Acid Dz@

Question 1

Which meds dec risk of gastric ulcers when on NSAIDs?

Answer 1

Misoprostol, PPI, BID H2B (not once daily H2B)

Question 2

Which BAO:PAO ratio would make ZES likely after pentagastrin?

Answer 2

> 0.6

Question 3

Which type of HP preferentially affects D cells and leads to dec SS release?

Answer 3

Antral predominant with body sparing

Question 4

Which type of HP preferentially affects parietal cells and leads to dec acid production?

Answer 4

Body predominant

Question 5

Which type of HP leads to inc risk of ulcers and gastric AC?

Answer 5

Pangastritis

Question 6

What should make you suspect ZES?

Answer 6

Recurrent PUD, multiple ulcers, post bulbar ulcer, non HP/NSAID ulcer, diarrhea, erosive esophagitis, FH/PH MEN1

Question 7

MEN1 vignette

Answer 7

Hypercalcemia (HPTH), diarrhea, ulcers (ZES)

Question 8

What test to obtain to screen for ZES?

Answer 8

Fasting serum gastrin level and if elevated, gastric pH assessment +/- secretin stim test

Question 9

MC carcinoid type?

Answer 9

Type 1 (70-80%) AW chronic atrophic gastritis

Question 10

Which type of carcinoid AW gastrinomas/MEN1?

Answer 10

Type 2

Question 11

Which carcinoid has highest MAL potentia’?

Answer 11

Type 3

Question 12

Tx of Type 3 carcinoid?

Answer 12

Surgical resection if possible or EMR

Question 13

Which ICU pts at highest risk of stress ulcers? Name 2 biggest risks

Answer 13

MV > 48hrs, coagulopathy

Question 14

Once perform endoscopic tx of ulcer (like vis vessel), what tx should be done?

Answer 14

72 hours IV BID dosing

Question 15

Once find ulcer without HR features, what tx should be done?

Answer 15

PPI BID oral

Question 16

T/F: Chronic renal fx is a cause of appropriate hypergastrinemia?

Answer 16

True

Question 17

List the causes of appropriate hypergastrinemia?

Answer 17

CRF, PPI tx, atrophic gastritis, vagotomy, chronic HP with pangastritis

Question 18

Tx regimens for HP with pen allergy and recent clarithro use?

Answer 18

Bismuth + metro + tetra + ranitdiine OR

Levo + Omep + nitazoxanide + doxy

Question 19

Which NSAIDs have highest ulcer risk?

Answer 19

piroxicam, indomethacin, ketorolac (KIP)

Question 20

T/F: COX2 inhibitor is safer than standard NSAID in pts with CVD?

Answer 20

False

Question 21

Which NSAID is preferred in pts with CV risk and low GI risk?

Answer 21

Naproxen

Question 22

T/F: Pts with CVD on ASA and NSAID should be on ppi or misoprostol?

Answer 22

True

Question 23

IF secreted by which part of stomach?

Answer 23

Parietal cells which is in body and fundus

Question 24

Role of gastric acid in B12 abs?

Answer 24

Breaks bonds of R protein to B12 to allow IF to bind; If take PO supps of B12, no R protein present so acid not important

Question 25

CagA strain does what/

Answer 25

Inc risk of gastric AC or MALToma, inc risk of gastric/duod ulcers; protects against esoph dz

Question 26

Which ulcer locations have higher risk of rebleeding?

Answer 26

Posterior duodenal ulcers or higher lesser curvature in the stomach

Question 27

HP pt with duodenal ulcer typically have dz of what?

Answer 27

Antrum --> dec SS from D cells --> inc gastrin --> duod ulcer

Question 28

What is most common location(s) of gastrinoma?

Answer 28

Prox duodenum or panc head

Question 29

How does gastrin fcn?

Answer 29

Stims histamine release from ECLs leading to inc acid

Question 30

Which two NTs induce acid secretion?

Answer 30

ACh and Histamine

Question 31

Which cells secrete acid?

Answer 31

Parietal cells

Question 32

Which NT inhibits acid secretion?

Answer 32

Somatostatin

Question 33

Which cells release gastrin?

Answer 33

G cells

Question 34

T/F: Peptide YY induces secretion of gastric acid.

