SOI V - Módulo 14: Gastroenterologia

Prof. Marcos - ED 01

1. Farmacologia do Sistema Gastrintestinal

2. Doenças ácido pépticas: drge, doença ulcerosa péptica e H.pylori

Peptic [Gr. peptikos] 1. pertaining to pepsin. 2. pertaining to digestion or to other actions of

gastric juice. (Albert D et al. 2012)
Dyspepsia [dys- + Gr. peptein to digest] impairment of the power or function of digestion;
usually applied to epigastric discomfort following meals. (Albert D et al. 2012)
Sympathetic and Parasympathetic autonomous system: Principles of Neural Science
(2021), pág 1016
● E já mata o pré-ganglionar

Objetivo 01. Farmacologia do Sistema Gastrintestinal

Referências Páginas

(2016) Rang HP et al. Rang & Dale Farmacologia, 8ª ed. Elsevier Capítulo 30: 865 a 891 (35)

(2018) Bruton LL, Hilal-Dandan R, Knollmann BC. Goodman & Gilman's The Seção IV: 915 a 957 (39)
Pharmacological Basis of Therapeutics, 13ª ed. McGraw Hill Education

(2017) Katzung BG, Trevor AJ. Farmacologia Básica e Clínica. Artmed Capítulo 62: 1052 a 1078 (25)

(2016) Whalen K, Finkel R, Panavelil TA. Farmacologia Ilustrada, 6ª ed. Artmed Capítulo 31: 401 a 411 (12)

- Planejamento
● Nível 1: Rang & Dale (35)
● Nível 2: Goodman
● Nível 3: Katzung
● Nível 4: Farmacologia Ilustrada

- O que é secretado no estômago? E qual a composição?

● Ácido gástrico, muco e bicarbonato
 FISIOLOGIA DO SISTEMA GI

[Rang & Dale]

- “Os vasos sanguíneos e as glândulas (exócrinas, endócrinas e parácrinas) do trato

gastrointestinal estão sob duplo controle: neuronal e hormonal.”

SN ENTÉRICO E CONTROLE NEURONAL

Plexos intramurais principais: plexo mioentérico (plexo de Auerbach) e o plexo submucoso
(plexo de Meissner)
Neurônios no interior dos plexos = SN entérico
- Neurônios secretam:
● Acetilcolina
● Norepinefrina (noradrenalina)
● 5-hidroxitriptamina (5-HT)
● Purinas
● Óxido nítrico
● Uma variedade de peptídeos farmacologicamente ativos

- Há neurônios sensitivos (estímulos mecânicos e químicos)

 “Suas células ganglionares recebem fibras parassimpáticas pré-ganglionares do vago”
Fibras do vago: maioria colinérgicas e excitatórias (e algumas inibitórias)

- Fibras simpáticas
● A maioria: pós-ganglionares
 ● Inervam os vasos sanguíneos, músculo liso e algumas células glandulares diretamente
● Nos plexos: inibem a secreção de acetilcolina

CONTROLE HORMONAL

- Secreções endócrinas (na corrente sanguínea): peptídeos sintetizados por células endócrinas
na mucosa. Principalmente
● Gastrina
● Colecistoquinina
- Secreções parácrinas: peptídeos reguladores liberados de células especiais encontradas em
toda a parede do trato
● Mais importante no estômago: histamina
 SECREÇÃO GÁSTRICA

“Um antiporte Na+/H+ adicional situado na interface com o plasma também pode ter
participação (não mostrado).”
Principais mediadores que controlam direta ou indiretamente o ácido gerado pelas células
parietais
 Objetivo 02. Doenças ácido pépticas: drge, doença ulcerosa péptica e H.pylori

Referências Páginas

Doença do refluxo gastro-esofágico (DRGE): ICD-10 K21

(2016) Zaterga S et al. Tratado de gastroenterologia - da graduação à Capítulo 39: 500 a 510 (11)
pós-graduação, 2ª ed. Atheneu

(2016) Podolsky DK et al. Yamada’s Textbook of Gastroenterology, 6ª ed. Wiley Capítulo 49: 931 a 952 (22)
Blackwell Capítulo 52 (esofago de Barrett): 974 a ???

