Dr.

Alka
B.N.Y.S. M.D. Nutrition and Dietetics JR2
 Content
 Case Study
 Anatomy and Physiology of GIT
 Structure and Function of Stomach
 Physical Examination
 Introduction to Gastritis
 Epidemiology
 Etiology
 Pathophysiology
 Diagnosis
• Differential Diagnosis
• Management through Naturopathy and Yoga
 Preliminary Data
• Name- Shobhnath Pal
• Age- 45 Years
• Gender- Male
• Marital status: Married
• Address- Gaziabad
• Occupation- Truck Driver
Chief complaint/present illness:-
• C/o burning pain in upper abdomen and chest since 1 month
• C/o- Pain in abdomen i.e. epigastric and left hypochondriac and
indigestion since 20 days
• C/o- Passing black stool since 20 days
History of Chief Complaint: Patient was apparently well until 3
month back as he was suffered from abdominal pain , fullness of
upper abdomen after taking meal & loss of appetite from last 4-5
moths but he just usually took medicine from near by chemist but
before 1 month he started complaining of burning in chest , pain in
upper abdomen and indigestion since 20 days, passing black stool
and before 15 days he was complaint of nausea and vomiting.
Abdominal pain is aggravating after eating and drinking warm
liquid and tenderness was present, even though after taking
medicines for 5 days, patient’s condition didn’t improved. The
complaints were standstill.
.
• History of Past illness: not a case of DM, HTN and epilepsy.
• History of Past treatment: Patient was on allopathic
medications.
• Drug History: Syrup Antacid 2 tsf-TDS
Metronidazole-1 BD
Pantoprazole -1 AC
Mox-500mg -1BD
• Family History: Not relevant
 Personal History

 Diet- Mixed (Non Veg- 3-4 times/week)

 Appetite- Loss of appetite
 Thirst- Not adequate
 Habit: Tea- 2 times a day
 Sleep: Disturbed
 Bowel: Irregular
 Micturition: Less in frequency
 Addiction: Smoking- 1 bundle of bidi in a day
Alcohol- 3-4 drinks in a day
General Physical Examination
 Built: Fatigued
 Nutrition: Average
 Gait: Normal
 Icterus: absent
 Pallor: Present
 Cyanosis: absent
 Clubbing: absent
 Mouth: Halitosis
 Lips: Bluish black discolouration
 Hair: Greying of hairs
 Skin: Dry
 Tongue: coated
 Ear: no discharge
 Nose: no DNS
 Vital signs
 Pulse: 92 bpm
 BP: 130/80 mmHg
 RR: 14 cycles/min
 Temperature: Afebrile
 Weight: 75 kg
 Height: 5.7 inch
 BMI : 25.9 kg/m2
The gastrointestinal tract (GIT)
consists of a hollow muscular tube
starting from the oral cavity, where
food enters the mouth, continuing
through the pharynx, oesophagus,
stomach and intestines to the rectum
and anus, where food is expelled.
There are various accessory
organs that assist the tract by
secreting enzymes to help break down
food into its component nutrients.

Syed, Ayesha. (2020). 1.clinical applied anatomy and physiology of git system.
10.13140/RG.2.2.24737.63842.
 GI tract is formed by two types of organs:

1. Primary digestive organs

2. Secondary digestive organs

1. Primary Digestive Organs

i. Mouth
ii. Pharynx
iii. Esophagus
iv. Stomach
v. Small intestine
vi. Large intestine
2. Accessory Digestive Organs
i. Teeth
ii. Tongue
iii. Salivary glands
iv. Exocrine part of pancreas
v. Liver
vi. Gallbladder.
1. Mucus layer
2. Submucus layer
3. Muscular layer
4. Serous or fibrous layer.
NERVE SUPPLY TO GASTROINTESTINAL TRACT

GI tract has two types of nerve supply:

