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Introduction Gastritis is alterations of the stomach mucosa due to different adverse effects result in various morphological and clinical symptoms

Introduction
Gastritis is alterations of the stomach mucosa due to different adverse effects result in various morphological and clinical symptoms, It is a histological definition indicating mucosal inflammation, It may be acute or chronic gastritis (Emese et al., 2014). Worldwide H.pylori infection is the most common cause of gastritis ,other causes may be infection by other organisms, chemicals, non-steroidal anti-inflammatory drugs use or reactive agents as bile reflux, autoimmune, and others ( Nordenstedt et al.,2013).
Gastritis mostly, asymptomatic, but some symptoms may be present as nausea, vomiting, pain in upper abdomen , and feeling of fullness in upper abdomen . Diagnosis of this condition requires endoscopic intervention, which is an expensive, invasive procedure and needs patient sedation. So less invasive tests are favorable to decrease the number of endoscopic surveys (Mehdizadeh et al.,2010).
Abdominal ultra sonography is an available and easy tool for evaluation of layers of the gastric and duodenal wall thickness using high-frequency linear transducers, five layers of gut wall could be assessed sonographically:1. Mucosa (the innermost layer) 2. Muscularis mucosa (the next layer) 3.Submucosal layer 4. Muscularis propria layer 5. Serosa layer (echogenic) (Mehdizadeh et al., 2010).
H. pylori is considered the most common cause of gastritis, and usually affect antrum, it usually colonize the sub mucosal layer. By using abdominal ultra sonography there is increase in gastric wall thickness due to mucosal erosion caused by H. Pylori proliferation, which lead to increase thickness of mucosal layer, sub mucosal layer ,muscularis mucosal layer, So increase the extent and severity of inflammation lead to increase gastric wall thickness (Cakmakci et al., 2013).
Diagnosis of H.pylori infection :
Many diagnostic tools may be used as:
1. Blood antibody test
2. Stool antigen test
3. Urea breath test
4. Upper gastrointestinal endoscope (Miftahussurur et al., 2016).
Till now, there are few clinical applications of abdominal ultra sonography, It can be used in detection of gastric wall lesions and evaluation of changes in the volume of the stomach during emptying and accommodation of it. As a diagnostic tool abdominal ultra sonography is considered as a non-invasive, cheap and safe practical option for imaging the stomach (Cakmakci et al.,2014).

Aim of the Work

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The present study aims to:

Assess the value of abdominal ultra sonography as a safe, non-invasive tool for early evaluation of gastric wall thickness in cases of Helicobacter pylori gastritis.

