Anatomy of the Stomach: Regions and Parts

The stomach is a muscular organ located in the upper abdomen that plays a crucial role in digestion. It is divided into several regions and parts, each with its own unique function. Here is a breakdown of the anatomy of the stomach:

Cardia: This region surrounds the opening of the oesophagus into the stomach and is adjacent to the fundus. It is in continuity with the body of the stomach.

Fundus: The fundus is the uppermost region of the stomach that is in contact with the inferior surface of the diaphragm. It is located above the level of the cardial orifice.

Body: The body is the largest region of the stomach and is located between the fundus and pyloric antrum. It has a greater and lesser curvature.

Pyloric antrum: This region is the proximal part of the pylorus, which is the distal part of the stomach. It lies between the body of the stomach and the first part of the duodenum.

Pyloric canal: The pyloric canal is the distal part of the pylorus that leads to the muscular pyloric sphincter.

Understanding the different regions and parts of the stomach is important for diagnosing and treating various digestive disorders.

Treatment Options for Moderate Exacerbation of Distal Ulcerative Colitis

Distal ulcerative colitis can cause moderate exacerbation, which is characterized by 4-6 bowel movements per day, pulse rate <90 bpm, no anemia, and ESR 30 or below. The first-line therapy for this condition includes topical or oral aminosalicylate, with mesalazine or sulfasalazine being the most commonly used options. However, these medications can cause side-effects such as diarrhea, vomiting, abdominal pain, and hypersensitivity. In rare cases, they may also lead to peripheral neuropathy and blood disorders. Codeine phosphate is not used in the management of ulcerative colitis, while ciclosporin is reserved for acute severe flare-ups that do not respond to corticosteroids. Infliximab, a monoclonal antibody against tumour necrosis α, is used for patients who are intolerant to steroids or have not responded to corticosteroid therapy. However, it can cause hepatitis and interstitial lung disease, and may reactivate tuberculosis and hepatitis B. Steroids such as prednisolone can be used as second-line treatment if the patient cannot tolerate or declines aminosalicylates or if aminosalicylates are contraindicated. Topical corticosteroids are usually preferred, but oral prednisolone can also be considered.

Magnetic resonance defecography is the most appropriate investigation for a patient with abnormal pelvic floor muscle tone, perineal descent, and symptoms of incomplete evacuation during defecation. This test evaluates global pelvic floor anatomy and dynamic motion, identifying prolapse, rectocele, and pelvic floor dysfunctions. Other tests, such as abdominal ultrasound, barium enema, colonoscopy, and CT abdomen, may not provide sufficient information on the underlying pathology of the patient’s symptoms.

Obscure gastrointestinal bleeding can be either overt or occult, without clear cause identified by invasive tests. Video capsule endoscopy has become the preferred method of diagnosis, with other methods such as nuclear scans and push endoscopy being used less frequently. Small bowel angiography may be used after capsule endoscopy to treat an identified bleeding point. However, not all suspicious-looking vascular lesions are the cause of bleeding, so angiography is necessary to confirm the actively bleeding lesion. Wireless capsule endoscopy is contraindicated in patients with swallowing disorders, suspected small bowel stenosis, strictures or fistulas, those who require urgent MRI scans, and those with gastroparesis. Scintiscan involves the use of radiolabelled markers to detect points of bleeding in the GI tract. Double balloon endoscopy is a specialist technique that allows for biopsy and local treatment of abnormalities detected in the small bowel, but it is time-consuming and requires prolonged sedation or general anesthesia. Blind biopsy of the duodenum may be considered if all other tests are negative.

Differential Diagnosis for a Patient with Abdominal Pain and Infective Symptoms

A liver abscess is the most probable diagnosis for a patient presenting with fever, abdominal pain, chills, nausea, and vomiting after undergoing an MRCP. Disseminated intravascular coagulation (DIC) is unlikely as the patient does not exhibit characteristic symptoms such as multiorgan failure, shock, widespread bleeding, or clots. Fatty-liver disease could cause similar symptoms but would not have an acute onset or infective symptoms. Hepatitis is a possibility but would typically present with additional symptoms such as dark urine and pale stools. Liver metastases are unlikely to have a sudden onset and infective symptoms. While it is a possibility, a liver abscess is the most likely diagnosis, especially given the patient’s recent MRCP and suspected cholangiocarcinoma.

Differential Diagnosis for a Patient with Elevated Bilirubin Levels

One possible cause of elevated bilirubin levels is Gilbert syndrome, an autosomal recessive condition that results in a deficiency of glucuronyl transferase activity. This condition leads to an increase in unconjugated bilirubin levels, which can become more pronounced during periods of fasting or illness. Treatment for Gilbert syndrome is not necessary, and the prognosis is excellent without significant long-term effects.

