1- PUD and Gastric CA

Question 1

Parietal cells produce what?

Answer 1

HCl, IF

Question 2

Cheif cells secrete what?

Answer 2

Pepsinogen (converted to pepsin)

Question 3

Mucous neck cells secrete what?

Answer 3

Thin, acidic mucous

Question 4

Enteroendocrine cells secrete what?

Answer 4

Various hormones

G cells secrete gastrin

Question 5

What do G cells secrete?

Answer 5

Gastrin

Question 6

What are the 4 protective features of the stomach mucosa?

Answer 6

1. Coated w/ bicarbonate-rich mucous
2. Epithelial cells meet at tight junctions
3. Stem cells (where gastric glands join gastric pits) replace damaged epithelial mucosal cells
4. Production of prostaglandins (stimulate mucus & bicarb, ↑ blood flow → epithelial cell growth and inhibit acid secretion)

Question 7

Pt presents with abd discomfort, bloating, belching and distention. What disease are you concerned about?

Answer 7

Dyspepsia

Question 8

T or F: The cause of dyspepsia is unknown?

Answer 8

TRUE. Organic vs functional causes

Question 9

35 y/o F pt presents with chronic sx of dyspepsia. She denies any weight loss, vomiting, hematemesis or rectal bleeding, or difficulty or pain with swallowing. PE is normal. Do you need to order an EGD?

Answer 9

No. EDG is only ordered if clinically significant weight loss, overt GI bleeding, 2+ alarm features, rapidly progressing red flags

Question 10

The following are red flags for what medical condition? Unintentional weight loss, progressive dysphagia/odynophagia, unexplained iron deficiency anemia, persistent vomiting, palpable mass or lymphadenopathy, FHX of upper GI

Answer 10

Dyspepsia

Question 11

It pt is ≥ 60 yrs old do you need to order an EGD if suspected dyspepsia?

Answer 11

Yes. Order EGD if 60+

Question 12

If 60+ y/o pt presents with sx of dyspepsia but you can’t find any evidence of organic disease. How should you proceed?

Answer 12

Consider “functional dyspepsia & test for H. pylori

Question 13

What is the tx for pt w/ dyspepsia that is H.pylori (+)

Answer 13

Treat/ eradicate

Question 14

What is the tx for pt w/ dyspepsia that is H.pylori (-)

Answer 14

Treat w/ trial of PPI

Question 15

If you tx pt w/ dyspepsia, but no resolution w/ medical therapy what should you consider?

Answer 15

EGD

Question 16

What disease is characterized by a defect in gastric or duodenal mucosa that extends through the muscularis mucosa into the deeper layers of the wall?

Answer 16

PUD

Question 17

If hostile factors in the stomach are > protective factors. What can result?

Answer 17

Ulcers formation

Question 18

Does risk for PUD increase w/ age?

Answer 18

Yes

Question 19

What PUD risk factor disrupts balance of mucosal aggressive & protective factors, ↑ risk for ulcer perforation?

Answer 19

Smoking

Question 20

What PUD risk factor stimulates acid secretion, damages gastric mucosal barrier, ↑ risk of ulcer bleeding?

Answer 20

Alcohol

Question 21

What PUD risk factor is due gene variations in proinflammatory cytokines & has increased risk if blood types O & A?

Answer 21

Genetic factors

Question 22

What PUD risk factor generates toxin from food storage, possible protective effects from some foods?

Answer 22

Diet

Question 23

What PUD risk factor increases gastric acid secretion and impairs endoscopic healing?

Answer 23

Psych factors (stress, depression)

Question 24

What pathogen results in decreased gastric mucus and bicarb secretion?

Answer 24

H. pylori

Question 25

What is the most common cause of PUD worldwide?

Answer 25

H. pylori

Question 26

H. pylori predisposes pts to what?

Answer 26

Gastric CA

Question 27

What are virulence factors of H. pylori? (4)

Answer 27

flagella, urease, adhesins, inflammation (G cells increase HCl)

Question 28

How do NSAIDs contribute to PUD?

Answer 28

Inhibits COX → decreased PGE2 synthesis

Question 29

Chronic NSAID abuse and concamitant use of what other medications is a RF for PUD?

