‫د‪ .

‬ﻫﻴﺜﻢ ﺧﻮﺟﻪ‬

‫آﻓﺎت اﻟﺠﻬﺎز اﻟﻬﻀﻤﻲ ‪1‬‬

‫‪2‬‬ ‫ﻣﺮيء ﺑﺎرﻳﺖ‬

‫‪3‬‬ ‫أورام اﻟﻤﺮيء‬

‫‪6‬‬ ‫ﺗﻀﻴﻖ اﻟﺒﻮاب‬

‫‪6‬‬ ‫اﻻﻟﺘﻬﺎﺑﺎت‬

‫‪12‬‬ ‫اﻋﺘﻼﻻت اﻟﻤﻌﺪة اﻟﻀﺨﺎﻣﻴﺔ‬

‫‪13‬‬ ‫اﻟﺒﻮﻟﻴﺒﺎت اﻟﻤﻌﺪﻳﺔ واﻷورام‬

‫‪17‬‬ ‫اﻟﻠﻤﻔﻮﻣﺎ اﻟﻤﻌﺪﻳﺔ‬

‫‪18‬‬ ‫‪H3‬‬
 ‫ ﻫﻴﺜﻢ ﺧﻮﺟﺔ‬.‫د‬ 1 ‫آﻓﺎت اﻟﺠﻬﺎز اﻟﻬﻀﻤﻲ‬ 2 ‫ﻋﻠﻢ اﻷﻣﺮاض‬

‫آﻓﺎت اﻟﻤﺮيء‬

Barrett Esophagus ‫ﻣﺮيء ﺑﺎرﻳﺖ‬

 It is a complication of chronic GERD ‫ ﻳﻌﺪ اﺧﺘﻼﻃﺎ ﻟﺪاء اﻟﺠﺰر اﻟﻤﻌﺪي اﻟﻤﺮﻳﺌﻲ‬
(gastroesophageal reflux disease) ‫ واﻟﺬي )ﻧﻘﺼﺪ ﻫﻨﺎ ﻣﺮيء ﺑﺎرﻳﺖ( ﻳﺘﺼﻒ‬،‫اﻟﻤﺰﻣﻦ‬
characterized by intestinal metaplasia .‫ﺑﺎﻟﺤﺆول اﻟﻤﻌﻮي ﻓﻲ ﻣﺨﺎﻃﻴﺔ اﻟﻤﺮيء اﻟﺤﺮﺷﻔﻴﺔ‬
within the esophageal squamous mucosa.
 It occurs in an estimated 10% of ‫ ﻣﻦ اﻷﻓﺮاد اﻟﻤﺼﺎﺑﻴﻦ‬% 10 ‫ ﻳﺤﺪث ﺗﻘﺮﻳﺒﺎ ﻟﺪى‬
‫ﹰ‬
individuals with chronic GERD; the ‫ رﺟﻼ‬:‫ ﺗﻜﻮن ﺻﻔﺎت اﻟﻤﺮﻳﺾ اﻟﻤﺜﺎﻟﻲ‬،‫ ﻣﺰﻣﻦ‬GERD ‫ب‬
typical patient is a white man between ‫ﹰ‬
.‫ ﻋﺎﻣﺎ‬60 - 40 ‫أﺑﻴﻀﺎ ﻳﺘﺮاوح ﻋﻤﺮه ﺑﻴﻦ‬
ages 40 and 60 years.
 Barrett esophagus confers an ‫ ﻳﺰﻳﺪ ﻣﺮيء ﺑﺎرﯾﺖ ﻣﻦ ﺧﻄﺮ اﻹﺻﺎﺑﺔ ﺑﺎﻟﺴﺮﻃﺎﻧﺔ اﻟﻐﺪﻳﺔ‬
increased risk of esophageal ‫ﻓﻲ اﻟﻤﺮيء )ﻳﺸﺎﻫﺪ ﻋﺴﺮ اﻟﺘﺼﻨﻊ ﻣﺎ ﻗﺒﻞ اﻟﻐﺰو ﻛﻞ‬
adenocarcinoma; pre-invasive dysplasia ‫ ﻣﻦ اﻟﻤﺮﺿﻰ اﻟﻤﺼﺎﺑﻴﻦ ﺑﻤﺮيء‬٪2 ‫ إﻟﻰ‬0.2 ‫ﺳﻨﺔ ﻟﺪى‬
is detected each year in 0.2% to 2% of .(‫ﺑﺎرﻳﺖ‬
patients with Barrett esophagus.
‫ﹰ‬
Grossly ‫ﻋﻴﺎﻧﻴﺎ‬
‫ ﻣﺨﺎﻃﻴﺔ ﻣﺨﻤﻠﻴﺔ ﻧﺎﻋﻤﺔ ﻣﻠﻄﺨﺔ ﺑﺒﻘﻊ ﺣﻤﺮاء‬
 Patches of red, velvety mucosa extend
.‫ﺗﻤﺘﺪ ﻣﻦ اﻟﻮﺻﻞ اﻟﻤﺮﻳﺌﻲ اﻟﻤﻌﺪي‬
up from the gastroesophageal junction
Clinical Features ‫اﻟﻤﻈﺎﻫﺮ اﻟﺴﺮﻳﺮﻳﺔ‬
(‫ ﻳﺤﺘﺎج اﻟﺘﺸﺨﻴﺺ ﻛﻼ اﻟﺘﺄﻛﻴﺪﻳﻦ اﻟﻌﻴﺎﻧﻲ )ﺑﺎﻟﺘﻨﻈﻴﺮ‬
 Diagnosis requires both gross
.‫واﻟﺨﺰﻋﺔ‬
(endoscopic) and biopsy confirmation.
 once identified, a periodic surveillance ‫ ﻣﻦ‬،‫ ﻳﺠﺐ إﺟﺮاء ﺗﻨﻈﻴﺮ دوري ﻟﻠﻤﺮاﻗﺒﺔ‬،‫ ﻋﻨﺪ ﺗﺄﻛﻴﺪ وﺟﻮده‬
endoscopy is performed to look for .‫أﺟﻞ اﻟﺒﺤﺚ ﻋﻦ ﻋﺴﺮة اﻟﺘﺼﻨﻊ أو اﻟﺨﺒﺎﺛﺔ اﻟﺼﺮﻳﺤﺔ‬
dysplasia or frank malignancy.
 Multifocal high-grade dysplasia (with a ‫ ﻳﺘﻄﻠﺐ ﻋﺴﺮ اﻟﺘﺼﻨﻊ ﻋﺎﻟﻲ اﻟﺨﺒﺎﺛﺔ ﻣﺘﻌﺪد اﻟﺒﺆر )ﻣﻊ‬
high risk for progression) or carcinoma ‫ﺧﻄﻮرة ﻋﺎﻟﻴﺔ ﻟﻠﺘﺮﻗﻲ( أو اﻟﺴﺮﻃﺎن ﻋﺎدة اﺳﺘﺌﺼﺎل‬
typically requires esophagectomy, :‫اﻟﻤﺮيء )ﻋﻠﻰ اﻟﺮﻏﻢ ﻣﻦ وﺟﻮد اﻟﻮﺳﺎﺋﻞ اﻟﺤﺪﻳﺜﺔ( ﻣﺜﺎل‬
although newer modalities (e.g., laser ‫ اﻟﺘﻲ‬،‫ اﻟﻤﻌﺎﻟﺠﺔ اﻟﻀﻮﺋﻴﺔ اﻟﺪﻳﻨﺎﻣﻴﻜﻴﺔ‬،‫اﻻﺳﺘﺌﺼﺎل ﺑﺎﻟﻠﻴﺰر‬
ablation, photodynamic therapy) are .‫ﺗﺴﺘﺨﺪم أﻳﻀﺎ‬
also used.

2
 ‫د‪ .‬ﻫﻴﺜﻢ ﺧﻮﺟﺔ‬ ‫آﻓﺎت اﻟﺠﻬﺎز اﻟﻬﻀﻤﻲ ‪1‬‬ ‫ﻋﻠﻢ اﻷﻣﺮاض ‪2‬‬

‫‪ ‬ﻋﺴﺮة اﻟﺘﺼﻨﻊ ﻣﻤﻜﻦ أن ﻳﺘﺤﻮل إﻟﻰ ﺳﺮﻃﺎن وﺗﻜﻮن‬

‫ﻧﺴﺒﺔ اﻟﺘﺤﻮل ﻋﺎﻟﻴﺔ‪.‬‬
‫‪ ‬اﻟﺤﺆول ﻳﺤﺪث ﺑﺴﺒﺐ ﻋﺪم ﺗﺤﻤﻞ ﻣﺨﺎﻃﻴﺔ اﻟﻤﺮيء‬
‫ﻟﺤﻤﻮﺿﺔ اﻟﻤﻌﺪة‪.‬‬
‫‪ ‬ﺳﺮﻃﺎﻧﺎت اﻟﻤﺮيء ﻧﻮﻋﻴﻦ‪:‬‬
‫ﹰ‬
‫• أوﻻ ‪Adenocarcinoma‬‬
‫ﹰ‬
‫• ﺛﺎﻧﻴﺎ ‪Squamous cell carcinoma‬‬
‫‪ ‬وﺟﺐ اﻟﺘﻨﻮﻳﻪ أن ﻣﺮيء ﺑﺎرﻳﺖ ﻟﻴﺲ ﺣﺎﻟﺔ ﻣﺎ ﻗﺒﻞ‬
‫ﺳﺮﻃﺎﻧﻴﺔ ﺑﻨﺴﺒﺔ ‪ ،٪١٠٠‬وإﻧﻤﺎ ﻳﺰﻳﺪ ﺧﻄﺮ اﻟﺘﺤﻮل إﻟﻰ‬
‫ﺳﺮﻃﺎﻧﺔ ﻏﺪﻳﺔ ﻓﻘﻂ‪.‬‬

‫‪Esophageal Tumors‬‬ ‫أورام اﻟﻤﺮيء‬

‫‪ largely evolve from dysplasia changes‬‬ ‫‪ ‬ﻏﺎﻟﺒﺎ ﻣﺎ ﺗﺘﻄﻮر ﻣﻦ ﺗﺤﻮﻻت ﻋﺴﺮ اﻟﺘﺼﻨﻊ ﻓﻲ‬
‫‪in Barrett mucosa.‬‬ ‫ﻣﺨﺎﻃﻴﺔ ﻣﺮيء ﺑﺎرﻳﺖ‬
‫‪ they occur most frequently in white‬‬ ‫‪ ‬واﻟﺘﻲ ﺗﺤﺪث ﺑﺸﻜﻞ أﻛﺜﺮ ﺷﻴﻮﻋﺎ ﻟﺪى اﻟﺮﺟﺎل اﻟﺒﻴﺾ‬
‫‪men (i.e., 7:1 male to female ratio) and‬‬ ‫)‪ 1:7‬ﺑﻤﻌﺪل اﻟﺮﺟﺎل إﻟﻰ اﻟﻨﺴﺎء(‪ ،‬وﻳﻘﺪر ﺑﺤﻮاﻟﻲ اﻟﻨﺼﻒ‬
‫‪account for half of all esophageal‬‬ ‫ﻣﻦ ﺟﻤﻴﻊ ﺳﺮﻃﺎﻧﺎت اﻟﻤﺮيء ﻓﻲ اﻟﻮﻻﻳﺎت اﻟﻤﺘﺤﺪة‪.‬‬
‫‪cancers in the United States.‬‬
‫ﹰ‬
‫‪Grossly‬‬ ‫ﻋﻴﺎﻧﻴﺎ‬
‫‪ ‬ﺗﺘﻔﺎوت اﻵﻓﺎت ﻣﺎ ﺑﻴﻦ ﻋﻘﻴﺪات ﻧﺎﺑﺘﺔ )ﻣﺘﺒﺎرزة( وﻣﺎ ﺑﻴﻦ‬
‫‪ Lesions range from exophytic‬‬
‫ﮐﺘﻞ ﻣﺠﻮﻓﺔ ﻋﻤﻴﻘﺔ اﻻرﺗﺸﺎح‪ ،‬وﻏﺎﻟﺒﺎ ﻣﺎ ﻳﺸﺎﻫﺪ ﻓﻲ اﻟﺜﻠﺚ‬
‫‪nodules to excavated and deeply‬‬
‫اﻟﻘﺎﺻﻲ ﻣﻦ اﻟﻤﺮيء‪.‬‬
‫‪infiltrative masses, mostly in the distal‬‬
‫‪third of the esophagus.‬‬ ‫ﻣﺎ ورم ﻳﻨﻤﻮ ﻋﻠﻰ ﺳﻄﺢ اﻟﻤﺮيء ﻣﻦ اﻟﺨﺎرج أو‬
‫ورم ﻳﻨﻤﻮ ﻓﻲ ﺳﻤﺎﻛﺔ ﺟﺪار اﻟﻤﺮيء‪.‬‬

