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TIM II Gastrointestinal - Diseases of the Stomach

Terms in this set (61)

Peptic Ulcer Disease (PUD)
- Definition
Excoriation of gastric or duodenal mucosa
Peptic Ulcer Disease (PUD)
- Epidemiology
Duodenal Ulcers
- 95% duodenal bulb or pylorus
- common ages 30-55
- MC peptic ulcers

Gastric Ucers
- 85% antrum or lesser curvature
- common ages > 55 yo
Peptic Ulcer Disease (PUD)
- Etiology
- H. Pylori infection
- NSAIDs
- Cortisol hypersecretion
- Gastrin Hypersecretion
- genetic predisposition
- Alcohol, smoking
- Obesity
- Cirrhosis
- Over the age of 65
Peptic Ulcer Disease (PUD) - Pathophysiology
Disruption of normal mucosal defense and repair
- Inhibition of prostaglandin synthesis
- Reduced bicarbonate secretion
- Decreased cellular replication
- Increased acid production

Direct irritation of mucosal lining
Peptic Ulcer Disease (PUD)
- S/Sx
- Often none
- Epigastric or LUQ burning, gnawing, hunger sensation
- Better with food but may be worse post-prandial (especially gastric)
- Obstructive symptoms if pyloric location or peptic stricture: bloating, early satiety, nausea, vomiting
- Pain awakening patient at night
- Fatigue, anemia (iron-deficiency)
- Acute GI Bleeding: hematemesis, melena, gross hematochezia, hypotension, orthostatic changes, syncope
Peptic Ulcer Disease (PUD)
- Diagnostics
Gold Standard: EGD with biopsy to rule out cancerous ulcer
- This can also stop the bleeding?

Other Tests
1. UGI Barium Swallow
- If it is abnormal you still need an EGD for a definitive dx
- False negatives
Peptic Ulcer Disease (PUD)
- Stop Bleeding
Stop bleeding as needed with electrocautery, heat probe, laser, clips, injection of alcohol or epinephrine, embolization of the branch vessels
Peptic Ulcer Disease (PUD)
- Complications
1. Anemia and sequelae
2. Penetration
- Adhesions may prevent complete perforation
3. Perforation
- risk of peritonitis and shock, exsanguination, death
4. Gastric Outlet Obstruction
- Scarring (stricture), spasm, or edema at pylorus
- May need surgery
5. Recurrent PUD
6. Adenocarcinoma (Ulcerated CA) body and Antrim not cardia
7. MALT Lymphomas (ulcerated CA)
Perforation of the Stomach
- S/Sx
1. Free air by X-ray
2. S/Sx of acute abdomen
- rebound tenderness, rigidity
Peptic Ulcer Disease (PUD)
- Treatment
1. Control bleeding; if > 6 units/24 hrs needs surgery
Peptic Ulcer Disease (PUD)
- Goals of Pharmacotherapy
The treatment of chronic PUD varies depending on
- etiology of the ulcer (NSAID or H pylori)
- Ulcer is initial or recurrent
- Whether complications have occurred

Overall treatment is. Aimed at relieving ulcer pain, healing the ulcer, preventing ulcer recurrence, and reducing ulcer related complications
Peptic Ulcer Disease (PUD)
- H. Pylori Tx goals
Positive patients with an active ulcer, a previously documented ulcer, or history of an ulcer-related complication
1. Eradicate H. Pylori
2. Heal the Ulcer - continue PPI. For 2-3 months to promote healing
3. Cure the disease
Peptic Ulcer Disease (PUD)
- NSAID-induced ulcer Tx goals
Goal is to heal ulcers as rapidly as possible
- high risk of developing NSAID ulcers should receive ppx co-therapy or be switched to a selective COX-2 inhibitor NSAID
H Pylori Tx Regimens
- Types
1. Helidec - PBMT: PPI, Metronidazole, Bismuth, Tetracycline
2. PAMC - PPI, Amoxicillin, Metronidazole, Clarithromycin
3. Prevpac - PAC: PPI, Amoxicillin, Clarithromycin
4. PMC - PPI, Metronidazole, Clarithromycin
H. Pylori Tx Regimen
- Note about Triple Therapy
Clarithromycin triple therapy can be considered in areas with documented clarithromycin-resistance rates < 15%, unfortunately these are not always available and change all the time
H. Pylori Tx Regimen
- Duration
14 days
H. Pylori
- What
Common bacterial infection
- G- microaerophile, curved rod and coccoid form
- Screening in asymptomatic persons not indicated
H. Pylori
- Prevalence
High in developing countries, childhood acquisition 80%