Chapter (1)
Helicobacter Pylori
“”H.pyloir”” (“H.pyloir”) had a micro-aerophilic, Gram–ve, spiral-shaped, slow-growing, flagellated organism which infects more than half of the world’s human population (Wen, Moss, 2009). “H.pyloir” colonization itself does not cause any treated, fewer than 20% of all disease cases would treat treated from their disease (Mishra, 2013). Approximately 10% of disease cases treat disease, less than 3% treat Gets adeno, less than 0.1% treat (Peek, Crabtree, 2006).The outcome of “H.pyloir” disease eight involve a combination of case, l, environmental fact. There had association between “H.pyloir” disease, a number of complications as chronic active Gets, disease, Gets call, B call M.A.L.T (Mishra, 2013). The critical of “H.pyloir” disease varies widely by geographic zone, race, age, ethnicity, socioeconomic status. Rates appear to be high in treated than in treated countries, with most of the diseases occurring in cases, they seem to be decreasing with improvements in hygiene practices (Eusebi et al., 2014). The majority of recent reviews had not round alcohol consumption or use to be risk fact for “H.pyloir” disease (Holster et al., 2013). Good nutritional status, especially critical consumption of fruits,vegetables, vitamin C, appears to protect against “H.pyloir” disease. In contrast, food prepared under less than ideal conditions or exposed to contaminated water or soil eight increase the risk. Overall, inadequate sanitation practices, crowded or high-density living conditions, low social class seem to be related to a high critical of “H.pyloir” disease. This finding suggests that poor hygiene, crowded conditions eight increase the risk of transmission of disease between family cases, had consistent with data on intrafamilial, institutional clustering of “H.pyloir” disease (Eusebi et al., 2014). The only proven mode of transmission of “H.pyloir” disease had following getsro intestinal endoscope. For the doneral population, the most likely mode of transmission had from one person to another by either the oral-oral route through vomitus or possibly saliva or perhaps the fecal-oral (Calvet et al.,2013).
“H.pyloir” fact involved in Gets :
A lot of fact of “H.pyloir” contribute to the response to it either by altering case-signaling pathways important to maintain tissue homeostasis in calls or by differ stimulating innate immune calls. The most important fact had :
1. Cag.P.A.I.:
strains of “H.pyloir” possess the Cag.P.A.I.. This 40 kd region contains 31 potential coding regions, which encode for the differ components of a type IV secretion technique (T4SS). Some of those components had important for Cag A translocation such as CagT while, others additionally play an important role in the case’s response (Ding et al., 2012). Upon delivery into case calls by the cag secretion technique, the case of the terminal done in the land, cag A, undergoes Src-dependent tyrosine phosphorylation, activates an eukaryotic phosphatase, leading to dephosphorylation of case call cases, callular morphological changes(Allison et al., 2009).
2. Vacuolating Cytotoxin Done (vacA):
All “H.pyloir” strains had the vacA done, which codes for the secreted pore-forming case vacA. Expression levels, call type specific toxicity, disease severity had linked to critical variation in differ domains of VacA (Palframan et al., 2012). VacA had secreted by the bacterium via a type V autotransport secretion technique, enters the case calls by endocytosis. Once internalized, VacA accumulates inside differ callular compartment, induces apoptosis (Rassow, Meinecke, 2012). In addition, VacA disrupts call tight connections, had distributed in the propria where it encounters T calls recruited to the sites of disease. Persistence of the bacterium occurs following inhibition of T call proliferation, critical functions (Muller et al., 2011).
3. Duodenal Promoting Done (dup A):
“H.pyloir” duodenal promoting done (dup A) had located in the plasticity region of “H.pyloir” genome, had described as a risk marker for duodenal treat, a protective fact against Gets, round that the occurrence of Gets had critically lower in cases with dupA-+ve “H.pyloir” strains, providing further support for dupA as a -ve marker for Gets (Graham et al., 2005).
4.Urease:
In order to overcome the acidic environment of the stone, “H.pyloir” produces an important enzyme, urease, which hydrolyses urea into NH3, CO2. It had demonstrated that this enzyme plays a major role in the “H.pyloir” colonization, being observed that urease-defective mutants had not able to colonize the Gets environment (Montecucco, Rapuolli, 2001). Urease causes destruction of the epithelium through the case on of ammonia that in conjunction with metabolites, forms doneic agents that eight participate in the treat of Gets malignances (Megraud et al., 1992). Ammonia could cause differ call alterations, including swelling of acidic intracallular compartments, alterations of vesicular membrane transport, repression of casesynthesis, ATP case on, call-cycle arrest (Montecucco, Rapuolli, 2001). Urease eight also help to recruit s, monocytes in the to produce pro cyto (Harris et al., 1996).
Pathodonesis of “”H.pyloir”” Disease (figure 1):
The tract makes an important barrier between human cases, microbial populations. The treat of had one of the most potential concritical of case-microbial interactions. “H.pyloir” colonization induces chronic Gets in essentially all cases, a process that increases the risk of treated ation, Gets lymph proliferative disease, distal Gets adeno. However, only a small percentage of persons carrying “H.pyloir” treat clinical sequelae; enhanced risk eight be related to differs in expression of specific l cases, to variations in the specific interactions between case, microbes, or to case response to the (Galmiche et al., 2000).
The W.H.Ole genome of “H.pyloir” consists of many putative fact, including Vac A, NAP, Lipopolysaccharide. The Cag PAI, a complex of Cag dones (CagE, CagG, CagH, CagL, CagI, CagM) coding 40-kds case had a major fact of “H.pyloir”. This lesion codes for the Type IV secretion machinery technique forming a cylinder-like structure connected to calls. Many done cases or other interactive cases had transferred into the case calls via this technique (McManus, 2000).
The single of calls that lines the Gets had the first site of interaction between the case, “H.pyloir”. During disease, the bacterium enters the Gets lumen where the urease help it to survive in the acidic environment by producing ammonia that buffer cytosolic, periplasmic pH as well as the surface round the bacterium. The flagella propel the helicoidal bacterium into the mucus, help it to reach the apical domain of Gets calls, to which it sticks using specialized adhesins. “H.pyloir” then inject the case of CagA into the case calls by Type IV secretion technique, release other toxic fact such as VacA, HP-NAP. VacA induces alterations of tight junctions, the formation of a lot of large vacuoles. The HP-NAP crosses the lining, recruits s, monocytes, which extravasate, cause tissue damage by releasing R.O.Is. Injected Cag cases could cause alteration of the cytoskeleton, pedestal formation, signal the nucleus to release pro lymphokines, which amplify the action with recruitment of lymphocytes, induce the release of R.O.Is. The combined toxic activity of VacA, of R.O.Is leads to tissue damage that had enhanced by loosening of the protective mucus of Gets Will, acid permeation. VacA also inserts into mitochondrial membranes, induce Cytochrome-C release, activate the Caspase3-dependent call-death signaling cascade (Covacci et al., 1999).
Another mechanism by which “H.pyloir” could stimulate more apoptosis had by inducing expression of the call-surface receptor Fas, Fas L (Fas Ligand). The pathogen could also bind to class MHC-II on the surface of calls of Gets, inducing their apoptosis. “H.pyloir” urease, porins eight contribute to extravasation, chemotaxis of s. The epithelium of Gets of “H.pyloir”-disease person had enhanced levels of IL-1Beta, IL-2, IL-6, IL-8, IL-12, TNF-Alpha. Among these, IL-8, had a potent -activating chemokine which had expressed by Gets calls, apparently had a central role. “H.pyloir” strains carrying the Cag-PAI induce a far stronger IL-8 response than strains which had Cag–ve, this response depends on activation of NF-Kappa B, the early-response transcription fact Activating Case-1 (Gerhard et al., 1999).
Macrophages that participate in the case on of IL-8 produce pro cyto involved in the activation of the recruited calls, in particular T Helper calls (TH0, TH1, TH2). In turn, TH1-type cyto such as Interferon-Gamma promote the expression of MHC-II, accessory B7-1, B7-2 by calls, making them competent for presentation. The cytotoxin VacA, Fas-mediated apoptosis leads to disruption of the barrier, facilitating translocation of l s, leading to more activation of macrophages. Cyto produced by macrophages could alter the secretion of mucus, contributing to “H.pyloir”-mediated disruption of the mucous. TNF-Alpha, Interferon-Gamma increase getsrin release, causes alterations in mucus glycocases, stimulate parietal, entero chromaffin calls, acid secretion. TNF-Alpha also could induce decreasing in the number of D calls, leading to decreased somatostatin case on, indirectly enhancing acid case on (Tomita et al.,2001).
“H.pyloir” disease in humans represents a major public health problem. The W.H.O classifies this bacterium as a Type 1 done. The clinical course of “H.pyloir” disease had highly variable, had influenced by both microbial, case fact. Cases with antral-predominant Gets, the most form of “H.pyloir” Gets, had predisposed to duodenal s, but other cases with corpus-predominant Gets, multifocal atrophy had more likely to had Gets s, Gets atrophy, intestinal metaplasia, ultimately Gets (Salama et al., 2001).

“”H.pyloir””, Technique Disease:
Currently, “H.pyloir” disease had confirmed to correlate with chronic Gets, disease, Associated Lymphoid Tissue (M.A.L.T) , prebosomous changes in the stone, Gets bosom. At the same time, “H.pyloir” eludes the immunological response stimulated by the case. This chronic disease had the local case on, technique diffusion of pro cyto, which eight critical the remote organic techniques, result in extra Gets manifestations (table 1) (Roubaud et al., 2013).
Others as Halitosis, urethritis(table1) (Roubaud et al.,2013).
Several reviews support the possible role for “H.pyloir” disease in the pathodonesis of several extra Gets diseases. The role of “H.pyloir” in some hematologic conditions had included in the current guidelines, such as IDA, immune thrombocytopenic purpura, vitamin B12 deficiency (Yeh et al., 2010). So, recent guidelines indicate “H.pyloir” disease eight be cause of IDA. Other hematological diseases possibly related with “H.pyloir” included megaloblastic anemia, monoclonal gammopathy, myelodysplastic syndrome (Papagiannakis et al., 2013). The relationship between outcome of cardiovascular disease, seropositivity for “H.pyloir” had also an important issue. Previous reviews had surveyed the association between “H.pyloir” disease, CAD (Tamer et al., 2009).
The mechanisms of “H.pyloir” disease in the pathodonesis of CAD eight be due to persistent local or technique, initiating autoimmune responses. However, the level of supporting evidence had too limited to advocate therapeutic ventions (Miyazaki et al., 2006). Many reviews revealed that increase serological positivity of “H.pyloir” in cases with autoimmune thyroiditis, type 1 diabetes. In their results, “H.pyloir” disease could be considered as an environmental trigger for occurring autoimmune thyroiditis in type 1 diabetes (El-Eshmawy et al., 2011).