(2020) Goldman L, Schafer AI. Goldman-Cecil Medicine, 26ª ed. Elsevier Capítulo 129: 1517 a 1520

(2018) Jamerson JL et al. Medicina interna de Harrison, 20ª ed. McGraw Hill Parte 10, cap. 316: 7920 a 7926

(2021) Fass R et al. Gastro-oesophageal reflux disease. Nature Reviews Disease Prime:
Primers https://www.nature.com/articles/s41572-021-0
0295-w

(2013) Bredenoord AJ, Pandolfino JE, Smout AJPM. Gastro-oesophageal reflux

disease. The Lancet

Medical management of gastroesophageal reflux disease in adults - UpToDate

- Planejamento
● Nível 1: Tratado (11)
● Nìvel 2: Nature
● Nível 3: Yamada
● Nível 4: UpToDate
● Nível 5: Demais

Doença ulcerosa péptica: ICD-10 K27

(2017) Lanas A, Chan FKL. Peptic ulcer disease. The Lancet

(2016) Zaterga S et al. Tratado de gastroenterologia - da graduação à 648 a 672 (25)

pós-graduação, 2ª ed. Atheneu

(2020) Goldman L, Schafer AI. Goldman-Cecil Medicine, 26ª ed. Elsevier Capítulo 130: 1529 a 1539

(2018) Jamerson JL et al. Medicina interna de Harrison, 20ª ed. McGraw Hill Capítulo 317: 7941 a 7990 (50)

(2016) Podolsky DK et al. Yamada’s Textbook of Gastroenterology, 6ª ed. Wiley Capítulo 56: 1057 a 1102 (46)
Blackwell

Artigos UpToDate
- Planejamento
● Nível 1: Tratado (25)
● Nível 2: Lancet
● Nível 3: Yamada
● Nível 4: Demais

H.pylori

(2016) Zaterga S et al. Tratado de gastroenterologia - da graduação à 588 a 615

pós-graduação, 2ª ed. Atheneu

Artigos do UpToDate

- Ver as definições no CID

Doença do Refluxo Gastroesofágico (DRGE)

(2016) Podolsky DK et al. Yamada’s Textbook of Gastroenterology, 6ª ed. Wiley Blackwell

DEFINIÇÕES

- Gastroesophageal reflux is the retrograde movement of gastric content into the esophagus.
● This physiological phenomenon becomes pathological when it is associated with
symptoms or mucosal complications.
- Montreal consensus of gastroesophageal reflux disease (GERD) = “a condition which
develops when the reflux of stomach contents causes troublesome symptoms and/or
complications”

EPIDEMIOLOGIA

FISIOPATOLOGIA

(2021) Fass R et al. Gastro-oesophageal reflux disease. Nature Reviews Disease Primers

- Multifatorial!
● Gastric acid pocket
● Abnormal gastric emptying
● Failure of anti-reflux barrier
● Crural diaphragm
● Factors that affect the extent of mucosal damage
○ Refluxate characteristics
○ Oesophageal clearance mechanisms
 ● Symptom perception
○ Mucosal integrity
○ Peripheral, central and psychological mechanisms

(2016) Podolsky DK et al. Yamada’s Textbook of Gastroenterology, 6ª ed. Wiley Blackwell

- Esophageal symptoms and injury

- The fundamental abnormality is excessive exposure of esophageal mucosa to gastric
contents
- Multitude of reasons
● Excessive nº of reflux events
● Prolonged mucosal exposure to reflux
● Impaired mucosal integrity
● Hypersensitivity

(2020) Mittal R, Vaezi MF. Esophageal Motility Disorders and Gastroesophageal Reflux
Disease. The New England Journal of Medicine

LOWER ESOPHAGEAL SPHINCTER

- Smooth muscle (Internal LES) + Crural diaphragm (External LES)

