Disorders of the Stomach and Duodenum Flashcards
Inflammation of the lining of the stomach
Seen with endoscopic or radiologic evaluation
Multiple variety of causes
Gastritis
Why can gastritis be worrisome?
erosions can progress to ulcers
What are some signs/symptoms of gastritis?
Epigastric abdominal pain – gnawing or aching
Nausea
Indigestion
Loss of appetite
Vomiting (+/- hematemesis)
How is gastritis diagnosed?
History and PE
endoscopy
What are some treatment options for gastritis?
Treat the underlying cause
Mostly symptomatic:
H2 blockers
PPIs
carafate
List some causes of gastritis
H. pylori
NSAIDs/ASA
Alcohol
Caffeinated beverages
Medical or surgical stress
Autoimmune gastritis (Pernicious anemia)
Viral
Duodenogastric reflux
Fungal
Granulomatous (Crohns disease, Tuberculosis, Syphilis, sarcoid)
Hypersensitivity reactions
Eosinophilic Lymphocytic
Infection
Hyperplastic (Zollinger-Ellison syndrome, Menetrier’s disease)
Caused due to the inhibition of prostaglandin synthesis (Prostaglandins are needed for mucosal protection and healing)
Stomach lining constantly being turned over- prostaglandins are vital
Affects approximately 2/3 of patients on this medication chronically
NSAID Gastritis
Important to eradicate
Associated with chronic gastritis, PUD, gastric carcinoma
Transmission uncertain
Creates persistent inflammation
H. Pylori Infection
spiral, gram negative urease producing bacterium
H. pylori
Recurrence rate of ulcer is what percentage if patient is infected with H. pylori and not treated?
85%
If patient has PUD and not on NSAID/ASA, assume or test for what?
H. pylori
What are some non-invasive methods used to diagnose H. pylori infections?
Non-invasive:
Urea breath test - Must be off PPI, bismuth, antibiotics; Detects active infection – 90% PPV (Only for 18+ year olds)
Serology IgG antibody - Not useful for confirming eradication
Stool testing – H. pylori antigen; Useful for confirmation eradication
What are some invasive methods used to diagnose H. pylori infections?
Invasive:
Endoscopy with biopsy
Rapid urease test (Biopsies added to urea solution containing phenol red)
What is the treatment and follow up for H. pylori infections?
Treatment: triple therapy (abx and anti-ulcer)
Follow up with urea breath test or stool 1-3 months after completion (still need to be off PPI for accurate test)
Confined to the rugae in the gastric body and fundus
Associated with an excessive number of mucosal epithelial cells
Two major types
Hyperplastic Gastritis
What are the two major types of hyperplastic gastritis?
Menetrier’s disease
Zollinger-Ellison syndrome
Which type of hyperplastic gastritis is described below?
Large gastric folds
Decreased gastric acid secretion
Enhanced protein loss into the stomach
Menetrier’s disease
Which type of hyperplastic gastritis is described below?
Increased number of parietal cells with no change in surface and mucous cells
Caused by a gastrin-secreting neuroendocrine tumors (gastrinomas)
<1% of PUD
Zollinger-Ellison Syndrome
What amount of gastrinomas are malignant?
2/3 of gastrinomas are malignant
When a gastrinoma is diagnosed, what amount of cases have already metastasized to liver?
1/3 have already metastasized to liver at time of diagnosis
In patients with Zollinger-Ellison Syndrome, what percentage of patients will develop PUD?
90% of patients will develop PUD
How is Zollinger-Ellison Syndrome diagnosed?
Fasting serum gastrin
In the presence of gastric pH <4.0, a serum gastrin value >1000 pg/mL is virtually diagnostic of ZES
What is a test you can use to differentiate gastrinomas from other causes of hypergastrinemia?
Secretin stimulation test
What is the treatment for Zollinger-Ellison Syndrome?
PPIs (90-100% ulcer healing within 4 weeks)
Surgery
chemotherapy
Consider this gastritis if you have a younger person who comes in with asthma and trouble eating
Eosinophilic Gastritis
What are the most common causes of gastric ulcers?
NSAIDs and H. pylori are the most common causes of ulcers
Loss of surface epithelium that extends to penetrate muscularis mucosae
Ulcer: >5mm in diameter
Erosions: <5mm in diameter
Which type of ulcer is described below?
Pain worse at night or in a fasting state
Occurs 2-3 hours after eating
Relieved by food ingestion
Have to rule out ZE with duodenal ulcers
Majority secondary to H. pylori
Duodenal ulcer
Which type of ulcer is described below?
Worsened with food
Gastric Ulcer
Which type of ulcer is the most common?
Duodenal ulcers are 5x more common than gastric ulcers
Stress- related mucosal erosions that lead to upper GI hemorrhage
Develop within 72 hours in critically ill patients
Pathogenesis poorly understood
Bleeding is associated with a HIGH mortality
Stress Ulcers
Stress ulcers are associated with what conditions?