Answer 29

Steroids, anticoagulants, aspirin SSRIs, alendronate

Question 30

Pt presents with CC of upper abd pain/discomfort, hematemesis and fatigue. Further hx reveals 3 yr hx of dyspepsia sx w/ increasing episode of N/V and early satiety/ What disease are you concerned about?

Answer 30

Late stage PUD (other late stage sx inclue: melena and dyspnea)

Question 31

The following are red flags for what medical condition? Bleeding, unexplained iron deficiency anemia, early satiety, unintentional weight loss, progressive dysphagia/odynophagia, acute onset of intense upper abd pain, persistent vomiting, FHX of upper GI

Answer 31

PUD

Question 32

Gastric vs Duodenal Ulcers. Which will cause pain 30 min-1 hr postprandial?

Answer 32

Gastric

Question 33

Gastric vs Duodenal Ulcers. Which will cause pain 2-3 hr postprandial?

Answer 33

Duodenal

Question 34

Gastric vs Duodenal Ulcers. Which is more likely to cause vomiting/hematemesis & hemorrhage?

Answer 34

Gastric

Question 35

Gastric vs Duodenal Ulcers. Which is less likely to cause vomiting and hemorrhage that will manfest a melana if it occurs?

Answer 35

Duodenal

Question 36

Gastric vs Duodenal Ulcers. Which will cause weight loss?

Answer 36

Gastric

Question 37

Gastric vs Duodenal Ulcers. Which will cause weight gain?

Answer 37

Duodenal

Question 38

What is the succussion splash test? What does it indicate?

Answer 38

stethoscope over upper abd & rock pt back and forth at hips → retained gastric material > 3 hours after a meal → splash sound = indicates presence of a hollow viscus filled w/ fluid & gas

Question 39

What might the vitals for pt with PUD show?

Answer 39

Hypotension, tachycardia

Question 40

GI exam for pt with suspected PUD may show what?

Answer 40

Epigastric/RUQ TTP, + peritoneal signs

Question 41

Exam for pt w/ suspected PUD should include what?

Answer 41

Rectal exam. Possible melena (in rectal vault), hemoccult +, bright red blood per rectum

Question 42

What is the diagnostic test of choice for PUD?

Answer 42

EGC (upper GI = 2nd)

Question 43

Urea breath test, stool antigen test, serology and biopsy (during EDG) are used to dx what disease?

Answer 43

PUD

Question 44

What will Urea breath test & Stool antigen test show in pt w/ PUD? What must be discontinued prior to starting either test?

Answer 44

Identifies active H. pylori infection/ eradication D/c PPI use 1-2 wks prior

Question 45

What IG Ab are you looking for with H. pylori serology test? Is it recommend?

Answer 45

IgG. No recommended due to high false positive rate

Question 46

What is the tx in all pts w/ PUD?

Answer 46

D/C all exacerbating factors (NSAIDs, aspirin, EtOH/tobacco), consider long-term daily PPI

Question 47

Pt w/ PUD tests + for H. pylori. How do you tx?

Answer 47

treat w/ Clarithromycin Triple therapy or Bismuth quadruple therapy. Confirm eradication 4 weeks after tx completion

Question 48

Clarithromycin triple therapy consists of what?

Answer 48

14 days (PPI BID, Clarithro 500mg BID, Amoxicillin 1000mg BID)

Question 49

Bismuth quadruple therapy consists of what?

Answer 49

14 days (PPI, Bismuth subsalicylate, Metronidazole, Tetracycline)

Question 50

What is the most common complication of PUD?

Answer 50

Bleeding

Question 51

PT with hx of PUD presents with hematemesis, melena or hematochezia. What complication are you concerned about?

Answer 51

Bleeding

Question 52

What test id both diagnostic and therapeutic for bleeding peptic ulcer?

Answer 52

EGD

Question 53

What is the TX for bleeding PUD?

Answer 53

Stabilize w/ IV fluids, PRBCs, start IV PPI, perform, thermal coagulation, hemoclip placements, injection therapy

Question 54

What complication of PUD occurs when an ulcer extends through a bowel wall without free perforation/ leakage of luminal contents into peritoneal cavity?