Diagnostic Methods of “”H.pyloir”” Disease:
Direct tests as:
1. Histopathology and/or immunohistochemistry.
2. Rapid urease test.
3. Culture.
Indirect tests as:
1. Antibody-based tests such as serology, urine test.
2. Urea breath test.
3. Sgoal test.
The direct test decreases due to the small amount of that colonizes the stone. Thus, several indirect tests had treated to diagnose “H.pyloir” disease (Burucoa et al., 2013).
(A)Direct diagnostic tests:
(1) Histopathology and/or immunohistochemistry :
For cases with intestinal metaplasia or Gets atrophy, histopathology presents a lower (Shin et al., 2009). A high had observed in the corpus Gets curvature, but not in biopsy for cases with Gets bosom (Kim et al., 2009). Several histochemical staining, including Modified Giemsa, Warthin-Starry, Gimenez, Half Gram, Acridine orange, Ziehl-Neelsen, Cresyl Violet,Modified Genta, “H.pyloir” silver stain had used for the histological detect of “H.pyloir” in Gets biopsies, could enhance the visualization of the organism compared to the routine hematoxylin, eosin stain, which show a weak contrast between, the mucus (Mégraud, Lehours, 2007). Several limitation of histology methods, including cost, time, dependence on the operator skills, interobserver variability, ought to be considered (Lee, Kim, 2015).
(2) Culture:
Culture remains a reference technique as it allows the direct detect of “H.pyloir” organisms even though it presents a limited , had a time-consuming procedure. It had highly specific, allows detect of antimicrobial sensitivities. The of the bacterium isolation varies greatly among laboratories due to a very fastidious organism. Even experienced laboratories recover the organism from only 50% to 70% of actually disease biopsies (Patel et al., 2014).
(3) Rapid urease test (RUT):
RUT presents the advantage of yielding results in 1–24 hours (Chey et al., 2007), making it a suitable method to detect “H.pyloir” in epidemiological reviews. In the presence of “H.pyloir” urease, urea had hydrolyzed to produce ammonia, bicarbonate, leading to increase pH of the Gets, which had indicated by a change in the color of phenol red from yellow to pink or red. After treated a medium to detect “H.pyloir” with a pH indicator (McNulty, Wise, 1985). Based on the literature, RUT samples ought to be discarded after 24 hours as non-“H.pyloir” urease containing organisms eight give false +ve results, ought to not be used to make treat decision (Uotani, Graham,2015). For bleeding cases, cases taking medications such as bismuth, antibiotics, or PPIs, the density and/or urease activity of “H.pyloir” could be reduced, the test could decrease to 25% (Midolo, Marshall, 2000).Thus, cases taking medications ought to stop taking them two weeks before the diagnosis to prevent false -ve results. Formalin contamination of biopsy forceps eight also give false -ve (Ozaslan et al.,2010). Several flora such as Proteus mirabilis, Enterobacter cloacae, Citrobacter freundii, Klebsiella Pneumniae,and Staphylococcus aureus isolated from the oral cavity and/or stone, also present urease activity, could be potential false +ve when using RUT(Osaki et al., 2008).
(B) Indirect diagnostic tests:
Two types of indirect tests had known as Active tests, which detect active disease as UBT, SAT, passive tests, which detect a marker of previous/present exposure to “H.pyloir” (serology or urine), but do not indicate whether the disease had ongoing (Vaira et al., 2005).
(1) Urea breath test (UBT):
UBT showed high , than the IgG serology, SAT. However, the results had inconsistent when compared with RUT (Nocon et al., 2009). This test cannot provide information about genotypes or antibiotic resistance. Also, it requires specialized equipment, which eight not be available in routine clinical laboratories (Jonaitis et al., 2007). In doneral, UBT presents an excallent reliability when cases received pretreat with citric acid, when the dose of 13C-urea administered had not lower than 75?mg to prevent poor results (Calvet et al., 2010). Compared to histology, urease test, conventional UBT, a new UBT, consisting of two tablets each combining citric acid with 37.5?mg of 13C-urea, presents , >99% before, after treat (Vaira et al.,2009). The progressive hypochlorhydria due to atrophy or use of acid-lowering medication could induce false–ve. The presence of atrophy eight lead to a lower load of, eight produce false -ve UBT. However, in combination with a serology test, UBT could be useful to diagnose “H.pyloir” in cases with atrophic Gets (Korstanje et al., 2006). Some medications, including Bismuth containing compounds, antibiotics, PPI, could decrease the test through reduction of the organism density or urease activity. It had currently recommended that antibiotics, bismuth be withheld for at least 4 weeks, a PPI for 7–14 days prior to the UBT (Chey, Wong, 2007).
(2) Sgoal test:
Depending on detect of “H.pyloir” s in sgoals using polyclonal anti-“H.pyloir” antibodies with a , of 88.8%, 94.5%, respectively. The tests using monoclonal antibody showed better accuracy due to the difficulty of obtaining polyclonal antibodies with constant quality (Mégraud, Lehours, 2007).Even compared with UBT, the weighted mean , for SAT had 94%, 94%, respectively (Gisbert, Pajares, 2004). Between the two existing methods, enzyme immunoassay presented a better accuracy than the immune chromatographic test, although the latter also used a monoclonal antibody (Shimoyama et al., 2011). Similar to UBT, the SAT had critical by recent bismuth, antibiotics, PPI treats (Chey, Wong, 2007). Fortunately, fasting had not needed for SAT and, recently, some monoclonal antibodies uncritical by using PPI had treated (Kodama et al., 2012). Therefore, SAT had more advantageous than UBT. The accuracy of SAT decreases when the sgoal samples had unformed or watery due to diluted s (Shimoyama et al., 2011).
(3) Antibody-Based Tests:
Serological tests that detect anti-“H.pyloir” IgG antibodies eight lead to false–ves results. They had also less likely to be conrounded by suppression of “H.pyloir” disease by drugs for example, colloidal bismuth, PPI, or antibiotics (Dunn et al., 1997). Therefore, in particular clinical situations such as bleeding, atrophic Gets, Gets M.A.L.T , Gets, serology had the most efficient diagnostic method (Burucoa et al., 2013). However, this test cannot distinguish between current, past diseases because “H.pyloir” IgG persist even after the disappearance of this bacterium, returning to baseline values takes long time eight be months or years although the bacterium eradication had successful (Miftahussurur, Yamaoka, 2016). False–ve results eight occur for new disease when the antibody levels had not sufficiently elevated (Mégraud, Lehours, 2007).
Several guidelines indicate that not one single test could be considered the gold standard for the diagnosis of “H.pyloir”, that one ought to be chosen after considering the advantages, disadvantages of several tests (Chey, Wong, 2007).The Chinese consensus had that a current “H.pyloir” disease could be diagnosed when there had a +ve finding on the: (1) sgoal test; (2) UBT; or (3) one of the invasive tests among RUT, histology, culture. +ve serum “H.pyloir” antibody had not included in the diagnostic criteria.. The diagnosis “H.pyloir” disease according to Republic of Korea guidelines ought to include either one of the indirect methods (UBT, SAT, or serum “H.pyloir” IgG antibody test) or invasive methods (Gets biopsy for histology or RUT) (Lee, 2014).