● Anatomically super-imposed → 2 leaves of phrenoesophageal ligament

INTERNAL LES

- Smooth muscle
- Microarchitecture is kinda messy
- Clasp and sling fibers
Independente da seção do esôfago, haverão 2 camadas musculares: camada circular, e
camada longitudinal
Obs.: para Liebermann-Meffert D et al. (1979), as fibras circulares não são contínuas
(formadas, simplificadamente, por 2 semi-círculos)
 Camada muscular externa (fibras transversais; músculo esquelético)
Após GER, as fibras continuam longitudinais nas curvaturas maior e menor, mas, anterior e
posteriormente, mudam a orientação e se encontram perpendicularmente às fibras da curvatura
maior
Na terminação das fibras → entrelaçam-se com a camada muscular interna OU com a camada
serosa
Liebermann-Meffert D et al. (1979)
 Camada muscular interna (fibras semicirculares; músculo liso)
Semicírculos que se estendem para a curvatura menor mantém o formato (“clasps”)
Semicírculos que se estendem para a curvatura maior se organizam em fibras oblíquas
Na junção entre fibras oblíquas e semicirculares, as semicirculares não inseridas no tecido
conjuntivo submucoso
Liebermann-Meffert D et al. (1979)
 Fibras gástricas circulares: Middle gastric muscle coat
Aparecem primeiro no corpo do estômago. Não participam do LES
Liebermann-Meffert D et al. (1979)
Sobotta
Disponível em: https://www.nature.com/gimo/contents/pt1/fig_tab/gimo56_F1.html
 Disponível em:
https://www.researchgate.net/profile/Enrique-Lanzarini/publication/40690497/figure/fig2/AS:341
268346490894@1458376123032/Muscle-fibers-component-of-LES-Claps-fibers-and-sling-fiber.
png
- Sinônimos: sling fibers
● Inner oblique layer of the stomach
● The collar of Helvetius (named in 1719)
● The cardiac loop of Willis (named in 1674)
EXTERNAL LES

- Crural diaphragm

Crural diaphragm (CD)

Sobotta
Yamada
Microscopic anatomy of the esophageal hiatus in superior view and posterior view, respectively
The two bundles of the right crus cross each other first and then encircle the esophagus to form
the esophageal hiatus at the posterior–inferior and anterior–superior ends

PHRENOESOPHAGEAL LIGAMENT

- Or: Phrenico-esophageal ligament

- “The lower esophageal sphincter and crural diaphragm are anatomically superimposed and
tightly anchored by the two leaves of phrenoesophageal ligament”
Sobotta
Netter, plate 232 (2019)
 A three-dimensional diagram of the gastroesophageal region
Phrenoesophageal ligament (PEL); esophagus (E), stomach (S); diaphragmatic crus (C);
peritoneum (P) (incised and reflected)
Kwok H. et al. (1999)
 Enlarged view of the rectangle in (a)
Phrenoesophageal ligament (PEL); esophagus (E), diaphragmatic crus (C); The upper leaf (U)
and the lower leaf (L) of the ligament
Kwok H. et al. (1999)

ANTI-REFLUX BARRIER

(2021) Fass R et al. Gastro-oesophageal reflux disease. Nature Reviews Disease Primers

- High-pressure zone between the stomach and the oesophagus

- Mainly composed of:
● LES
● CD
● Gastro-oesophageal flap valve (supported by the phrenoesophageal ligament)
● Gastric sling fibres of the gastric cardia
 REFLUXO DE CONTEÚDO GÁSTRICO

- Gastro-oesophageal reflux usually occurs through:

● Transient LES relaxations (TLESRs)
○ Definição: LES relaxation that is not induced by swallowing
○ Persists for longer periods than swallow- induced LES relaxations (>10 seconds)
○ Accompanied by:
■ Diaphragmatic inhibition
■ Substantial oesophageal shortening (contraction of the longitudinal
muscle layer)
○ Obs.: During TLESRs, the LES is relaxed but reflux occurs only when the CD
stops contraction
● Low LES pressure (LESP)
● Swallow- associated LES relaxations
● Straining (tensão/esforço/empenho) during periods with low LES pressure

PATOGENESE DA DRGE

(2020) Mittal R, Vaezi MF. Esophageal Motility Disorders and Gastroesophageal Reflux
Disease. The New England Journal of Medicine

[Esquema 01]