‫‪Clinical Features‬‬ ‫اﻟﻤﻈﺎﻫﺮ اﻟﺴﺮﻳﺮﻳﺔ‬

‫‪ ‬ﻋﻠﻰ اﻟﺮﻏﻢ ﻣﻦ اﺣﺘﻤﺎل وﺟﻮدﻫﺎ أﺣﻴﺎﻧﺎ ﺧﻼل ﺗﻘﻴﻴﻢ درﺟﺔ‬
‫‪ Although occasionally found during‬‬
‫‪evaluation for GERD or surveillance for‬‬ ‫ال ‪ GERD‬أو ﺧﻼل ﻣﺮاﻗﺒﺔ ﻣﺮيء ﺑﺎرﻳﺖ‪ ،‬ﻓﺈن اﻟﺴﺮﻃﺎﻧﺔ‬
‫‪Barrett esophagus, esophageal‬‬ ‫اﻟﻐﺪﻳﺔ ﻓﻲ اﻟﻤﺮيء ﺗﺘﻈﺎﻫﺮ ﺑﻌﺴﺮ اﻟﺒﻠﻊ وﻓﻘﺪان اﻟﻮزن‬
‫‪adenocarcinomas typically present with‬‬
‫واﻟﺘﻘﻴﺆ اﻟﺪﻣﻮي واﻷﻟﻢ اﻟﺼﺪري واﻹﻗﻴﺎء‪.‬‬
‫‪dysphagia, weight loss, hematemesis,‬‬
‫‪chest pain, or vomiting.‬‬
‫‪ Because most tumors are detected at‬‬ ‫‪ ‬ﻣﻌﺪل اﻟﺒﻘﻴﺎ ل‪ 5‬ﺳﻨﻮات ﻳﻜﻮن أﻗﻞ ﻣﻦ ‪ ٪25‬ذﻟﻚ ﻷن‬
‫‪advanced stages, the 5-year survival‬‬ ‫ﻣﻌﻈﻢ اﻷورام ﺗﺸﺨﺺ ﻓﻲ اﻟﻤﺮاﺣﻞ اﻟﻤﺘﻘﺪﻣﺔ‪.‬‬
‫‪rate is less than 25%.‬‬
‫‪3‬‬
 ‫ ﻫﻴﺜﻢ ﺧﻮﺟﺔ‬.‫د‬ 1 ‫آﻓﺎت اﻟﺠﻬﺎز اﻟﻬﻀﻤﻲ‬ 2 ‫ﻋﻠﻢ اﻷﻣﺮاض‬

 Typically occurs in adults older than 45 ،‫ ﺳﻨﺔ‬45 ‫ ﺗﺤﺪث ﻋﺎدة ﻟﺪى اﻟﺒﺎﻟﻐﻴﻦ اﻷﻛﺒﺮ ﻣﻦ‬
years, in men four times more frequently ‫ وﻟﺪى‬،‫ ﻣﺮات أﻛﺜﺮ ﻣﻦ اﻟﻨﺴﺎء‬4 ‫ﺗﺼﻴﺐ اﻟﺮﺟﺎل ﺑﻤﻌﺪل‬
than women, and in blacks six times more .‫ ﻣﺮات أﻛﺜﺮ ﻣﻦ اﻟﺒﻴﺾ‬6 ‫اﻟﺴﻮد ﺑﻤﻌﺪل‬
frequently than whites.
Risk factors ‫ﻋﻮاﻣﻞ اﻟﺨﻄﻮرة‬
 Include alcohol and tobacco use, - ‫ إﺻﺎﺑﺔ اﻟﻤﺮيء ﺑﺎﻟﻜﺎوﻳﺎت‬- ‫ اﻟﺘﺪﺧﻴﻦ‬- ‫ اﻟﻜﺤﻮل‬
caustic esophageal injury, achalasia, ‫ اﻻﺳﺘﻬﻼك اﻟﻤﺘﻜﺮر‬- ‫ ﻣﺘﻼزﻣﺔ ﺑﻠﻮﻣﺮ ﻓﻨﺴﻮن‬- ‫اﻟﻼارﺗﺨﺎﺋﻴﺔ‬
Plummer-Vinson syndrome, and .‫ﻟﻠﻤﺸﺮوﺑﺎت اﻟﺤﺎرة اﻟﺤﺎرﻗﺔ اﻟﻼذﻋﺔ‬
frequent consumption of scalding
hot beverages.
 There is considerable geographic ‫ ﻣﻊ‬،‫ ﻳﻼﺣﻆ ﺗﻔﺎوت واﺿﺢ ﻓﻲ اﻟﺘﻮزع اﻟﺠﻐﺮاﻓﻲ‬
variability, with highest incidences in ‫ ﻫﻮﻧﻎ‬،‫ اﻟﺼﻴﻦ اﻟﻤﺮﻛﺰﻳﺔ‬،‫ إﻳﺮان‬:‫أﻋﻠﻰ ﻣﻌﺪﻻت وﻗﻮع ﻓﻲ‬
Iran, central China, Hong Kong, Brazil, .‫ ﺟﻨﻮب أﻓﺮﻳﻘﻴﺎ‬،‫ اﻟﺒﺮازﻳﻞ‬،‫ﻛﻮﻧﻎ‬
and South Africa.
Morphology ‫اﻟﺼﻔﺎت اﻟﺸﻜﻠﻴﺔ‬
 Half of esophageal SCC occur in the ‫ ﺗﺤﺪث ﻧﺼﻒ ﺣﺎﻻت ﺳﺮﻃﺎﻧﺔ اﻟﺨﻼﻳﺎ اﻟﺤﺮﺷﻔﻴﺔ اﻟﻤﺮﻳﺌﻴﺔ‬
middle third of the esophagus. ‫ واﻟﺘﻲ ﺗﺒﺪأ ﻋﺎدة‬،‫ﻓﻲ اﻟﺜﻠﺚ اﻷوﺳﻂ ﻣﻦ اﻟﻤﺮيء‬
They typically begin as in situ gray ‫ ﻣﻊ ﺗﺜﺨﻦ اﻟﻤﺨﺎﻃﻴﺔ‬،(‫ﻛﺴﺮﻃﺎﻧﺔ ﻻﺑﺪة )ﺑﻴﻀﺎء ﻓﻀﻴﺔ‬
white, plaque-like mucosal thickenings. .‫ﺑﺸﻜﻞ ﺻﻔﺎﺋﺤﻲ‬
 Lesions can subsequently expand as ‫ ﻗﺪ ﺗﻤﺘﺪ ﻫﺬه اﻵﻓﺎت ﻓﻴﻤﺎ ﺑﻌﺪ ﻛﺂﻓﺎت ﻧﺎﺑﺘﺔ )ﻣﺘﺒﺎرزة( أو‬
exophytic lesions, ulcerate, or become ‫ﻗﺮﺣﺎت أو ﺗﺼﺒﺢ ارﺗﺸﺎﺣﻴﺔ ﺑﺸﻜﻞ واﺳﻊ ﻣﻊ‬
diffusely infiltrative with wall thickening .‫ﺗﺨﻦ ﺟﺪار اﻟﻤﺮيء وﺗﻀﻴﻖ ﻟﻤﻌﺘﻪ‬
and luminal stenosis. ‫ﹰ‬
 A rich submucosal lymphatic network ‫ ﺗﺤﺮض ﺷﺒﻜﺔ اﻟﻠﻤﻔﺎوﻳﺎت ﺗﺤﺖ اﻟﻤﺨﺎﻃﻴﺔ اﻟﻐﺰﻳﺮة اﻧﺘﺸﺎرا‬
‫ﹰ‬ ‫ﹰ‬
promotes circumferential and .‫ﻣﺤﻴﻄﻴﺎ وﻃﻮﻻﻧﻴﺎ‬
longitudinal spread.
 Tumors can invade deeply into .‫ ﻗﺪ ﺗﻐﺰو اﻷورام ﻋﻤﻴﻘﺔ إﻟﻰ اﻟﺒﻨﻰ اﻟﻤﻨﺼﻔﻴﺔ اﻟﻤﺠﺎورة‬
adjacent mediastinal structures. .‫ ﺗﻌﺘﺒﺮ ﻣﻌﻈﻢ اﻷورام ﻣﺘﻮﺳﻄﺔ إﻟﻰ ﺟﻴﺪة اﻟﺘﻤﺎﻳﺰ‬
 Most tumors are moderately to well .‫ﻧﺘﻴﺠﺔ ﺗﻀﻴﻖ اﻟﻠﻤﻌﺔ ﺳﻴﻔﻘﺪ اﻟﻤﺮﻳﺾ وزﻧﻪ‬
differentiated.

4
 ‫ ﻫﻴﺜﻢ ﺧﻮﺟﺔ‬.‫د‬ 1 ‫آﻓﺎت اﻟﺠﻬﺎز اﻟﻬﻀﻤﻲ‬ 2 ‫ﻋﻠﻢ اﻷﻣﺮاض‬

Clinical Features ‫اﻟﻤﻈﺎﻫﺮ اﻟﺴﺮﻳﺮﻳﺔ‬

‫ ﻳﺒﺪأ ﺑﺸﻜﻞ ﻣﺨﺎﻳﻞ )ﻣﺨﺎدع( وﺗﻜﻮن اﻷﻋﺮاض اﻟﺒﺪﺋﻴﺔ‬
 Onset is insidious and symptom onset is
‫ ﻓﻘﺪان‬- ‫ اﻧﺴﺪادات‬- ‫ وﻳﻈﻬﺮ اﻟﻤﺮﺿﻰ ﻋﺴﺮ ﺑﻠﻊ‬،‫ﻣﺘﺄﺧﺮة‬
late; patients develop dysphagia,
‫ إﻧﺘﺎن ﺛﺎﻧﻮي ﺗﺎﻟﻲ ﻟﻠﺘﻘﺮﺣﺎت أو ﻧﻮاﺳﻴﺮ‬- ‫ ﻧﺰف دﻣﻮي‬- ‫وزن‬
obstruction, weight loss, hemorrhage,
.‫ﺗﻨﻔﺴﻴﺔ ﻣﻊ رﺷﻒ‬
sepsis secondary to ulceration, or
respiratory fistulae with aspiration.

Prognosis ‫اﻹﻧﺬار‬
 Superficial carcinomas have a 5-year 5‫ ﺗﻤﺘﻠﻚ اﻟﺴﺮﻃﺎﻧﺎت اﻟﺴﻄﺤﻴﺔ ﻣﻌﺪل ﺑﻘﻴﺎ ﻳﻘﺪر ب‬
survival rate of 75%, but the overall 5- ‫ وﻟﻜﻦ ﻣﻌﺪل اﻟﺒﻘﻴﺎ‬،‫ ﻣﻦ اﻟﺤﺎﻻت‬%75 ‫ﺳﻨﻮات ﻟﺪى‬
year survival rate is 9%. .٪9 ‫ ﺳﻨﻮات ﻳﻘﺪر ب‬5‫اﻟﻜﻠﻲ ل‬
 SCC in the skin has a good prognosis, ‫ﹰ‬ ‫ﹰ‬
‫ ﻟﻜﻦ إﻧﺬاره ﺳﻲء ﺟﺪا‬،‫ ﻓﻲ اﻟﺠﻠﺪ ﺟﻴﺪا‬SCC ‫ ﻳﻌﺘﺒﺮ إﻧﺬار‬
opposed to SCC in the esophagus which ‫ واﻟﺴﺒﺐ وراء ذﻟﻚ ﻫﻮ أن اﻷوﻋﻴﺔ‬،‫ﻓﻲ اﻟﻤﺮيء‬
is considered very bad, And this is due ‫ﹰ‬
‫اﻟﻠﻤﻔﺎوﻳﺔ ﻗﻠﻴﻠﺔ ﻧﺴﺒﻴﺎ ﻓﻲ اﻟﺠﻠﺪ ﻣﻘﺎرﻧﺔ ﺑﺎﻷﻏﺸﻴﺔ‬
to poor lymphatic network in the skin in ‫ ﻣﻤﺎ ﻳﺰﻳﺪ ﻣﻦ ﺧﻄﺮ اﻧﺘﻘﺎل‬،‫اﻟﻤﺨﺎﻃﻴﺔ ﻓﻲ اﻟﻤﺮيء‬
comparison with the esophagus, which .‫اﻟﻨﻘﺎﺋﻞ اﻟﻠﻤﻔﺎوﻳﺔ‬
subsequently increases the risk of
lymphatic metastases.