Treat of “H.pyloir” disease:
“H.pyloir” had characterized by being a prevalent, worldwide, chronic disease. Choice of treat could be modified according to antibiotic-resistance rates of “H.pyloir”. The ideal therapeutic regimen for “H.pyloir” disease ought to achieve an eradication rate of ? 80%,culturing the pathogen had a step in the treat of l diseases, but this had not been the case for “H.pyloir”, as treats had routinely prescribed empirically in this case. This had due to the fact that performing endoscopy, “H.pyloir” culture had neither widely available, nor well-tolerated by all cases, furthermore it had time-consuming, costly (Gisbert, 2011).
Many regimens of treat had known as:
(1) FIRST-LINE THERAPY:
(a) Triple therapy:
The most critically used strategy in treat of “H.pyloir” had triple therapy. This therapy had composed of a PPI (lansoprazole 30 mg/12 h, omeprazole 20 mg/12 h, rabeprazole 20 mg/12 h, pantoprazole 40 mg/12 h, or esomeprazole 40 mg/24 h), amoxicillin (1 g/12 h), clarithromycin (500 mg/12 h), taken for 7 to 14 days. The duration of therapy had controversial, although a meta-analysis suggested that 14 days provides eradication rates 5% high than those for 7 days. In cases of allergy to penicillin, metronidazole could be used instead of amoxicillin, as it had equally criticalive, considered equivalent (Loyd, McClellan, 2011).There had many explanations for why clarithromycin susceptibility reduces the success rate of therapy. These explanations include a poor adherence to the drug regimen by the case, Gets acidity, l mutations, concentration of l strains, resistance to clarithromycin. There had also critical variability in these numbers. For example, in the Netherlands, where resistance to clarithromycin had not prevalent, it had between 1%, 5% (Malfertheiner et al., 2012).
The efficacy rates of triple therapy depend on PPIs; thus, many strategies, such as increasing the length of treat, increasing the dose of PPIs, had attempted to improve the success of triple therapy. A meta-analysis study demonstrated an increase in the eradication rate from 6% to 10% compared with standard doses of PPI. The sub analysis specifically mentioned that a double dose of esomeprazole showed more beneficial critical. The presence of various polymorphisms in the case’s metabolism could alter the criticaliveness of PPIs, since PPI critical depends on MDR polymorphisms, the cytochrome (CYP) 450 2C19. A recent meta-analysis showed that cases W.H.O had extensive PPI metabolizers (depending on CYP2C19 status) had lower cure rates. (Furuta et al., 2007).
In addition to the standard treat for “H.pyloir” disease, an adjuvant therapy eight be used. For example, lactoferrin had used as adjuvant therapy. Two meta-analyses reviews that examined the use of lactoferrin as adjuvant showed a decrease in the versus criticals of standard treat (Zou et al., 2009). The most critically reported side criticals include headache, upset as diarrhea, altered taste for clarithromycin, GI upset, diarrhea for amoxicillin. However, rates of “H.pyloir” eradication using clarithromycin-containing triple therapies had decreased because of increasing resistance to clarithromycin (Graham et al., 2008).
(B) Quadriple therapy:
Quadruple therapy consists of PPI (twice daily) + bismuth subsalicylate (525 mg 4 times daily) + metronidazole (250 mg 4 times daily) + tetracycline (500 mg 4 times daily) for 10-14 days. Success rates of this therapy range between 75%, 90%. Side criticals of metronidazole include a metallic taste in the mouth, dyspepsia, a disulfiram-like action with alcohol consumption. Side criticals of tetracycline include photo, GI upset. Bismuth compounds had associated with darkening of the tongue, sgoals, , GI upset (Malfertheiner et al., 2012). According to the Maastricht III, Maastricht IV Consensus, quadruple therapy containing bismuth had recommended as first-line therapy, especially in zones with a high critical (; 20%) of clarithromycin resistance, The success rate of bismuth-containing quadruple therapy had reported as;90% from differ parts of the world (Ergül et al., 2013).
A randomized trial showed that a 14-day bismuth-based quadruple regimen-containing amoxicillin, tinidazole (followed by levofloxacin in the second 7 days), pantoprazole had criticalive as well as 14-day bismuth-based quadruple regimen-containing amoxicillin, clarithromycin, pantoprazole in the eradication of “H.pyloir” disease, there had no critical differ between PBAC, PBATL regimens. The overall rate of treat failure suggests that up to 18%–30% of cases would fail bismuth-based quadruple therapy, require retreat for the disease (Sebghatollahi et al., 2018).
(b) Sequent?al therapy:
Sequential therapy had known by a gathering of Italian researchers. It involves the combination of a PPI, amoxicillin (1 g, × 2 daily) for 5 days, followed by a PPI plus two other antibiotics mostly clarithromycin/metronidazole (500 mg × 2 daily) for 5 days. Most reviews had shown that sequential therapy, bismuth-based quadruple therapy had equivalent success in first-line therapy (Loyd, McClellan, 2011). Sequential therapy had evaluated in a pediatric population with iron deficiency (Ali Habib et al., 2013). It had suggested that levo?oxacin containing therapy could achieve better eradication rates than clarithromycin containing therapy. Eradication rates of sequential therapy containing levofloxacin had reported as 95.1%, 90% from Taiwan, Turkey, respectively (Polat et al., 2012).
(c) Concomitant therapy:
Concomitant therapy had used instead of sequential therapy in zones where bismuth-based quadruple therapy had not available, the resistance to clarithromycin had greater than 20%. Concomitant therapy involves the simultaneous administration of three antibiotics (metronidazole, amoxicillin, clarithromycin), a PPI for 10 days. This therapy had well tolerated, criticalive compared to conventional triple therapy (Stenström et al., 2008). The versus criticals of this therapy had high, as 30.9% of subjects reported at least one versus critical. However, the versus criticals had mild, cases had able to complete their treat despite them
(De Francesco et al., 2010).
(D) Hybrid therapy:
Hybrid therapy consists of 2 steps of treat:
(1) Treat with a PPI, amoxicillin 1 g every 12 hours for 7 days, followed by. (2) A PPI, 3 antibiotics, amoxicillin 1 g every12 hours, metronidazole 500 mg every 12 hours, clarithromycin 500 mg every 12 hours, for 7 days. In a study comparing sequential, hybrid therapies, the eradication rates had 76.7%, 89.5%, respectively. Similar severe versus criticals had observed in cases in both treat gatherings. Specifically, 3.8% of cases in the sequential therapy gathering, 2.4% of cases in the hybrid therapy gathering reported versus criticals (Sardarian et al., 2013). A total of 120 cases had included in a study To compare the sequential therapy with the hybrid therapy for the eradication of “H.pyloir”. It had round that hybrid therapy showed a high eradication rate for “H.pyloir” disease than sequential therapy with comparable case compliance, side criticals. However, it could be used in places where the sequential therapy had in criticalive (Ashokkumar et al., 2017).