REFLUX OF GASTRIC CONTENT

- 3 mecanismos:
● Transient relaxation of lower esophageal sphincter
○ Longitudinal muscle contraction of the distal esophagus + inhibition of the crural
diaphragm
 ○ Belching and reflux in healthy persons and in patients with GERD without hiatus
hernia
○ Obs.: drugs targeting transient relaxation of the lower esophageal sphincter have
limited benefit and substantial adverse events
● Low pressure of the lower esophageal sphincter
● Sliding hiatus hernia
○ Anatomic separation of lower esophageal sphincter and the crural diaphragm

[Imagem aqui]

(2021) Fass R et al. Gastro-oesophageal reflux disease. Nature Reviews Disease Primers

- Diferenciando o refluxo fisiológico do patológico

● Low LES pressure (LESP)
○ Patients with oesophagitis: lower mean basal LESP x individuals with other
GERD phenotypes or without GERD
● Transient LES relaxations (TLESRs)
○ In patients with GERD:
■ Similar rate
■ 65% of TLESRs accompanied by acid reflux (in healthy individuals: 30%)
● “In healthy individuals and patients with mild oesophagitis, most reflux episodes
occur during TLESRs. In those with more severe reflux oesophagitis and those with
hiatal hernia, a greater proportion of reflux occurs during absent basal LES pressure
and swallow- induced LES relaxations”

REFLUXATE CONTENT

- Existem 4 tipos de refluxo

● Refluxo ácido: pH < 4
● Weakly acidic/non-acid reflux
● Bile reflux: include bile acids such as cholic and deoxycholic acids.
Duodenogastro-oesophageal reflux
● Gas reflux

- Tipos de refluxo na fisiopatologia da DRGE

● Refluxo ácido
○ ↑ exposição esofágica → ↑ severidade do dano à mucosa
○ In patients with GERD
■ Higher rate and proportion of acid reflux
■ Higher proportion of acid pure liquid reflux (without gas)
● Refluxo não ácido/fracamente ácido
○ Pode gerar sintomas
 ○ Might be involved in persistent mucosal damage in patients with BE and in
those with oesophagitis not responding to a double dose of PPI treatment.
● Refluxo biliar
○ Healthy individual → esofagite → BE: Gradual increase in severity of both acid
and duodenogastro-oesophageal reflux (including bile reflux)
○ Perfusions of non-acidic solutions containing bile acids were found to provoke
heartburn [102]
○ Exposure of rabbit oesophageal mucosa to weakly acidic solutions containing
bile acids increased mucosal permeability and induced dilated intercellular
spaces (DIS)
● Refluxo gasoso
○ The presence of gas in the refluxate increases the perception of reflux events

ACID POCKET

- Pacientes com DRGE não secretam mais ácido do que um indivíduo saudável. A localização
proximal do conteúdo gástrico, no entanto, contribui para a a fisiopatologia
- Acid pocket
● Source of postprandial acid reflux
● In patients with GERD, it extends higher up into the lower oesophageal sphincter (LES)
and distal oesophagus (up to 6 cm above the squamocolumnar junction),

Fig. 3 | Mechanisms of symptom and mucosal injury generation in GERD

Patients may harbour different mechanisms leading to GERD, resulting in a wide array of
disease manifestations
PROTECTION FROM REFLUXATE

(2020) Mittal R, Vaezi MF. Esophageal Motility Disorders and Gastroesophageal Reflux
Disease. The New England Journal of Medicine

- Esophageal peristalsis
● ↓ time of exposure to gastric content
- Restoration of the esophageal pH after a reflux event
● Neutralization by saliva and bicarbonate-rich secretions of the esophageal submucosal
glands

- Obs.: The upper esophageal sphincter is the final line of defense against reflux of gastric
contents into the oropharynx and possible aspiration

Bottom line: Transition from physiologic to pathologic reflux is a consequence of defects

in one or more of the defensive mechanisms.