I. Intrinsic nerve supply

II. Extrinsic nerve supply.
INTRINSIC NERVE SUPPLY –
EXTRINSIC NERVE SUPPLY
Stomach is a hollow organ situated just
below the diaphragm on the left side in
the abdominal cavity.
•Shape:- ‘J’ shaped
•Location:- 10th Thoracic and 3rd
lumber.
•Volume of empty stomach is 50 mL.
Under normal conditions, it can expand
to accommodate 1 L to 1.5 L of solids
and liquids.
„ PARTS OF STOMACH
In humans, stomach has four parts:
1. Cardiac region
2. Fundus
3. Body or corpus Syed, Ayesha. (2020). 1.clinical applied anatomy and
4. Pyloric region. physiology of git system. 10.13140/RG.2.2.24737.63842.
 Storage Formation
function of Chyme

Digestive Function of pepsin

Function
 Appearance of the Vital Signs Skin
Patient

May appear pale. Vital signs are Pallor may

Some patients may usually normal. observed in
appear fatigued patients
Normal vesicular Chest tenderness may be Epigastric tender
present on palpation in
breath sounds are case of H.pylori infection
ness may be
observed. associated gastritis present.

Halitosis may be Gastritis associated

with gastric ulcers
observed in case of S1 and S2 are normal
may result in blood
chronic gastritis. loss.
ABDOMINAL EXAMINATION
ABDOMINAL REGION

Dr. Navneet Vats

 Inspection
1. Shape of the abdomen /Contour – Distention (5Fs) or
retardation and Flat .
2. Skin of the abdomen – Straie, discoloration, Scars , dilated
veins
3. Umblicus – Inverted (Normal) and Everted (Ascites) or Hernia
4. Abdominal movements
 Auscultation
● Bowel sounds –
 Gurgling sound- Normal
 Grumbling sound- Bowel obstruction
 No sound- Peritonitis, Intestinal ischemia.
● Bruits
 Abdominal Aortic Bruit
 Renal artery Bruit
 Iliac bruit
Best sites for picking up Bruits
 Hepatic bruit
• Rubs
 Percussion
● Shifting Dullness
● Horseshoe shaped dullness
● Fluid thrill
(Tympany sound – Air, Dull sound – Fluid and organ)
 Palpation
1. Superficial palpation/ light palpation-
a. Feel of the abdomen: Elastic or rigidity
b. Tenderness and Temperature
2. Deep palpation for liver , spleen, kidney
• What is gastritis?
 Inflammation of gastric mucous membrane is called gastritis.
 It may be acute or chronic.
• Acute form (Sudden or transient)
• Chronic form (prolonged).
• Acute gastritis:
 It is characterized by inflammation of superficial layers of mucous
membrane and infiltration with leukocytes, mostly neutrophills.
• Chronic gastritis:
 It involves inflammation of even the deeper layers and infiltration
with more lymphocytes. It results in the atrophy of the gastric mucosa
with loss of chief cells and parietal cells of gland, therefore the
secretion of gastric juice decreases.

Syed, Ayesha. (2020). 1.clinical applied anatomy and physiology of git system.
10.13140/RG.2.2.24737.63842.
• Gastritis may be acute or chronic. Sudden, severe inflammation of
the stomach lining is called acute gastritis. Inflammation that lasts
for a long time is called chronic gastritis.
•Acute gastritis is more common in the young; chronic gastritis is
more often found in adults.
 Epidemiology
• Autoimmune gastritis is more common in women and older people. The
prevalence is estimated to be approximately 2% to 5%. Helicobacter
pylori (H. pylori) is the most common cause of gastritis worldwide
• The prevalence of H. pylori infection in children in the western population is
approximately 10% but about 50% in developing countries.
• In developing countries, the overall prevalence of H. pylori varies
depending on geographical region and socioeconomic conditions. It is
approximately 69% in Africa, 78% in South America, and 51% in Asia.
• Socioeconomic and environmental hygiene are the essential factors in the
transmission of H. pylori infection worldwide. These factors include family-
bound hygiene, household density, and cooking habits

Azer SA, Akhondi H. Gastritis. [Updated 2022 Jul 4]. In: StatPearls [Internet]. Treasure Island (FL):
StatPearls Publishing; 2022 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK544250
 Etiology
• What are the most common causes of acute gastritis?
.Heavy use of Aspirin (most common) and others NSAIDs .1
.Infection- H.pylori infection (Urease positive bacilli) .2
Sepsis (Streptococcal sepsis& Viral gastritis in .3
immunosuppression) e.g. CMV and Candida in AIDS patients

.Excessive Alcohol consumption .4

.Heavy Smoking .5
.Stress (major surgery, burns and trauma).6

Azer SA, Akhondi H. Gastritis. [Updated 2022 Jul 4]. In: StatPearls [Internet]. Treasure Island (FL):
StatPearls Publishing; 2022 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK544250/
 • What are the most common causes of acute gastritis?