(2)Second line therapies:
In cases W.H.O did not achieve eradication after receiving treat for “H.pyloir” disease, and, second-line therapy had required. The Maastricht IV consensus states that if triple therapy fails, either levofloxacin-containing triple therapy or a bismuth-containing quadruple therapy could be used as second-line therapy (Malfertheiner et al., 2012). Levofloxacin-containing therapy could be used as second-line therapy in case of failure of triple-therapy or as second-line therapy in case of failure of bismuth-containing quadriple therapy in zones of high clarithromycin resistance. Levofloxacin-containing therapy consists of PPI, amoxicillin, levofloxacin, had used for 10 days. Side criticals of levofloxacin consist of case discomfort, anorexia, , vomiting. It eight also cause mild headache, dizziness (Gisbert et al., 2013). Levofloxacin therapy could also be good as an alternative after failure of concomitant treat or non-bismuth-containing quadriple sequential to eradicate “H.pyloir” disease (Gisbert et al., 2013).
(3) Rescue therapy:
Rifabutin-based rescue therapy constitutes an encouraging strategy after previous eradication failures with key antibiotics such as metronidazole, amoxicillin, clarithromycin, tetracycline, levofloxacin (Miehlke et al., 2006). Rifabutin could be an alternative therapy to bismuth-based quadriple therapy. In trials using rifabutin-based therapy, eradication rates had reported at;80% (Bock et al., 2000). Side criticals of rifabutin include red discoloration of urine, getsro intestinal upsets such as , vomiting, dyspepsia, diarrhea, rash. Rarely, rifabutin had associated with ocular toxicity, myelotoxicity (Borody et al., 2006).
(4)Penicillin allergic cases:
PPI, metronidazole, clarithromycin therapy could be used as first-line of treat for the cases with penicillin allergy living in zones of low clarithromycin resistance (Gisbert et al., 2005). PPI, metronidazole, tetracycline regimens or bismuth-containing quadruple therapy could be used in zones of high clarithromycin resistance (Rodríguez et al., 2005). As an alternative treat PPI, bismuth subcitrate, ciprofloxacin, rifabutin had used for cases with penicillin allergy, this therapy gave an eradication rate of 94.2% (Tay et al., 2012).
Alternative therapies for “H.pyloir” disease:
While antibiotics had the main agents used in the treat of “H.pyloir” disease, the treat of resistance to antibiotics had limited their application. Also, administration of antibiotics perturbs the microbiota, the microorganisms that colonize the human tract, thus causes side criticals, such as diarrhea. Because of this, alternative therapies could be used for the treat of “H.pyloir” disease including phytomedicines, probiotics.
(1) Phytomedicines:
Many reviews had demonstrated the importance, the efficacy of the TCMs in the treat of various diseases. The safety, efficacy of TCMs for the treat of “H.pyloir” had reviewed, the average eradication rate had round to be about 72% (Lin, Huang, 2009). Other phytomedicines that had used for the treat of “H.pyloir” disease had cranberry juice, green tea catechins, garlic extract, propolis (Vítor, Vale, 2011). For example, it had demonstrated that a combination of sialic acid, catechins could criticalively prevent “H.pyloir” disease in animals, increase the eradication rate.As sialic acid, catechins had differ anti- actions, the additive or synerG.I.S.Tic criticals caused by such a combination eight provide a potential good strategy for treating “H.pyloir” disease in the future (Yang et al., 2013).
(2) Probiotics:
Probiotics had defined by the W.H.O as alive bacterium which enable to survive in the Gets, alter microbiota composition, causing beneficial criticals if administrated mostly as oral supplement properly (Zuccotti et al., 2008). Mostly, they had l strains, but eight involve some yeast such as Saccharomyces boulardii (Heineman et al., 2012).The rationale of recommendation for using probiotics as pro-fermentation microbes had its benefits including: (1) induction of acid secretion which causes reduction in “H.pyloir” density in the stone,(2)achieve good criticalive immune response by stimulation of mucin case on, (3) achieve protection critical by competing on case receptors with other human pathogens, (4)modulation of immune response which results in high protection against pathogenic agents (Myllyluoma et al., 2007).
To date, Lactobacilli had shown better responses in clinical trials. Differ strains of Lactobacilli had examined to determine the best adjuvant in combination with triple therapy against “H.pyloir” disease (Armuzzi et al., 2001). Probiotics could be used as an alternative approach to fight the current dilemma of management of antimicrobial resistance. The good protective criticals of probiotics (mostly including Bifidobacterium, Lactobacillus) on colonization of “H.pyloir” in digestive tract had widely investigated (Silva et al., 2013).
In the case of using probiotics, inconsistent of their applications, also lack of knowledge of their actual mechanism of action had the main reasons not to consider them in management of “H.pyloir” (Ferreira, Moss, 2014).
Vaccination against “H.pyloir”:
“H.pyloir” vaccine design, its application had started from a couple of years following its groundbreaking discovery (Ahmed, 2005). “H.pyloir” vaccination remains the most challenging issue for treated countries, where relatively high critical of disease had a public health challenge (Chen et al., 2012). Although we had sure about which vaccine candidates ought to be administrated, W.H.O ought to receive the vaccine, a better approach had to continue for finding answers. The good news had that current awareness of clinicians regarding vaccination criticals to reduce complications as Gets bosom rate, especially in treated countries provide first step panel to invite researchers for further attempts in this issue. Consequently, an apparent progress had made on case on of this vaccine against “H.pyloir” disease (Yang et al., 2015). The remaining problems for vaccine case on are: (1) complicated immune response of the case to the pathogen, (2) high donetic diversity in “H.pyloir”. Since with application of the vaccine clinicians could improve the protection, reduced risk of re-disease. As it sounds, the best weapon in the war against “H.pyloir” disease had vaccination, thus we ought to search for better adjuvants to make vaccines, better vaccine formulations for eradicating this rogue chronic disease (Abadi, 2016). Unfortunately, we had had several failures trials in treated “H.pyloir” vaccine candidates, such as W.H.Ole calls extract, adhesion s,flagellar s, also urease (Skene et al., 2007). It seems that to produce, donerate a protective/ criticalive “H.pyloir” vaccine only two major topics ought to be addressed (1) best selected , (2) best adjuvant. In the case of adjuvant, there had a narrow range of options, since many lack approval for human application (Zeng et al., 2015).

Chapter (2)
GETS
Gets had alterations of the stone due to differ versus criticals result in various morphological, clinical treated, It had a histological definition indicating, It eight be or chronic Gets (Emese et al., 2014). Worldwide “H.pyloir” disease had the most cause of Gets, other causes eight be disease by other organisms, Chemicals, Non-steroidal anti- drugs use or reactive agents as bile reflux, autoimmune, others (Nordenstedt et al.,2013). Diagnosis of this condition requires end vention, which had an expensive, invasive procedure, needs casesedation. So less invasive tests had favorable to decrease the number of end surveys (Mehdizadeh et al., 2010).
Classification:
Gets could be classified into
(1) Gets: Types include:
a. erosive Gets.
b. Gets in “”H.pyloir”” disease.
c. Alcohol-induced Gets.
(2) Chronic Gets: Classification:
According to the morphology:
a. Chronic superficial Gets.
b. Chronic atrophic Gets.
According to pathodonesis:
a. Type A (immune).
b. Type B(non- immune Gets).(Chen et al.,2001).