5
 ‫ ﻫﻴﺜﻢ ﺧﻮﺟﺔ‬.‫د‬ 1 ‫آﻓﺎت اﻟﺠﻬﺎز اﻟﻬﻀﻤﻲ‬ 2 ‫ﻋﻠﻢ اﻷﻣﺮاض‬

Gastric Lesion ‫آﻓﺎت اﻟﻤﻌﺪة‬

pyloric stenosis ‫ﺗﻀﻴﻖ اﻟﺒﻮاب‬

 Occurs in roughly 1 in 500 births, with ‫ﻳﺼﻴﺐ‬.‫ وﻻدة‬500 ‫ ﻣﻦ أﺻﻞ‬1 ‫ ﻳﺤﺪث ﺗﻘﺮﻳﺒﺎ ﻟﺪى‬
a male to female ratio of 4:1. .4:1‫اﻟﺬﻛﻮر أﻛﺜﺮ ﺑﻤﻌﺪل‬
 Patient classically presents with ‫ ﻳﺄﺗﻲ اﻟﻤﺮﻳﺾ ﺑﺸﻜﻞ ﻛﻼﺳﻴﻜﻲ ﺑﺸﻜﺎﻳﺔ ﻗﻠﺲ‬
regurgitation and projectile vomiting ‫ وﺗﻼﺣﻆ‬،‫ أﺳﺎﺑﻴﻊ ﻣﻦ اﻟﻮﻻدة‬3 ‫وﺗﻘﻴﺆ ﻗﺬﻓﻲ ﺧﻼل‬
within 3 weeks of birth; there is ‫ وﻛﺘﻠﺔ ﺑﻴﻀﻮﻳﺔ‬،‫اﻟﺘﻤﻌﺠﺎت اﻟﻤﻌﻮﻳﺔ ﺑﺸﻜﻞ ﻣﺮﺋﻲ ﺧﺎرﺟﻴﺎ‬
externally visible peristalsis and a .‫ﻣﺠﺴﻮﺳﺔ‬
palpable firm ovoid mass.
 Full-thickness, muscle-splitting incision ‫ ﻳﻌﺘﺒﺮ اﻟﺸﻖ اﻟﺸﺎﻃﺮ ﻟﻠﻌﻀﻠﺔ ﻛﺎﻣﻞ اﻟﺜﺨﺎﻧﺔ )ﺑﻀﻊ‬
(myotomy) is curative. .‫اﻟﻌﻀﻼت( ﺷﺎﻓﻴﺎ‬

 Is a complication of chronic antral ‫ ﻳﻌﺘﺒﺮ اﺧﺘﻼﻃﺎ ﻻﻟﺘﻬﺎب ﻏﺎر اﻟﻤﻌﺪة اﻟﻤﺰﻣﻦ واﻟﻘﺮﺣﺎت‬
gastritis, peptic ulcers close to the .‫اﻟﻬﻀﻤﻴﺔ اﻟﻘﺮﻳﺒﺔ ﻣﻦ اﻟﺒﻮاب واﻟﺨﺒﺎﺛﺔ‬
pylorus, and malignancy.

Inflammations ‫اﻻﻟﺘﻬﺎﺑﺎت‬

 A transient mucosal inflammatory .‫ ﻫﻮ ﻋﻤﻠﻴﺔ اﻟﺘﻬﺎﺑﻴﺔ ﻋﺎﺑﺮة ﺗﺼﻴﺐ اﻟﻤﺨﺎﻃﻴﺔ‬

process.
 it can be asymptomatic or cause ‫ وﻗﺪ ﻳﻜﻮن ﻻﻋﺮﺿﻴﺔ أو ﻳﺴﺒﺐ درﺟﺎت ﻣﺨﺘﻠﻒ ﻣﻦ اﻷﻟﻢ‬
varying degrees of pain, nausea, and .‫واﻟﻐﺜﻴﺎن واﻹﻗﻴﺎء‬
vomiting.
 Severe cases exhibit ulceration with ‫ ﺗﻈﻬﺮ اﻟﺤﺎﻻت اﻟﺸﺪﻳﺪة ﺗﻘﺮﺣﺎ ﻣﻊ اﻟﻨﺰف ﻳﺘﻈﺎﻫﺮ ﺑﺎﻹﻗﻴﺎء‬
hemorrhage presenting as hematemesis .‫اﻟﺪﻣﻮي أو اﻟﺘﻐﻮط اﻟﺰﻓﺘﻲ‬
or melena.

6
 ‫ ﻫﻴﺜﻢ ﺧﻮﺟﺔ‬.‫د‬ 1 ‫آﻓﺎت اﻟﺠﻬﺎز اﻟﻬﻀﻤﻲ‬ 2 ‫ﻋﻠﻢ اﻷﻣﺮاض‬

Pathogenesis ‫اﻹﻣﺮاﺿﻴﺎت‬
 Acute gastritis occurs when one or ‫ ﻳﺤﺪث ﻋﻨﺪﻣﺎ ﺗﺘﺨﺮب أو ﻳﺘﻢ اﻟﺘﻐﻠﺐ ﻋﻠﻰ واﺣﺪة أو أﻛﺜﺮ‬
more of the mechanisms that protect ‫ﻣﻦ اﻵﻟﻴﺎت اﻟﺘﻲ ﺗﺤﻤﻲ ﻣﺨﺎﻃﻴﺔ اﻟﻤﻌﺪة ﻣﻦ اﻟﺒﻴﺌﺔ‬
gastric mucosa from the acidic :‫ وﻣﻦ ﻫﺬه اﻟﺤﺎﻻت‬،‫اﻟﺤﺎﻣﻀﻴﺔ‬
environment is overwhelmed or
defective, including:
• Increased acid production, .‫• زﻳﺎدة إﻓﺮاز اﻟﺤﻤﺾ‬
• decreased bicarbonate or mucin .‫• ﻧﻘﺺ إﻓﺮاز اﻟﺒﻴﻜﺮﺑﻮﻧﺎت أو اﻟﻤﺨﺎط‬
production
• or direct mucosal damage. .‫• أو اﻹﺻﺎﺑﺔ اﻟﻤﺒﺎﺷﺮة ﻟﻠﻤﺨﺎﻃﻴﺔ‬
 Thus, chronic use of nonsteroidal anti- ‫ ﻓﺈن اﻻﺳﺘﺨﺪام اﻟﻤﺰﻣﻦ اﻟﻤﻀﺎدات اﻻﻟﺘﻬﺎب‬،‫ ﻟﺬﻟﻚ‬
inflammatory drugs (NSAIDs) reduces ‫اﻟﻼﺳﺘﻴﺮوﺋﻴﺪﻳﺔ ﻳﻘﻠﻞ ﻣﻦ إﻧﺘﺎج اﻟﺒﻴﻜﺮﺑﻮﻧﺎت وﻳﺘﺪﺧﻞ‬
bicarbonate production and interferes ‫ﻓﻲ ﻋﻤﻞ اﻟﺒﺮوﺳﺘﺎﻏﻼﻧﺪﻳﻨﺎت اﻟﻤﺪاﻓﻊ ﻋﻦ اﻟﺨﻼﻳﺎ‬
with the cytoprotective action of ‫ ﺗﻌﺰﻳﺰ اﺻﻄﻨﺎع‬،‫)اﻟﺬي ﻳﺘﻤﺜﻞ ﻓﻲ ﺗﺜﺒﻴﻂ إﻓﺮاز اﻟﺤﻤﺾ‬
prostaglandins (these inhibit acid .(‫ وزﻳﺎدة اﻟﺘﺮوﻳﺔ اﻟﺪﻣﻮﻳﺔ‬،‫اﻟﻤﺨﺎط‬
production, promote mucin synthesis,
and increase vascular perfusion).
 Excessive alcohol consumption and ‫ ﻛﻤﺎ ﻳﻤﻜﻦ أن ﻳﻜﻮن اﻻﺳﺘﻬﻼك اﻟﺸﺪﻳﺪ ﻟﻠﻜﺤﻮل‬
‫ﹼ‬
heavy smoking can be directly toxic, ‫ ﺑﻴﻨﻤﺎ‬،‫واﻹﺳﺮاف ﻓﻲ اﻟﺘﺪﺧﻴﻦ ﺳﻤﻴﺎن ﺑﺸﻜﻞ ﻣﺒﺎﺷﺮ‬
and ischemia and shock secondarily ‫ﻧﻘﺺ اﻟﺘﺮوﻳﺔ واﻟﺼﺪﻣﺔ ﻳﺆذﻳﺎن اﻟﻤﺨﺎﻃﻴﺔ ﺑﺸﻜﻞ‬
injure the mucosa. .‫ﺛﺎﻧﻮي‬
‫ﹰ‬
Grossly ‫ﻋﻴﺎﻧﻴﺎ‬
 There is moderate edema and ‫ وأﺣﻴﺎﻧﺎ ﻧﻼﺣﻆ اﻟﻨﺰف‬،‫ ﻧﺸﺎﻫﺪ اﺣﺘﻘﺎﻧﺎ ووذﻣﺔ ﻣﻌﺘﺪﻟﺔ‬
hyperemia, occasionally with .(‫اﻟﺪﻣﻮي )اﻟﺘﻬﺎب اﻟﻤﻌﺪة اﻟﺘﺂﻛﻠﻲ اﻟﻨﺰﻓﻲ اﻟﺤﺎد‬
hemorrhage (acute hemorrhagic
erosive gastritis).

7
 ‫د‪ .‬ﻫﻴﺜﻢ ﺧﻮﺟﺔ‬ ‫آﻓﺎت اﻟﺠﻬﺎز اﻟﻬﻀﻤﻲ ‪1‬‬ ‫ﻋﻠﻢ اﻷﻣﺮاض ‪2‬‬

‫‪ Characterized by ongoing mucosal‬‬ ‫‪ ‬ﻳﺘﻤﻴﺰ ﺑﺎﻟﺘﻬﺎب ﻣﺨﺎﻃﻲ ﻣﺴﺘﻤﺮ ﻣﻊ ﺿﻤﻮر ﻟﻠﻤﺨﺎﻃﻴﺔ‪.‬‬
‫‪inflammation with mucosal atrophy.‬‬
‫‪ it provides a substrate in which‬‬ ‫‪ ‬وﻳﺸﻜﻞ أرﺿﻴﺔ ﻟﻌﺴﺮ اﻟﺘﺼﻨﻊ وﻧﺸﻮء اﻟﺴﺮﻃﺎﻧﺎت‪.‬‬
‫‪dysplasia (and carcinoma) can arise.‬‬
‫‪ Compared to acute gastritis The‬‬ ‫‪ ‬ﺑﺎﻟﻤﻘﺎرﻧﺔ ﻣﻊ اﻟﺘﻬﺎب اﻟﻤﻌﺪة اﻟﺤﺎد‪ ،‬ﻋﺎدة ﻣﺎ ﺗﻜﻮن‬
‫ﹰ‬
‫‪symptoms are usually less severe but‬‬ ‫اﻷﻋﺮاض أﻗﻞ ﺷﺪة وﻟﻜﻦ أﻛﺜﺮ اﺳﺘﻤﺮارا‪.‬‬
‫‪are more persistent.‬‬
‫‪ Causes include Helicobacter pylori‬‬ ‫‪ ‬ﺗﺘﻀﻤﻦ اﻷﺳﺒﺎب‪ :‬اﻟﺨﻤﺞ ﺑﺎﻟﻤﻠﺘﻮﻳﺔ اﻟﺒﻮاﺑﻴﺔ )اﻷﻛﺜﺮ‬
‫‪infection (most common), alcohol,‬‬ ‫ﺷﻴﻮﻋﺎ(‪ ،‬اﻟﻜﺤﻮل‪ ،‬اﻟﺘﺪﺧﻴﻦ‪ ،‬اﻟﻀﻐﻂ اﻟﻨﻔﺴﻲ واﻟﻜﺎﻓﺌﻴﻦ‬
‫‪tobacco, psychological stress, and‬‬ ‫واﻟﺘﻬﺎب اﻟﻤﻌﺪة اﻟﻤﻨﺎﻋﻲ )‪ ٪ 10‬ﻣﻦ اﻟﺤﺎﻻت(‪ ،‬و ﺗﻌﺘﺒﺮ‬
‫‪caffeine; autoimmune gastritis (10% of‬‬ ‫ﻫﺬه اﻷﺳﺒﺎب اﻷﻛﺜﺮ ﺷﻴﻮﻋﺎ ﻓﻲ ﺣﺎل ﻏﻴﺎب اﻹﺻﺎﺑﺔ‬
‫‪cases) is the most common cause in the‬‬ ‫ﺑﺎﻟﻤﻠﺘﻮﻳﺔ اﻟﺒﻮاﺑﻴﺔ‪.‬‬
‫‪absence of H. pylori.‬‬