US acquired as adults 30% prevalence
- Suboptimal sanitation
- overcrowding
- Fecal oral transmission, stool, saliva, dental plaque, iatrogenic
- Occupational exposure (GI doctors)
H. Pylori
- Dx
Best Test: EGD with biopsy

Other Tests
- Serum antibody (IgG) - exposure indicator
- Urease breath test
- Tissue sample CLO Test: tests for urease
H. Pylori
- Confirmation of eradication
Needs to be confirmed because there is risk of gastric CA, recurrent PUD/bleed if not eradicated
- Stool antigen test 2 months post tx (off PPI)
- Urea breath test off PPI
- Repeat biopsy if EGD will be repeated
- CLO test of biopsy tissue off PPI

NOT Serum IgG (will always be positive)
*Repeat EGD with Bx is indicated in most gastric ulcers to R/o carcinoma
Zollinger-Ellison Syndrome
- Distribution
Duodenal wall - 45%
Pancreas - 25%
Lymph nodes - 5-15%
Other sites - 20%
Zollinger Ellison Syndrome
- Etiology
PUD cased by Gastrin hypersecretion/hypergastrinemia
1. Gastrinoma, 50% malignant
- pancreatic
- duodenal
- gastric, lymph node, ovarian
2. MEN
- Screen with PTH, LH-FSH and GH
Zollinger-Ellison Syndrome
- S/Sx
- Complicated/refractory/recurrent PUD that is usually duodenal
- Diarrhea, steatorrhea, weight, epigastric pain, GI bleeding, anemia
Zollinger-Ellison Syndrome
- Dx
Best Initial Test: Serum gastrin (1000pg/mL)

Other Tests:
- EGD/Biopsy indistinguishable from PUD
- Gastric pH < 2.0
- Somatostatin scintigraphy for liver mets
Confirms: Secretin provocative test confirms (paradoxical increase in Gastrin)
Zollinger-Ellison Syndrome
- Treatment
1. High-dose, indefinite PPI gives symptom relief with ulcer healing
2. Surgical resection if indicated
3. Consider laparotomy in all the patients with negative work-up for mets
Zollinger-Ellison Syndrome
- Prognosis
- Slow growing tumor
- 30% 10 year survival rate if metastatic at presentation
- 80% 15 year survival rate if no liver mets at presentation
Pyloric Stenosis
- 2 Causes
1. PUD in adults - healing/fibrosis (AKA Gastric Outlet Obstruction)
2. Hypertrophy in peds
Adult Pyloric Stenosis
- S/Sx
- Nausea/Vomiting
- Early satiety
- Anorexia
- Weight loss
Adult Pyloric Stenosis
- Dx
EGD
Pediatric Pyloric Stenosis
- S/Sx
- Projectile, non-bilious vomiting
- Poor feeding
- Palpable olive mass in upper abdomen
Pediatric Pyloric Stenosis
- Dx
US
Pyloric Stenosis
- Tx
Laparoscopic pyloromyotomy
Gastritis
- Types
Acute vs. Chronic
Erosive vs. Non-erosive
Type A - autoimmune, corpus
Type B - more common, antrum
Acute Gastritis
- Etiology
- Infectious
- Stress
- Injury, trauma, NG tube
Acute Gastritis
- S/Sx
- Epigastric burning pain and tenderness
- Dyspepsia
- N/V
- Blood in NG tube if hemorrhage
Acute Gastritis
- Ddx
- Gastropathy
- Gallstones
- Pancreatitis
- AIG (acute infectious gastritis)
- Angina
Acute Gastritis
- Dx
Biopsy shows PMNs infiltrating gastric antrum/body mucosa
Acute Gastritis
- Tx
PPI
H2RA
Treat the cause
Stress Gastritis
- Epidemiology
Acutely Ill
- burns, post-op, trauma, sepsis, shock, multi-system failure
Stress Gastritis
- Pathophysiology
Decreases mucosal defenses causing inflammation/ulceration bleed
- hypoperfusion + serum cortisol elevation
- Acid hypersecretion and decreased prostaglandin synthesis
Stress Gastritis
- PPX
Identify pts at risk
- 2% of ICU patients will have torrential bleed with mortality risk of 60%
- Early enteral feeding
- IV H2 blockers or PPIs
- Antacids
Stress Gastritis
- Tx
- Surgical vs. medical treatment have the same mortality and rebleeding is common
- Transfusion
- Anti-secretory drugs
- Vasoconstrictors
- Embolization, coagulation
Chronic Gastritis
- Etiology
- NSAIDs
- H. Pylori
- Eosinophilic
- Atrophic (autoimmune)
- Diet-related (e.g. Alcohol)
- Medications/herbs
- Uremia
- Bile Reflux
- Crohn's
- Injury
Chronic Gastritis
- S/Sx
- Asymptomatic, may be incidental finding on biopsy
- Vague Dyspepsia
- Epigastric pain
- Nausea, rarely vomiting
Gastroparesis
- What
Delayed gastric emptying
Gastroparesis
- Etiology
Idiopathic
Diabetic
Medication-induced
Gastric outlet obstruction
Gastroparesis
- S/Sx
Nausea
Vomiting
Reflux/Regurgitation
Early satiety
Post-prandial bloating
Belching/gas
Gastroparesis
- Dx
Best: Gastric emptying study