Answer 34

False, it inhibits it

Question 35

``` Name fcn of each cell type G cell ECL cells Chief cells D cells Vagal nerve ```

Answer 35

G cells - secrete gastrin which inc acid production and stims ECLs ECL cells - secrete histamine which leads to acid Chief cells - secrete pepsinogen to break down protein D cells - secrete SS which inhibits G and ECL cells Vagal - secrete ACh which inc acid production

Question 36

What is the dose of epi for injection?

Answer 36

1:10,000

Question 37

How does GOO lead to inc acid?

Answer 37

Distention of stomach leads to gastric phase of acid release triggered by gastrin which leads to high acid output

Question 38

What are the 2 biggest RFs for stress ulcers?

Answer 38

MV > 48 hrs, coagulopathy

Question 39

How long after tx to use urease breath test for cure if sxs remain?

Answer 39

4 weeks after tx of H pylori | 2 weeks off of PPI

Question 40

If a gastric ulcer is present which requires tx due to visible vessel, what is the best PPI regimen?

Answer 40

IV BID PPI therapy for 72 hours followed by oral dosing

Question 41

If gastric ulcer is present which has pigmented spot, which is best PPI tx?

Answer 41

BID dosing immediately

Question 42

T/F: Duodenal bulb ulcer in H pylori infxn likely to be due to HP of the antrum. This leads to dec in SS.

Answer 42

True - antral D cells are inflamed and secrete less SS, therefore, inc in gastrin production

Question 43

T/F: Both Cag PAI and VacA have inc risk of HP ulcers.

Answer 43

True

Question 44

What is the MC location of a gastrinoma?

Answer 44

"Gastrinoma triangle" - jxn of cystic and common hepatic ducts, jxn of 2nd and 3rd portions of duodenum, jxn of H&N of panc

Question 45

How do each of these fxn? Gastrin Histamine ACh

Answer 45

Gastrin stims histamine secretion from ECL | Histamine and ACh directly lead to acid release from parietal cells

Question 46

Where are G cells located?

Answer 46

Gastric epithelium

Question 47

What role do prostaglandins play in mucosal barrier protection of stomach?

Answer 47

Play role in mucous layer thickness, mucosal blood flow, and HCO3 secretion

Question 48

Name conditions that lead to appropriate hypergastrinemia (where acid is deficient).

Answer 48

CRF, chronic HP pangastritis, atrophic gastritis, PPIs, vagotomy

Question 49

Name conditions that lead to inappropriate hypergastrinemia (where acid is not deficient).

Answer 49

ZES, GOO, antral predominant HP, retained antrum syndrome, massive SI resection

Question 50

Which NSAIDs have the highest ulcer risk?

Answer 50

Piroxicam, indomethacin, tometin, ketorolac, azapropazone, meclofenamate

Question 51

N/V, satiety, bloating, discomfort - name which symptoms are MOST to LEAST likely to respond to PPIs.

Answer 51

Discomfort, satiety, bloating, N/V

Question 52

Pt on ASA 81, which NSAID is best to use in combo?

Answer 52

Naproxen and should add PPI or misoprostol also

Question 53

If high gastrin level and suspect ZES, what should be done next?

Answer 53

Assess gastric pH.

Question 54

How do PPIs work?

Answer 54

Irreversibly inhibit H-K ATPase

Question 55

What level of gastric pH tells us that PPI is working?

Answer 55

pH > 4

Question 56

T/F: PPIs delay gastric emptying

Answer 56

True

Question 57

How does CRF lead to high gastrin and acid?

Answer 57

Poor clearance of gastrin allows it to circulate longer

Question 58

Where does IF come from?

Answer 58

Parietal cells, mainly located in fundus and body

Question 59

What basal to peak acid output is suggestive of ZES?

Answer 59

Basal:Peak of 0.6 or greater

Question 60

What are the effects of HP of the antrum only?

Answer 60

D cells affected and so more acid and gastrin

Question 61

What are the effects of HP of the body only?

Answer 61

Parietal cells affected in large part leading to decreased acid

Question 62

What other condition besides ZES can lead to gastrin ~1000? How do you differentiate the two?

Answer 62

Pernicious anemia; Secretin stim test - will lead to decreased acid in pernicious anemia but not in ZES