INTRODUCTION

INTRODUCTION
The human gastrointestinal tract (GI tract) is an organ system responsible for
consuming and digesting foodstuffs, absorbing nutrients, and expelling waste.The tract is
commonly defined as the stomach and intestine, and is divided into the upper and lower
gastrointestinal tracts.[1] However, by the broadest definition, the GI tract includes all
structures between the mouth and the anus.[2] On the other hand, the digestive system is a
broader term that includes other structures, including the digestive organs and their
accessories.[2] The tract may also be divided into foregut, midgut, and hindgut, reflecting the
embryological origin of each segment.The whole digestive tract is about nine metres
long.[1]The GI tract releases hormones to help regulate the digestive process. These
hormones, including gastrin, secretin, cholecystokinin, and ghrelin, are mediated through
either intracrine or autocrine mechanisms, indicating that the cells releasing these hormones
are conserved structures throughout evolution.[3]

Structure:
The structure and function can be described both as gross anatomy and as microscopic
anatomy or histology. The tract itself is divided into upper and lower tracts, and the intestines
small and large parts.[3]

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Fig.01.Human Digestive System

Upper gastrointestinal tract:

The upper gastrointestinal tract consists of the mouth,pharynx, esophagus, stomach,
and duodenum.[2]
The Mouth:
The mouth is the beginning of the digestive system, and, in fact, digestion starts here
before you even take the first bite of a meal. The smell of food triggers the salivary glands in
your mouth to secrete saliva, causing your mouth to water. When you actually taste the food,
saliva increases.

Once you start chewing and breaking the food down into pieces small enough to be
digested, other mechanisms come into play. More saliva is produced to begin the process of
breaking down food into a form your body can absorb and use. In addition, "juices" are

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produced that will help to further break down food. Chew your food more -- it helps with
your digestion. [4]

The Pharynx and Esophagus:

Also called the throat, the pharynx is the portion of the digestive tract that receives the
food from your mouth. Branching off the pharynx is the esophagus, which carries food to the
stomach, and the trachea or windpipe, which carries air to the lungs.

The act of swallowing takes place in the pharynx partly as a reflex and partly under
voluntary control. The tongue and soft palate -- the soft part of the roof of the mouth -- push
food into the pharynx, which closes off the trachea. The food then enters the esophagus.

The esophagus is a muscular tube extending from the pharynx and behind the trachea
to the stomach. Food is pushed through the esophagus and into the stomach by means of a
series of contractions called peristalsis.

Just before the opening to the stomach is an important ring-shaped muscle called the
lower esophageal sphincter (LES). This sphincter opens to let food pass into the stomach and
closes to keep it there. If your LES doesn't work properly, you may suffer from a condition
called GERD, or reflux, which causes heartburn and regurgitation (the feeling of food coming
back up).

Structure of the stomach:

The stomach lies in the upper abdominal cavity, just below the diaphragm. It is
continuous with the oesophagus at the cardiac sphincter and the duodenum at the pyloric
sphincter. It is divided into three regions: the fundus, body and the antrum. The walls of the
stomach are made up of muscle layer (longitudinal, circular and oblique muscle), submucosa
and mucosa. [4]
Functions of the stomach:
These include:
Temporary storage allowing time for digestive enzymes to act
Chemical digestion
Mechanical breakdown and production of chyme
Limited absorption of water, alcohol and some fat-soluble drugs
Non-specific defense against microbes

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Preparation of ion for digestion further along the tract

Production of intrinsic factor needed for absorption of vitamin B12 in the terminal
ileum
Regulation of the passage of gastric contents into the duodenum

Secretion and functions of gastric juice:

There is always a small amount of gastric juices in the stomach, even when it contains
no food. Secretion reaches its maximum level about one hour after a meal.

About two litres of gastric juices are secreted daily by glands in the mucosa. Gastric juice
consists of:

Water and mineral salts, secreted by gastric glands

Mucus secreted by goblet cells in the glands and on the stomach surface
Hydrochloric acid and intrinsic factor, secreted by parietal cells in the gastric glands
Inactive enzyme precursors

Functions:
The water further liquefies the food swallowed.
The hydrochloric acid:
o acidifies the food and stops the action of enzymes from saliva;
o kills ingested microbes;
o provides the acid environment required for effective digestion by pepsin.
The mucus prevents accidental injury to the stomach by lubricating the contents, and
prevents chemical injury by acting as a barrier to the corrosive gastric juice.

