2 MTB Step 3 - Epigastric Pain (Non-Ulcer Dyspepsia, PUD, Gastritis, Stress Ulcer Prophylaxis) Flashcards
Cards Complete:
NON-ULCER DYSPEPSIA
SAMPLE QUESTION
A 58-year-old man comes to the office for evaluation of epigastric discomfort for the last several weeks. He is otherwise asymptomatic with no weight loss. His stool is heme-negative. What is the next best step in management?
Upper Endoscopy
Upper endoscopy should be performed in any patient older than 45 years with persistent symptoms of epigastric discomfort. This is, essentially, to exclude the possibility of gastric cancer. There is no way to be certain, without endoscopy, who has gastric cancer.
NON-ULCER DYSPEPSIA
What (3) Disorders must be excluded using Endoscopy prior to diagnosing Non-Ulcer Dyspepsia?
- Ulcer Disease
- Gastric Cancer
- Gastritis
NON-ULCER DYSPEPSIA
What are (3) Drug Therapies used for Non-Ulcer Dyspepsia?
- Proton Pump Inhibitors (PPIs)
- H2 Blockers (ie, Cimetadine, Famotadine, etc.)
- Liquid Antacids
PEPTIC ULCER DISEASE (PUD)
What are the (2) Types of PUD?
Gastric Ulcer
or
Duodenal Ulcer
PEPTIC ULCER DISEASE (PUD)
What are the (7) Most Common Causes of Peptic Ulcer Disease (PUD)?
- Helicobacter pylori (Most Common Cause)
- NSAIDs
- Head Trauma
- Burns
- Intubation
- Crohn’s Disease
- Zollinger-Ellison Syndrome (ZES)
PEPTIC ULCER DISEASE (PUD)
What disorder occurs in 4% of PUD patients with Gastric Ulcers (GU)?
Gastric Cancer
PEPTIC ULCER DISEASE (PUD)
- How do PUD patients with Gastric Ulcers (GU) initially react to food more often than not?
- How do PUD patients with Duodenal Ulcers (DU) initially react to food more often than not?
- GU pain gets WORSE with food more often than not.
- DU pain gets BETTER with food more often than not.
PEPTIC ULCER DISEASE (PUD)
What are the presenting criteria for a patient with PUD to receive a mandatory Endoscopy, and what is the reason for doing so?
> Age 45 + Epigastric Pain
Must Scope these PUD patients to exclude Gastric Cancer
PEPTIC ULCER DISEASE (PUD)
What is the treatment for PUD associated with H. pylori?
PPI
+
Clarithromycin
+
Amoxicillin
GASTRITIS
What are the (2) possible associated causes of Gastritis?
H. pylori
or
Vitamin B12 Deficiency
GASTRITIS
- What is the Best INITIAL Diagnostic Test for Gastritis associated with H. pylori?
- What is the Most ACCURATE Test for Gastritis associated with H. pylori?
- Which (2) Test can be used to distinguish between New and Old Gastritis associated with H. pylori?
- Which Test from question 3 can be used to assess for cure AFTER treatment of Gastritis associated with H. pylori?
- Serology - if Negative rules out H. pylori (High Sensitivity). If Positive needs further testing for H. pylori.
- Endoscopy w/ Biopsy - if done no other testing needed.
- Breath Testing & Stool Antigen Testing
- Stool Antigen Testing
GASTRITIS
What is the First-Line treatment for Gastritis associated with H. pylori?
PPI
+
Clarithromycin
+
Amoxicillin
GASTRITIS
What is the Second-Line treatment for Gastritis associated with H. pylori if First-Line therapy fails to control symptoms?
PPI
+
Metronidazole
+
Tetracycline
GASTRITIS
What is the Next Step in Management for a patient with Gastritis associated with H. pylori if Second-Line therapy fails to control symptoms?
Evaluate for Zollinger-Ellison Syndrome (Gastrinoma)
GASTRITIS
What are (6) Adverse Effects of Proton Pump Inhibitors (PPIs)?