‫ﻓﻲ اﻟﺘﻬﺎب اﻟﻤﻌﺪة اﻟﻤﻨﺎﻋﻲ اﻟﺬاﺗﻲ ﺗﻬﺎﺟﻢ اﻟﺨﻼﻳﺎ‬

‫ﹶ‬ ‫ﹸ‬
‫اﻟﻤﻨﺎﻋﻴﺔ اﻟﺨﻼﻳﺎ اﻟﺠﺪارﻳﺔ )اﻟﺘﻲ ﺗﻌﻤﻞ ﻋﻠﻰ إﻓﺮاز‬
‫اﻟﻌﺎﻣﻞ اﻟﺪاﺧﻠﻲ وال‪ ( HCL‬ﻣﻤﺎ ﻳﺆدي إﻟﻰ ﺣﺪوث‬
‫ﻓﻘﺮ دم ﺑﻌﻮز ‪.VitB12‬‬

‫‪Epidemiology‬‬ ‫اﻟﻮﺑﺎﺋﻴﺎت‬
‫ﹰ‬
‫‪ Although H. pylori is a widely‬‬ ‫‪ ‬ﻋﻠﻰ اﻟﺮﻏﻢ ﻣﻦ أن اﻟﻤﻠﺘﻮﻳﺔ اﻟﺒﻮاﺑﻴﺔ ﺗﻌﺘﺒﺮ ﺳﺒﺒﺎ‬
‫ﹰ‬
‫‪prevalent gastric infection‬‬ ‫ﻣﺴﻴﻄﺮا ﺑﺸﻜﻞ ﻛﺒﻴﺮ ﻋﻠﻰ أﺧﻤﺎج اﻟﻤﻌﺪة )ﻣﻌﺪﻻت‬
‫‪(colonization rates from 10% to 80% of‬‬ ‫اﻻﻧﺘﺸﺎر ﻣﺎ ﺑﻴﻦ ‪ ٪ 80 - 10‬ﻣﻦ اﻟﺴﻜﺎن(‪ ،‬ﻓﺈن ﻧﺴﺒﺔ‬
‫‪the population), a much smaller‬‬ ‫أﺻﻐﺮ ﺑﻜﺜﻴﺮ ﻣﻦ ﻫﺆﻻء اﻟﻤﺼﺎﺑﻴﻦ ﺑﻬﺎ ﻳﺘﻄﻮر ﻟﺪﻳﻬﻢ‬
‫‪percentage of those infected actually‬‬ ‫اﻟﺘﻬﺎب ﻣﻌﺪة‪.‬‬
‫‪develop gastritis.‬‬
‫‪ Nevertheless, H. pylori infection is the‬‬ ‫‪ ‬وﻟﻜﻦ ﻧﺠﺪ اﻟﺨﻤﺞ ﺑﺎﻟﻤﻠﺘﻮﻳﺔ اﻟﺒﻮاﺑﻴﺔ اﻟﺴﺒﺐ اﻷﻛﺜﺮ‬
‫ﹰ‬
‫‪most common cause of chronic‬‬ ‫ﺷﻴﻮﻋﺎ اﻟﺘﻬﺎب اﻟﻤﻌﺪة اﻟﻤﺰﻣﻦ‬
‫‪gastritis.‬‬

‫‪8‬‬
 ‫د‪ .‬ﻫﻴﺜﻢ ﺧﻮﺟﺔ‬ ‫آﻓﺎت اﻟﺠﻬﺎز اﻟﻬﻀﻤﻲ ‪1‬‬ ‫ﻋﻠﻢ اﻷﻣﺮاض ‪2‬‬

‫‪ Organisms are present in up to 90% of‬‬ ‫‪ ‬ﺗﺘﻮاﺟﺪ ﻫﺬه اﻟﻌﻀﻴﺎت ﻓﻲ أﻛﺜﺮ ﻣﻦ ‪ % 90‬ﻣﻦ اﻷﻓﺮاد‬
‫‪individuals with disease.‬‬ ‫اﻟﻤﺼﺎﺑﻴﻦ ﺑﺎﻻﻟﺘﻬﺎب اﻟﻤﺰﻣﻦ‪.‬‬
‫‪ Humans are the only host-spread is via‬‬ ‫‪ ‬ﻳﻌﺘﺒﺮ اﻹﻧﺴﺎن اﻟﻤﻀﻴﻒ اﻟﻮﺣﻴﺪ‪ ،‬وﻳﻜﻮﻧﺎ اﻻﻧﺘﺸﺎر ﻋﺒﺮ‬
‫‪fecal-oral, oral-oral, or environmental‬‬ ‫اﻟﻄﺮﻳﻖ اﻟﻔﻤﻮي اﻟﺒﺮازي أو اﻟﻔﻤﻮي اﻟﻔﻤﻮي أو ﺑﻄﺮق‬
‫‪routes; consequently, Tower‬‬ ‫ﺑﻴﺌﻴﺔ‪ ،‬وﺑﺎﻟﺘﺎﻟﻲ ﻳﺆدي ﺗﺪﻧﻲ اﻟﺤﺎﻟﺔ اﻻﻗﺘﺼﺎدﻳﺔ‬
‫‪socioeconomic status and crowding lead‬‬ ‫اﻻﺟﺘﻤﺎﻋﻴﺔ واﻻزدﺣﺎم إﻟﻰ ﻣﻌﺪﻻت اﺳﺘﻴﻄﺎن أﻋﻠﻰ‬
‫‪to higher colonization rates.‬‬ ‫)إﺻﺎﺑﺎت أﻛﺜﺮ(‪.‬‬
‫‪ A related organism, Helicobacter‬‬ ‫‪ ‬ﻫﻨﺎﻟﻚ ﻋﻀﻮﻳﺔ ﻣﺸﺎﺑﻬﺔ )اﻟﻤﻠﺘﻮﻳﺔ ﻫﻴﻠﻤﺎﻧﻲ( ﺗﺼﻴﺐ‬
‫‪heilmannii, can infect humans as well as‬‬ ‫اﻹﻧﺴﺎن ﺑﺎﻹﺿﺎﻓﺔ ﻟﻠﻘﻄﻂ واﻟﻜﻼب واﻟﺨﻨﺎزﻳﺮ واﻟﺮﺋﻴﺴﺎت‬
‫‪cats, dogs, pigs, and non-human‬‬ ‫ﻏﻴﺮ اﻟﺒﺸﺮﻳﺔ )أﻋﻠﻰ رﺗﺒﺔ ﻓﻲ اﻟﺜﺪﻳﻴﺎت ﻣﺜﻞ اﻟﻘﺮود(‪،‬‬
‫‪primates; recognition of this organism‬‬ ‫واﻟﺘﻌﺮف ﻋﻠﻰ ﻫﺬه اﻟﻌﻀﻴﺎت ﻓﻲ اﻟﻤﻀﻴﻒ اﻟﺒﺸﺮي‬
‫ﹰ‬
‫‪in a human host is an indication for‬‬ ‫ﻳﻌﺘﺒﺮ اﺳﺘﻄﺒﺎﺑﺎ ﻟﻌﻼج اﻟﺤﻴﻮان اﻷﻟﻴﻒ اﻟﻤﻨﺰﻟﻲ ﻟﺘﺠﻨﺐ‬
‫‪treatment of a household pet to‬‬ ‫واﺳﺘﺒﻌﺎد ﺣﺪوث ﻣﺴﺘﻮدع ﻟﻬﺬه اﻟﺠﺮﺛﻮﻣﺔ‪.‬‬
‫‪eliminate a reservoir.‬‬

‫إذا ﻗﻤﻨﺎ ﺑﺨﺰﻋﺔ ﻣﻦ اﻟﻤﻌﺪة ﻟﺴﻜﺎن اﻟﻌﺎﻟﻢ )اﻟﻤﺼﺎﺑﻮن وﻏﻴﺮ اﻟﻤﺼﺎﺑﻮن( ﻧﺠﺪ ‪ %80-10‬ﻣﻨﻬﻢ ﻟﺪﻳﻬﻢ اﻟﻤﻠﺘﻮﻳﺔ اﻟﺒﻮاﺑﻴﺔ‪،‬‬
‫وﻟﻜﻦ اﻟﺘﻬﺎب اﻟﻤﻌﺪة ﻻ ﻳﺤﺪث إﻻ ﻋﻨﺪ ﻧﺴﺒﺔ ﻗﻠﻴﻠﺔ ﻣﻨﻬﻢ‪.‬‬

‫‪Pathogenesis‬‬ ‫اﻹﻣﺮاﺿﻴﺎت‬
‫‪ H. pylori induces predominantly an‬‬ ‫‪ ‬ﺗﺤﺮض اﻟﻤﻠﺘﻮﻳﺔ اﻟﺒﻮاﺑﻴﺔ ﺑﺎﻟﺪرﺟﺔ اﻷوﻟﻰ اﻟﺘﻬﺎب ﻏﺎر‬
‫‪antral gastritis, characterized:‬‬ ‫اﻟﻤﻌﺪة‪ ،‬ﻳﺘﺼﻒ ب‪:‬‬
‫‪• Increased acid production and‬‬ ‫• ﻟﻪ زﻳﺎدة إﻓﺮاز اﻟﺤﻤﺾ وﺗﻌﻄﻴﻞ اﻵﻟﻴﺎت اﻟﻄﺒﻴﻌﻴﺔ‬
‫‪disruption of the normal mucosal‬‬ ‫ﻟﺤﻤﺎﻳﺔ اﻟﻤﺨﺎﻃﻴﺔ‪.‬‬
‫‪protection mechanisms.‬‬
‫‪• Over time, the initial antral gastritis‬‬ ‫• ﻣﻊ ﻣﺮور اﻟﻮﻗﺖ‪ ،‬ﻳﺘﻄﻮر اﻟﺘﻬﺎب ﻏﺎر اﻟﻤﻌﺪة اﻟﺒﺪﺋﻲ‬
‫‪progresses to multifocal atrophic‬‬ ‫إﻟﻰ اﻟﺘﻬﺎب ﻣﻌﺪة ﺿﻤﻮري ﻣﺘﻌﺪد اﻟﺒﺆر )أي‪ :‬ﺿﻤﻮر‬
‫‪gastritis (i.e., mucosal atrophy with‬‬ ‫اﻟﻤﺨﺎﻃﻴﺔ ﻣﻊ إﻓﺮاز ﺣﻤﻀﻲ ﻣﺘﻨﺎﻗﺺ( وﺣﺆول‬
‫‪reduced acid production) and‬‬ ‫ﻣﻌﻮي‪.‬‬
‫‪intestinal metaplasia‬‬
‫‪Grossly‬‬ ‫ﻋﻴﺎﻧﻴﺎ‬
‫ﹸ‬
‫‪ Infected mucosa is erythematous and‬‬ ‫‪ ‬ﺑﻪ ﺗﻜﻮن اﻟﻤﺨﺎﻃﻴﺔ اﻟﻤﺼﺎﺑﺔ ﺣﻤﺎﻣﻴﺔ ﺗﺘﺮاوح ﻣﺎ ﺑﻴﻦ‬
‫ﹸ‬
‫‪coarse to nodular.‬‬ ‫ﺧﺸﻨﺔ وﻗﺎﺳﻴﺔ إﻟﻰ ﻋﻘﻴﺪﻳﺔ‪.‬‬