Lower gastrointestinal tract:

The lower gastrointestinal tract includes most of the small intestine and all of the large
intestine.[2] In human anatomy, the intestine (or bowel, hose or gut) is the segment of the
gastrointestinal tract extending from the pyloric sphincter of the stomach to the anus and, in
humans and other mammals, consists of two segments, the small intestine and the large
intestine. In humans, the small intestine is further subdivided into the duodenum, jejunum and
ileum while the large intestine is subdivided into the cecum and colon.[5]

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Small Intestine:
The small intestine begins at the duodenum, which receives food from the stomach. The
duodenum is a short structure which receives both pancreatic juices and bile. The duodenum
transmits food to the jejunum and ileum. The main function of the small intestine is to absorb
proteins, lipids, and vitamins, has three major divisions:

1. Duodenum:
Here the digestive juices from the pancreas (digestive enzymes) and the gall
bladder (bile) mix with hormones. The digestive enzymes break down proteins and
bile and emulsify fats into micelles. The duodenum contains Brunner's glands, which
produce a mucus-rich alkaline secretion containing bicarbonate, which, in
combination with bicarbonate from the pancreas, neutralizes HCl of the stomach.
The exact demarcation between the upper and lower tracts is the suspensory
ligament of the duodenum (also known as the Ligament of Treitz). This delineates the
embryonic borders between the foregut and midgut, and is also the division
commonly used by clinicians to describe gastrointestinal bleeding as being of "upper"
or "lower" origin. Upon dissection, the duodenum may appear to be a unified organ,
but it is divided into four segments based upon function, location, and internal
anatomy. The four segments of the duodenum are as follows (starting at the stomach,
and moving toward the jejunum): bulb, descending, horizontal, and ascending. The
suspensory ligament attaches the superior border of the ascending duodenum to the
diaphragm.
The suspensory muscle of duodenum is an important anatomical landmark
which shows the formal division between the duodenum and the jejunum, the first and
second parts of the small intestine, respectively.[4]This is a thin muscle which is
derived from the embryonic mesoderm.

2. Jejunum:
This is the midsection of the intestine, connecting the duodenum to the ileum.
It contains the plicae circulares (also called circular folds or valves of Kerckring), and
villi that increase the surface area of this part of the GI Tract. Products of digestion
(sugars, amino acids, and fatty acids) are absorbed into the bloodstream here.

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3. Ileum:
Has villi similar to the jejunum, and absorbs mainly vitamin B12 and bile
acids, as well as any other remaining nutrients. [2]
Large Intestine:
The large intestine consists of the colon and rectum. The colon ascends in the back wall
of the abdomen, passes across the back wall, and then falls down the left side of the abdomen.
The colon connects to the rectum, and finally the anus. The main function of the large
intestine is to absorb water, is divided as well:

1. Cecum: The vermiform appendix is attached to the cecum.

2. Colon
1. Ascending colon
2. Transverse colon
3. Descending colon
4. Sigmoid Flexure
3. Rectum
4. Anal canal: The terminal part of the large intestine.

The Colon, Rectum, and Anus:

The colon (large intestine) is a five- to seven -foot -long muscular tube that connects
the small intestine to the rectum. It is made up of the ascending (right) colon, the transverse
(across) colon, the descending (left) colon and the sigmoid colon, which connects to the
rectum. The appendix is a small tube attached to the ascending colon. The large intestine is a
highly specialized organ that is responsible for processing waste so that defecation (excretion
of waste) is easy and convenient.

Stool, or waste left over from the digestive process, passes through the colon by
means of peristalsis, first in a liquid state and ultimately in solid form. As stool passes
through the colon, any remaining water is absorbed. Stool is stored in the sigmoid (S-shaped)
colon until a "mass movement" empties it into the rectum, usually once or twice a day.

It normally takes about 36 hours for stool to get through the colon. The stool itself is
mostly food debris and bacteria. These bacteria perform several useful functions, such as
synthesizing various vitamins, processing waste products and food particles, and protecting

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against harmful bacteria. When the descending colon becomes full of stool, it empties its
contents into the rectum to begin the process of elimination.

The rectum is an eight-inch chamber that connects the colon to the anus. The rectum:

Receives stool from the colon

Lets the person know there is stool to be evacuated
Holds the stool until evacuation happens

When anything (gas or stool) comes into the rectum, sensors send a message to the brain.
The brain then decides if the rectal contents can be released or not. If they can, the sphincters
relax and the rectum contracts, expelling its contents. If the contents cannot be expelled, the
sphincters contract and the rectum accommodates so that the sensation temporarily goes
away.

The anus is the last part of the digestive tract. It consists of the muscles that line the pelvis
(pelvic floor muscles) and two other muscles called anal sphincters (internal and external).

The pelvic floor muscle creates an angle between the rectum and the anus that stops stool
from coming out when it is not supposed to. The anal sphincters provide fine control of stool.
The internal sphincter is always tight, except when stool enters the rectum. It keeps us
continent (not releasing stool) when we are asleep or otherwise unaware of the presence of
stool. When we get an urge to defecate (go to the bathroom), we rely on our external
sphincter to keep the stool in until we can get to the toilet.

Development:
The gut is an endoderm-derived structure. At approximately the sixteenth day of
human development, the embryo begins to fold ventrally (with the embryo's ventral surface
becoming concave) in two directions: the sides of the embryo fold in on each other and the
head and tail fold toward one another. The result is that a piece of the yolk sac, an endoderm-
lined structure in contact with the ventral aspect of the embryo, begins to be pinched off to
become the primitive gut. The yolk sac remains connected to the gut tube via the vitelline
duct. Usually this structure regresses during development; in cases where it does not, it is
known as Meckel's diverticulum.