Hepatitis A is another possible cause of elevated bilirubin levels, particularly in individuals who have traveled to areas where the virus is common or who have occupational exposure to contaminated materials. Symptoms of hepatitis A include flu-like symptoms, anorexia, nausea, vomiting, and malaise, followed by acute hepatitis with jaundice, pale stools, and dark urine. However, the absence of risk factors and normal alanine aminotransferase levels make hepatitis A unlikely.

Infectious mononucleosis, caused by the Epstein-Barr virus, can also cause elevated bilirubin levels. Symptoms typically include acute tonsillitis and flu-like symptoms, as well as viral hepatitis. However, the absence of upper respiratory tract infection symptoms, normal ALT levels, and the lack of lymphocytosis make this diagnosis unlikely.

Autoimmune hemolysis is another possible cause of elevated bilirubin levels, but normal hemoglobin and lactate dehydrogenase levels make this diagnosis unlikely.

Hepatitis B is a viral infection that is primarily transmitted through sexual contact and intravenous drug use. Symptoms include acute hepatitis with jaundice, and chronic infection can develop in some cases. However, normal ALT levels and the absence of risk factors make this diagnosis unlikely.

Confirming Nasogastric Tube Placement: The Role of Chest Radiograph

Confirming the placement of a nasogastric tube (NGT) is crucial to prevent potential harm to the patient. While pH testing was previously used, chest radiograph has become the preferred method due to its increasing availability and negligible radiation exposure. The NGT has two main indications: enteral feeding/medication administration and stomach decompression. A chest radiograph should confirm that the NGT is passed down the midline, past the carina, past the level of the diaphragm, deviates to the left, and the tip is seen in the stomach. Respiratory distress absence is a reliable indicator of correct placement, while aspirating or auscultating the tube is unreliable. Abdominal radiographs are not recommended due to their inability to visualize the entire length of the NGT and the unnecessary radiation risk to the patient.

Criteria for Urgent Endoscopy Referral

Criteria for urgent endoscopy referral include various symptoms such as dysphagia, dyspepsia, weight loss, anaemia, vomiting, Barrett’s oesophagus, family history of upper gastrointestinal carcinoma, pernicious anaemia, upper GI surgery more than 20 years ago, jaundice, and abdominal mass. Dysphagia is a symptom that requires urgent endoscopy referral at any age. Dyspepsia combined with weight loss, anaemia, or vomiting at any age also requires urgent referral. Dyspepsia in a patient aged 55 or above with onset of dyspepsia within one year and persistent symptoms requires urgent referral. Dyspepsia with one of the mentioned conditions also requires urgent referral.

In the presented cases, the 56-year-old man has dyspepsia with an aortic aneurysm, which requires an ultrasound and vascular opinion. On the other hand, the case of unexplained weight loss, tenesmus, and upper right mass is likely to be a colonic carcinoma. It is important to be aware of these criteria to ensure timely and appropriate referral for urgent endoscopy.

Common Abdominal Exam Findings and Their Significance

Abdominal exams are an important part of diagnosing various medical conditions. Here are some common findings and their significance:

Tenderness over McBurney’s point: This is a sign of possible appendicitis. McBurney’s point is located a third of the way from the right anterior superior iliac spine to the umbilicus.

Grey–Turner’s sign: Flank bruising is a sign of retroperitoneal hemorrhage, which is commonly associated with acute pancreatitis.

Murphy’s sign: This suggests cholecystitis. The examiner places their hand below the right costal margin and the tender gallbladder moves inferiorly on inhalation, causing the patient to catch their breath.

Tinkling bowel sounds: High-pitched, ‘tinkling’ bowel sounds are typically associated with mechanical bowel obstruction.

Absent bowel sounds: This is suggestive of paralytic ileus, which most commonly occurs after abdominal surgery.

Diagnostic and Treatment Options for Non-Ulcer Dyspepsia in Older Patients

Non-ulcer dyspepsia (NUD) is a common condition characterized by upper gastrointestinal (GI) symptoms without any identifiable cause. However, in older patients, these symptoms may be indicative of a more serious underlying condition. Therefore, the National Institute for Health and Care Excellence (NICE) guidelines recommend upper GI endoscopy for patients over the age of 55 with treatment-resistant symptoms.

Gastric motility studies are indicated in gastric disorders like gastroparesis but are not necessary for NUD diagnosis. Proton pump inhibitors or H2 blockers may be tried if alarm symptoms are not present. Anti-Helicobacter pylori treatment may also be considered. However, acupuncture is not validated as an effective treatment for NUD.

In summary, older patients with NUD should undergo endoscopic evaluation to rule out any serious underlying conditions. Treatment options include proton pump inhibitors, H2 blockers, and anti-Helicobacter pylori treatment, but acupuncture is not recommended.