‫‪9‬‬
 ‫ ﻫﻴﺜﻢ ﺧﻮﺟﺔ‬.‫د‬ 1 ‫آﻓﺎت اﻟﺠﻬﺎز اﻟﻬﻀﻤﻲ‬ 2 ‫ﻋﻠﻢ اﻷﻣﺮاض‬
‫ﹰ‬
Microscopically ‫ﻣﺠﻬﺮﻳﺎ‬
 H. pylori are typically found in the .‫ ﺗﺘﻮاﺟﺪ اﻟﻤﻠﺘﻮﻳﺔ اﻟﺒﻮاﺑﻴﺔ ﺑﺸﻜﻞ ﻧﻤﻮذﺟﻲ ﻓﻲ اﻟﻐﺎر‬
antrum.
 gastric biopsy usually demonstrates ‫ ﺗﻈﻬﺮ اﻟﺨﺰﻋﺔ اﻟﻤﻌﻮﻳﺔ ﻋﺎدة اﻟﻌﻀﻴﺎت ﻣﺘﺮﻛﺰة ﻓﻲ‬
organisms concentrated in the ‫اﻟﺴﻄﺢ اﻟﻤﺘﻮﺿﻊ ﻓﻮق اﻟﻤﺨﺎط اﻟﺴﻄﺤﻲ وﻇﻬﺎرﻳﺔ‬
superficial mucus overlying surface and ‫ ﻣﻊ أﻋﺪاد ﻣﺨﺘﻠﻔﺔ ﻣﻦ اﻟﻌﺪﻻت اﻟﻠﻤﻌﻴﺔ وﻣﺎ ﺑﻴﻦ‬،‫اﻟﻌﻨﻖ‬
‫ ﻧﺮى‬،‫اﻟﻈﻬﺎرﻳﺔ )ﻣﺸﻜﻠﺔ ﺧﺮاﺟﺎت ﻧﻘﻴﺮﻳﺔ( )ﻣﺜﻞ اﻟﻨﻘﺮ ﻋﻠﻰ اﻟﺨﺸﺐ‬
neck epithelium. There are variable
(‫وﻫﺪات واﻧﺪﺧﺎﻻت إﻟﻰ اﻟﻤﺨﺎﻃﻴﺔ‬
numbers of intraepithelial and luminal
neutrophils (forming pit abscesses).
 and the lamina propria contains ‫ وﺗﺤﻮي اﻟﺼﻔﻴﺤﺔ اﻟﻤﺨﺼﻮﺻﺔ ﻛﻤﻴﺎت واﻓﺮة ﻣﻦ اﻟﺨﻼﻳﺎ‬
abundant plasma cells, macrophages, and .‫اﻟﺒﻼزﻣﻴﺔ واﻟﺒﺎﻟﻌﺎت اﻟﻜﺒﻴﺮة واﻟﻠﻤﻔﺎوﻳﺎت‬
lymphocytes.
 Long-standing gastritis is associated ‫ وﻳﺮﺗﺒﻂ اﻟﺘﻬﺎب اﻟﻤﻌﺪة ﻃﻮﻳﻞ اﻷﻣﺪ ﻣﻊ ﺿﻤﻮر ﻣﺨﺎﻃﻴﺔ‬
with diffuse mucosal atrophy, with ‫ ﻣﻊ ﺗﺠﻤﻌﺎت ﻟﻤﻔﺎوﻳﺔ واﺿﺤﺔ )أﺣﻴﺎﻧﺎ ﻣﻊ ﻣﺮﻛﺰ‬،‫ﻣﻨﺘﺸﺮ‬
prominent lymphoid aggregates .(‫ﻧﺘﻮج‬
occasionally with germinal centers.
Clinical Features ‫اﻟﺼﻔﺎت اﻟﺴﺮﻳﺮﻳﺔ‬
 H. pylori can be diagnosed by antibody ‫ ﻳﻤﻜﻦ ﺗﺸﺨﻴﺺ اﻹﺻﺎﺑﺔ ﺑﺎﻟﻤﻠﺘﻮﻳﺔ اﻟﺒﻮاﺑﻴﺔ ﻋﺒﺮ اﺧﺘﺒﺎر‬
serologic test, bacterial culture, direct ‫اﻷﺿﺪاد اﻟﻤﻨﺎﻋﻴﺔ اﻟﻤﺼﻠﻲ واﻟﺰرع اﻟﺠﺮﺛﻮﻣﻲ واﻹﻇﻬﺎر‬
bacterial visualization in gastric biopsy .‫اﻟﻤﺒﺎﺷﺮ ﻟﻠﺠﺮﺛﻮﻣﺔ ﻓﻲ اﻟﺨﺰﻋﺔ اﻟﻤﻌﺪﻳﺔ‬
 H. pylori infection is a risk factor for ‫ ﻳﻌﺪ اﻟﺨﻤﺞ ﺑﺎﻟﻤﻠﺘﻮﻳﺔ اﻟﺒﻮاﺑﻴﺔ ﻋﺎﻣﻞ ﺧﻄﺮ‬
peptic ulcer disease, gastric ‫ﻟﻺﺻﺎﺑﺔ ﺑﺪاء اﻟﻘﺮﺣﺔ اﻟﻬﻀﻤﻴﺔ واﻟﺴﺮﻃﺎﻧﺔ اﻟﻐﺪﻳﺔ‬
adenocarcinoma, and .‫اﻟﻤﻌﺪﻳﺔ واﻟﻠﻤﻔﻮﻣﺎ اﻟﻤﻌﺪﻳﺔ‬
gastric lymphoma.

10
 ‫ ﻫﻴﺜﻢ ﺧﻮﺟﺔ‬.‫د‬ 1 ‫آﻓﺎت اﻟﺠﻬﺎز اﻟﻬﻀﻤﻲ‬ 2 ‫ﻋﻠﻢ اﻷﻣﺮاض‬

 This form of gastritis typically spares ‫ ﻫﺬا اﻟﺸﻜﻞ ﻣﻦ اﻟﺘﻬﺎب اﻟﻤﻌﺪة ﻳﺘﺠﻨﺐ اﻟﻐﺎر وﻳﺮﺗﺒﻂ‬
the antrum and is associated with .‫ﺑﻔﺮط ﻏﺎﺳﺘﺮﻳﻦ اﻟﺪم‬
hypergastrinemia. .‫اﻧﺘﺒﻪ ﻫﺬا اﻟﻨﻮع ﻳﺨﺘﻠﻒ ﻋﻦ ﺳﺎﺑﻘﻪ ﺑﺄﻧﻪ ﻳﺘﺠﻨﺐ اﻟﻐﺎر‬

Pathogenesis ‫اﻹﻣﺮاﺿﻴﺎت‬
 CD4 T cell-mediated autoimmune ‫ إن اﻵﻟﻴﺔ اﻹﻣﺮاﺿﻴﺔ اﻟﻜﺒﺮى اﻟﻤﺴﺒﺒﺔ ﻟﻪ ﻫﻲ اﻟﺘﺪﻣﻴﺮ‬
destruction of parietal cells is the T ‫اﻟﻤﻨﺎﻋﻲ اﻟﺬاﺗﻲ ﻟﻠﺨﻼﻳﺎ اﻟﺠﺪارﻳﺔ اﻟﻤﺘﻮاﺳﻂ ﺑﺨﻼﻳﺎ‬
major pathogenic mechanism. .CD4
 Parietal cell cytotoxicity leads in turn to ‫ ﺗﺆدي ﺳﻤﻴﺔ اﻟﺨﻼﻳﺎ اﻟﺠﺪارﻳﺔ إﻟﻰ إﻓﺮاز ﻣﻌﻴﺐ‬
defective gastric acid secretion ‫ واﻟﺘﻲ ﺗﺜﻴﺮ ﺣﺪوث‬،(‫ﻟﻠﺤﻤﺾ اﻟﻤﻌﺪي )اﻻﻛﻠﻮرﻳﺪﻳﺔ‬
(achlorhydria) that triggers .‫ اﻟﻐﺎرﻳﺔ‬G ‫ﻓﺮط ﻏﺎﺳﺘﺮﻳﻦ اﻟﺪم وﻓﺮط ﺗﺼﻨﻊ ﻓﻲ ﺧﻼﻳﺎ‬
hypergastrinemia, and antral G-cell
hyperplasia.
 Reduced intrinsic factor production ‫ ﻛﻤﺎ أن اﻧﺨﻔﺎض إﻓﺮاز اﻟﻌﺎﻣﻞ اﻟﺪاﺧﻠﻲ ﻳﻌﻴﻖ اﻣﺘﺼﺎص‬
impedes B12 absorption and causes .‫ وﻳﺴﺒﺐ ﻓﻘﺮ دم ﺧﺒﻴﺚ‬B12 ‫ﻓﻴﺘﺎﻣﻴﻦ‬
pernicious anemia.
 Secondary damage to chief cells ‫ واﻹﺻﺎﺑﺔ اﻟﺜﺎﻧﻮﻳﺔ ﻟﻠﺨﻼﻳﺎ اﻟﺮﺋﻴﺴﻴﺔ ﺗﻘﻠﻞ ﻣﻦ إﻓﺮاز‬
reduces the pepsinogen production. .(‫اﻟﺒﻴﺒﺴﻴﻨﻮﺟﻴﻦ )ﻣﻮﻟﺪ اﻟﺒﺒﺴﻴﻦ‬
Morphology ‫اﻟﺼﻔﺎت اﻟﺸﻜﻠﻴﺔ‬
 Rugal folds are lost ad there is diffuse (‫ ﻧﻼﺣﻆ ﻏﻴﺎب ﻃﻴﺎت روﻏﺎل )ﻃﻴﺎت اﻟﻤﻌﺪة اﻟﻤﺨﺎﻃﻴﺔ‬
mucosal damage of the acid producing ‫ﻣﻊ ﺿﺮر ﻣﺨﺎﻃﻲ ﻣﻨﺘﺸﺮ ﻳﺼﻴﺐ اﻟﺨﻼﻳﺎ اﻟﺠﺪارﻳﺔ اﻟﻤﻔﺮزة‬
parietal cells, primarily in the body and ‫ وﻳﺸﺎﻫﺪ ﺑﺸﻜﻞ أﺳﺎﺳﻲ ﻓﻲ ﺟﺴﻢ وﻗﺎع‬،‫ﻟﻠﺤﻤﺾ‬
fundus. .‫اﻟﻤﻌﺪة‬
 The inflammatory infiltrate is ‫ ﺗﻜﻮن اﻟﺮﺷﺎﺣﺔ اﻻﻟﺘﻬﺎﺑﻴﺔ ﻣﻜﻮﻧﺔ ﺑﺸﻜﻞ أﺳﺎﺳﻲ ﻣﻦ‬
predominantly lymphocytes, ‫اﻟﻠﻤﻔﺎوﻳﺎت )وﻗﺪ ﺷﺎﻫﺪ أﻳﻀﺎ اﻟﺒﺎﻟﻌﺎت واﻟﺨﻼﻳﺎ اﻟﺒﻼزﻣﻴﺔ‬
macrophages, and plasma cells; lymphoid .(‫واﻟﺘﺠﻤﻌﺎت اﻟﻠﻤﻔﺎوﻳﺔ‬
aggregates can be present.

11
 ‫ ﻫﻴﺜﻢ ﺧﻮﺟﺔ‬.‫د‬ 1 ‫آﻓﺎت اﻟﺠﻬﺎز اﻟﻬﻀﻤﻲ‬ 2 ‫ﻋﻠﻢ اﻷﻣﺮاض‬

Clinical Features ‫اﻟﺼﻔﺎت اﻟﺴﺮﻳﺮﻳﺔ‬

 Autoantibodies are detected early in .‫ ﻗﺪ ﺷﺎﻫﺪ اﻷﺟﺴﺎم اﻟﻤﻀﺎدة اﻟﻤﻨﺎﻋﻴﺔ ﺑﺎﻛﺮا‬
the course.
 Progression to gastric atrophy occurs 20 ‫ ﻳﺤﺪث اﻟﺘﻄﻮر إﻟﻰ اﻟﻀﻤﻮر اﻟﻤﻌﺪي ﺧﻼل أﻛﺜﺮ ﻣﻦ‬
over 20 to 30 years. .‫ ﺳﻨﺔ‬30 -
 Patients present with symptoms ‫ وﻗﺪ‬.‫ ﻳﺘﻈﺎﻫﺮ اﻟﻤﺮﺿﻰ ﺑﺄﻋﺮاض ﻣﺘﻌﻠﻘﺔ ﺑﻔﻘﺮ اﻟﺪم‬
referable to anemia; B12 deficiency can ‫ أﻳﻀﺎ ﻣﻊ اﻟﺘﻬﺎب اﻟﻠﺴﺎن‬B12 ‫ﻳﺘﻈﺎﻫﺮ ﻋﻮز ﻓﻴﺘﺎﻣﻴﻦ‬
also manifest with atrophic glossitis, ‫اﻟﻀﻤﻮري وﺳﻮء اﻻﻣﺘﺼﺎص واﻋﺘﻼل اﻷﻋﺼﺎب‬
malabsorption, peripheral neuropathy, .‫اﻟﻤﺤﻴﻄﻲ وآﻓﺎت اﻟﺤﺒﻞ اﻟﺸﻮﻛﻲ وﺧﻠﻞ وﻇﺎﺋﻒ اﻟﻤﺦ‬
spinal cord lesions, and cerebral
dysfunction.