Other tests:
EGD for rule outs
Swallowing Studies
Gastroparesis
- Treatment Principles
- correct fluid, electrolyte and nutritional deficiencies
- Identify and rectify the underlying cause of gastroparesis if possible
- Glycemic control in pts with DM
- Reduce symptoms
Gastroparesis
- Dietary Modifications
- Increase liquid nutrient intake
- Minimize fat and fiber
- Eat small meals 4-5 times a day
- Avoid carbonated beverages, alcohol and smoking
- Enteral feedings J-Tube
- TPN in severe cases
Gastroparesis
- Pharm Tx Types
1. Antiemetics
- Phenothiazines
- 5-HT3 Antagonists
- Antihistamines
2. Prokinetics
- Reglan
- Erythromycin
Gastroparesis
- Antiemetics
1. Phenothiazines
Trimethobenzamide
Prochlorperazine
Promethazine

2. 5-HT3 Antagonists
- Ondansdetron
- Granisetron
- Dolasetron
Less evidence, no advantage over Phenothiazines

3. Antihistamines
- Diphenhydramine
- Dimenhydrinate
- meclizine
Not well supported anticholinergic effects may actually delay gastric emptying even more
Gastric Cancer
- What
Adenocarcinoma 95%
Gastric Cancer
- Epidemiology
- Japan, Chile, Iceland
- US: Poor, Northerners, African Americans
- 8/100,00, 7th most common CA death
- Age > 50 yo
Gastric Cancer
- Etiology
- H. Pylori
- Environmental carcinogens: tobacco, alcohol, smoked fish
- Gastric polyps: Adenomas > 2cm villainous histology, multiple (not fundic gland)
Gastric Cancer
- S/Sx
- None if early stage
- Obstruction: early satiety, nausea, vomiting
- Ulcer: Abdominal pain
- If in cardia: Dysphagia
- Anemia
- Weight loss
Gastric Cancer
- Buzz words
- Signet-ring cell carcinoma
- Kurkenberg tumor
- Linitis plastics
Gastric Cancer
- Dx
EGD with Bx from margin of ulcer, brush cytology from base and edges
Gastric Cancer
- Tx
- Excision of tumor
- Gastrectomy with nodes
- Gastroenterostomy
Gastric Cancer
- Prognosis
5 yr survival rates
Good if limited to mucosa and submucosa 71%
- Screening in Japan
- Rarely identified early in unscreened populations
Poor in general 27%
- With PUD symptoms in ulcerative cancer caught earlier
Zollinger-Ellison Syndrome
- Prevalence
< 1% of PUD
2/3 gastrinoma are malignant
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