe ts a en5t su e how people become infected with these bacte ia' but H" p%lo i ma% be ca ied in food and wate " An inhe ited colon cance s%nd ome" Familial adenomatous pol%posis is an inhe ited s%nd ome that inc eases the is( of colon cance and othe conditions' such as stomach pol%ps" Ce tain medications" &ong/te m use of p oton pump inhibito s ())#s!' which a e medications used to t eat gast oesophageal eflu* disease (6E=7!' has been lin(ed to fundic gland pol%ps" ))#s include esomep a8ole (Ne*ium!' lansop a8ole () e$acid!' omep a8ole () ilosec =*!' pantop a8ole () otoni*! and abep a8ole (Aciphe*!"

Tests and p ocedu es used to diagnose stomach pol%ps include2 9sing a scope to see inside %ou stomach" 7u ing an uppe endoscop% p ocedu e' %ou docto inse ts a fle*ible' lighted tube into %ou mouth and down %ou th oat" The de$ice has a came a at the tip that allows %ou docto to see inside %ou stomach" =emo$ing a sample of tissue fo testing (biops%!" 7u ing the endoscop% p ocedu e' %ou docto ma% feed special tools th ough the tube" The tools allow %ou docto to emo$e a small piece of suspicious tissue fo testing in a labo ato %" These tests ma% help %ou docto dete mine what t%pe of stomach pol%ps %ou ha$e

T eatment ma% not be necessa % Small pol%ps that a en5t adenomas ma% not e:ui e t eatment" These pol%ps t%picall% don5t cause signs and s%mptoms and onl% a el% become cance ous" #nstead' %ou docto ma% ecommend pe iodic monito ing of %ou stomach pol%ps" You ma% unde go endoscop% to see whethe %ou stomach pol%ps ha$e g own" )ol%ps that g ow o that cause signs and s%mptoms can be emo$ed" =emo$ing adenomas and la ge stomach pol%ps T eatment to emo$e stomach pol%ps ma% be ecommended if %ou pol%ps a e adenomas o if the% a e la ge than .D, inch (- cm! in diamete " Most pol%ps can be emo$ed du ing an endoscop% e*am" Stopping H" p%lo i infection to t eat and p e$ent pol%ps #f %ou ha$e gast itis caused b% H" p%lo i bacte ia in %ou stomach' %ou docto will li(el% ecommend (illing the bacte ia with antibiotics" Stopping an H" p%lo i infection ma% ma(e h%pe plastic pol%ps disappea " #t ma% also stop pol%ps f om etu ning in the futu e" Tests can help %ou docto dete mine whethe %ou ha$e H" p%lo i infection" Then' %ou docto ma% p esc ibe antibiotics fo %ou to ta(e fo se$e al wee(s to (ill the H" p%lo i bacte ia"

7#E9&AFOY5S &ESS#ON 7ieulafo%5s &esions a e cha acte i8ed b% a single la ge to tuous a te iole in the submucosa which does not unde go no mal b anching o a b anch with calibe of -H, mm (mo e than -1 times the no mal diamete of mucosal capilla ies!" The lesion bleeds into the gast ointestinal t act th ough a minute defect in the mucosa which is not a p ima % ulce of the mucosa but an e osion li(el% caused in the submucosal su face b% p ot usion of the pulsatile a te iole" App o*imatel% ?,@ of 7ieulafo%5s lesions occu in the uppe pa t of the stomach within E cm of the gast oesophageal <unction' most commonl% in the lesse cu $atu e" E*t agast ic lesions ha$e histo icall% been thought to be uncommon but ha$e been identified mo e f e:uentl% in ecent %ea s' li(el% due to inc eased awa eness of the condition" The duodenum is the most common location (-+@! followed b% the colon (,@!' su gical anastamoses (,@!' the <e<unum (-@! and the esophagus (-@!"I+J The patholog% in these e*t agast ic locations is essentiall% the same as that of the mo e common gast ic lesion" #nte estingl% and in cont ast to peptic ulce disease' a histo % of alcohol abuse o NSA#7 use is usuall% absent in 7&" 7ieulafo%5s lesions occu twice as often in men as women and patients t%picall% ha$e multiple como bidities' including h%pe tension' ca dio$ascula disease' ch onic (idne% disease' and diabetes"