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During fetal life, the primitive gut can be divided into three segments: foregut,
midgut, and hindgut. Although these terms are often used in reference to segments of the
primitive gut, they are also used regularly to describe components of the definitive gut as
well. [6]

Table.01.Different parts of gut

Arterial
Part Part in adult Gives rise to
supply
Esophagus, Stomach,
Duodenum (1st and 2nd
parts), Liver, Gallbladder,
Pancreas, Superior
Esophagus to first 2 portion of pancreas
Foregut sections of the (Note that though the celiac trunk
duodenum Spleen is supplied by the
celiac trunk, it is derived
from dorsal mesentery
and therefore not a
foregut derivative)
lower duodenum,
branches of
lower duodenum, to jejunum, ileum, cecum,
the superior
Midgut the first two-thirds of appendix, ascending
mesenteric
the transverse colon colon, and first two-third
artery
of the transverse colon
last third of the last third of the transverse branches of
transverse colon, to colon, descending colon, the inferior
Hindgut
the upper part of the rectum, and upper part of mesenteric
anal canal the anal canal artery

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Each segment of the gut gives rise to specific gut and gut-related structures in later
development. Components derived from the gut proper, including the stomach and colon,
develop as swellings or dilatations of the primitive gut. In contrast, gut-related derivatives,
that is, those structures that derive from the primitive gut but are not part of the gut proper, in
general develop as out-pouchings of the primitive gut. The blood vessels supplying these
structures remain constant throughout development.[1]

Histology:

Fig.02.General structure of the gut wall

1: Mucosa: Epithelium
2: Mucosa: Lamina propria
3: Mucosa: Muscularis mucosae
4: Lumen
5: Lymphatic tissue
6: Duct of gland outside tract
7: Gland in mucosa
8: Submucosa
9: Glands in submucosa
10: Meissner's submucosal plexus
11: Vein

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12: Muscularis: Circular muscle

13: Muscularis: Longitudinal muscle
14: Serosa: Areolar connective tissue
15: Serosa: Epithelium
16: Auerbach's myenteric plexus
17: Nerve
18: Artery
19: Mesentery

The gastrointestinal tract has a form of general histology with some differences that
reflect the specialization in functional anatomy.[2] The GI tract can be divided into four
concentric layers in the following order:

Mucosa
Submucosa
Muscularis externa (the external muscular layer)
Adventitia or serosa

Mucosa:
The mucosa is the innermost layer of the gastrointestinal tract. that is surrounding the
lumen, or open space within the tube. This layer comes in direct contact with digested food
(chyme). The mucosa is made up of:

Epithelium - innermost layer. Responsible for most digestive, absorptive and

secretory processes.
Lamina propria - a layer of connective tissue. Unusually cellular compared to most
connective tissue
Muscularis mucosae - a thin layer of smooth muscle that aids the passing of material
and enhances the interaction between the epithelial layer and the contents of the
lumen by agitation and peristalsis.

The mucosae are highly specialized in each organ of the gastrointestinal tract to deal with the
different conditions. The most variation is seen in the epithelium.

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Submucosa:
The submucosa consists of a dense irregular layer of connective tissue with large
blood vessels, lymphatics, and nerves branching into the mucosa and muscularis externa. It
contains Meissner's plexus, an enteric nervous plexus, situated on the inner surface of the
muscularis externa.

Muscularis externa:
The muscularis externa consists of an inner circular layer and a longitudinal outer
muscular layer. The circular muscle layer prevents food from traveling backward and the
longitudinal layer shortens the tract. The layers are not truly longitudinal or circular, rather
the layers of muscle are helical with different pitches. The inner circular is helical with a
steep pitch and the outer longitudinal is helical with a much shallower pitch.

The coordinated contractions of these layers is called peristalsis and propels the food
through the tract. Food in the GI tract is called a bolus (ball of food) from the mouth down to
the stomach. After the stomach, the food is partially digested and semi-liquid, and is referred
to as chyme. In the large intestine the remaining semi-solid substance is referred to as faeces.

Between the two muscle layers are the myenteric or Auerbach's plexus. This controls
peristalsis. Activity is initiated by the pacemaker cells (interstitial cells of Cajal). The gut has
intrinsic peristaltic activity (basal electrical rhythm) due to its self-contained enteric nervous
system. The rate can of course be modulated by the rest of the autonomic nervous system.

Adventitia/serosa:
The outermost layer of the GI tract consists of several layers of connective
tissue.Intraperitoneal parts of the GI tract are covered with serosa. These include most of the
stomach, first part of the duodenum, all of the small intestine, caecum and appendix,
transverse colon, sigmoid colon and rectum. In these sections of the gut there is clear
boundary between the gut and the surrounding tissue. These parts of the tract have a
mesentery.Retroperitoneal parts are covered with adventitia. They blend into the surrounding
tissue and are fixed in position. For example, the retroperitoneal section of the duodenum
usually passes through the transpyloric plane. These include the esophagus, pylorus of the
stomach, distal duodenum, ascending colon, descending colon and anal canal. In addition, the
oral cavity has adventitia.