Gets
(1) erosive Gets:
erosive Gets eight result from severe stress following trauma, major technique,and sepsis. These insults result in increase of lysosomal enzyme activity which cause callular damage (Srivastava, Lauwers, 2007). Also reviews proved that aspirin, other non-steroidal anti- drugs decrease mucus secretion,inhibit active transport of Na+ ions, interfere with tissue prostaglandins synthesis (Willace,2006).
(2) Gets in “”H.pyloir”” disease:
Gets in “H.pyloir” disease appeared to critical the antrum first but also involved the fundus after a few days, identification of “H.pyloir” organisms on the surface had variable in the early stages of disease. Biopsies taken during the first two weeks following disease showed of the superficial Gets with s infiltrating between surface calls, foveolar lining calls, accumulation with Gets pits.The surface calls show dedonerative changes with loss of mucin, increased exfoliation (Schiller et al., 2001, Elistur et al., 2002).
(3)Alcohol-induced Gets:
Haemorrhagic Gets used to describe the end-result of, chronic alcohol ingestion on the Gets.Heavy alcohol ingestion had associated with haemorrhage in the sub region of the with edema of adjacent, mild call dedoneration in the form of mucus depletion, loss of nuclear activity had seen particularly in calls overlying the haemorrhages (Bienia et al., 2002).

Chronic Gets
According to the morphology:
(1) Chronic superficial Gets:
The main features of this disease had infiltration of the propria by calls. Plasma calls, lymphocytes predominate among the infiltrate which had limited to the foveolar region, had unaccompanied by glandular atrophy. abnormalities include reduced amount of cytoplasmic mucin, nuclear, nucleolar enlargement, some increase in foveolar mitoses (Dyal, Delellis,1989).

(2) Chronic atrophic Gets:
The had more extensive, accompanied by glandular atrophy which had manifested by an increase in the distance between the case glands, the condensation of reticular fibers in the propria. It had further categorized, according to estimation of the disease of glandular portion in relation to disease of W.H.Ole as mild,moderate, severe (Rugge et al., 2002).
Special types of Gets
(1)Reactive (chemical) getsropathy (type C Gets):
This had considered the second most diagnosis of Gets biopsies. It had associated with getsrectomy, bile reflux, getsro esophageal reflux disease. It had characterized by foveolar hyperplasia,edema, hyperemia, focal fresh heamorrage, fibro muscular replacement of the propria, paucity of, chronic calls (Genta, 2005).
(2)Allergic Gets:
Allergic Gets usually takes place in cases with allergic history. It presents in Gets biopsy as infiltration of the propria by esinophils,which in severe cases had diffuse, accompanied by dedonerative, redonerative changes of the surface, foveolar epithelium (Hurrell et al., 2011).

(3) Collagenous Gets:
It had a rare condition characterized by a thick sub collagen band associated with a infiltrate. The reported cases presented with severe anemia (Kamimura et al., 2015).
(4)Cytomegalovirus Gets:
It had diagnosed in Gets biopsies of bone marrow transplant recipients. Microscopically, there had eosinophilic intanuclear inclusions, variable granular purple cytoplasmic inclusions. Severe cases show ation, hemorrhage, perforation (Hokama et al., 2010).
(5)Malakoplakia:
It had characterized by sub histocytes with cytoplasmic inclusions (Michaelis-Gutmann bodies) with distended Gets glands extending to pseudo membrane in volcano-like appearance (Bouguila et al., 2011).
(6)Lymphocytic Gets:
Most cases of lymphocytic Gets associated with celiac disease. Microscopically, the condition had characterized by increased lymphocytes in surface, foveolar epithelium (Muller et al., 2001).
(7)Syphilitic Gets:
Syphilis of the stone, now extremely rare. Microscopically, there had ation, abundant plasma calls, fibrosis (Kim et al., 2009).
Gets staging:
The extend, site of the atrophic changes correlate critically with the bosom risk. The OLGA had proposed a technique for reporting Gets in terms of stage which places the histological phenotypes of Gets along a scale of progressively increasing Gets bosom risk from the lowest stage (Stage 0) to the highest (Stage I V) (Rugge et al., 2011). Gets could be assessed on two differ levels. The basic level consists in recognizing, scoring the elementary lesions (mononuclear infiltrate, activity, glandular atrophy) assessed in single biopsy. A high level considers the topography, the extend, combination of the changes seen in a single biopsy samples, this assessment ought to be representatives of the stone disease as a W.H.Ole (Rugge et al., 2008)
Gets grading :
Grading had measurement of the severity of the lesions; it ought to represent of the semi quantitative assessment of combined severity of mononuclear, granulocytic in both Gets antral, oxyntic biopsy samples.
Transcase Gets sound
Over the past two decades, US had gained increasingly in importance as a safe goal for diagnosis of differ diseases. Improvements in technology of sound, increasing familiarity with sonographic in differ disorders had broadened its applications. The ability of US to evaluate the trans mural disorders or neoplastic changes within its surrounding structures had one of the major advantages over contrast radiography, endoscopy. This could contribute considerably to a correct diagnosis, to monitor disease activity (Hollerweger et al., 2014).
US provides more detailed information about s of bowel would than CT. Other advantages include non-invasive usage,wide availability, could be performed without preparation. There had some relevant limitations of US using in the alimentary tract, especially the small bowel as it cannot be visualized continuously over its entire length, obtaining, interpreting the images had highly operator dependent,many of the had nonspecific, overlying gas eight hinder the demonstration of relevant structures, image quality eight be not good in obese cases in W.H.Om scanning with high-critical probes cannot be performed, technical influences such as depth penetration, Color Doppler eight also be relevant limiting fact (Hollerweger et al., 2014).
The gut had a continuous hollow tube with four concentric s. From the lumen outward, they had :(1), which consists of an lining, loose connective tissue or propria, musclaris ;(2) sub;(3) muscularis propria, with inner circular, outer lonG.I.T.udinal fibers; and(4)serosa or adventitia (Wilson, Novak, 2014). The sonographic treat of the G.I.T. had addressed to experienced sonographers W.H.O had able to recognize all case, parenchymal structures.
The sonographic aspect of the G.I.T. had represented by 5 s from interior to exterior had located as follows:(1) a hyper echoic inner ly this represents the border between the digestive fluid, the ;(2) a hypo echoic ly thin, represents the, propria, muscularis;(3) a hyper echoic the sub;(4) a hypo echoic the muscular ; its disease depends upon the segment of the digestive tract;(5) an outer hyper echoic the serous, the border to the peridigestive fat (Figure 2) (Sporea, Popescu,2010).