Complications of Chronic Gastritis: :‫ﻣﻀﺎﻋﻔﺎت اﻟﺘﻬﺎب اﻟﻤﻌﺪة اﻟﻤﺰﻣﻦ‬

 Peptic Ulcer Disease. .‫ داء اﻟﻘﺮﺣﺔ اﻟﻬﻀﻤﻴﺔ‬
 Dysplasia. .‫ ﻋﺴﺮ اﻟﺘﺼﻨﻊ‬

Hypertrophic Gastropathies ‫اﻋﺘﻼﻻت اﻟﻤﻌﺪة اﻟﻀﺨﺎﻣﻴﺔ‬

 There is diffuse foveolar cell ‫ ﻣﻊ اﻋﺘﻼل‬،‫ ﻳﻼﺣﻆ ﻓﺮط ﺗﻨﺴﺞ ﺧﻼﻳﺎ ﻧﻘﻴﺮﻳﺔ ﻣﻨﺘﺸﺮ‬
hyperplasia, with a protein-losing ‫ﻣﻌﻮي ﻣﻔﻘﺪ ﻟﻠﺒﺮوﺗﻴﻦ واﻟﺬي ﻳﺴﺒﺐ ﻧﻘﺺ ﺑﺮوﺗﻴﻦ دم‬
enteropathy that causes systemic ‫ واﻟﺬي ﻳﺤﺪث ﺑﺴﺒﺐ ﻓﺮط ﺗﻌﺒﻴﺮﻳﺔ ﻋﺎﻣﻞ اﻟﻨﻤﻮ‬،‫ﺟھﺎزي‬
hypoproteinemia. It is caused by .TGF-a ‫اﻟﻤﺤﻮل أﻟﻔﺎ‬
overexpression of transforming growth
factor-a (TGF-a).
 Risk of gastric adenocarcinoma is .‫ وﻫﺬا اﻟﺪاء ﻳﺰﻳﺪ ﻣﻦ ﺧﻄﺮ اﻹﺻﺎﺑﺔ ﺑﺎﻟﺴﺮﻃﺎﻧﺔ اﻟﻐﺪﻳﺔ‬
increased.

 This is caused by gastrin-secreting (‫ ﺗﺤﺪث ﺑﺴﺒﺐ اﻷورام اﻟﻤﻔﺮزة ﻟﻠﻐﺎﺳﺘﺮﻳﻦ )اﻟﻐﺎﺳﺘﺮﻳﻨﻮﻣﺎ‬

tumors (gastronomes) typically in the .‫واﻟﺘﻲ ﺗﻜﻮن ﻋﺎدة ﻓﻲ اﻷﻣﻌﺎء اﻟﺪﻗﻴﻘﺔ أو اﻟﺒﻨﻜﺮﻳﺎس‬
small bowel or pancreas.
 Patients classically present with multiple ‫ ﻳﺘﻈﺎﻫﺮ اﻟﻤﺮﺿﻰ ﺑﺸﻜﻞ ﻛﻼﺳﻴﻜﻲ ﺑﻘﺮﺣﺎت ﻋﻔﺠﻴﺔ‬
duodenal ulcers and/or chronic diarrhea. .‫أو إﺳﻬﺎل ﻣﺰﻣﻦ‬/‫ﻣﺘﻌﺪدة و‬

12
 ‫ ﻫﻴﺜﻢ ﺧﻮﺟﺔ‬.‫د‬ 1 ‫آﻓﺎت اﻟﺠﻬﺎز اﻟﻬﻀﻤﻲ‬ 2 ‫ﻋﻠﻢ اﻷﻣﺮاض‬

Gastric Polyps and Tumor ‫اﻟﺒﻮﻟﻴﺒﺎت اﻟﻤﻌﺪﻳﺔ واﻷورام‬

 Polyps are nodules or masses that ‫ وﻫﻲ ﻋﻘﻴﺪات أو ﻛﺘﻞ ﺗﺒﺮز ﻓﻮق ﻣﺴﺘﻮى اﻟﻤﺨﺎﻃﻴﺔ‬
project above the level of the ‫ ﻓﺮط ﺗﻨﺴﺞ ﻇﻬﺎري‬:‫ وﻗﺪ ﺗﻜﻮن ﻧﺘﻴﺠﺔ ل‬،‫اﻟﻤﺤﻴﻄﺔ ﺑﻬﺎ‬
surrounding mucosa; they can result .‫ او ﺗﻨﺸﺆات ورﻣﻴﺔ‬،‫ اﻧﺘﺒﺎذات‬،‫ اﻟﺘﻬﺎﺑﺎت‬،‫أو ﺳﺪوي‬
from epithelial or stromal hyperplasia,
inflammation, ectopia, or neoplasia.

 Constitute 75% of gastric polyps. .‫ ﻣﻦ اﻟﺒﻮﻟﻴﺒﺎت اﻟﻤﻌﺪﻳﺔ‬75% ‫ﺗﺸﻜﻞ‬ 

 They are most common between ages ‫ وﻋﺎدة ﻣﺎ ﺗﻨﺸﺄ ﺑﺎﻟﺘﺮاﻓﻖ‬،‫ ﻋﺎﻣﺎ‬50-60 ‫أﻛﺜﺮ ﺷﻴﻮﻋﺎ ﻣﺎ ﺑﻴﻦ‬ 
50 and 60 years, and they typically .‫ﻣﻊ اﻟﺘﻬﺎب اﻟﻤﻌﺪة اﻟﻤﺰﻣﻦ‬
arise in association with chronic
gastritis.
 The majority are less than 1 cm and are ‫ ﺳﻢ وﻋﺎدة ﻣﺎ‬1 ‫اﻷﻏﻠﺒﻴﺔ اﻟﻌﻈﻤﻰ ﻣﻨﻬﺎ ﺗﻜﻮن أﺻﻐﺮ ﻣﻦ‬ 
frequently multiple. .‫ﺗﻜﻮن ﻣﺘﻌﺪدة‬
 Risk of dysplasia increases with size: ‫ ﺣﻴﺚ ان اﻟﺒﻮﻟﻴﺒﺎت‬،‫ﻳﺰداد ﺧﻄﺮ ﻋﺴﺮ اﻟﺘﺼﻨﻊ ﺑﺎزدﻳﺎد اﻟﺤﺠﻢ‬ 
polyps more than 1.5 cm should be .‫ ﺳﻢ ﻳﺠﺐ ان ﺗﺴﺘﺄﺻﻞ‬1.5 ‫اﻟﺘﻲ ﺗﻜﻮن أﻛﺒﺮ ﻣﻦ‬
resected.

 Comprise 10% of gastric polyps. .‫ ﻣﻦ ﻣﺠﻤﻞ ﺑﻮﻟﻴﺒﺎت اﻟﻤﻌﺪة‬%10 ‫ ﻳﺸﻜﻞ‬

 These almost always occur on a ‫ ﻳﺤﺪث ﻋﺎدة ﻋﻠﻰ أرﺿﻴﺔ اﻹﺻﺎﺑﺔ ﺑﺪاء اﻟﺴﻼﺋﻞ‬
background of FAP (familial ‫( او اﻟﺘﻬﺎب ﻣﻌﺪي‬FAP) ‫اﻟﻘﻮﻟﻮﻧﻲ اﻟﻮرﻣﻲ اﻟﻐﺪي‬
adenomatosis polyposis) or chronic .‫ﻣﺰﻣﻦ ﻣﻊ ﺿﻤﻮر وﺣﺆول ﻣﻌﻮي‬
gastritis with atrophy and intestinal
metaplasia.
 The male to female ratio is 3:1 and the ‫وﺗﺼﻴﺐ‬،‫ ﻳﺰداد ﻣﻌﺪل اﻹﺻﺎﺑﺔ ﺑﻬﺎ ﻣﻊ اﻟﺘﻘﺪم ﺑﺎﻟﻌﻤﺮ‬
incidence increases with age. .‫ أﺿﻌﺎف اﻹﻧﺎث‬3 ‫اﻟﺬﻛﻮر ﺑﻤﻌﺪل‬
 Usually solitary and less than 2 cm. .‫ ﺳﻢ‬2 ‫ ﻳﻜﻮن ﻋﺎدة ﻣﻔﺮدا وﺣﺠﻤﻪ أﻗﻞ ﻣﻦ‬
 Gastric adenomas all exhibit some ‫ ﺟﻤﻴﻊ اﻟﻐﺪوﻣﺎت اﻟﻤﻌﺪﻧﻴﺔ ﺗﻈﻬﺮ ﻋﻼﻣﺎت اﻟﺘﺜﺪن )ﻋﺴﺮ‬
degree of dysplasia: 30% can harbor ،‫ ﻣﻨﻬﺎ ﻗﺪ ﻳﺘﺤﻮل اﻟﺴﺮﻃﺎن‬%30‫ و‬،‫ﺗﺼﻨﻊ( ﻟﺪرﺟﺔ ﻣﺎ‬
carcinoma, and lesions more than 2 cm .‫ ﺳﻢ ﻣﺜﻴﺮة ﻟﻠﻘﻠﻖ‬2 ‫واﻵﻓﺎت اﻷﻛﺒﺮ ﻣﻦ‬
are particularly concerning.

13
 ‫ ﻫﻴﺜﻢ ﺧﻮﺟﺔ‬.‫د‬ 1 ‫آﻓﺎت اﻟﺠﻬﺎز اﻟﻬﻀﻤﻲ‬ 2 ‫ﻋﻠﻢ اﻷﻣﺮاض‬

Gastric adenoma ‫ﺑﻮﻟﻴﺒﺎت اﻟﺘﻬﺎﺑﻴﺔ‬

 Constitute more than 90% of gastric .‫ ﻣﻦ اﻟﺨﺒﺎﺛﺎت اﻟﻤﻌﺪﻳﺔ‬%90 ‫ ﺗﺸﻜﻞ أﻛﺜﺮ ﻣﻦ‬
malignancies.
 They are divided into intestinal and ‫ ﻣﻊ اﺧﺘﻼف ﻓﻲ‬،‫ ﺗﻘﺴﻢ إﻟﻰ اﻟﻤﻌﻮﻳﺔ واﻟﻤﻨﺘﺸﺮة‬
diffuse forms with different risk ‫ﻋﻮاﻣﻞ اﻟﺨﻄﺮ واﻻﺿﻄﺮاﺑﺎت اﻟﻮراﺛﻴﺔ واﻟﻌﻼﻣﺎت اﻟﺴﺮﻳﺮﻳﺔ‬
factors, genetic perturbations, and .‫واﻟﻤﺮﺿﻴﺔ‬
clinical and pathologic presentations.
Epidemiology ‫اﻟﻮﺑﺎﺋﻴﺔ‬
‫ﹰ‬
 Worldwide distribution is widely. .‫ ﺗﺨﺘﻠﻒ ﻣﻌﺪﻻت اﻧﺘﺸﺎر اﻟﻤﺮض ﻋﺎﻟﻤﻴﺎ‬
 variable; the incidence in Japan, Chile, ‫ ﻣﻌﺪل اﻟﻮﻗﻮع ﺑﺎﻟﻴﺎﺑﺎن وﺗﺸﻴﻠﻲ وﻛﻮﺳﺘﺎرﻳﻜﺎ وﺷﺮﻗﻲ‬
Costa Rica, and Eastern Europe is 20- ‫ ﺿﻌﻒ ﻣﻦ ﺷﻤﺎل أﻣﺮﻳﻜﺎ وأوروﺑﺎ‬20‫أوروﺑﺎ أﻛﺜﺮ ب‬
fold greater than in North America and .‫اﻟﺸﻤﺎﻟﻴﺔ‬
northern Europe.
 The United States incidence decreased ‫ ﺑﺎﻟﻘﺮن‬%85 ‫ ﻣﻌﺪل اﻹﺻﺎﺑﺔ ﺑﺄﻣﺮﻳﻜﺎ ﻗﺪ اﻧﺨﻔﺾ ﺑﻨﺴﺒﺔ‬
85% in the 20th century (mostly due ‫اﻟﻌﺸﺮﻳﻦ )ﻣﻌﻈﻢ اﻻﻧﺨﻔﺎض ﻗﺪ ﺣﺪث ﺑﺎﻟﻨﻤﻂ اﻟﻤﻌﻮي‬
to decreases in the intestinal form .(‫اﻟﻤﺘﺮاﻓﻖ ﻣﻊ اﻟﺘﻬﺎب اﻟﻤﻌﺪة اﻟﻀﻤﻮري‬
that is associated with atrophic
gastritis).
 Gastric carcinoma now constitutes less ‫ ﺗﺸﻜﻞ ﻧﺴﺒﺔ اﻟﻮﻓﻴﺎت ﺑﺎﻟﺴﺮﻃﺎﻧﺔ اﻟﻤﻌﺪﻳﺔ أﻗﻞ ﻣﻦ‬
than 2.5% of all cancer deaths in the .‫ ﻣﻦ وﻓﻴﺎت اﻟﺴﺮﻃﺎن ﺑﺎﻟﻮﻻﻳﺎت اﻟﻤﺘﺤﺪة‬%2.5
United States.
 The epidemiology suggests a role for ‫ ﻳﻔﺘﺮض ﻋﻠﻢ اﻷوﺑﺌﺔ وﺟﻮد دور ﻟﻠﻌﻮاﻣﻞ اﻟﺒﻴﺌﻴﺔ‬
environmental factors (e.g., H. pylori .(‫)ﻛﺎﻹﺻﺎﺑﺔ ﺑﺎﻟﻤﻠﺘﻮﻳﺔ اﻟﺒﻮاﺑﻴﺔ‬
infections)