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Function:
The time taken for food or other ingested objects to transit through the gastrointestinal
tract varies depending on many factors, but roughly, it takes less than an hour after a meal for
50% of stomach contents to empty into the intestines and total emptying of the stomach takes
around 2 hours. Subsequently, 50% emptying of the small intestine takes 1 to 2 hours.
Finally, transit through the colon takes 12 to 50 hours with wide variation between
individuals.[7,8]

Immune function:
The gastrointestinal tract is also a prominent part of the immune system.[15] The
surface area of the digestive tract is estimated to be the surface area of a football field. With
such a large exposure, the immune system must work hard to prevent pathogens from
entering into blood and lymph.[6]

The low pH (ranging from 1 to 4) of the stomach is fatal for many microorganisms
that enter it. Similarly, mucus (containing IgA antibodies) neutralizes many of these
microorganisms. Other factors in the GI tract help with immune function as well, including
enzymes in saliva and bile. Enzymes such as Cyp3A4, along with the antiporter activities,
also are instrumental in the intestine's role of detoxification of antigens and xenobiotics, such
as drugs, involved in first phase metabolism.

Health-enhancing intestinal bacteria of the gut flora serve to prevent the overgrowth
of potentially harmful bacteria in the gut. These two types of bacteria compete for space and
"food," as there are limited resources within the intestinal tract. A ratio of 80-85% beneficial
to 15-20% potentially harmful bacteria generally is considered normal within the intestines.
Microorganisms also are kept at bay by an extensive immune system comprising the gut-
associated lymphoid tissue (GALT).

Intestinal flora:
The large intestine hosts several kinds of bacteria that deal with molecules the human
body is not able to break down itself.[9] This is an example of symbiosis. These bacteria also
account for the production of gases inside our intestine (this gas is released as flatulence
when eliminated through the anus). However the large intestine is mainly concerned with the
absorption of water from digested material (which is regulated by the hypothalamus) and the

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re absorption of sodium, as well as any nutrients that may have escaped primary digestion in
the ileum.

Stomach Conditions:

Gastroesophageal reflux: Stomach contents, including acid, can travel backward up

the esophagus. There may be no symptoms, or reflux may cause heartburn or
coughing.
Gastroesophageal reflux disease (GERD): When symptoms of reflux become
bothersome or occur frequently, theyre called GERD. Infrequently, GERD can cause
serious problems of the esophagus.
Dyspepsia: Another name for stomach upset or indigestion. Dyspepsia may be caused
by almost any benign or serious condition that affects the stomach.
Gastric ulcer (stomach ulcer): An erosion in the lining of the stomach, often causing
pain and/or bleeding. Gastric ulcers are most often caused by NSAIDs or H. pylori
infection.
Peptic ulcer disease: Doctors consider ulcers in either the stomach or the duodenum
(the first part of the small intestine) peptic ulcer disease.
Gastritis: Inflammation of the stomach, often causing nausea and/or pain. Gastritis
can be caused by alcohol, certain medications, H. pylori infection, or other factors.
Stomach cancer: Gastric cancer is an uncommon form of cancer in the U.S.
Adenocarcinoma and lymphoma make up most of the cases of stomach cancer.
Zollinger-Ellison syndrome (ZES): One or more tumors that secrete hormones that
lead to increased acid production. Severe GERD and peptic ulcer disease result from
this rare disorder.
Gastric varices: In people with severe liver disease, veins in the stomach may swell
and bulge under increased pressure. Called varices, these veins are at high risk for
bleeding, although less so than esophageal varices are.
Stomach bleeding: Gastritis, ulcers, or gastric cancers may bleed. Seeing blood or
black material in vomit or stool is usually a medical emergency.
Gastroparesis (delayed gastric emptying): Nerve damage from diabetes or other
conditions may impair the stomachs muscle contractions. Nausea and vomiting are
the usual symptoms. [10]

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Chronic disorders:
Disorders of the stomach are very common and induce a significant amount of
morbidity and suffering in the population. Data from hospitals indicate that more than 25% of
the population suffers from some type of chronic stomach disorder including abdominal pain
and indigestion. These symptoms occur for long periods and cause prolonged suffering, time
off work and a poor quality of life. Moreover visits to doctors, expense of investigations and
treatment result in many days lost from work and a colossal cost to the financial system.[11]
Gastritis:
In the stomach there is a slight balance between acid and the wall lining which is
protected by mucus. When this mucus lining is disrupted for whatever reason, signs and
symptoms of acidity result. This may result in upper abdominal pain, indigestion, loss of
appetite, nausea, vomiting and heartburn. When the condition is allowed to progress, the pain
may become continuous; blood may start to leak and be seen in the stools. If the bleeding is
rapid and of adequate volume it may even result in vomiting of bright red blood
(hematemesis). When the acidity is uncontrolled, it can even cause severe blood loss
(anemia) or lead to perforation (hole) in the stomach which is a surgical emergency. In many
individuals, the progressive bleeding from an ulcer mixes with the feces and presents as black
stools. Presence of blood in stools is often the first sign that there is a problem in the
stomach.[4]
Gastroparesis:
Another very common long term problem which is now more appreciated is
gastroparesis. Gastroparesis affects millions of individuals and is often never suspected and
most patients have a delay in diagnosis. Basically in gastroparesis, the stomach motility
disappears and food remains stagnant in the stomach. The most common cause of
gastroparesis is diabetes but it can also occur from a blockage at the distal end of stomach, a
cancer or a stroke. Symptoms of gastroparesis includes abdominal pain, fullness, bloating,
nausea, vomiting after eating food, loss of appetite and feeling of fullness after eating small
amounts of food.
Diarrhoea:
During digestion, food is stored in the liquid present in the stomach. The food that is
not digested travels to the large intestine and colon in liquid form. These organs begin to
absorb the water turning the food into a more solid form. Different viruses or bacteria can
increase the amount of liquid that is secreted and moves too quickly through the digestive