.Shock-related mucosa ischemia (burns, brain trauma, surgery) .7

.Ingestion of acids and alkali (accidently, suicidal ingestion) .8
. Parasitic: Anisakis (worm associated with eating raw fish) .9
.Radiation (radiotherapy), and chemotherapy .10
Bile reflux gastritis and uremia .11

Azer SA, Akhondi H. Gastritis. [Updated 2022 Jul 4]. In: StatPearls [Internet]. Treasure Island (FL):
StatPearls Publishing; 2022 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK544250/
 PATHOPYSIOLOGY
•H.pylori-associated gastritis transmission is via the fecal-oral route.
•H. pylori possess several virulence factors which facilitate cell adhesion
,cell damage and disruption of tight junctions, and evasion from the
immune response .
• In particular, the cytotoxin-associated gene a (CagA) is considered a
potent inducer of inflammation and correlate with gastric cancer
development.
•Another factor influencing H. pylori pathogenic effects is host factors.
•The infection with H. pylori triggers IL-8, which attracts neutrophils
which release oxyradicals leading to cell damages. Lymphocyte
infiltration is also present in H. pylori infection.
•NSAIDs cause gastritis through inhibition of prostaglandin synthesis.
Prostaglandins are responsible for the maintenance of protective
mechanisms of gastric mucosa from injuries caused by hydrochloric
acid.
 ETIO PATHOGENESIS

•Gastritis develop because of –

•Fall in mucosal defenses.
•Decreased mucosal blood flow.
•Delayed gastric emptying.
•Impaired epithelial restitution.
•Impaired prostaglandin synthesis.

Vinay kumar, Abul K.Abbas, Nelson Fausto, Jon C. Aster. Robbins and Cotran Pathologic
basis of disease. 8th edition
 ETIOLOGICAL FACTORS

H.PYLORI INFECTION
• Host factors as well as variation among H.pylori strains
determine the clinical outcomes.
• Helicobacter Pylori is Gram negative, nonsporing curvilinear
bacilli, measuring 5 x 0.5 µm.
• H.pylori genome encodes 1500 proteins
• H.pylori causes gastritis by 2 ways :
 Direct injury of epithelial cells.
Stimulating production of pro-inflammatory cytokines
(IL – 1β and TNF).

Dixon MF, Genta RM, Yardley JH, Correa P. Classification and grading of gastritis. The updated
Sydney System. International Workshop on the Histopathology of Gastritis, Houston 1994. Am J
Surg Pathol. 1996 Oct;20(10):1161-81.
 •H.pylori moves in the viscous mucin layer via flagella .
•It has Urease which produces ammonia from endogenous urea
and buffers gastric acid in the immediate vicinity of organism.
•Expresses of Bacterial adhesins that enhances the bacterial
adherence to foveolar cells

Dr.A.K Mandal, Dr. Sharmana Choudhary. Diseases of Gastrointestinal tract. In: Text Book
for Pathology for MBBS Second series, volume II:2018
Pathogenesis of Helicobacter pylori Infection
Johannes G. Kusters , Arnoud H. M. van Vliet , and Ernst J. Kuipers
H.pylori gastritis –
• Gastric mucosal defense is broken down by bacterial urease,
protease, catalase and phospholipase.
• Host factors – H.pylori infected mucosal epithelium and
releases proinflammatory cytokines such as IL-1, IL-6, Il-8 and
tumor necrosis factor –alpha.
• Bacterial factors – epithelial injury induced by Cag A protein
and Vac A which induces secretion of cytokines
 Clinical features of Acute gastritis

• Most critically ill patients admitted to hospital ICU.