(2021) Fass R et al. Gastro-oesophageal reflux disease. Nature Reviews Disease Primers

- Reflux clearance mechanisms: peristalsis and salivation

● Rapid initial volume clearance by peristalsis (followed by ↓)
● Stepwise chemical clearance by the arrival of bicarbonate-rich saliva and subsequent
swallows

MOTILIDADE ESOFÁGICA

- “Gastro-oesophageal reflux events are immediately followed by a reflex that triggers swallow-
induced peristalsis and/or secondary peristalsis”
- “Another relevant factor is the integrity of the peristaltic sequence”
● Abnormal fragmentation of peristalsis is associated with poor clearance [119,120]

CHEMICAL CLEARANCE

- After initial volume clearance by peristalsis, the distal oesophageal mucosa remains acidic.
- Subsequent swallows of saliva rich in bicarbonate → neutralizes the acidic milieu

-💊 Correlação 💊 : “Connective tissue disorders, such as scleroderma, or chronic xerostomia

(dry mouth) and Sjögren syndrome are associated with prolonged oesophageal chemical
clearance and GERD”
MUCOSA ESOFÁGICA

- Mechanisms underlying the most frequent GERD symptom — heartburn — remain

incompletely understood
- Reflux contents to permeate into the inflamed and damaged oesophageal wall

Sensory afferent nerves in deep epithelium

“Sensory neurons transmit impulses activated by mechanical or chemical stimuli in the mucosa”
[Netter]

- Hypothesis of heartburn in NERD: microscopic and functional barrier defects

● Functional evidence of increased permeability
● DIS
 Rabbit esophageal mucosa
(A) Mucosa from control animals. (B) Mucosa exposed to a weakly acidic solution that contains
bile acids
Dilated intercellular spaces (DIS)

Fig. 4 | Possible integrated model of mucosal pathogenesis in GERD oesophageal injury

and symptoms
Epithelial aggression → pro- inflammatory cytokines secretion → epithelial proliferative changes
+ attraction of T lymphocytes and other inflammatory cells
 Cytokine-induced inflammation → activation of acid-sensing ion channel; pro‐inflammatory
cytokines → activation of deep nerves of the papillae

- “Furthermore, microscopic inflammation with neutrophil and eosinophilic infiltration is

frequently observed in biopsy samples from patients with NERD”

HIPERSENSIBILIDADE

- Increased sensitivity to the presence of acid or mechanical distension

- Oesophageal hypersensitivity may be due to peripheral sensitization, central sensitization or a
combination of both
● Peripheral: decreased threshold for and an increased magnitude of the sensory
response to a stimulus
● Central sensitization: alteration of central processing of visceral sensory information

Obs.I: Reflux-induced oesophageal distension has been suggested to be critical for symptom
perception, particularly in patients with refractory GERD
Obs. II: Psychiatric comorbidity and hypervigilance have been proposed as a mechanism
(psycho-neuroimmune modulation). I am not going to delve into it now

APRESENTAÇÃO CLÍNICA E HISTÓRIA NATURAL

- The cardinal symptoms of GERD are heartburn and acid regurgitation

- Heartburn: 54% têm GERD
- Regurgitação: 29% têm GERD
- Nenhuma das minhas referências falou da especificidade em pacientes com pirose +
regurgitação
● Porém, posso dizer que é maior ou igual a 54%
- Obs. outras condições: gastroparesis, FEDs, dispepsia funcional e eosinophilic
oesophagitis, por exemplo [Nature]
● Some patients who complain of heartburn do not have gastro-oesophageal reflux
disease; rather, they have a syndrome called functional heartburn [Lancet]
 Sintomas DRGE

Sintomas cardinais

Sintoma % com DRGE Características semiológicas Diagnósticos diferenciais

Pirose 54% - Timing:

● Comumente 60 min após
refeições
● Durante atividade física
● Deitado reclinado
- Fatores de melhora
● Beber água
● Antiácido

Regurgitação 29% - Percepção de movimento do refluxo

(fluído amargo ou queimando na
garganta ou boca, podendo conter
partículas indigestas de comida)
- Provocação da regurgitação:
● Curvar-se
● Arrotar
● Manobras que aumentam a
pressão intra-abdominal

Sintomas típicos, menos comuns

Sintoma % com DRGE Características semiológicas Diagnósticos diferenciais

Disfagia (30% dos pcts

com DRGE)

“Water brash”

Sensação de globus
 Odinofagia Mais comum: pill or
infectious esophagitis

Ruminação

Sintomas atípicos

Sintoma % com DRGE Características semiológicas Diagnósticos diferenciais

Dor torácica “The most frequent - Priorizar avaliação cardíaca!