Answer 54

Penetration

Question 55

Pt w/ hx of PUD presents with sever diffuse abd pain and on exam you note “board-like abd rigidity. What complication are you concered about?

Answer 55

Perforation

Question 56

What is the dx study to evaluate if ulcer has cause gastric perforation?

Answer 56

Upright CXR and 2 view abd XR. You will see free air under the diaphragm

Question 57

What test should NOT be performed if you suspect gastric perforation from PUD?

Answer 57

UGI w/ barium

Question 58

What is the tx for PUD w/ perforation? (3)

Answer 58

Stabilize (IV fluids, NG tube/ NG suction for gastric decompression, IV PPI), spectrum abx, surgery

Question 59

What organ is most commonly affected if penetration from PUD occurs?

Answer 59

Pancreas

Question 60

Why is dx of penetration from PUD difficult?

Answer 60

Sx/presentation vary based on involvement of other affected structures

Question 61

What tests can be used to DX penetration from PUD?

Answer 61

UGI, CT

Question 62

What is a rare complication of PUD that results from scarring/ fibrosis or inflammation/ edema in pyloric channel?

Answer 62

Gastric outlet obstruction

Question 63

Pt w/ hx of PUD presents with vomiting, epigstric pain, early statiety and weight loss. What complication should you be concerned about?

Answer 63

Gastric outlet obstruction

Question 64

How is gastric outlet obstruction dx?

Answer 64

Dilated stomach on imaging, + succussion splash

Question 65

What is the tx for gastric outlet obstruction?

Answer 65

Stabilize (IV fluids, NG tube, gastric decompression, IV PPI)

Question 66

If pt w/ gastric outlet obstruction fails medical tx what is the next step?

Answer 66

EGD w/ endoscopic balloon dilation or surgery

Question 67

What disease is due to hypersecrete gastrin → ↑HCl & stomach motility caused by duodenal or pancreatic gastrinomas ?

Answer 67

Zollinger-Ellison Syndrome (ZES)

Question 68

What % of ZES is associated w/ MEN1?

Answer 68

20%

Question 69

What % of ZES is sporadic?

Answer 69

80%

Question 70

Pt presents w/ recurrent PUD to the distal duodenal bulb, upper abd pain, and steatorrhea. What disease should you be concerned about?

Answer 70

Zollinger-Ellison Syndrome (ZES)

Question 71

What is diagnostic for ZES?

Answer 71

Fasting serum gastrin > 1000 pg/mL + gastric pH < 2

Question 72

If pt w/ suspected ZES is given secretin stimulation test, what is the expected effect on gastrin?

Answer 72

Levels w/ increase by > 200 pg/mL

Question 73

What imaging can be used to help dx ZES?

Answer 73

CT Abd. Used to localize tumor

Question 74

What is the tx for ZES?

Answer 74

PPIs and surgical resection if possible

Question 75

More commonly is gastric cancer asymptomic or symptomatic?

Answer 75

Asymptomatic

Question 76

Pt w/ hx of gastric ulcer presents w/ recent unintentional weight loss, persistent abd pain. On exam you note + succusion splash and palpable stomach mass. What disease are you concerned about?

Answer 76

Gastric CA

Question 77

What is first line for dx of gastric CA?

Answer 77

EDG (UGI = 2nd line)

Question 78

Most gastric CA are what?

Answer 78

adenocarcinomas

Question 79

On EGD you note subtle polypoid, protrusion, superficial plaque, mucosal discoloration, depression or ulcer. As a PA this is what until proven otherwise?

Answer 79

Gastric CA

Question 80

What staging system is used for gastric CA?

Answer 80

TNM

Question 81

Virchow's node, Sister Mary Joseph’s node, and Irish node are all signs of what?

Answer 81

Sign of gastric CA w/ mets. Virchow's node (L supraclavicular,) Sister Mary Joseph’s node (periumbilical), Irish node (L axillary)

Question 82

What is the tx for early gastric CA? (very rare)

Answer 82

Endoscopic mucosal resection

Question 83

What is the tx for advanced gastric CA?

Answer 83

Total or partial gastrectomy

Question 84

What is the tx for unresectable gastric CA?

Answer 84

Chemo vs chemoradiotherapy