1.Asymptomatic.
2.Epigastric pain.
3.Nausea.
4.Vomiting.

5.Bleeding from superficial gastric erosions or ulcers that may

require transfusion (Gastric Mucosal damage).
Common risk factors in the development of gastritis include alcohol, NSAIDs,
cocaine, crohn’s disease, HIV/AIDS and bacterial infections such as
Helicobacter pylori.[1][2][3][4][5]

Common Risk Factors

Excessive amounts of alcohol (acute gastritis)
Cigarette smoking
Excessive amounts of caffeine or acidic beverages
Medications such as aspirin or other nonsteroidal anti-inflammatory drugs
(NSAIDs)
Cocaine addiction
Stress resulting in excessive gastric acid secretion
Bacterial infection such as Helicobacter pylori (H. pylori)
Increasing age
HIV/AIDS
Specific areas of focus when obtaining a history from the patient include
history of:

• Nausea & vomiting

• Previous laboratory findings
• Epigastric or abdominal pain
of anemia
• Bloating
• A positive family history
• Pain aggravating or relieving of gastrointestinal
with food diseases or H. pylori nfection
• Gastrointestinal bleeding • History of medication use
• Anorexia (e.g. NSAIDS)
• Weight loss • Food and drinking water
• Pallor hygiene
 Differentiating gastritis from other Diseases:
Acute Gastritis
Crohn's Disease
Gallstones (Cholelithiasis)
Gastric cancer
Peptic Ulcer Disease
Viral Gastroenteritis
Chronic Gastritis
Atrophic Gastritis
Gastroesophageal Reflux Disease (GERD)

Sipponen P (1989). "Atrophic gastritis as a premalignant condition". Ann Med. 21 (4): 287–90. PMID 2789799.
Jump up↑ Badillo R, Francis D (2014). "Diagnosis and treatment of gastroesophageal reflux disease". World J Gastrointest Pharmacol
Ther. 5 (3): 105–12. doi:10.4292/wjgpt.v5.i3.105. PMC 4133436. PMID 25133039.
Jump up↑ Ramakrishnan K, Salinas RC (2007). "Peptic ulcer disease". Am Fam Physician. 76 (7): 1005–12. PMID 17956071
 Investigations in a patient of Chronic Gastritis

Investigation Significance

Gastric mucosal biopsy For diagnosis of chronic gastritis &

indicates etiology.
Parietal cell antibody (serum) Presence indicates chronic gastritis.

H.PYLORI antibody (IgG) Indicates past H pylori infection

Urea Breath Test Confirmation eradication or presence of

H.pylori
H.pylori faecal antigen test Confirmation eradication or presence of
H.pylori

Dr. Navneet Vats

Endoscopic diagnostic tests are biopsy-based diagnostic
methods for H. pylori infection. This include:
Histology
Rapid urease test
Culture
Polymerase chain reaction
 Endoscopic testing
1. Histology
2. Rapid urease testing
3. Culture
4. Polymerase chain reaction
Advantages
Excellent sensitivity (>95%) and
specificity (95%)
Inexpensive and provides rapid
results
Excellent specificity (98%) and
very good sensitivity in properly
selected patients
Excellent specificity (99%)
Excellent specificity
Allows determination of antibiotic Poor sensitivity if adequate
sensitivities
Excellent sensitivity and
specificity
Allows determination of antibiotic
sensitivities
Disadvantages
Expensive and requires
infrastructure and trained
personnel
Detection improved by use of spec
ial stains- e.g. the Warthin-Starry s
ilver stain, or the cheaper giemsa s
tain protocol
Sensitivity significantly reduced
in the post-treatment setting
Expensive, difficult to perform
and not widely available
transport media are not available
Experience/ expertise required
Methodology not standardized
across laboratories and not widely
available
Considered experimental
• Relieve the Symptoms
• To prevent further complication .
• Prevention
– Risk factors & change faulty lifestyle and diet pattern
• Life style modification
 NATUROPATHY & YOGA