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tract for the water to be absorbed. Diarrhea comes in two types: acute diarrhea and chronic
diarrhea. The acute diagnosis can last for a few days up to a week of time. Chronic diarrhea
lasts for several days or longer periods of time lasting a few weeks. The difference in
diagnosis will help determine the cause of the illness.
Crohn's disease:
Crohn's disease is an inflammatory bowel disease that can affect any part of the
digestive tract, even the stomach, although it's a rare presentation. Its main feature is
inflammatory ulcers that can affect the total thickness of the stomach wall and can bleed but
rarely perforate. Symptoms include abdominal pain, loss of appetite, and weight loss.
Diarrhea is also a symptom that can develop, so checking stools for the appearance of blood
is important. It is possible for symptoms of Crohn's Disease to remain with a person for
weeks or go away on their own. Reporting the symptoms to a doctor is recommended to
prevent further complications.
Cancers:
Cancers of the stomach are rare and the incidence has been declining worldwide.
Stomach cancers usually occur due to fluctuations in acidity level and may present with
vague symptoms of abdominal fullness, weight loss and pain. The actual cause of stomach
cancer is not known but has been linked to infection with Helicobacter pylori, pernicious
anemia, Menetriere's disease, and nitrogenous preservatives in food.[12]

Causes and treatment:

Smoking has been linked to a variety of disorders of the stomach. Tobacco is known
to stimulate acid production and impairs production of the protective mucus. This leads to
development of ulcers in the majority of smokers. Chronic stomach problems have also been
linked to excess intake of alcohol. It has been shown that alcohol intake can cause stomach
ulcer, gastritis and even stomach cancer. Thus, avoidance of smoking and excess alcohol
consumption can help prevent the majority of chronic stomach disorders.

One of the most causes of chronic stomach problems is use of medications. Use of
aspirin and other non-steroidal anti-inflammatory drugs to treat various pain disorders can
damage lining of the stomach and cause ulcers. Other medications like narcotics can interfere
with stomach emptying and cause bloating, nausea, or vomiting.

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The majority of chronic stomach problems are treated medically. However, there is
evidence that a change in life style may help. Even though there is no specific food
responsible for causing chronic stomach problems, experts recommend eating a healthy diet
which consists of fruits and vegetables. Lean meat should be limited. Moreover people
should keep a diary of foods that cause problems and avoid them.[4]

Endoscopy:
There are many tools for investigating stomach problems. The most common is
endoscopy. This procedure is performed as an outpatient and utilizes a small flexible camera.
The procedure does require intravenous sedation and takes about 3045 minutes; the
endoscope is inserted via the mouth and can visualize the entire swallowing tube, stomach
and duodenum. The procedure also allows the physician to obtain biopsy samples. In many
cases of bleeding, the surgeon can use the endoscope to treat the source of bleeding with
laser, clips or other injectable drugs.
Symptoms:
Several symptoms are used to indicate problems with the gastrointestinal tract:
Vomiting, which may include regurgitation of food or the vomiting of blood
Diarrhoea, or the passage of looser or more frequent stools
Constipation, which refers to the passage of fewer stools
Blood in stool, which includes fresh red blood, maroon-coloured blood, and tarry-
coloured blood.

Imaging:
Various methods of imaging the gastrointestinal tract are used:
Radioopaque dyes may be swallowed to produce a Barium swallow
Parts of the tract may be visualised by camera. This is known as endoscopy if
examining the upper gastrointestinal tract, and colonoscopy or sigmoidoscopy if
examining the lower gastrointestinal tract. Capsule endoscopy is where a capsule is
swallowed in order to examine the tract. Biopsies may also be taken when examined.
An abdominal x-ray may be used to examine the lower gastrointestinal tract.

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Other diseases:
Celiac Disease
Cholera
Diarrhoea
Enteric duplication cyst
Giardiasis
Irritable bowel syndrome
Pancreatitis
Peptic ulcer disease
Yellow Fever

Intestinal Pseudo-Obstruction is a syndrome caused by a malformation of the

digestive system, characterized by a severe impairment in the ability of the intestines
to push and assimilate. Symptoms include daily abdominal and stomach pain, nausea,
severe distension, vomiting, heartburn, dysphagia, diarrhea, constipation, dehydration
and malnutrition. There is no cure for intestinal pseudo-obstruction. Different types of
surgery and treatment managing life threatening complications such as ileus and
volvulus, intestinal stasis which lead to bacterial overgrowth, and resection of affected
or dead parts of the gut may be needed. Many patients require parenteral nutrition.
Ileus is a blockage of the intestines.

