Gastric contents examination

Gastric contents examination

1. GASTRIC CONTENTS EXAMINATION SUNIL KUMAR.P DEPARTMENT OF CLINICAL PATHOLOGY ST.JOHN’S MEDICAL COLLGE BANGALORE 4/18/2018 1 SUNIL KUMAR.P

2. Contents ……….. Introduction Composition Gastric fluid secretion Indications & Contraindications Collection Analysis Disadvantages of GA 4/18/2018 2 SUNIL KUMAR.P

3. Gastric Juice A colorless to grayish or yellowish watery fluid w/ a low specific gravity secreted by the surface epithelium, gastric cells and the various glands of the gastric tract. 4/18/2018 3 SUNIL KUMAR.P

4. GASTRIC ACID SECRETION There are three phases of gastric acid secretions : 1.Cephalic phase : Caused by Sight, smell, taste, or thought of food 2.gastric Phase : Caused by entry of food into stomach….Increased pH caused by food 3.Interstital phase : hormones produced by small intestine. 4/18/2018 4 SUNIL KUMAR.P

5. Function of Gastric Secretion The gastric chief cells of the stomach secrete enzymes for protein breakdown (inactive pepsinogen, and in infancy rennin). Hydrochloric acid activates pepsinogen into the enzyme pepsin, which then helps digestion by breaking the bonds linking amino acids, a process known as proteolysis. 4/18/2018 SUNIL KUMAR.P 5

6. INTRODUCTION Gastric analysis involves quantification of gastric acid produced by the stomach. It is usually collected by inserting a nasogastric tube into the stomach and aspirating the contents for analysis. 4/18/2018 6 SUNIL KUMAR.P

7. Chemical examination of gastric contents has limited but specific value in diagnosis & assessment of disorders of upper GIT 4/18/2018 7 SUNIL KUMAR.P

8. Normal fasting gastric juice per day is about 1L Stomach of a person taking a normal diet secretes 2L-3L of gastric juice per day 4/18/2018 8 SUNIL KUMAR.P

9. During resting period During digestion after meals After s timul a tion 4/18/2018 9 SUNIL KUMAR.P

10. HCl secreted by PARIETAL CELLS Pepsinogen Secreted by CHIEF CELLS Intrinsic factor Required for absorption of Vitamin B 12 Al k al i ne mu c ous Which coats the gastric walls act as lubricant 4/18/2018 10 SUNIL KUMAR.P

11. I N D I C A T I O N S To diagnose Gastric Ulcers To exclude the diagnosis of Pernicious anaemia & Peptic ulcer For presumptive diagnosis of Zollinger Ellison Syndrome To determine the completeness of Surgical Vagotomy. 4/18/2018 11 SUNIL KUMAR.P

12. Indications of G astric Analysis 1.Recurrent peptic ulcer disease ( gastrin -produced tumour etc) 2.To diagnose pernicious anaemia 3.Help to differentiate b/w benign ulcer and malignant ulcer (benign usually associated with increased acid secretion) 4/18/2018 12 SUNIL KUMAR.P

13. Contra indications of GA 1. Oesophageal varices or stricture 2.Esophageal malignancy 3. Severe hemorrhage 4.Heart ailments : arrhythmias, heart failure 5.pyloric stenosis 4/18/2018 13 SUNIL KUMAR.P

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15. NASOGASTRIC TUBE INSERTION Requirements : 1. Fine bore nasogastric feeding tube with radio-opaque line and g uide wire. 2.pH indicator paper 3.Non sterile gloves 4 .Clinically cleaner receiver 5.Tissues 6.Fixative tape 4/18/2018 15 SUNIL KUMAR.P

16. METHOD OF NASOGASTRIC TUBE INSERTION ( PROCEDURE) 1. The procedure should be explained to the patient beforehand. 2.The patient should ideally be sitting in an upright position with slight flexion of head. 3.If unable to sit the patient may be allowed to lie on any side. 4.wear gloves after cleaning the hands 5.The distance of the tube to be inserted is measure by measuring distance from the patients bridge of the nose to the ear lobe and adding the distance from the bridge of the nose to xiphisterneum 4/18/2018 16 SUNIL KUMAR.P

17. 6.the tip of the tube needs a little lubrication before inserting into nose.(sterile water or saline) 7.The tube is advanced slowly into the nostril pointing horizontally towards the floor of the nasal cavity. 8.Once the Pt. Feels tube in his nasopharynx , he is instructed to perform swallowing action. 9.As he swallows the tube is gently pushed forward. 4/18/2018 17 SUNIL KUMAR.P

18. 10.When the limiting mark on the tube is reached, stop advancing the tube. 11.Lightly tape the tube to the cheek. 4/18/2018 18 SUNIL KUMAR.P

19. Analysis of Resting contents Gastric Residuum Fractional gastric analysis using a test ‘meal’ Fractional Test Meal Analysis St imul a ti o n b y A l c oho l o r C a f f eine o r Hi s t amine or Insulin or Pentagastrin Analysis after Stimulation Used as screening test Tubeless Gastric Analysis 4/18/2018 19 SUNIL KUMAR.P

20. V olume Consistency Colour Bi l e Blo o d Mucus Pepsin Free acidity Total acidity O r g anic acid 4/18/2018 20 SUNIL KUMAR.P

