SPECIFIC DISEASES

SPECIAL PATHOLOGY
 Peptic Ulcers
• Ulcer – any discontinuation or breach in lining epithelium.
• Peptic ulcer – hole in the mucosa of any portion of
gastrointestinal tract exposed to acid peptic secretion.
• 98% of them located in first part of duodenum or in
stomach (4:1 ratio).
• Distinctive features of Peptic ulcer.
– Usually single lesion.
– Small mucosal defect (<4cm dia).
– Penetrated to muscularis mucosae (may perforate wall).
– Frequently recurrent.
– Located at sites in descending order,
• Duodenum – first portion.
• Stomach – pyloric antrum.
• Esophagus – (Barret’s type).
• Gastroenterostomy (stomal ulcer).
• Duodenum, stomach or jejunum (Zollinger Ellison syndrome).
• Meckle’s diverticulum (ectopic gastric mucosa).
 Peptic Ulcers
Major Factors in Pathogenesis of Peptic Ulcers

• Defensive forces • Aggressive forces

• Mucus secretion by mucosa. • Acid secretion.
• Bicarbonate secretion. • Peptic activity by Pepsinogen.
• Specialized apical surface of • Helicobacter Pylori infection in
gastric mucosal cells inhibit gastric antrum.
diffusion of H+ ions in mucosa. • NSAIDs, specially Aspirin, time
• Mucosal prostaglandins, dose dependant relationship,
cytoprotective activity by interfering with prostaglandin
enhancing blood flow & activity in gastro-intestinal
secretion of mucus & mucosa.
bicarbonate. • Ectopic gastric mucosa
(Meckle’s diverticulum).
Major Risk Factors.
Stress, Tobacco, Alcohol, Steroids, NSAIDs, Spicy foods, Dietary deficiencies,
H. Pylori, Blood group association, Gastrinomas.
 Stomach
Gastric Mucosa & Glands
 Peptic Ulcers
• Clinically Peptic Ulcers – Acute, Subacute or Chronic.
– Acute peptic ulcer – mucosa & submucosa involved, may be single or
multiple, less than 1 cm, punched out lesions, occur in various parts of
stomach & Ist part of duodenum.
– Acute Hemorrhagic Erosion – tiny ulcer, few mm diameter, multiple in all
parts of stomach, on mucosal folds, digestion of mucosa over small
hemorrhages.
– Subacute peptic ulcer – similar to acute ulcers but penetrate to deep
submucosal layer, commonly single & occur on lesser curvature, may cause
hemorrhage.
– Chronic peptic ulcer – larger 2-4 cm, penetrate to muscular coat, oval
shaped, 95% found on lesser curvature, peripyloric region, anterior or
posterior wall of duodenum Ist part.
• Clinical Features.
– Epigastric pain, burning or boring pain, worse at night, 2 to 3 hours after
meals, relieved by antacids, nausea, vomiting, flatulence, bloating, belching,
dyspepsia, anorexia & weight loss. Atypically pain may radiate to back,
shoulder, left upper quadrant & chest. Hematemesis or malena.
 Peptic Ulcers
• Diagnosis.
– History & clinical examination.
– Barium meal & follow through radiology.
– Upper G.I Endoscopy & Biopsy.
– Gastric acid secretion analysis.
– Gastric aspirate cytology.
– Biopsy & tests for Helicobacter Pylori.
• Treatment.
– Antacid & alkalis.
– H2 receptor antagonists.
– Mucosal Protectants.
– Proton pump inhibitors (PPI).
– Pro-motility drugs.
– Anticholinergics.
• Complications.
– Bleeding (25%), Perforation (5%), Obstruction
(scarring), Malignancy (1%)
 Peptic Ulcers
Factors Duodenal Ulcer Gastric Ulcer
Incidence Common (4:1) Infrequent.

Age Young adulthood & Later age group.

early middle age.
Sex Mainly Males. Common in Females.

Social Class All classes affected. More in Lower class.

Family History Common in relatives. Common in relatives.

Condition of Stomach Normal. Atonic & Chronic

gastritis.
Gastric Acidity Hyperacidity. Low normal acidity.

Blood Group Frequent in O group. Frequent in A group.