esophageal causes of chest - Esophageal motor
pain are GERD and abnormalities (ex.: diffuse
hypersensitivity” esophageal spasm;
hypertensive peristalsis; more
recently, jackhammer
esophagus, which is
hypercontractility associated
with multipeaked contractions)

Tosse*

Asma** 59% prevalence of reflux

symptoms (adultos com
asma)

A variety of ear, nose,

and throat (ENT)
symptoms

Dental erosions Especially on the lingual and palatal

tooth surfaces
*Obs.: 50% a 75% dos pacientes com tosse NÃO relatam sintomas de refluxo!
**Obs.: “However, despite the association, it is less clear whether or not GERD causes asthma” (asthma → reflux?)
(2021) Fass R et al. Gastro-oesophageal reflux disease. Nature Reviews Disease Primers

- Esofágicos e extra-esofágicos

- Cite as 3 apresentações típicas da DRGE

● Non- erosive reflux disease (NERD)
● Erosive oesophagitis (EE)
● Esôfago de Barrett

- Defina: NERD (consenso de Montreal)

NERD is defined by the Montreal consensus as “the presence of troublesome reflux- associated
symptoms and the absence of mucosal breaks at endoscopy”

- Defina: NERD (consenso de Vevey)

“Troublesome symptoms in the absence of oesophageal mucosal erosions/breaks at
conventional endoscopy and without recent acid-suppressive therapy”
- Defina: erosive oesophagitis (EE)
Presence of visible mucosal breaks in the distal oesophagus

- Cloze: Common oesophageal signs and symptoms include [peptic stricture], [oesophageal
ulceration], [Barrett oesophagus (BE)], [oesophageal adenocarcinoma (EAC)], [chest pain],
[water brash], [belching] and [dysphagia]

- Cloze: Extra- oesophageal signs and symptoms are classified as [laryngeal], [oropharyngeal],
[pulmonary], [cardiac], [sleep-related] and [abdominal]
Extra: most in the proximity to the oesophagus

- Gastroparesis
A neuromuscular disorder of the stomach that is characterized by delayed solid food emptying
in the absence of mechanical obstruction.

DIAGNÓSTICO

- Q: quais são os diagnósticos diferenciais de pirose e/ou regurgitação?

- Esofagite eosinofílica
A chronic immune-antigen mediated oesophageal disorder, characterized by symptoms related
to oesophageal dysfunction and, histologically, by eosinophil- predominant inflammation.

- Qual o problema dos testes diagnósticos de DRGE?

Diagnostic tests are neither sensitive (30–76%) nor specific (62–96%) enough by themselves to
enable a definitive diagnosis of GERD

- Cite 3 diagnósticos diferenciais de pirose e regurgitação, além da DRGE

Gastroparesia
Dispepsia funcional
Esofagite eosinofílica

- Cite 4 testes diagnósticos mais comuns da DRGE

Ambulatory reflux monitoring
● Catheter- based pH monitoring
● Catheter- based pH–impedance monitoring
 ● Wireless pH monitoring
Endoscopia
Biópsia
Estudos de bário

- Em DRGE, a quem é indicada endoscopia?

Patients with chronic GERD at risk of BE (white men with a high body mass index, ≥50 years of
age and with chronic GERD symptoms)
Patients with warning symptoms (for example, dysphagia, weight loss, haematemesis and
vomiting)
Patients suspected of having eosinophilic oesophagitis (EoE), infection or pill- induced injury,
Patients with suspected GERD whose symptoms do not respond to appropriate anti- secretory
medical therapy

- Quais as desvantagens da endoscopia?

↓ sensibilidade (70% of patients have normal mucosa)
↑ custo

- No que consiste o monitoramento ambulatorial de refluxo?

These techniques measure reflux of acid (pH) or non- acid (impedance) material at a specified
location in the distal oesophagus over a 24–96- hour period.

TRATAMENTO

- Quais as classes medicamentosas existentes para o tratamento da DRGE?