21. Macroscopic Examination Volume: 30 – 60 ml Fasting sample – contains few ml to 50 ml w/ an average of 30 ml Color: Colorless, yellowish or pale gray w/ varying amounts of mucus and food particles Abnormalities in Color: 1.) brownish red or coffee color – presence of large amount of blood. 2.) opaque gray – seen after a test meal 3.) yellow – presence of fresh bile 4/18/2018 21 SUNIL KUMAR.P

22. Abnormalities in Color: 4.) greenish – presence of old bile 5.) red – presence of small amount of blood Odor: Odorless or maybe slightly sour or faintly pungent Abnormalities in Odor: 1.) fecal odor – seen in intestinal obstruction or gastrocolic-fistula 2.) foul or putrid odor – seen in carcinomatous ulcer 3.) alcoholic odor – seen in alcoholic coma, or after alcohol test meal 4.) ammoniacal odor – seen in case of uremia 5.) rancid odor – due to butyric (fatty acid) and lactic acid (present in sour milk) indicating stenosis and fermentation 4/18/2018 22 SUNIL KUMAR.P

23. pH or Reaction: Normally acidic – pH 1.6 to 1.8 High acidity – pH 1.4 or lower Low acidity – pH 2.0 or 2.8 Euchlorhydria – refers to normal secretion w/ a pH bet. 1.6 to 1.8 Hyperchorhydria – increase free HCl above normal around 60 ml i.e . peptic ulcer Hypochlorhydria – decreased free HCl i.e. 1.) carcinoma of the stomach 2.) chronic gastritis 3.) gastric syphilis Achlorhydria – absence of free HCl i.e. 1.) pernicious anemia 2.) pellagra 3.) advanced gastric cancer 4/18/2018 23 SUNIL KUMAR.P

24. Specific Gravity Varies from 1.001 – 1.010 w/ an average of 1.007 CHEMICAL EXAMINATION Acid contents of gastric juice are of 2 types: 1.) Free HCl an acid w/ a pH less than 3.5 2.) Combined HCl or organic acid – an acid w/c combines w/ proteins or protein-like subs to form protein salts of HCl. Test for Free HCl 1.) Topfer’s method 2.) Tubeless gastric Analysis –Diagnex Blue 3.) Boa’s method 4.) Gunzberg method 4/18/2018 24 SUNIL KUMAR.P

25. MICROSCOPIC EXAMINATION Normal Structures 1.) yeast cell – small amounts 2.) epithelial cells 3.) starch granules 4.) bacteria – lesser amounts 5.) fat globules Pathologic Structures 1.) fragments of tissues 2.) rbc 3.) yeast – large amounts 4.) pus cells 5.) muscle fibers 6.) large number of bacteria and maybe seen are: a.) Sarcinae b.) Oppler-Boas bacilli 4/18/2018 25 SUNIL KUMAR.P

26. NORMAL ABNORMAL CAUSES Volume 20 - 50 m L >100-120mL Hypersecretion of Gastric juice Retention due to delayed emptying Regurgitation of duodenal contents Consistency - Fluid Food residues Carcinoma of stomach Colour – clear- colourless or slightly yellowish or green Dark red or brown* Due to blood Bleeding Gastric ulcer Carcinoma of stomach Bile – occasionally Increased amount Intestinal Obstruction and ileal stasis. Mucus - small amount Increased amount Gastritis and carcinoma of stomach 4/18/2018 26 SUNIL KUMAR.P

27. NORMAL ABNORMAL CAUSES Organic acid Lactic acid , butyric acid present in large amount Hypochlorhydria, achlorhydria and Ca stomach Free acidity-measures only HCl. 0-30mEq/L >50mEq/L Hyperacidity Total acidity – includes HCl and other organic acids. Normal 10-40mEq/L Pepsin Decreased levels Increased levels Atrophic gastritis, Ca stomach Zollinger-Ellison syndrome 4/18/2018 27 SUNIL KUMAR.P

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29. Procedure After removing residual contents, meal is given. With intervals of 15 minutes contents of stomach are removed ,strained & analysed Normal response Free acid rises steadily from 15 min – ½ hr/45 min, and decreases 4/18/2018 29 SUNIL KUMAR.P

30. Hyperchlorhydria Free acid >50mEq/L Duodenal ulcer Gastric ulcer Gastric cell hyperplasia Zollinger Ellison Syndrome Hypochlorhydria Ca of stomach Atonic dy s p e p sia Achlorhydria No HCl but pepsin is present Seen in Ca stomach, chronic gastritis Achylia gastrica Both HCl and pepsin are absent Later stage of Ca stomach Chronic g as t r i t i s Pernicious anaemia 4/18/2018 30 SUNIL KUMAR.P

31. Disadvantages of Gastric analysis 1.Unpleasent experience for the patient 2.None of the tests are confirmatory Endoscopy offers more advantages over this method. 4/18/2018 31 SUNIL KUMAR.P

32. Method Acid secretions in the stomach is measured at basal levels and then repeated after stimulation with drugs . Acidity is estimated by the titration method 4/18/2018 32 SUNIL KUMAR.P

33. Duodenal Content examination Sampling of duodenal contents is reliable means of recovery of strongyloides larvae and any other small intestinal parasites. Specimens can be obtained endoscopic ally by intubation or by the use of enteric capsule or string test (Enterotest). With the advent of antigen detection tests these testing's have largely been replaced for gardia and Cryptosporidium, 4/18/2018 33 SUNIL KUMAR.P

34. THANKS 4/18/2018 SUNIL KUMAR.P 34