Blood group substances Usually absent. Present.

in gastric secretion
 Hypertension
• An elevated arterial pressure is a major health problem as it is very
common, remains asymptomatic but has devastating effects on
body organs if left unidentified & untreated.
• Major risk factor for, coronary artery disease, congestive heart
failure, cerebrovascular accidents, retinal damage & renal failure.
• Arterial pressure is maintained by various factors and both the
systolic & diastolic pressures are variable in each person at times.
• Therefore no magic threshold of blood pressure can be defined
above which a person is labeled hypertensive and below which one
is safe.
• Hence hypertension is defined somewhat arbitrarily.
• Most agree that sustained Diastolic pressure more than 90 mm of
Hg and sustained Systolic pressure of more than 140 mm of Hg is
a feature of Hypertension.
• Blood pressure should be measured at least twice at two separate
occasions under basal conditions after initial screening.
 Hypertension
• Prevalence in general population in screening programs is 25%.
• It varies with age, sex, race & screening value (B.P) criteria.
• Prevalence increases with age & when present in young adults it
tends to be more severe and detrimental.
• Female more hypertensive than males but in older age group in
which disease is relatively benign. Before 50 years hypertension is
more common in males.
• Black affected twice as compared to whites & more vulnerable to
complications.
• With screening criteria of 160/95 mm of Hg prevalence is about 18%.
• About 90% of cases hypertension is Essential or Idiopathic or
Primary Hypertension. 10% cases it is Secondary Hypertension.
• Labile Hypertension – patients who sometimes not always have
arterial pressures within hypertensive range.
• White Coat Hypertension – hypertensive recordings seen only in a
clinician’s office or settings.
 Hypertension
Classification of Blood Pressure according to JNC 7th Report

BP classification Systolic BP mmHg Diastolic BP mmHg

Normal < 120 < 80

Pre-hypertension 120 – 139 80 – 89

Stage – 1 140 – 159 90 – 99

hypertension

Stage – 2  160  100

hypertension
Normal Control of Blood Pressure Humoral Factors

Blood volume Constrictors Dilators

Sodium Angiotensin Prostaglandin
Mineralocorticoids Cathecolamines Kinins
ANP Thromboxane NO & EDRF
Leukotrines
Endothelin

B.P = CARDIAC OUTPUT x PERIPHERAL RESISTANCE

Constrictors Autoregulation
- adrenergic Ionic (pH) &
Cardiac Factors Hypoxia
Dilators
Heart Rate
Contractility -adrenergic
Neural Factors Local Factors

ANP= Atrial natriuretic peptide, NO= Nitric oxide, EDRF= Endothelium derived growth factor.
 Hypertension

Reduction in Renin release

Blood pressure or from Kidneys
Distal tubular Sodium

Angiotensinogen

Angiotensin I Angiotensin II

Aldosterone secretion
RENIN
Vasoconstriction
ANGIOTENSIN
ALDOSTERONE Sodium & fluid
SYSTEM retention
 Peripheral
resistance Cardiac output

Elevation of Blood Pressure

 Hypertension
Hypothetical Pathogenesis of Essential Hypertension

Defect in Renal Sodium Excretion

+  Neurohormonal release
Excess Salt intake

Inadequate Sodium excretion

+ Generalized
defect in
Excess salt intake + Sodium/Calcium
transport
Salt & water retention
 ANP
 Plasma & ECF volume  Vascular reactivity