- Hypocalcemia (decreases Ca absorption; possible fractures)
- Hypomagnesemia (decreases Mg absorption)
- Vitamin B12 Absorption (acid frees B12 from food)
- Iron Absorption (low acid blocks iron absorption)
- Resistance to Bacterial Invasion - PPIs reduce the acid barrier, increasing the risk of pneumonia and C. difficile
- Kidney function, leading to nephritis (urinating Eosinophils)
BASIC SCIENCE CORRELATE
What are the ONLY (4) types of patients who should receive PROPHYLACTIC G.I. therapy?
- Head Trauma
- Burns
- Intubated
- Coagulopathy + Steroid use OR Sepsis
STRESS ULCER PROPHYLAXIS
What are (3) Medications used for Stress Ulcer Prophylaxis?
- Proton Pump Inhibitors
- H2 Blockers
- Sucralfate
SAMPLE QUESTION
“A 52-yo man has epigastric discomfort. He is seropositive for Helicobacter pylori (H. pylori). Upper endoscopy reveals no gastritis and no ulcer disease. Biopsy of the stomach shows Helicobacter.”
How should you treat this patient?
PPI alone as Symptomatic Therapy for Non-Ulcer Dyspepsia
- You do not need to treat H. pylori unless there is Gastritis, Mucosa-Associated Lymphoid Tissue Lymphoma (MALToma), or Ulcer Disease.*
- This patient has Non-Ulcer Dyspepsia, of which, H. pylori is not the cause.*
ZES
DIAGNOSIS
What are the (2) Diagnostic Test findings necessary for diagnosing Zollinger-Ellison Syndrome (ZES)?
- Elevated Gastrin Level
- Elevated Gastric Acid Output
REMEMBER: Everyone on a PPI or H2 Blocker will also have an Elevated Gastrin Level
ZES
DIAGNOSIS
Under which (4) conditions should you Test the Gastrin Level and Gastric Acid Output?
- Large Ulcer (> 1 cm)
- Multiple Ulcers
- Distal Location of Ulcer (near the Ligament of Treitz)
- Recurrent or Persistent Ulcers despite H. pylori treatment (PPI + Clarithromycin + Amoxicillin)
If both the Gastrin Level and Gastric Acid Output are elevated, the next step is to Localize the Gastrinoma
ZES
DIAGNOSIS
Most Ulcers have what (4) characteristics?
- Small Ulcer (< 1 cm)
- Single Ulcer
- Proximal Location (near the Pylorus)
- Easily Resolve with H. pylori treatment (PPI + Clarithromycin + Amoxicillin)
ZES
DIAGNOSIS
Which (3) Diagnostic Tests are considered the Most ACCURATE for diagnosing Zollinger-Ellison Syndrome (ZES), and which one is the MOST ACCURATE of the three?
- Endoscopic Ultrasound: similar to a TEE. very sensitive.
- Nuclear Somatostatin Scan: very sensitive. patients with ZES have an enormous increase in the number of Somatostatin receptors.
- Secretin Suppression: the MOST ACCURATE test for ZES.
ZES
SECRETIN SUPPRESSION TEST
- What is the Normal Effect of infusing Secretin (IV) on Gastrin Level and Gastric Acid Output?
- What is the Effect of infusing Secretin (IV) on Gastrin Level and Gastric Acid Output in a patient with Zollinger-Ellison Syndrome (ZES)?
- DECREASES both Gastrin Level and Gastric Acid Output
- NO CHANGE in either Gastrin Level or Gastric Acid Output.
ZES
TREATMENT
- What is the Treatment for LOCAL DISEASE Zollinger-Ellison Syndrome (ZES)/Gastrinoma?
- What is the Treatment for METASTATIC DISEASE Zollinger-Ellison Syndrome (ZES)/Gastrinoma?
- Surgical Resection
- Lifelong PPIs
ZES
ASSOCIATED DISORDERS
- What is the Clue to the presence of a Parathyroid problem with Zollinger-Ellison Syndrome?
- What disorder is a Parathyroid problem with Zollinger-Ellison Syndrome a clue for?
- Hypercalcemia
- Multiple Endocrine Neoplasia (MEN) Syndrome
SAMPLE QUESTION
“A man is found to have ulcer disease. There are 3 ulcers in the distal esophagus 1 - 2 cm in size. The ulcers persist despite treatment for H. pylori.”
What is the Next BEST Step in Management?
Gastrin Level
&
Gastric Acid Output Testing
should be done when there is the possibility of Zollinger-Ellison Syndrome.