14
 ‫ ﻫﻴﺜﻢ ﺧﻮﺟﺔ‬.‫د‬ 1 ‫آﻓﺎت اﻟﺠﻬﺎز اﻟﻬﻀﻤﻲ‬ 2 ‫ﻋﻠﻢ اﻷﻣﺮاض‬

 Diet also influences risk, thus ‫ ﻳﻌﺘﺒﺮ اﻟﻨﻈﺎم اﻟﻐﺬاﺋﻲ ﻣﻦ اﻟﻌﻮاﻣﻞ اﻟﻤﺆﺛﺮة‬
decreased consumption of carcinogens N- ‫ﻓﺎﻟﺘﻘﻠﻴﻞ ﻣﻦ اﻣﺘﺼﺎص اﻟﻤﻮاد اﻟﻤﺴﺮﻃﻨﺔ )ﻣﺮﻛﺒﺎت‬
(e.g., N-nitroso compounds and benzo benzo [a] pyrene ‫ و‬itroso
[a] pyrene, associated with some forms ‫اﻟﻤﺘﺮاﻓﻖ ﻣﻊ اﻟﻤﻮاد اﻟﺤﺎﻓﻈﺔ( وزﻳﺎدة ﺗﻨﺎول ﻣﻀﺎدات‬
of food preservation) and increased ‫اﻷﻛﺴﺪة ﻓﻲ اﻟﻔﻮاﻛﻪ واﻟﺨﻀﺮوات اﻟﻄﺎزﺟﺔ ﻳﻨﻘﺺ‬
intake of antioxidants in fruits and .‫ﻣﻌﺪﻻت اﻹﺻﺎﺑﺔ‬
green leafy vegetables reduce gastric
cancer incidence.
 Conversely, partial gastrectomy ‫ ﻳﺰﻳﺪ اﻻﺳﺘﺌﺼﺎل اﻟﺠﺰﺋﻲ ﻟﻠﻤﻌﺪة ﺧﻄﺮ اﻹﺻﺎﺑﺔ‬،‫ ﺑﺎﻟﻤﻘﺎﺑﻞ‬
increases the risk by permitting bile ‫ﻷﻧﻪ ﻳﺴﻤﺢ ﺑﺤﺪوث اﻟﻘﻠﺲ اﻟﺼﻔﺮاوي وﺗﻄﻮر اﻟﺘﻬﺎب‬
reflux and the development of chronic .‫ﻣﻌﺪة ﻣﺰﻣﻦ‬
gastritis.
Pathogenesis ‫اﻹﻣﺮاﺿﻴﺔ‬
 Loss of Intercellular adhesion is a key ‫ إن ﺿﻌﻒ اﻟﺘﻼﺻﻖ ﺑﻴﻦ اﻟﺨﻠﻮي ﻫﻮ ﻣﻔﺘﺎح اﻟﺒﺪء ﻟﺘﻜﻮن‬
step in oncogenesis, particularly of .‫اﻷورام وﺧﺎﺻﺔ ﺑﺎﻟﺴﺮﻃﺎن اﻟﻤﻌﺪي اﻟﻤﻨﺘﺸﺮ‬
diffuse gastric cancer.
 Thus, germline mutations in the CDH1 ‫ ﻳﺘﺮاﻓﻖ ﺣﺪوث ﻃﻔﺮة ﺑﺎﻟﺨﻼﻳﺎ اﻟﻤﻨﺘﺸﺔ ﻋﻠﻰ اﻟﻤﻮرﺛﺔ‬
gene encoding E-cadherin are ‫ ﻣﻊ اﻟﺴﺮﻃﺎﻧﺔ‬E-Cadherin‫ اﻟﻤﺸﻔﺮة ﻟﻞ‬CDH1
associated with familial gastric ‫ ﻣﻦ اﻵﻓﺎت‬٪50 ‫اﻟﻤﻌﺪﻧﻴﺔ اﻟﻌﺎﺋﻠﻴﺔ وﺗﺤﺪث ﻓﻲ‬
carcinomas and also occur in 50% of .‫اﻹﻓﺮادﻳﺔ‬
sporadic lesions.
 Intestinal- type gastric cancers are FAP ‫ أﻣﺎ اﻟﺴﺮﻃﺎن اﻟﻤﻌﺪي اﻟﻤﻌﻮي ﻓﻴﺘﺮاﻓﻖ ﻣﻊ‬
associated with FAP, mutations in (b- E-cadherin ‫وﻃﻔﺮات ﺑﺮوﺗﻴﻨﻴﺔ ﻣﺘﻌﻠﻘﺔ ب‬
proteins that associate with E-cadherin ‫ وﻓﺮط إﺿﺎﻓﺔ زﻣﺮ اﻟﻤﻴﺜﻴﻞ ﻓﻲ اﻟﺠﻴﻨﺎت‬Catenin)
(e.g., b-catenin), and hypermethylation
TGFbRIL, BAX, IGFRII, and p16/INK4a
of TGFRII, BAX, IGFRII, and
p16/INK4a.
 In both types of gastric cancer ‫ ﻳﺘﺮاﻓﻖ ﻛﻼ ﻧﻮﻋﻲ ﺳﺮﻃﺎن اﻟﻤﻌﺪة ﻣﻊ اﻹﺻﺎﺑﺔ ﺑﺎﻟﻤﻠﺘﻮﻳﺔ‬
associated with H. pylori infections. .‫اﻟﺒﻮاﺑﻴﺔ‬

15
 ‫ ﻫﻴﺜﻢ ﺧﻮﺟﺔ‬.‫د‬ 1 ‫آﻓﺎت اﻟﺠﻬﺎز اﻟﻬﻀﻤﻲ‬ 2 ‫ﻋﻠﻢ اﻷﻣﺮاض‬

‫ﹰ‬
Grossly ‫ﻋﻴﺎﻧﻴﺎ‬
 Gastric cancers involve the antrum more ‫ ﺗﺼﻴﺐ اﻟﺴﺮﻃﺎﻧﺎت اﻟﻤﻌﺪﻳﺔ اﻟﻐﺎر ﺑﺎﻟﻤﺮﺗﺒﺔ اﻷوﻟﻰ ﺛﻢ‬
than the lesser curvature more than the .‫ﻣﻨﻄﻘﺔ اﻻﻧﺤﻨﺎء اﻟﺼﻐﻴﺮ ﺛﻢ اﻻﻧﺤﻨﺎء اﻟﻜﺒﻴﺮ‬
greater curvature.
 Tumors with intestinal morphology tend ‫ ﺗﻤﻴﻞ اﻷورام ذات اﻟﺸﻜﻞ اﻟﻤﻌﻮي ﻟﺘﺸﻜﻴﻞ أورام ﻣﻨﺘﺒﺬة‬
to form bulky exophytic tumors .‫ﺿﺨﻤﺔ ﺗﺘﺄﻟﻒ ﻣﻦ ﺑﻨﻲ ﻏﺪﻳﺔ‬
composed of glandular structures.
 These develop from precursor lesions ‫ وﺗﺘﻄﻮر ﻫﺬه اﻟﺴﺮﻃﺎﻧﺎت ﻣﻦ آﻓﺎت ﺳﺎﺑﻘﺔ ﻛﺎﻟﻐﺪوﻣﺎت‬
including flat dysplasia and adenomas. .‫واﻟﺘﺜﺪن اﻟﻤﺴﻄﺢ‬
 Tumors with a diffuse infiltrative ‫ أﻣﺎ اﻷورام اﻟﻤﻨﺘﺸﺮة اﻟﻤﺮﺗﺸﺤﺔ ﻓﺘﺘﺄﻟﻒ ﻋﺎدة ﻣﻦ ﺧﻼﻳﺎ‬
pattern of growth tend to be composed ‫ﺧﺎﺗﻤﻴﺔ )ﺗﺴﻤﻰ ﺑﺴﺒﺐ وﺟﻮد ﻓﺮاﻏﺎت ﻣﻦ ﻣﻴﻮﺳﻴﻦ داﺧﻞ‬
of signet-ring cells (intracellular mucin ‫اﻟﺨﻠﻴﺔ ﺗﺪﻓﻊ اﻟﻨﻮاة ﻟﻠﻤﺤﻴﻂ( واﻟﺘﻲ ﺗﻜﻮن ﺿﻌﻴﻔﺔ اﻻرﺗﺒﺎط‬
vacuoles push the nucleus to the ‫ وﻳﻤﻴﻞ ﻫﺬا اﻟﻨﻤﻂ ﻋﺎدة اﻟﺘﺤﺮﻳﺾ‬،‫وﻻ ﺗﺸﻜﻞ اي ﻏﺪد‬
periphery) that are discohesive and do ‫ وﻻ ﻳﻮﺟﺪ آﻓﺎت ﺳﺎﺑﻘﺔ ﻣﻌﺮوﻓﺔ‬.‫ﺗﺸﻜﻴﻞ اﺳﺘﺠﺎﺑﺔ ﻟﻴﻔﻴﺔ‬
not form glands, and these also tend to .‫ﺗﺤﺪث ﻗﺒﻞ اﻹﺻﺎﺑﺔ‬
induce a fibrous desmoplastic response.
There are no identified precursor
lesions.
 The gross correlate to these tumors is a ‫ ﻳﻜﻮن اﻟﺸﻜﻞ اﻟﻌﻴﺎﻧﻲ ﻟﻬﺬه اﻷورام ﻗﺎﺳﻴﺎ ذا ﺳﻤﺎﻛﺔ ﻓﻲ‬
rigid, thickened gastric wall termed ‫ وﻳﺴﻤﻰ ﻫﺬا اﻟﺸﻜﻞ ﺑﺰﺟﺎﺟﺔ اﻟﺠﻠﺪ‬،‫ﺟﺪران اﻟﻤﻌﺪة‬
linitus plastica (literally "leather .‫اﻟﻤﺪﺑﻮغ‬
bottle").

Clinical Features (‫اﻟﻌﻼﻣﺎت اﻟﺴﺮﻳﺮﻳﺔ )ﻫﺎم‬

 Gastric carcinoma is an insidious ،(‫ إن اﻟﺴﺮﻃﺎﻧﺔ اﻟﻤﻌﺪﻳﺔ ﻣﺮض ﻣﺨﺎﺗﻞ )ﻣﺨﺎدع‬
disease; early symptoms resemble ‫ﺣﻴﺚ ﺗﺘﺸﺎﺑﻪ اﻷﻋﺮاض اﻷوﻟﻰ ﻣﻊ اﻟﺘﻬﺎب اﻟﻤﻌﺪة اﻟﻤﺰﻣﻦ‬
those for chronic gastritis (i.e., .(‫ وﻏﺜﻴﺎن‬،‫ ﻋﺴﺮ ﻫﻀﻢ‬،‫)ﻋﺴﺮ ﺑﻠﻊ‬
dysphagia, dyspepsia, and nausea).
 Advanced stages announce themselves ‫ أﻣﺎ اﻟﺤﺎﻻت اﻟﻤﺘﻘﺪﻣﺔ ﻟﻠﻤﺮض ﻓﻬﻲ واﺿﺤﺔ اﻟﺘﺸﺨﻴﺺ‬
with weight loss, anorexia altered ‫ ﻓﻘﺮ دم‬،‫ ﺗﻐﻴﺮ ﻋﺎدات اﻟﺘﻐﻮط‬،‫ ﻗﻬﻢ‬،‫ﺑﻮﺟﻮد ﻓﻘﺪان وزن‬
bowel habits, anemia, and hemorrhage. .‫وﻧﺰف‬