Symptoms The s%mptoms due to bleeding a e hematemesis andDo melena' possibl% with shoc(" Presenting Symptoms =ecu ent hematemesis with melena ,-@ of cases Hematemesis without melena .K@ of cases Melena with no hematemesis -K@ of cases A 7ieulafo%5s lesion is difficult to diagnose' because of the inte mittent patte n of bleeding" Endoscopicall% it is not eas% to ecogni8e and the efo e sometimes multiple $iews ha$e to be pe fo med o$e a longe pe iod" Toda% angiog aph% is a good additional diagnostic' but then it can onl% be seen du ing a bleeding at that e*act time"

Endoscopic appearance of non&leeding !ieulafoy(s lesion The apeutic endoscop% has been used successfull%' and is now the modalit% of choice fo the initial t eatment of 7ieulafo% lesions" Endoscopic modalities used include bipola elect ocoagulation' monopola elect ocoagulation' in<ection scle othe ap%' heate p obe' lase photocoagulation' epineph ine in<ection' haemoclipping and banding" The in<ection of epineph ine has been used in combination with othe modalities' as a means to slow o stop bleeding and allow bette $isualisation of the lesion and successful t eat/ ment" The specific the apeutic modalit% used seems to depend on the a$ailabilit% and pe sonal e*pe ience with a pa ticula techni:ue" Endoscopic the ap% is said to be successful in achie$ing pe manent haemostasis in K,@ of cases" Of the emaining -,@ in whom e/ bleeding occu s' -1@ can successfull% be t eated b% epeat endoscopic the ap% and ,@ ma% ultimatel% e:ui e su gical inte $ention

MA&&O=Y 3E#SS TEA=

Mallo %/3eiss tea " =et ofle*ed $iew of the ca dia showing the t%pical location of the tea with a clean base"

Mallo %/3eiss tea with a pigmented p otube ance and acti$e oo8ing"

Causes Man% unde l%ing diso de s that cause $omiting and etching esult in a Mallo %/3eiss tea " 6# disease #nfectious gast oente itis 6ast ic outlet obst uction 9lce s Hiatal he nias Mal otation >ol$ulus #nflammato % conditions of the stomach and intestine ) egnanc%2 Some women de$elop h%pe emesis g a$ida um' a s%nd ome cha acte i8ed b% pe sistent se$e e $omiting and etching' in the fi st t imeste of p egnanc%" 6ast ic d%s h%thmias and p olonged small/bowel motilit% cause the de$elopment of h%pe emesis g a$ida um" Some women lose as much as -1@ of thei bod% weight du ing this pe iod" Hepatitis2 Acute inflammation of the li$e causes $omiting in -1/.1@ of patients" Ci hosis 4ilia % t act disease2 Although a e in child en' these conditions can cause $omiting t%picall% associated with meals" 6allstones Cholec%stitis 4ilia % ci hosis

 =enal disease2 >omiting is often associated with diseases affecting the (idne%s' including the following2 9 ina % t act infections ;idne% stones 9te opel$ic <unction (9)L! obst uction =enal failu e #nc eased int ac anial p essu e2 #nt ac anial lesions that cause h%d ocephalus o inc eased int ac anial p essu e ma% lead to $omiting in child en" Most common causes of h%d ocephalus include tumo s' c%sts' and congenital abno malities" Othe causes of inc eased int ac anial p essu e consist of t auma' infections (eg' meningitis!' medications' and pseudotumo ce eb i" #at ogenic causes2 Complications of endoscop% ma% cause esophageal tea s (M1"1-@ in child en! and a e almost alwa%s associated with a patient who is etching o st uggling du ing the p ocedu e" The use of pol%eth%lene gl%col la$age' when used fo ingestions' se$e e constipation' o p epa ation fo colonoscop%' ma% cause se$e e $omiting" Othe causes Se$e e diabetic (etoacidosis To*ins 7 ugs (eg' chemothe apeutic agents!

Methods of diagnosis Esophagogast oduodenoscop% 9ppe endoscop% is the diagnostic tool fo esophageal tea s >isual inspection of the esophagus' stomach' and duodenum is essential in the e$aluation of a child p esenting with hematemesis" The hallma ( of a Mallo %/3eiss tea is the $isual appea ance of one o mo e linea bleeding lesions at o <ust p o*imal to the esophagogast ic <unction" )e fo m endoscop% within .+ hou s of the bleeding episode" Tea s $isuali8ed within .+ hou s usuall% ha$e a soft' f esh' mounded' b ownish/ ed appea ance on the su face of the mucosa" Afte +K/?. hou s' the tea loo(s li(e a mucosal cleft that ma% be su ounded b% e %thematous mucosa" 4% NE hou s' most Mallo %/3eiss lesions a e well healed and ma% be difficult to $isuali8e"