Sepsis
Multiorgan failure
Hypotension
Trauma
Major surgery
Severe burns
Prolonged mechanical ventilation
Caused when normal mucosal defenses are impaired or overwhelmed by acid or pepsin
Loss of surface epithelium that extends to penetrate muscularis mucosae (Ulcer >5mm in diameter; Erosions <5mm in diameter)
Many upper GI bleeds are due to this
Lifetime prevalence 10%
Slight male propensity (1.3:1)
Peptic Ulcer Disease
delay healing of ulcer
EtOH, smoking
Which ulcers have a higher incidence of recurrence throughout life?
Duodenal ulcers
Describe the clinical presentation of peptic ulcer disease?
May be asymptomatic
Dyspepsia - 80-90% of patients (But <25% of patients with dyspepsia will have PUD)
Frequently relieved by food – duodenal
Worse after eating - gastric
Mild epigastric pain - Gnawing, aching feeling
Anemia
Occult blood in stool
Hematemesis
Melena
Coffee-ground emesis
What is the procedure of choice to diagnose PUD?
Endoscopy
What are some red flags with peptic ulcer disease?
Anemia
Weight loss
Positive hemoccult
Hematemesis/melena
Persistent vomiting
Hepatomegaly/abdominal mass
Dysphagia
Progressive symptoms
What are some complications with peptic ulcer disease?
GI hemorrhage
Ulcer perforation/penetration
Gastric outlet obstruction
Abdominal xray: free air under the diaphragm suggests what?
Ulcer perforation/penetration
In an otherwise healthy infant aged 2-3 months; seems to be in pain
and cries for >3 hours a day, >3 days a week, for more than 3 weeks
(rule of threes)
Most common cause is GERD
Colic
What is the clinical presentation of infants with colic?
Severe and paroxysmal crying that occurs mainly in the late afternoon
Knees drawn up into chest
Fists are clenched
Flatus is expelled
Faces are pained in appearance
Minimal response to soothing techniques
Olive shaped mass right of midline
Projectile vomiting – sometimes can see visible peristalsis after feeding
Post-prandial, projectile, non-bilious vomiting
Begins between the ages of 2-4 weeks (Rare at birth or over 6 months of age)
More prevalent in males
Pyloric Stenosis
What is the pathophysiology of pyloric stenosis?
Caused by hypertrophy of muscles of the pylorus with elongation and
thickening leading to obstruction
Avoid giving Zithromax in kids under 3 because it can cause what?
pyloric stenosis
How is pyloric stenosis diagnosed?
Ultrasound – highly sensitive and specific; Can see hypertrophied pyloric valve (stenosis)
Barium swallow - will see tapering
What is the treatment for pyloric stenosis?
Surgical repair
The congenital absence or complete closure of a portion of the lumen
of the duodenum (during gestation)
Duodenal Atresia
Duodenal atresia is also associated with what other conditions/disorders?
Can be associated with Down Syndrome
Associated with cardiac anomalies and GI defects: Malrotation of intestines, Imperforate anus, Annular pancreas
How does duodenal atresia typically present?
Bilious emesis (vomiting bile) and epigastric distension within the first few hours of birth
What Xray finding would you see in duodenal atresia?
“double bubble” sign
What is the treatment for duodenal atresia?
Surgical repair
2nd most common cancer worldwide
Uncommon in US
Gastric Adenocarcinoma
What is the strongest risk factor for gastric adenocarcinoma?
Chronic H. pylori infection – stronger risk factor
What are some risk factors for gastric adenocarcinoma?
H. pylori
High salt diets
Dietary nitrates
Smoking
First-degree relatives of patients with gastric cancer have a 2-3 fold chance of developing the disease
In gastric adenocarcinoma, what are two signs of metastatic spread?
Virchow’s node - Left supraclavicular node/area
Sister Mary Joseph node - umbilical
In gastric adenocarcinoma, what percentage will survive 5 years after
“curative” resection?
25-35%
2nd most common gastric tumor
> 95% are B cell non-Hodgkins lymphoma
Gastric Lymphoma
Rare (<1% of gastric tumors)
More common in the bowel - 95% present in rectum, small intestine, appendix
Sporadic or secondary to chronic gastrinemia
Carcinoid Tumors
Symptomatic delay in gastric emptying of solid or liquid meals in absence of obstruction
Gastroparesis
What are the most common causes of gastroparesis?
Diabetic autonomic neuropathy (poorly controlled diabetes)
Post-vagotomy
What is the treatment for gastroparesis?
Prevention/Maintenance: Small frequent meals, Avoid agents that slow down gastric motility, Maintain good control of DM
Acute exacerbations: NG tube, IV fluids
Chronic or Subacute exacerbations: Metoclopramide (reglan), Domperidone, Erythromycin, Gastric pacemaker?