 Cardiac output (Autoregulation)  Total peripheral resistance

HYPERTENSION
 Hypertension
MAIN CAUSES & FACTORS IN PATHOGENESIS OF HYPERTENSION
• Essential Hypertension
– Genetic defect in Renal Sodium excretion.
– Genetic defect in Sodium/Calcium transport in vascular smooth muscle.
– Increased vasoconstrictive influences – behavioral, neurogenic, hormonal.
• Secondary Hypertension
– Renal Parenchymal disease – glomerular, tubular interstitial & polycystic kidneys.
– Renovascular diseases – renal A stenosis, fibromuscular dysplasia, vasculitis.
– Endocrine causes – hyperaldosteronism, cushing’s syndrome, pheochromocytoma,
thyroid & parathyroid diseases.
– Vascular causes – coarctation of Aorta, vasculitis.
– Drug induced & drug related – chronic steroid therapy, oral contraceptives, NSAIDs,
sympathomimetics, TCAs, erythropoietin, licorice, illicit drugs (cocaine etc).
– Neurogenic causes – psychogenic, raised intracranial pressure, sleep apnoea
syndrome.
– Pregnancy induced hypertension.
• Risk Factors
– Genetic factors, sex, age, stress, obesity, inactivity, high salt intake, smoking,
alcohol, illict drugs, dyslipidemia, diabetes mellitus, metabolic syndrome X.
 Hypertension
Complications of untreated Hypertension
(TOD – Target organ damage)
• Related to sustained elevation of blood pressure (systolic/diastolic or
both) progressive causing excess morbidity & mortality.
• The risk is almost doubled for each 6 mm Hg increase in diastolic B.P.
1. Hypertensive Cardiovascular disease.
• Left ventricular hypertrophy, LV diastolic dysfunction, Congestive Cardiac
failure, Myocardial ischemia, Ventricular arrhythmias, Sudden death.
2. Hypertensive Cerebrovascular disease.
• Stroke, Infarction or Hemorrhage, Hypertensive Encephalopathy, Cognitive
Brain dysfunction, Dementia.
3. Hypertensive Renal Disease.
• Hypertensive nephropathy, Benign nephrosclerosis, Malignant
nephrosclerosis, acceleration of other renal diseases.
4. Hypertensive Retinopathy.
• A.V nipping, hemorrhages, exudates, papilloedema.
5. Aortic dissection.
6. Atherosclerotic complication.
 Hypertension
• CLINICAL FEATURES.
– SYMPTOMS – (related to type, cause, duration & TOD)
– Asymptomatic, non-specific headache, pulsating occipital or temporal
headaches, palpitation, giddiness, somnolence, confusion, visual
disturbance, tinnitis, vertigo, nausea & vomiting.
– Symptoms related to target organ damage (TOD).
– Symptoms related to underlying disease in case of secondary hypertension.
– SIGNS – (related to type, cause, duration & TOD)
– Elevated blood pressure (B.P should be checked in 2 arms, leg, supine,
sitting, lying, two different times under basal conditions)
– Rarely intra-arterial pressure measurements.
– Examination of Retina for hypertensive retinopathy.
– Examination of peripheral pulses for Coarctation, vasculitis & dissention.
– Examination of Heart & Arteries for rhythm, heart sounds, murmurs, bruits.
– Examination of Nervous, Endocrine & Renal systems.
– Identification of resistant hypertension, hypertensive urgencies &
emergencies.
 Hypertension
• Resistant Hypertension
– Defined in JNC 7 report as failure to reach blood pressure control in patient
who are adherent to full dose of an appropriate three-drug regimen
including a diuretic.
• Hypertensive Urgencies
– Situations in which blood pressure must be reduced within few hours.
– Asymptomatic severe hypertension (systolic > 220 & diastolic > 125 mmHg)
– Optic disc edema & progressive TOD.
• Hypertensive Emergencies
– Situations in which substantial reduction in blood pressure is essential
within 1 hour to avoid risk of serious morbidity or death.
– Hypertensive Encephalopathy & Nephropathy.
– Intra-cranial hemorrhage.
– Aortic dissection.
– Pre-eclampsia & Eclampsia.
– Pulmonary edema, unstable angina, Myocardial infarction.
– Malignant hypertension.
 Hypertension
• Malignant Hypertension
– Characterized by sever hypertension ( diastolic B.P > 130 mmHg)
encephalopathy or nephropathy with accompanying papilledema and
progressive renal failure ensues if treatment is not provided.
• Accelerated Hypertension
– 5% of hypertensive patients show a rapidly rising blood pressure which if
untreated leads to death within a year or two due to TOD or malignant
hypertension.
• LABORATORY INVESTIGATIONS.
– Routine Blood & Urine examination. – Chest X-Ray.
– Urinary Sodium excretion.
– Echocardiography.
– Renal function tests.
– Serum Electrolytes. – Abdominal Ultrasonography.
– Plasma Renin & Aldosterone levels. – Renal Imaging studies.
– Blood Glucose levels. – CT – scan or MRI.
– Fasting Lipid profile.
– Renal Arteriography.
– Tests for Endocrine disorders.
 Hypertension
• MANAGEMENT OF HYPERTENSION
• Non-pharmacological Therapy.
– Life style modification, relaxation & recreation.
– Dietary modification, low sodium intake, fruits, vegetables, low fat dairy
foods & low in saturated fats.
– Weight reduction & treatment of Obesity.
– Healthy exercise programs.
– Reduction in Alcohol intake, quit smoking.
– Calcium & Potassium supplements.
– Control of illicit & other drugs causing hypertension.
• Pharmacological Therapy.
– Diuretics. –  - Adrenoceptor antagonists.
–  - Adrenergic blocking agents. – Centrally acting sympatholytics.
– Calcium channel blocking agents. – Arteriolar dilators.
– ACE – inhibitors. – Peripheral sympathetic inhibitors.
– Angiotensin II receptor blockers. – Parenteral antihypertensives.