Title and Author Journal and Year Intervention Conclusion

EFFICACY OF YOGA European Journal of Patients were given There is strong

AND NATUROPATHY IN Biomedical Naturopathy evidence from
THE MANAGEMENT OF AND Pharmaceutical and Yoga prospective results to
GASTRITIS. sciences. interventions. It support the positive
2020 includes yoga, effects of alternative
Sudhamshi Beeram et hydrotherapy, systems of
al. diet therapy, mud medicine on Gastritis
therapy and by expanded use of
manipulative therapy. healthy bland
The following and alkaline diet,
integrated yoga and stress management,
naturopathy protocol hydrotherapy and
was used for all the mud therapy
subjects for ten days treatments and
duration. practice of yoga
among
individuals victimized
by gastritis.
 Diet and Nutrition

Title and Author Journal and Year Intervention Conclusion

Nutritional care in ABCD = Brazilian Probiotics for treating A balanced diet is

peptic ulcer. archives of digestive infection by H. pylori, vital in the treatment
surgery. because it plays a of peptic ulcer and
Nathália Dalcin VOME 2014 crucial role in the chronic gastritis, once
RO pathogenesis of food can prevent,
et al. chronic gastritis and treat or even alleviate
peptic ulcer. the symptoms
Thus, an intake of 10⁹ involving this
to 10¹¹ CFU/day of pathology.
lactic acid bacteria is
recommended in
adults.
Title and Author Journal and Year Intervention Conclusion

Honey and green/black Diagnostic Helicobacter pylori In conclusion, honey

tea consumption may Microbiology and infection in 150 and green/black tea
reduce the risk of Infectious Disease. dyspeptic patients intake is associated
Helicobacter pylori 2015 examined with reduced
infection. endoscopically and by prevalence of H. pylori
Lyudmila Boyanova et the urea breath test. infection.
al. Positivity rate was
lower (50.6%) in
patients consuming
honey ≥1 day weekly
compared with the
remainder (70.8%)
and in those
consuming
green/black tea ≥1
day weekly (45.2%)
compared with the
other patients (64.8%)
Title and Author Journal and Year Intervention Conclusion

The Gastro-protective Advanced This is a pilot study 3 g/d ginger powder

Effect of Ginger pharmaceutical on 15 patients supplementation in
(Zingiber bulletin. with H. pylori positive patients with H.
officinale Roscoe) 2019 FD received 3 g/d pylori positive FD
in Helicobacter ginger powder as accompanied by
pylori Positive three 1-g tablets for significant
Functional Dyspepsia. 4-weeks. eradication of H.
Vahideh Ebrahimzade pylori and
h Attari improvement in
et al. dyspeptic symptoms.
Title and Author Journal and Year Intervention Conclusion

Assessment of Avicenna journal of In this clinical trial, 15 Raw garlic has anti-
antibacterial effect of phytomedicine. patients were studied bacterial effects
garlic in patients 2016 in which 3rd Urea against H.
infected breath test was pylori residing in the
with Helicobacter diagnosed three days stomach and may be
pylori using urease after prescribing two prescribed along
breath test. medium-sized cloves with routine drugs
Mahmoud Zardast et of garlic (3 g) with for the treatment of
al. their meal, twice a gastric H.
day (at noon and in pylori infection.
the evening).
Title and Author Journal and Year Conclusion

Impact of Dietary Patterns Pathogens, 2021 Dietary consumption of walnuts

on H. pylori Infection and
the Modulation of
Microbiota to Counteract Its
Effect. A Narrative Review.
Ascensión Rueda-Robles et
al.
rich in n-3 polyunsaturated fatty
acids were proposed as a
nutritional intervention to
prevent H. pylori .
Omega-3 polyunsaturated fatty
acids, present in many fish and
seafood species, as well as plenty of
nuts and seeds, were proposed as a
therapy against H. pylori infection.
Dr. Navneet Vats
Title and Author
Growth inhibitory action of
cranberry on Helicobacter
pylori.
Masashi Matsushima et al.
Journal and Year Conclusion
J Gastroenterol Hepatol. Cranberry extract suppressed
2008 bacterial proliferation in a dose-
dependent manner.
In the comparison with other juices,
polyphenol-rich fruits (cranberries,
blueberries, and red grapes) showed
growth inhibitory activity, whereas
polyphenol-poor fruits (oranges,
pineapples, apples, and white grapes)
did not show any activity. The
polyphenol-rich fraction of cranberry
maintained the H. pylori-growth
inhibitory activity.
Title and Author Journal and Year Conclusion