Antiácidos
Alginato
Sucralfate
Procinéticos
Baclofeno
Antagonistas do receptor H2 de histamina
IBPs

- Possíveis efeitos adversos de antiácidos contendo magnésio

Diarréia

- Possíveis efeitos adversos de antiácidos contendo alumínio

Constipação
Doença Ulcerosa Péptica (DUP)

[ICD-11]

- DA61: Peptic ulcer, site unspecified

● Description: Peptic ulcer is defined as a distinct breach in the mucosa of the
gastrointestinal tract as a result of caustic effects of acid and pepsin in the lumen. A
peptic ulcer may develop in any part of the gastrointestinal tract exposed to acid and
pepsin. The most common locations are the stomach and duodenal bulb, but peptic
ulcer may also develop in the oesophagus in gastro-oesophageal reflux diseases, and in
the distal ileum as a result of a Meckel’s diverticulum lined with heterotopic gastric
mucosa.
● Disponível em:
https://icd.who.int/browse11/l-m/en#/http%3a%2f%2fid.who.int%2ficd%2fentity%2f11458
13715

[Tratado]

- Q: o que é a úlcera péptica? E a doença ulcerosa péptica?

● “As úlceras pépticas constituem soluções de continuidade da mucosa gastrointestinal
secundárias ao efeito corrosivo do ácido clorídrico (HCl) e da pepsina, estendendo-se
através da muscularis mucosae, atingindo a camada submucosa e, mesmo, a
muscularis propria. Lesões mais superficiais são definidas como erosões, não atingem a
camada submucosa e, portanto, não deixam cicatrizes”
● “The term peptic ulcer refers to acid peptic injury of the digestive tract, resulting in
mucosal break reaching the submucosa” [Lanas A, Chan FKl. 2017]
● Peptic ulcers are localized defects of the gastrointestinal (GI) mucosa, most commonly
found in the duodenum or stomach (Figure 56.1), for which acid-peptic activity plays a
role in pathophysiology [Yamada]
- Acreditava-se ser de evolução crônica, de etiologia desconhecida
- Nobel de Medicina de 2005, Warren e Marshall: H. Pylori
- Etiologias mais comuns: uso indiscriminado de AINEs + H. pylori
● Não são as únicas
- Localizações mais comuns
- Úlceras
● Duodenal (95% na 1ª porção do duodeno)
● Gástrica (80% na pequena curvatura)
 ETIOLOGIA E FISIOPATOLOGIA

- 🧬: determina o fenótipo secretor de determinada população

●
 UNCOMPLICATED ULCER

(2016) Podolsky DK et al. Yamada’s Textbook of Gastroenterology, 6ª ed. Wiley Blackwell

- Em geral, pacientes se apresentam com dispepsia

● Definição da International Rome III consensus group: “a symptom or set of symptoms
that most physicians consider to originate from the gastroduodenal area”, including
postprandial heaviness, early satiety, and epigastric pain or burning [194].”

- Apresentação clínica geralmente de pouca utilidade, e com uma miríade de diagnósticos

diferenciais
● Diagnósticos diferenciais: “Only 5% to 10% of patients presenting with simple dyspepsia
in developed countries will have a peptic ulcer”
● Dispepsia + outras queixas gastrointestinais
● Assintomáticos: “Interestingly in a European population around 1 in 5 participants with
ulcers were asymptomatic, whereas in a Chinese study 72% of individuals reported no
symptoms [33].”

- Differential diagnosis of dyspepsia (além de DUP):

● Functional dyspepsia (in up to 60% to 75%)
● GERD
● Malignancy (though cancer is often asymptomatic when at an early stage)
Sem sinais de alarme → tratar como dispepsia não investigada

Podem indicar malignidade

- Além disso:
● Comprehensive drug history (ulcerogenic drugs, or related to dyspepsia)
● Antecedentes pessoais de ulceração péptica
● Fatores de risco para H. pylori (HF, migração recente, certas bagagens étnicas)

Epilogue

(2012) Albert D et al. Dorlands Illustrated Medical Dictionary, 32ª ed. Elsevier Saunders

- Brash: heartburn
● Water b.: heartburn with regurgitation into the mouth of fluid that may be sour or almost
tasteless.
- Belching: eructation.
● Eructação: arroto [Aulete]
- Stricture: stenosis.
 ● Stenosis: an abnormal narrowing of a duct or canal; called also arctation, coarctation,
and stricture

- Pill-induced injury
Oesophageal injury due to direct damage to the oesophageal mucosa by a pill