Coeliac disease is a common form of malabsorption, affecting up to 1% of people of

northern European descent. An autoimmune response is triggered in intestinal cells by
digestion of gluten proteins. Ingestion of proteins found in wheat, barley and rye,
causes villous atrophy in the small intestine. Lifelong dietary avoidance of these
foodstuffs in a gluten-free diet is the only treatment.

Enteroviruses are named by their transmission-route through the intestine (enteric

meaning intestinal), but their symptoms aren't mainly associated with the intestine.
Irritable bowel syndrome (IBS) is the most common functional disorder of the
intestine. Functional constipation and chronic functional abdominal pain are other
disorders of the intestine that have physiological causes, but do not have identifiable
structural, chemical, or infectious pathologies. They are aberrations of normal bowel
function but not diseases.[11]

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Endometriosis can affect the intestines, with similar symptoms to IBS.

Bowel twist (or similarly, bowel strangulation) is a comparatively rare event (usually
developing sometime after major bowel surgery). It is, however, hard to diagnose
correctly, and if left uncorrected can lead to bowel infarction and death. (The singer
Maurice Gibb is understood to have died from this.)
Angiodysplasia of the colon
Chronic functional abdominal pain
Constipation
Diarrhea
Hirschsprung's disease (aganglionosis)
Intussusception
Polyp (medicine) (see also Colorectal polyp)
Pseudomembranous colitis

Ulcerative colitis and toxic megacolon

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PEPTIC ULCERS:

Fig.03.Structure of stomach

The word peptic is defined as pertaining to, or associated with, digestion. The term
peptic ulcer refers to a break in the surface lining of the stomach or duodenum which is deep
enough to produce a shallow crater (ulcer) in its wall.

Peptic ulcers are found approximately four times as often in the duodenum than in the
stomach, and can also be found, albeit rarely, in the lower esophagus or beyond the
duodenum in the small intestine. [4,6]

Some other facts include:

duodenal ulcers are more common in men, whereas gastric ulcers affect men and
women more or less equally
ulcers are found at all ages but are more common with increasing age
ulcers may appear acutely or develop slowly and chronically
close to 10% of all adults may suffer from peptic ulcer disease at some time in their
lives.

Helicobacter Pylori:
Helicobacter pylori (or H. pylori) is a bacteria commonly found in the stomach. In
fact, it is suggested that more than half the world's population has this bacteria, yet never
experience any problems. However, an H. pylori infection can increase the risks of
developing gastric cancer, gastritis and/or peptic ulcers.

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Benign or Malignant?
Duodenal ulcers are always benign, but gastric ulcers can be benign or malignant
requiring careful investigation and follow up to ensure that they heal completely with
treatment.
What causes peptic ulcers?
It is now known that over 90% of duodenal ulcers are the result of infection with
Helicobacter pylori (HP). It is not known for certain how this bacteria is transmitted but
infection is more common in areas of poverty, poor sanitation and overcrowding.

The vast majority of infected people remain healthy and without symptoms but for
unknown reasons, a small percentage develop peptic ulcer disease. After infection, the
bacteria lives close to the surface lining of the stomach, underneath the layer of mucus, where
it is protected from acid.

As a result, acid secretion, in response to a meal, increases. It is thought that this

excessive amount of acid causes further damage to the stomach and/or duodenum, thus
leading to ulcer development.

H Pylori is also thought to be responsible for 6070% of gastric ulcers. Other gastric
ulcers usually occur in patients taking aspirin or other non-steroidal anti-inflammatory drugs
(NSAIDs). [10]

Aspirin and NSAIDs:

Aspirin and NSAIDs damage the lining of the stomach and make it more susceptible
to damage from acid and enzymes. These drugs, however, only play a small role in causing
ulcers but may flare up existing ulcers. Not everybody is at risk of the side effects of aspirin
and NSAIDs. People at higher risk of complications include those over the age of sixty, those
taking high doses, and those with a past history of peptic ulcer or complications from these
drugs. Some NSAIDs are safer than others and if prescribed one of these medications, you
should check with your doctor that it is safe to take it.
Family history and peptic ulcers:
There is often a family history of peptic ulcer disease but reasons for this are unclear
and peptic ulcers are not strictly a "genetic" disease.

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Smoking also carries an increased risk of ulcers. Complications of ulcers, including

delayed healing, are more common in smokers than in non-smokers. Lastly, ulcers may very
rarely be the result of a hormone-producing tumor ("gastrinoma") which leads to massive
acid production. Ulcers in this condition are often multiple, aggressive and resistant to
therapy. This condition is rare and accounts for only approximately 1% of all ulcers. [13]

Fig.04.An internal image of duodenal ulcer

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Fig.05. An internal image of a gastric ulcer

Can peptic ulcers be prevented?