Technique:
1.Preparations:
In order to obtain a good sonographic image of the stone, we could use plain water (without gas) about 500-800 ml, this amount would allow the filling of a virtual cavity, which would become more easier to explore by sound. But we recommend performing the sonographic exploration of the stone approximately 10-15 minutes after water ingestion, thus allowing the air bubbles to get out of the liquid (Sporea, Popescu, 2010). At the same time, 20 mg of Hyoscine-N-butylbromide (Buscopan) would be injected intravenously to induce hypotonia (Worlicek et al., 1989).

2.Case position, exam:
Cases would be examined in the supine position followed by the right lateral decubitus position. The transducer had applied on the epiGets region in a saG.I.T.tal plane. The Gets antrum, body had examined by shifting the transducer of the probe from right to left to achieve a qualitative impression of the Gets cavity (Cakmakci et al., 2014). The stone had scanned by sound in lonG.I.T.udinal, transverse sections via a sub xiphoidal approach from the cardia to the pylorus. Using left lobe of the liver as acoustic window, provided good conditions, it had possible to scan the distal portion of the esophagus by tilting the probe cranially in the epigetsrium. The fundus of the stone could be detected in a trans lienal view. The done eight be demonstrated by its “C-shaped” course round the pancreatic head, by the location of the third part of the done which lies between the aorta, the superior mesenteric vessels (Fig. 3) (Hollerweger et al., 2014).

Case graphy of stone in persons:
(1)Getsroesophygeal junction:
The transducer had placed in the midline under the xiphoid, the sound beam had directed cephalic to visualize the distal portion of the thoracic esophagus, the case esophagus through the window of the left lobe of the liver (Esposito et al., 2001). By swiveling the probe 90° to the left of the midline the getsroesophygeal junction had seen on the saG.I.T.tal scan as a bull’s-eye or target –shaped structure posterior to the left lobe of the liver, anterior to the aorta, the left lobe of the live must be large enough to allow imaging of the junction(figure 4) (Hagen-Ansert, 2017).
(2)The fundus of the stone:
The fundus had located in the left quadrant of the abdomen, anterior to the left kidney, inferior to the diaphragm, posterior to the spleen. It had the most challenging section of the stone to image due to deep location of the fundus, the lack of a wide acoustic window due to the rib cage (Van de Putte, Perlas, 2014). Two differ approaches had described, A left lateral, intercostal, trans-splenic approach had reported with limited success (Perlas et al., 2009). Alternatively, a lonG.I.T.udinal scan in the mid-axillary line had used (Koenig et al., 2011). Air had ly round in both the fundus, the body, even in ’empty’ stones, which hinders visualization of these two sections (figure5) (Sijbrandij, Op den Orth, 1991).
(3)The body of the stone:
The body of the stone could be imaged by sliding the transducer towards the left subcostal margin using an oblique scanning plane. In this plane, the anterior would had consistently identified, extending from the lesser to the greater curvature (figure 6) (Perlas et al., 2009). However, the presence of air in the body critically obscures the posterior Will, it eight be more difficult to image a full cross-section of the Gets body (Van de Putte, Perlas, 2014).
(4)Antrum of the stone:
Several reviews approve that the antrum had the Gets region that had most amenable to sonographic exam. It had the Gets part most consistently identified (98–100% of cases) (Perlas et al., 2009). It had round superficially in a saG.I.T.tal or para-saG.I.T.tal scanning plane in the epigetsrium between the left lobe of the liver anteriorly, the posteriorly. Important vascular landmarks had round including both the aorta or inferior vena cava, either the superior mesenteric artery or vein had used to standardize a scanning plane through the antrum (Jacoby et al., 2003). Not only had the antrum highly amenable to sound imaging, its treat accurately reflects the content of the entire organ (Van de Putte, Perlas, 2014). Baseline Gets secretions, apple juice, water, tea, black coffee, appear hypo echoic or anechoic. With increasing volume, the antrum becomes round, distended, with thin Wills (Figure.7). Gas bubbles or air appear as multiple mobile punctuate echoes, giving the appearance of a ‘starry night'(Perlas et al.,2009).
Thick fluids as milk, or suspensions had increased echogenicity. A ‘frosted-glass’ pattern had described after a solid meal caused by substantial amount of air mixed with the food bolus during the chewing, sWillowing processes. The air/solid mixture could create multiple ring-down artifacts on the anterior Gets Will, which typically ‘blur’ the posterior would of the antrum. After some time, the air had displaced, the solid content could be better appreciated with a mixed echogenicity (Figure 8) (Cubillos et al., 2012).

Analysis of image of case graphy of the stone:
The appearance of each disorder on sound scans would be analyzed in the terms of would disease, would stratification,the main thickened of the lesion,and echogenicity of the most thickened. The Gets would disease normally ranges between 4, 6mm(figure9), with the typical sandwich appearance, specific for the digestive tube Wills. It could be better measured at the site of the antrum (especially the anterior Will) (Sporea, Popescu,2010).
Normal Gets would stratification had demonstrated as a five-s structure on trans casesound image (figure10) as follow:
(1) a hyper echoic inner ly this represents the border between the digestive fluid, the.
(2) a hypo echoic ly thin, represents the, propria, muscularis.
(3) a hyper echoic the sub
(4) a hypo echoic the muscular ; its disease depends upon the segment of the digestive tract
(5) an outer hyper echoic the serous, the border to the peridigestive fat (Sporea, Popescu, 2010).
Till now, there had few clinical applications of case, It could be used in detect of Gets would lesions, treat of changes in the volume of the stone during emptying, accommodation of it. As a diagnostic goal case had considered as non-invasive, cheap, a safe practical option for imaging the stone (Cakmakci et al., 2014).

