Diseases of the Stomach Flashcards
Describe the manifestation of Peptic Ulcer disease.
Risk factors?
- Mucosal defects of stomach and duodenum
- pepsin and gastric acid
- Risks
- equal risk between men and women
- most between 25-64 (but incidence increases with age)
- Helicobater pylori
- NSAID use
What are the characteristics of H. pylori?
Increased risk factors for infection?
- H. pylori
- curved, gram (-) rods
- flagellated
- urease producing
- found only in gastric mucosa
- curved, gram (-) rods
- Infection
- 50% world population
- increased poor people/regions
- minority develop PUD or gastric cancer
What is the most commonly used class of drugs to treat peptic ulcer disease?
Describe the strategy utilized by these drugs
- Nonsteroidal anti-inflammatory drugs
- Dual-injury model
- direct toxic effects on mucosa
- indirect effects through metabolites activated in the liver
- Prostaglandin inhibition
- reduction in epithelial mucus
- decreased bicarbonate secretion
- decreased mucosal blood flow
What are the two enzymes responsible for prostaglandin production?
What are the differences between them? What is the precursor for prostaglandin?
- Prostaglandin production through breakdown of arachidonic acid
- Cyclooxygenase
- COX-1
- primarily expressed constitutively
- “housekeeping” enzyme in tissues
- adverse effects of NSAIDs through inhibition
- COX-2
- inducible
- anti-inflammatory properties of NSAIDs mediated
- COX-1
What are the possible NSAID related injuries?
- Subepithelial hemorrhage
- erosions
- small and superficial
- ulcerations
- most frequent area involved is the antrum
- endoscopic studies
- 10-25% chronic users have PUD
Characteristics of Zollinger Ellison Syndrome?
- Hypersecretory state
- elevated levels of serum gastrin
- gastrin secreting tumors (gastrinoma)
- 75% of gastrinomas are spontaneous
- 25% MEN I syndrome
- Characteristics
- PUD
- need to consider in patients without H. pylori or NSAID use
- ulcers in unusual site
- distal duodenum & jejunum
- multiple or recurrent ulcers
- chronic diarrhea
- duodenojejunitis
- esophagitis
- PUD
Clinical presentation of PUD?
Symptoms can mimic what other diseases?
- Clinically silent to profound manifestations
- abdominal pain, iron deficiency anemia, obstruction, perforation, and hemorrhage
- epigastric pain- dull ache (may be sharp & burning)
- 20% describe hunger-like pain
- duodenal vs. gastric
- nausea and vomiting
- Mimics many other disease states
- less serious- GERD
- more serious- pancreatitis, myocardial infarction
PUD diagnostic criteria?
Follow up?
- Diagnosis
- imaging studies usually required
- endoscopy is preferred
- H. pylori test
- serologic testing
- urea breath test
- stool antigen testing
- rapid urea test- mucosal biopsy
- Follow up
- contol of hemorrhage
- biopsy tissue to look for cancer or complications
PUD treatment goals and regimen?
- Acid suppression (cornerstone of therapy)
- antacids-require multiple doses/day but provide relief of symptoms
- H2 receptor blockers
- inhibit histamine on the parietal cell-increase pH and inhibit pepsin activity
- 4 weeks for duodenal ulcers
- 8 weeks for gastric ulcers
- cimetidine, ranitidine, famotidine, nizadine
- Enhancing mucosal defense
- sucralfate and aluminum hydroxide (better for duodenal ulcers)
- Treat H. pylori
- Treatment and Prevention of NSAID ulcers
- Surgery
What drugs are the most potent inhibitors of gastric acid secretion?
Treatment duration?
special considerations?
- Proton Pump Inhibitors
- omeprazole, pantoprazole, rabeprazole, lansoprazole, esomeprazole
- duration of treatment is 4 weeks
- should be taken before a meal
- most effective when more proton pumps are turned on
- usually before breakfast
- heal ulcers more rapidly than H2 inhibitors
What is the general treatment regimen for H. pylori?
What are common reasons and considerations for treatment failure?
- 2 antibiotics adn either a PPI or H2 blocker
- prevent resistance
- recomended course is 14 days
- eradication shoudl be attempted in all patients with PUD
- Treatment failure
- resistance
- noncompliance
- don’t repeat the same regimen after treatment failure
Treatment of NSAID induced ulcers?
What increases risk of development?
Prevention?
- treatment
- discontinuation of offending agent
- Co-administration of a PPI
- PPIs better than H2 blockers
- risk increases with
- age
- anticoagulant use
- corticosteroid use
- prior history of PUD
- Prevention
- misoprostol (prostaglandin E1 analogy)
- better than PPIs to decerease ulcer complications in prospective trial
- use of COX-2 inhibitors
- misoprostol (prostaglandin E1 analogy)
What are some complications of PUD?
- Bleeding
- 50% of cases of GI bleedign caused by PUD
- major risk factor is NSAID use
- endoscopy
- Perforation
- peritonitis/sepsis
- treatment is surgical
- Gastric Outlet obstruction
- incidence decreased with PUD treatment
- early satiety, bloating, N/V, weight loss
- endoscopy
What is gastritis?
common causes?
- nonspecific inflammation of themucosal surface
- causes
- H. pylori
- NSAIDS
- Stress related
- critical illness and shock
- aggressive colume resuscitation
- autoimmune gastritis
Symptoms of nonulcer dyspepsia?
Diagnosis?
Treatment?
- Symptoms
- pain and discomfort in the upper abdomen
- afferent visceral hypersensitivity
- chronic, recurrent or acute
- Diagnosis
- exclude other causes of the symptoms
- endoscopy for red flags
- weight loss, recurrent comiting, anemia, family history of GI cancer
- endoscopy for red flags
- exclude other causes of the symptoms
- Treatment
- antisecretory meds
- testing for H. pylori
