Clinical Presentation of the Diseases of the Stomach Flashcards
A 74 y.o. female, PMHx significant for longstanding diabetes for 23 years, presents with complaints of early satiety, bloating, and intermittent vomiting of undigested food. What is her most likely diagnosis?
gastroparesis (delayed gastric emptying)= disorder that slows or stops the movement of food from the stomach to the small intestine.
What are the symptoms of gastroparesis (delayed gastric emptying)?
epigastric pain, nausea, vomiting, bloating, and early satiety
What is the most recognized disorder of delayed gastric emptying?
DIABETIC gastroparesis
*bare in mind, gastroparesis can also often be seen in non-diabetic patients
What is the best test to confirm gastroparesis?
gastric scintigraphy (nuclear medicine test) after anatomic obstruction is ruled out. After about 90 mins if more than 50% of the nuclear tracing is still visible in the stomach, you can diagnose gastroparesis.
What specifically is impaired in diabetic gastroparesis?
both phase 3 of the interdigestive migrating motor complex (MMC), and phasic activities of the postprandial antral motility
How do you treat gastroparesis?
- dietary modifications
- prokinetic agents (be wary of tardive dyskinesia side effect).
- G and/or J tubes
- gastric electrical pacing for DM related
- gastrectomy
What else can cause gastroparesis?
after gastric operations, progressive systemic sclerosis, or primary or secondary amyloidosis
*most common cause is idiopathic (we don’t know)
What are some acid peptic disorders?
gastritis, gastric ulcers, duodenal ulcers that occur due to a break in the mucosal lining.
*affects millions each year
Can peptic ulcers be caused by chronic NSAID use?
YES
What are the aggressive factors that can lead to acid peptic disorders?
Endogenous factors= acid and pepsin
Exogenous factors= H. pylori and NSAIDS
*Ischemia (in ICU settings especially)
What are the 2 largest risk factors for ulcer bleeding in the ICU?
- coagulopathy
- intubation
* If a patient has either of these PUT THEM ON A PPI (NOT H2 blocker, because a patient will build a tolerance to H2 blockers after a few days).
Why would you put a patient on a PPI to help reduce the risk of an ulcer bleeding?
because elevating the pH helps a clot to stabilize :)
What is Helicobacter pylori?
- spiral shaped, gram negative, flagellated bacterium that is able to live is gastric acidic environment.
- causes chronic gastritis, most peptic ulcers, and gastric adenocarcinoma and lymphoma
How do we get H. pylori?
route of transmission remains unknown
Is reinfection after cure unusual?
YES
Could H. pylori be associated with nongastrointestinal disorders?
YES including chronic urticaria, CHD, HTN, migraine, raynaud…
How do you test for H. pylori?
Invasive techniques= urease test, histology, bacterial culture.
Noninvasive testing= urea breath test (used more for confirming eradication), stool antigen, serology, or PCR.
When should you test for H. pylori?
- active peptic ulcer
- PMHx of ulcer
- Hastric MALT (mucoas-associated lymphoid tissue) lymphoma.
- Testing should only be performed if treatment is intended.
Are DUODENAL ulcers often associated with H. pylori?
YES 95%
Are GASTRIC ulcers often associated with H. pylori?
YES 75%
Is dyspepsia (nausea, uncomfortable, queasiness) often associated with H. pylori?
YES 20-60%
Is gastric cancer often associated with H. pylori?
YES 70-90%
** What percentage of patients with H. pylori infection will develop ulcer disease? (TEST QUESTION)
only 10-15%
*Thus there must be other factors important in peptic ulcer disease.
Does eradication of H. pylori reduce the risk of ulcer recurrence?
YES
How do we treat H. pylori?
mono, dual, triple (PPI, clarithromycin, and amoxicillin), or quadruple therapy
What is Zollinger-Ellison syndrome?
- ulceration of the upper jejunum, hypersecretion of gastric acid, and non-beta islet cell tumors of the pancreas.
- gastric tumor secreting gastrin (gastrinoma)
- could be sporadic or associated with MEN1= 3 Ps: pituitary, parathyroid, and pancreas.
Where are most gastrinomas found?
duodenum
*majority of pts develop peptic ulcer disease
What are the 2 most common symptoms of gastrinoma?
abdominal pain and diarrhea
** How do you test for gastrinoma if you suspect it? (TEST QUESTION)
- fasting serum gastrin level (first option)
2. secretin stimulation test (second option)
How do we treat gastrinoma?
- acid suppression (PPI) usually higher dose
- surgery if not metastatic
- prognosis is good for 15 years if not metastatic
What test is a barium study called?
upper GI series. Ulcers will uptake barium!
A 42 y.o. male, Hx of several days of abdominal pain, now presents with bright red hematemesis. He admits to ingesting Motrin 800 mg every 8 hours for headaches over the past 2 weeks. After checking blood work including H/H, Plts, PT/PTT, and type and crossing him for blood, you recommend what?
Upper endoscopy because anyone who vomits up blood, means you have an UPPER GI BLEED.
*never order upper GI series for an active bleed, because barium won’t show bleeding, and now you can’t do an upper endoscopy for a while until the barium has cleared.
What is the difference between gastritis and gastropathy?
- gastrITIS= inflammation of the stomach with epithelial damage and repair.
- gastrOPATHY= epithelial damage and repair WITHOUT inflammation.
What can cause gastritis?
infectious agents, drugs, and autoimmune and hypersensitivity reactions
What can cause gastropathy?
drugs, bile reflux, stress, hypovolemia, and chronic vascular congestion
What is watermelon stomach?
erythematous radial stripes resembling the rind of a watermelon
What is the most common internal cancer worldwide?
gastric carcinoma (low in U.S., but high in Japan)
How do early and late gastric cancers differ?
early does not invade the muscularis propria.
Type 1= polyp like
Type2= flat
Type 3= ulceration
What is the prognosis for early gastric cancers?
GREAT
What is important to remember about all gastric ulcers and healing?
you must follow them until they are completely healed!
Must all gastric ulcers be biopsied?
YES
What are bezoars?
persistent concretions of foreign matter that are unable to exit the stomach.
*most common are plant and vegetable fibers (phytobezoars), persimmons (disopyrobezoars), hair (trichobezoars)
How do you diagnose bezoars?
UGI series and endoscopy
Will most swallowed foreign bodies pass from the stomach naturally?
YES
What is gastric volvulus?
abnormal degree of rotation of one part of the stomach around another
What is organoaxial volvulus?
around a line joining the pylorus to the CEF
What is mesenteroaxial volvulus?
around a horizontal line form the center of the greater curvature to the porta hepatis