 #n cases of se$e e bleeding with hemod%namic instabilit%' the patient should be stabili8ed p io to pe fo ming endoscop%" Mallo %/3eiss tea s can heal :uic(l% afte the cessation of $omiting and etching and ma% not be diagnosed if pe fo mance of the uppe endoscop% is dela%ed" Staging ) edicti$e facto s fo ecu ent bleeding include the following2 #nitial p esentation of shoc( &i$e ci hosis 7ec eased hemoglobin and platelet count Need fo blood t ansfusion #ntensi$e ca e management Acti$e bleeding noted at the time of endoscop%

Medical Ca e #nitial medical management is alwa%s suppo ti$e" )atients in whom conse $ati$e medical the ap% is ineffecti$e should ha$e a consultation with a gast oente ologist fo possible endoscop%" Monito $ital signs closel%' obtain a C4C count' and place a la ge/bo e int a$enous tube fo fluid esuscitation" &ess than ,@ of child en e:ui e a blood t ansfusion" 4egin wo (up to dete mine the unde l%ing cause of the etching and $omiting" #n most cases' Mallo %/3eiss tea s spontaneousl% esol$eC howe$e ' conside pha maceutical the ap% in cases of pe sistent bleeding o complications Esophageal balloon tamponade' although useful fo patients with esophageal $a ices' should be conside ed onl% in e*t eme cases because the use of an esophageal balloon inc eases the is( of e*tending the esophageal tea " Esophageal clips applied at the site of acti$e bleeding" Endoscopic band ligation has been used and was shown to be an effecti$e and safe p ocedu e fo patients with se$e e bleeding" Angiog aphic emboli8ation of the $essels suppl%ing blood flow to the esophageal tea has been epo ted in the adult lite atu e but should be conside ed in child en onl% unde di e ci cumstances" Su gical Ca e Onl% in e*t ao dina % cases should su gical inte $ention be e:ui ed" A consultation with a su geon should be conside ed onl% in patients with pe sistent bleeding e:ui ing t ansfusions and in whom the bleeding cannot be cont olled b% medication o b% the apeutic uppe endoscop% Consultations An uppe endoscop% (pe fo med b% a t ained pediat ic gast oente ologist! should be conside ed fo all patients with pe sistent bleeding fo whom medical the ap% is unsuccessful"

7iet 7u ing the acute p oblem' (eep patients on nothing b% mouth (N)O!" Once esol$ed' p o$ide the patient clea li:uids and ad$ance the diet as tole ated" Afte complete esolution' no special diet is e:ui ed" Howe$e ' foods o li:uids that ma% ha$e been identified as cont ibuting to the cause of the unde l%ing p oblem (eg' e*cessi$e alcohol inta(e' food alle gies! should be a$oided"

Two t%pes of endoscopic the ap% can be used to cont ol se$e e bleeding in patients who a e hemod%namicall% unstable because of bleeding f om a Mallo %/3eiss tea " #n<ection the ap% is fa$o ed as the fi st/line the ap% b% most endoscopists fo cont ol of bleeding esophageal lesions because of its ease of use' safet%' and cost" T%picall%' the in<ections a e made 0/, mm apa t ci cumfe entiall% a ound the site of bleeding in + a eas" The chemical agents used fo in<ection the ap% include dilute epineph ine' sodium mo huate' eth%l alcohol' o sodium tet adec%l sulfate" Heate p obe o bipola coagulation the apies use elect ical cu ent supplied b% cathete s that can be inse ted into an endoscope to cont ol bleeding" App o*imatel% .1 <oules (-1/-, 3atts! of cu ent a e used pe indi$idual pulse' and t eatment is complete when the bleeding has ceased" The cu ent is usuall% deli$e ed in epeated time/limited pulses" E$aluate the unde l%ing cause of $omiting" Fu the Outpatient Ca e Mallo %/3eiss tea s almost ne$e ebleedC thus' follow/up is not usuall% indicated" T ansfe T ansfe child en with se$e e uncont olled bleeding to a te tia % ca e hospital with an in/ house pediat ic gast oente ologist" 7ete enceD) e$ention A$oid and t eat causes of unde l%ing $omiting and etching" Complications Anemia 7eh%d ation ) ognosis ) ognosis is e*t emel% good in child en' with a less than 1"1-@ mo talit% ate" These tea s almost alwa%s espond to conse $ati$e the ap% and suppo ti$e ca e"