Effects of curcumin Annals of translational Curcumin has been evaluated as a

on Helicobacter medicine. potential anti-H. pylori agent.
pylori infection. 2016 A mouse study showed that orally-
given curcumin caused significant
Vaclav Vetvicka et al. inhibition of gastric inflammation
induced by H. pylori infection
Title and Author Journal and Year Conclusion

The In Vitro Activity of Molecules. The activity in vitro of the five

Essential Oils 2020 essential oils silver fir, pine needle,
against Helicobacter tea tree, lemongrass, and
Pylori Growth and Urease cedarwood oils against H. pylori was
Activity. found in this paper for the first time.
The most active against clinical
strains of H. pylori were cedarwood
and oregano oils. cedarwood oil
inhibited the urease activity at sub-
inhibitory concentrations. This
essential oil can be regarded as a
useful component of the plant
preparations supporting the
eradication H. pylori therapy.
 MASSAGE THERAPY

Title and Author Journal and Year Intervention Conclusion

Efficacy and safety of Medicine, Interventions will This proposed study

massage therapy for 2020 include any type of will evaluate the
chronic atrophic clinically performed effectiveness and
gastritis. massage for safety of massage
improvement of therapy for patients
Ke-Lin Zhou et al. chronic atrophic with chronic atrophic
gastritis. This will gastritis.
include Chinese
massage, Japanese
massage, Thai
massage,
Swedish massage,
Tuina, Shiatsu,
remedial massage.
 ACUPUNCTURE

The selection of acupoints in treating Peptic ulcer-

•CV-12
•St-36
Electro-acupuncture at St-2, St-25, St-36 has been shown to
enhance gastric motility, improve gastric mucosal blood flow.

Nair, Pradeep & Salwa, Hyndavi & K, Satyalakshmi. (2017). Clinical Naturopathy: A Manual for
physicians and students.
 HYDROTHERAPY & MUD THERAPY

•Gastro Hepatic Compress for 30 mins. ( It prevents or mitigates

congestion over the abdominal area which is the main reason for
inflammation and indurations.)
•Alternate Hot and cold hip bath for 20 mins. (This enhances blood
flow which helps to eliminate algogenic chemicals and facilitates muscle
relaxation.
•Cold Mud Pack (Influence prostaglandins and leukotrienes, which
prevent unwanted aggregation of platelets .)

Nair, Pradeep & Salwa, Hyndavi & K, Satyalakshmi. (2017). Clinical Naturopathy: A Manual for
physicians and students.
 HELIOTHERAPY AND CHROMOTHERAPY

• Exposure to Sun for 15-20mins is an effective treatment for

management of Peptic ulcer.
•Green color is used for treating ulcers as it restores the balance in the
body.
•Direct exposure of green color over the abdominal area through green
filters or charged water and chromothermoleum.

Nair, Pradeep & Salwa, Hyndavi & K, Satyalakshmi. (2017). Clinical Naturopathy: A Manual for
physicians and students.
 HERBOLOGY

• Aegle marmelos ( Indian Bael)- The aqueous extract of its leaves is to

be administered orally for 21 days in the daily dose of 1 gm/kg for
significant reduction in ulcer.
•Allium sativum (Garlic)- The extract of its bulb is known to increase
the healing of gatric ulcer and also prevents the development of gastric
and duodenal ulcer.
•Aloevera (Aloe gel)- Its oral intake has significant anti-ulcer activity.
•Annona squamosa (Custard apple, sitaphal) : The extract of its
leaves is known to heal gastric ulcers.

Nair, Pradeep & Salwa, Hyndavi & K, Satyalakshmi. (2017). Clinical Naturopathy: A Manual for
physicians and students.