At present there is no good evidence that widespread antibiotic therapy to eradicate
Helicobacter pylori(HP) in the population will prevent ulcer disease. This is the subject on
ongoing debate by specialists and may change in the future. Careful use of aspirin and
NSAIDs and their avoidance by people at high risk of complications is also recommended.
Stopping smoking may also reduce the chances of developing and ulcer.

Symptoms and signs of an ulcer:

Peptic ulcers are usually chronic and may come and go over a period of many years, even
without treatment. The most common symptoms are:

abdominal pain, usually located in the upper central abdomen

pain which may also be felt in the back
pain which may be worse when the stomach is empty; although not always the case,
this pain can sometimes be relieved by eating
pain which wakes a patient from sleep
indigestion or heartburn,
vomiting and anemia.

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 INTRODUCTION

In a few patients, an ulcer may be silent until it erodes completely through the gut wall
causing perforation, or erodes into a blood vessel causing bleeding. These complications are
serious and usually present as an emergency. [14]

Diagnosis:
In most cases the diagnosis is made by endoscopy, at which time the ulcer is usually
seen and can be biopsied if it appears suspicious for malignancy. Biopsies of the stomach can
also be taken to look for the presence of HP organisms. [12]
Biopsy:
A biopsy is a procedure that captures a small amount of tissue for examination by a
pathologist. The pathologist takes the tissue from the biopsy and creates a slide that can be
examined under a microscope. Often he will create several slides and stain them with colors
that allow better views of the cell structures.

A further advantage of endoscopy is that treatment can be carried out at the same time
if the ulcer is bleeding. The majority of ulcers can also be diagnosed by careful barium meal
examination and this is an alternative for patients who cannot or do not wish to have
endoscopy. Because of the ability to take biopsies and perform endoscopic treatment,
endoscopy is the perferred method of investigation.

Although biopsies of the stomach are the "gold standard" for diagnosing HP infection,
it is possible to diagnose the infection by using a simple breath test. A number of blood tests
for the infection are also available but these are less accurate.

Routine blood tests are usually normal in patients with ulcers apart from those where
bleeding has resulted in anemia. [12]

Treatment:
The goals of treatment for peptic ulcers are:
Relieve symptoms quickly
Heal the ulcer
Prevent it from recurring in the future

Treatment of HP infection is now recognized as the most important aspect of treatment.

All ulcer patients who are infected with bacteria should be offered antibiotic therapy. Usually

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 INTRODUCTION

this requires a combination of drugs for which many different combinations are available.
Usually an acid-suppressing drug is necessary to relieve symptoms and induce ulcer healing,
but also to boost the effects of the antibiotics. At the same time, two antibiotics are usually
necessary to ensure successful eradication of the infection.

This "triple therapy" (an acid-suppressing medication plus two antibiotics) is usually
taken for one to two weeks and is 8090% successful in getting rid of the infection.
Symptoms may take longer to disappear completely, but when they do there is little need to
perform further tests to ensure that treatment has worked.

Patients who have had serious complications from their ulcer (such as bleeding or
perforation) should undergo repeat testing to ensure that the treatment is successful. For
patients whose infection persists after antibiotic therapy, "second line" therapy (using a
different combination of medicines) is usually given and is successful most of the time. A
few patients fail this therapy and require long term acid-suppression therapy to prevent ulcer
recurrence. [13,14]

Managing ulcers:
Important steps in management of peptic ulcers include:
stopping smoking,
curtailing excessive alcohol intake, and
avoiding aspirin and NSAIDs, if possible.

No specific dietary measures are required. Long-term treatment with acid-suppressing drugs
is not usually necessary after successful HP therapy.

Drugs for treatment of Peptic Ulcer:

Aluminum Hydroxide and Magnesium Hydroxide:
Aluminum Hydroxide and Magnesium Hydroxide contains antacids, prescribed for
preventing ulcers, heartburn relief, acid indigestion and stomach upsets. Aluminum
Hydroxide and Magnesium Hydroxide neutralizes acid in the stomach.
Trade Names:
Aludrox | Aludrox | Aludrox (200 ml) | Aludrox (200ml) | Aludrox (840 mg) | Aludrox (840
mg) | Dizicum | Dizicum | Dizicum gel | Dizicum gel | Hegel -MPS | Hegel -MPS |

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Famotidine:
Famotidine is a histamine (H2-receptor antagonist), prescribed for ulcer.
Trade Names:
20 Famoflam (20 mg) | Acidosh (20 mg) | Acidosh (40 mg) | Acilo (20 mg) | Acilo (40 mg) |
Acipep (20 mg) | Acipep (40 mg) | Acredin (20 mg) | Acredin (40 mg) | Acredin tab (20 mg) |
Acredin tab (40 mg) | Advantac (20 mg) | Advantac (40 mg) | Andic - MR | Autidine (20 mg)
| Autidine (40 mg) | Avifam (20 mg) | Blocacid (20 mg) | Blocacid (40 mg) | Diclofam SP |