16
 ‫ ﻫﻴﺜﻢ ﺧﻮﺟﺔ‬.‫د‬ 1 ‫آﻓﺎت اﻟﺠﻬﺎز اﻟﻬﻀﻤﻲ‬ 2 ‫ﻋﻠﻢ اﻷﻣﺮاض‬

Prognosis ‫اﻹﻧﺬار‬
 critically depends on depth of invasion and ‫ﻳﻌﺘﻤﺪ ﺑﺸﻜﻞ أﺳﺎﺳﻲ ﻋﻠﻰ ﻋﻤﻖ اﻟﻐﺰو وﻣﺪی اﻻﻧﺘﺸﺎر‬ 
the extent of nodal or distant metastases. .‫ﻓﻲ اﻟﻌﻘﺪ ووﺟﻮد اﻟﻨﻘﺎﺋﻞ اﻟﺒﻌﻴﺪة‬
 After surgical resection, the 5-year ‫ ﺳﻨﻴﻦ ﻓﻲ‬5 ‫ ﻣﻌﺪل اﻟﺒﻘﻴﺎ ل‬،‫ﺑﻌﺪ اﻻﺳﺘﺌﺼﺎل اﻟﺠﺮاﺣﻲ‬ 
survival of early gastric cancer is more .٪90 ‫اﻟﺤﺎﻻت اﻟﻤﺸﺨﺼﺔ ﺑﺎﻛﺮة ﻣﻦ اﻟﺴﺮﻃﺎن أﻋﻠﻰ ﻣﻦ‬
than 90%.
 With nodal spread; in comparison, ‫وﻓﻲ ﺣﺎل اﻻﻧﺘﺸﺎر ﻓﻲ اﻟﻌﻘﺪ واﻟﺤﺎﻻت اﻟﻤﺘﻘﺪﻣﺔ ﻟﻠﺴﺮﻃﺎﻧﺔ‬ 
advanced gastric cancer has a 5-year .٪20 ‫ ﺳﻨﻴﻦ اﻗﻞ ﻣﻦ‬5 ‫اﻟﻤﻌﺪﻳﺔ ﻳﻜﻮن ﻣﻌﺪل اﻟﺒﻘﻴﺎ ل‬
survival of less than 20%. ‫ ﺳﻨﻴﻦ ﻓﻲ اﻟﻮﻻﻳﺎت اﻟﻤﺘﺤﺪة‬5 ‫ ﻣﻌﺪل اﻟﺒﻘﻴﺎ ل‬،‫ﺑﺎﻟﻤﺠﻤﻞ‬ 
 Overall, 5-year survival in the United .%30 ‫ﻫﻮ‬
States is 30%.
Adenocarcinoma ‫ ﻣﻦ ﺳﺮﻃﺎﻧﺎت اﻟﻤﻌﺪة‬٪90
.Lymphoma ‫ او‬sarcoma ٪10‫و‬

Gastric Lymphoma ‫اﻟﻠﻤﻔﻮﻣﺎ اﻟﻤﻌﺪﻳﺔ‬

 Extra-odal lymphomas can arise in any ‫ أي ﻧﺴﻴﺞ ﻣﻌﺮض ﻟﻺﺻﺎﺑﺔ ﺑﻠﻤﻔﻮﻣﺎ ﺧﺎرج اﻟﻌﻘﺪﻳﺔ وﻟﻜﻨﻪ‬
tissue, but they do so most commonly in .‫أﺷﻴﻊ ﻓﻲ اﻟﺴﺒﻴﻞ اﻟﻬﻀﻤﻲ وﺧﺼﻮﺻﺎ اﻟﻤﻌﺪة‬
the gastrointestinal tract and
especially the stomach.
 Patients typically present with ‫ ﻳﺸﻜﻮ اﻟﻤﺮﺿﻰ اﻟﻤﺼﺎﺑﻮن ﻣﻦ ﻋﺴﺮ ﻫﻀﻢ وأﻟﻢ‬
dyspepsia and epigastric pain; ‫ﺷﺮﺳﻮﻓﻲ وﻗﻲء دﻣﻮي وﺗﻐﻮط أﺳﻮد وﻗﺪ ﺗﺤﺪث‬
hematemesis, melena, or weight loss .‫ﺧﺴﺎرة اﻟﻮزن‬
can also OCCUR.
 Gastrointestinal lymphomas (also called ‫ ﻟﻤﻔﻮﻣﺎ اﻟﺴﺒﻴﻞ اﻟﻬﻀﻤﻲ )ﺗﺴﻤﻰ أﻳﻀﺎ ﻟﻤﻔﻮﻣﺎ اﻟﻨﺴﻴﺞ‬
mucosa-associated lymphoid tissue or ‫( ﺗﺸﻜﻞ‬MALTomas ‫اﻟﻠﻤﻔﺎوي اﻟﻤﺮﺗﺒﻂ ﺑﺎﻟﻤﺨﺎﻃﻴﺔ‬
MALTomas) constitute 5% of gastric .‫ ﻣﻦ ﺧﺒﺎﺛﺎت اﻟﻤﻌﺪة‬%5
malignancies.
 most are marginal zone B-cell ‫ ﻓﻲ‬B ‫ ﺗﻜﻮن ﻏﺎﻟﺒﻴﺘﻬﺎ ﻋﻠﻰ ﺷﻜﻞ ﻟﻤﻔﻮﻣﺎ اﻟﺨﻠﻴﺔ‬
lymphomas. A smaller fraction of ‫ وﻧﺴﺒﺔ أﻗﻞ ﻣﻦ اﻟﻠﻤﻔﻮﻣﺎت اﻟﺒﺪﺋﻴﺔ‬،‫اﻟﻤﻨﺎﻃﻖ اﻟﻬﺎﻣﺸﻴﺔ‬
primary gastrointestinal lymphomas are ‫ ﻛﺒﻴﺮة‬B ‫ﻓﻲ اﻟﺴﺒﻴﻞ اﻟﻬﻀﻤﻲ ﻣﻦ ﻧﻮع ﻟﻤﻔﻮﻣﺎ اﻟﺨﻠﻴﺔ‬
large B-cell lymphomas. .‫اﻟﺤﺠﻢ‬

17
 ‫د‪ .‬ﻫﻴﺜﻢ ﺧﻮﺟﺔ‬ ‫آﻓﺎت اﻟﺠﻬﺎز اﻟﻬﻀﻤﻲ ‪1‬‬ ‫ﻋﻠﻢ اﻷﻣﺮاض ‪2‬‬

‫‪Pathogenesis‬‬ ‫اﻹﻣﺮاﺿﻴﺔ‬
‫‪ Extra nodal marginal B-cell lymphomas‬‬ ‫‪ ‬ﺗﻨﺸﺄ ﻟﻤﻔﻮﻣﺎ اﻟﺨﻼﻳﺎ ‪ B‬ذات اﻟﻌﻘﺪ اﻹﺿﺎﻓﻴﺔ اﻟﻬﺎﻣﺸﻴﺔ‬
‫‪arise at sites of CHRONIC‬‬ ‫ﻣﻦ أﻣﺎﻛﻦ اﻻﻟﺘﻬﺎب اﻟﻤﺰﻣﻦ‪.‬‬
‫‪INFLAMMATION.‬‬
‫‪ In the stomach, this is typically‬‬ ‫‪ ‬ﻓﻲ اﻟﻤﻌﺪة‪ ،‬ﻳﺘﺮاﻓﻖ ﻫﺬا اﻟﻤﺮض ﻧﻤﻮذﺟﻴﺔ ﻣﻊ اﻹﻧﺘﺎن‬
‫‪associated with chronic H. pylori‬‬ ‫اﻟﻤﺰﻣﻦ ﺑﺎﻟﻤﻠﺘﻮﻳﺔ اﻟﺒﻮاﺑﻴﺔ‪.‬‬
‫‪INFECTION.‬‬
‫‪ interestingly, antibiotic treatment can‬‬ ‫‪ ‬ﻳﻤﻜﻦ ﻟﻠﻌﻼج ﺑﺎﻟﺼﺎدات اﻟﺤﻴﻮﻳﺔ أن ﻳﺆدي ﻟﺘﺮاﺟﻊ اﻟﻮرم‬
‫‪induce tumor regression.‬‬ ‫ﺑﺸﻜﻞ ﻣﻠﺤﻮظ‪.‬‬

‫‪ Tumors arise from diffusely‬‬ ‫‪ ‬ﻫﻲ أورام ﺗﻨﺸﺄ ﻣﻦ اﻟﺨﻼﻳﺎ اﻟﺼﻤﺎوﻳﺔ اﻟﻤﻨﺘﺸﺮة اﻟﻤﺘﻔﺮﻗﺔ‪.‬‬
‫‪distributed endocrine cells.‬‬
‫‪ Most arise in the gut (lungs are‬‬ ‫‪ ‬ﻣﻌﻈﻤﻬﺎ ﻳﻨﺸﺄ ﻓﻲ اﻷﻣﻌﺎء )اﻟﺮﺋﺔ ﺑﺎﻟﻤﺮﺗﺒﺔ اﻟﺜﺎﻧﻴﺔ(‬
‫‪second in frequency) and 40% occur in‬‬ ‫وﺗﺼﻴﺐ ﻓﻲ ‪ %40‬ﻣﻦ اﻟﺤﺎﻻت اﻷﻣﻌﺎء اﻟﺪﻗﻴﻘﺔ‪.‬‬
‫‪the small intestine.‬‬
‫‪ The cells of origin in the‬‬ ‫‪ ‬ﻫﺬه اﻟﺨﻼﻳﺎ ﻣﺴﺆوﻟﺔ ﻋﻦ اﻹﻓﺮاز اﻟﻬﺮﻣﻮﻧﻲ ﻓﻲ اﻟﺴﺒﻴﻞ‬
‫‪gastrointestinal tract are responsible‬‬ ‫اﻟﻬﻀﻤﻲ وﺗﻘﻮم ﺑﺘﻨﺴﻴﻖ اﻟﻮﻇﺎﺋﻒ ﻓﻴﻪ‪.‬‬
‫‪for hormone secretion that‬‬
‫‪coordinates gastrointestinal function.‬‬
‫ﹰ‬
‫‪Morphology‬‬ ‫ﺷﻜﻠﻴﺎ‬
‫‪ These are well-differentiated‬‬ ‫‪ ‬ﻫﻲ ﺳﺮﻃﺎﻧﺎت ﻋﺼﺒﻴﺔ ﺻﻤﺎوﻳﺔ ﺟﻴﺪة اﻟﺘﻤﺎﻳﺰ ﻟﻪ‬
‫‪neuroendocrine carcinomas.‬‬
‫‪ Carcinoids are usually indolent, slow‬‬ ‫‪ ‬اﻟﻮرم اﻟﺴﺮﻃﺎوي ﻳﻜﻮن ﻋﺎدة ﻋﻠﻰ ﺷﻜﻞ ﺧﺒﺎﺛﺎت ﻗﻠﻴﻠﺔ‬
‫‪growing malignancies, and symptoms‬‬ ‫اﻹﻳﻼم وﺑﻄﻴﺌﺔ اﻟﻨﻤﻮ‪ ،‬وﺗﻜﻮن اﻷﻋﺮاض ﻣﺘﻌﻠﻘﺔ ﺑﺸﻜﻞ‬
‫‪are largely a function of the hormones‬‬ ‫ﻛﺒﻴﺮ ﺑﻮﻇﻴﻔﺔ اﻟﻬﺮﻣﻮﻧﺎت اﻟﻤﻔﺮزة‪.‬‬
‫‪produced.‬‬ ‫ﹰ‬
‫‪ Thus, gastrin synthesis causes‬‬ ‫‪ ‬ﻓﻤﺜﻼ زﻳﺎدة اﺻﻄﻨﺎع اﻟﻐﺎﺳﺘﺮﻳﻦ ﺗﺆدي ﻟﻺﺻﺎﺑﺔ ﺑﻤﺘﻼزﻣﺔ‬
‫‪Zollinger-Ellison syndrome‬‬ ‫زوﻟﻴﻨﺠﺮ‪ -‬اﻟﻴﺴﻮن‪.‬‬

‫‪ ‬ﻋﻠﻰ ﺳﺒﻴﻞ اﻟﻤﺜﺎل‪ ،‬ﻫﻨﺎك ﻓﻲ ﺟﻴﺐ اﻟﻤﻌﺪة ﺧﻼﻳﺎ ﺻﻤﺎوﻳﺔ ﺗﺪﻋﻰ ﺑﺎﻟﺨﻼﻳﺎ ‪ G‬واﻟﺘﻲ ﺗﻔﺮز اﻟﻐﺎﺳﺘﺮﻳﻦ اﻟﺬي‬
‫ﹰ‬
‫ﻳﻘﻮم ﺑﺪوره ﺑﺘﺤﺮﻳﺾ إﻓﺮاز ﺣﻤﺾ ﻛﻠﻮر اﻟﻤﺎء‪ ،‬وﻛﻤﺎ ﻳﻮﺟﺪ أﻳﻀﺎ ﺧﻼﻳﺎ ‪ D‬واﻟﺘﻲ ﺗﺜﺒﻂ إﻓﺮاز ﺣﻤﺾ ﻛﻠﻮر اﻟﻤﺎء‪،‬‬
‫ﺑﺎﻟﺘﺎﻟﻲ ﻧﺘﻮﻗﻊ أن أﻋﺮاض اﻟﻮرم اﻟﺴﺮﻃﺎوي ﻫﻲ ﻣﻔﺮزات ﻫﺬه اﻟﺨﻼﻳﺎ اﻟﺼﻤﺎوﻳﺔ‪.‬‬

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