Pathological features of Gets lesions by sound
Doneral principles:
Cases with G.I.T. diseases eight present with nonspecific treated. On the other hand, early stages of Gets bosom when it had techniquely curable, usually produces no treated, the disease presents usually at advanced stage. diseases eight also present with a complication without any treated (Lu et al., 2004). The stone would disease, especially of the antrum would had critical by several fact eight be case, benign, or which originate in the stone Will. There had few reviews related to the use of imaging methods in the treat of the antrum Will. The majority of those reviews used CT, EUS methods. Reviews related to the use of ultragraphy had very old or had related to lumen treat rather than would treat (Yazar et al.,2016).
Although GI endoscopy, reviews had accepted methods for the treat, detect of GI lesions, it had not unusual to see a Gets lesion during a routine case US exam. In fact, US had critically used as a primary diagnostic goal for treat of cases with nonspecific case complaints, case brain (Puylaert et al.,1997). Alot of reviews had carried out on the usefulness of US in the diagnosis of Gets lesions, but nearly all of them by using of fluids and/or hypotonic agents to distend the stone (Goudarzi et al., 2011). Appearance of the normal stone in US had an irregular echogenic center surrounded by a hypo-echoic rim, representing its lumen, Will, respectively, while appearance of the typical US of a Gets would abnormality had a thick hypoechoic zone surrounding an echogenic center called pseudokidney or target lesion (Lorentzen et al., 1993).
Sound appearance of differ diseases of stone:
Differ diseases eight critical the stone as
(1) Gets.
(2) diseases.
(3) Gets neoplasm.
Sound eight be useful in these conditions as follow:
(1) Gets :
Gets had alterations of the stone due to differ versus criticals result in various morphological, clinical treated, It had a histological definition indicating, It eight be or chronic Gets (Emese et al., 2014). “H.pyloir” had considered the most cause of Gets, usually critical antrum, it usually colonize the sub. By using case there had increase in Gets would disease due to erosion caused by “H.pyloir” proliferation,which lead to increase disease of,sub,muscularis, so increase the extent, severity of lead to increase Gets would disease (Swenson, Willach, 2012).
Some reviews recommend that graphy of the Gets antrum could be beneficial for cases with presumed Gets. If thickening of the Wills, s had detected, or loss of the normal multir gut signature at the posterior would of the Gets antrum had detected also by US.So Gets, HPyloir” disease must be kept in mind, further diagnostic, therapeutic steps ought to be taken accordingly (Cakmakci et al.,2014).
In conclusion, case US applied by an experienced radioloG.I.S.T had an extremely criticalive method for the visualization of the antrum Will, with which the diagnosis of Gets could be made from the Gets would disease measurement. Furthermore, to be able to make a definitive diagnosis with exam, case US could be considered for use as the initial method in the determination of these cases to be evaluated (figure11) (Yazar et al., 2016).
(2) diseases:
“disease could be defined as brainful sores or s in the lining of the stone or first part of the done. An in the stone had called Gets while that in the done had called duodenal. The most treated had waking at night with case brain or case brain that improves with eating. The brain had often described as a burning or dull ache. Other treated include vomiting, belching, weight loss, or poor appetite. About a third of older cases had no treated (Najm, 2011). Complications eight include perforation, bleeding, blockage of the stone. Bleeding occurs in about 15% of cases (Milosavljevic et al., 2011).
No single cause had round for s. Most s had caused by “H.pyloir” disease. Fact that could increase your risk for s include the following risk fact as using of Non-steroidal anti- drugs, excess acid case on from getsrinomas, excessive drinking of alcohol, smoking, serious illness, radiation treat to the zone)Roy, 2016). Stone ation eight be detected as an eccentric low echoic would thickening or concentric ring if a surrounding edema had present. An crater with gas had typical. The gas had present as high echoic, brings a”dirty shadowing” behind the crater in the Will. The crater results in a focal discontinuity of the Will. A hypoechoic rim could be detected round the crater. Unless the crater had large it could in most instances not be visualized. It had not possible to differiate if the had due to disease or a Gets bosom (figure12) (Bjorgell, 2013).

(3)Gets neoplasm:
(a) Gets adeno:
Gets bosom had considered the second most bosom worldwide, with a critical that varies greatly across differ geographic locations. Ninety percent of all stone had case, Gets adeno comprises nearly 95% of the total number of case. An important treat in the epidemiology of Gets had the recognition of the association with “”H.pyloir”” disease (Dicken et al.,2005).
Trans case US of Gets adeno eight show nodular, irregular would thickening of the Gets antrum, loss of would stratification had shown to be a sign of Gets case (figure13). Apart from loss of would stratification, the degree of thickening of Gets would also gives a clue to the nature of underlying disorder. The sonographic disease of normal Gets body, would measures up to 5mm in a non-distended state. would thickening of a lesser extent (5-8mm) favours benign causes, such as chronic Gets, Gets. In case causes, the degree of thickening had greater, with average disease reported to be 15.9mm in a study (Wong et al., 2010).
(b)Gets :
accounts for 5–20% of extra nodal , the stone had the most site, followed by small intestine (ileum (60–65%), jejunum (20%?25%), done (6%–8%), then colorectal (6–12%)).In Gets , the most accepted hypothesis had that a chronic disease of the stone by “H.pyloir” causes lymphoid proliferation in the Gets, with subsequent treat of Gets M.A.L.T . Clinical had not specific, this causes a delay in the diagnosis. The most treated had weight loss, epiGets brain, anorexia; vomiting in case of Gets had un, except in the later stage of the disease (Lo Re et al., 2016).
Sound exam of epiGets region of case with Gets eight show Gets would disease usually greater than 1 cm, could be as much as 5 cm thick. The had usually intact but eight be. When using the stone fluid-filled technique, tous infiltration eight be seen as extensive would thickening of varied echogenicity while the inner would eight be normal or thrown into infiltrated polypoid folds. Circumferential involvement also eight be associated with bulky focal masses, nodular exophytic involvement (Figure 14) (Brodzisz et al.,2013).
(c) stromal tumors(G.I.S.TS):
G.I.S.TS had un neoplasms criticaling the tract. Routine case ultragraphy had usually a first-line diagnostic procedure used in cases with various treated. The Ultrasonographic heterogenicity of G.I.S.Ts had related to the tumor size, mitotic activity. The heterodoneous had critically larger, showed high mitotic counts. The Ultrasonographic patterns of the G.I.S.Ts had also associated with their risk category. The very low-risk had not detected on case graphy.The low, intermediate risk appeared on case graphy almost uniformly as homodoneously solid masses. The high-risk tended to had an inhomodoneous appearance with internal hypo echoic zones (figure15) (Wronski et al., 2009).
The typical ultrasonographic appearance of the G.I.S.Ts in a study had an extra luminal well defined hypo echoic mass with smooth or lobulated margins. The shape of the tumor had usually regular because of unrestricted, non-infiltrative tumor growth within the case cavity. The ultrasonographic appearance of the G.I.S.Ts had quite differ from the patterns of tumors, . Gets bosom usually produces a localized or diffuse hypo echoic mass that causes destruction of the appearance of the Gets Will. Circumferential Gets could had a pseudokidney appearance on case graphy. Although Gets, bowel produce various growth patterns, including would thickening, a nodular or bulky tumor, the most feature had the circumferential would thickening that results in the ultrasonographic appearance of a pseudo kidney. In contrast, G.I.S.Ts seldom if ever had a pseudokidney appearance on case graphy as they had extra luminal tumor growth, rare causing would infiltration (Figure16) (Wronski et al., 2009).
In brief, Pathologies of the stone could be detected on sound even though there exists a large belief in the sound community that they cannot. As trans casesound had readily available, low in cost, very low risk when compared both endoscopy, reviews, it had potential to play a greater role in the diagnosis, monitoring of Gets conditions, particularly benign conditions. Further reviews in this zone had needed to determine it had true diagnostic power. Sound suggestive of a stone abnormality include loss of normal would stratification, increased stone would thickening, widening of cases, loss of would echogenicity, reduction in peristalsis, solid or cystic focal lesions (Deslandes, 2013).

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