Glycopyrrolate:
Glycopyrrolate is a muscarinic anticholinergic agent, prescribed for peptic ulcer in
combination with other medicines and also used in anesthesia as preoperative medication. It
reduces acid and saliva secretions.
Trade Names:
Camolate (0.2 mg) | Glyco P (0.2 mg) | Glycolate (0.2 mg) | Glycolate (1 mg) |
Glycopyrrolate (0.2 mg) | Glycover (0.2 mg) | Glyprolate (2 mg) | Glyte (0.2 mg) | Hiclair (2
mg) | Licolate (2 mg) | Lycolate (0.2 mg) | Pyrolate (0.2 mg) | Pyrolate (2 mg) | Pyrolin (0.2
mg) | Pyrolin (2 mg) | Vagolate (0.2 mg) |

Lafutidine:
Lafutidine is an antacid, prescribed for ulcer.
Trade Names:
Laciloc (10mg) | Lafaxid (10mg) | Lafaxid D | Lafter (10 mg) | Lafudac (10mg) | Lafumac
(10mg) | Lafutax (10 mg) | Lafutax (5 mg) |

Mepenzolate:
Mepenzolate is an antimuscarinic agent, prescribed for the treatment of peptic ulcer
combined with other medication. It decreases acid secretion in the stomach and control
intestinal spasms.

Misoprostol:
Misoprostol is a synthetic prostaglandin; prescribed for ulcer, labor induction, induced
abortion, miscarriage, postpartum hemorrhage (blood loss during birth) and other
gynecological uses.

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 INTRODUCTION

Trade Names:
A Kare | Mifenac | Misonac | Misonac SR | Safeguard | Safeguard SR |

Omeprazole and Domperidone:

Omeprazole and Domperidone contains a proton pump inhibitor and
antidopaminergic agent, prescribed for ulcers, indigestion and acid stomach.

Oxyphenonium:
Oxyphenonium is an antimuscarinic agent, prescribed for peptic ulcer and it prevents
muscle spasm in the gastrointestinal tract.
Trade Names:
Alupromate D | Antigyl | Antigyl Compound | Antrenyl | Antrenyl Duplex | Oxyphenonium
Bromide | Ulpane | Ulpane (5 mg) |

Pantoprazole:
Pantoprazole is a proton-pump inhibitor, prescribed for gastroesophageal reflux
disease (GERD), ulcers, Zollinger-Ellison Syndrome, and erosive esophagitis. It decreases
the amount of acid made in the stomach.
Trade Names:
A - Pandom - SR | Acidwel - PD | Acipan Plus | Adezol | Alpan - D | Alpant (40mg) | Anto -
D | Anto - DM | Anzol -DP | Apan -D | Apentral - D | Aprilia (40mg) | Aprilia Inj (40mg) |
Arloc -D | Arthopan | Arthopan (500+20) | Askapan - DM | Asoprazole-D | Athzol - DM |
Azpan - DM |

Pirenzepine:
Pirenzepine is an antacid, prescribed for peptic ulcer.

Propantheline:
Propantheline is an antimuscarinic agent, prescribed for peptic ulcer, and urinary
incontinence.
Trade Names:
Pepler | Probanthine | Sere Banthine | Ulsedin |

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Ranitidine:
Ranitidine is an antacid, antireflux agent and antiulcerant, prescribed for peptic ulcer.
Trade Names:
Giran | Intac | M-Fast | Ortidin | Rdin-150 | Acidom | Aciloc | Aciloc | Aciloc D | Aciloc
RD | Acispas | Acispas | Acispas (150+20 mg) | Actiran - D | Actispas - R | Amylocarb |
Andom | Ani -Dom | Ani -Spa | Averine -R |[4,13,14]

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HERBAL MEDICINES:
Natural therapy for ulcer relief:
There are many herbs, nutrients, and plant products that have been found to play a
role in protecting or helping to heal stomach and peptic ulcers. Few human trials are
available, but many have show good potential in animal or in vitro studies. You may consider
ginger for nausea. Here are a few to look into. Before you start a supplement program discuss
with your health care provider to make sure you have no serious bleeding issues with the
ulcer and to make sure the supplements won't interfere with any prescription medicines you
may be taking. I want to emphasize that research with these supplements is very new and
limited and there is no definite proof yet that they are effective or should replace the meds
you are being prescribed.

Probiotics such as those found in yogurt probiotics are friendly bacteria such as
Acidophilus, Lactobacillus and Bifidobacterium.
Aloe vera herb may help with gastric ulcer healing.
Artichoke leaf extract has been tested in rodents as a beneficial supplement to reduce
gastritis.
Prickly pear fruit, also known as cactus pear, grows on nopal or cactus leaf.
Amla is used in Ayurvedic medicine. You can find amla research below on its influence on
ulcer.
Asparagus extract has been studied for ulcer prevention
Whey protein is available as a powder
Garcinia cambogia may have ulcer healing properties.
Gotu kola (Centella asiatica) has been studied for gastrointestinal symptoms.
Propolis extract is an interesting supplement.
Reishi is a mushroom
Parsley herb
Yarrow herb[4,13,14]

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