Exam 1 - PUD and Gastric Cancer Flashcards
What is the function of the parietal cells in the stomach?
Produce HCL and intrinsic factor
What is the function of the chief cells in the stomach?
Secrete pepsinogen
What is the function of the mucus neck cells in the stomach?
Secrete a thin, acidic mucus
What is the function of the enteroendocrine cells in stomach?
Secrete various hormones. Enteroendocrine G cells secrete gastrin
What are 4 protective features of the stomach mucosa?
- bicarbonate-rich mucus
- tight junctions
- Stem cells
- prostaglandins
What is a defect in the gastric or duodenal mucosa that extends through the muscularis mucosa into the deeper layers of the wall?
Peptic ulcer
What is the most common cause of PUD worldwide?
H. pylori
What does H. pylori predispose individuals to?
Gastric cancer
How does H. pylori cause disruption of the protective mechanisms of the stomach, leading to ulcers?
- Flagella - used to burrow into stomach
- Urease - produces neutralized area
- Adhesins
- Causes inflammation - inflammation causes G cells to secrete gastrin, therefore increasing HCL
How do NSAIDs cause disruption of the protective mechanisms of the stomach, leading to ulcers?
NSAIDs inhibit the production of cyclooxygenase, leading to decreased production of PGE2 which is a protective factor of the mucosa
What are some factors that increase the risk of PUD with the use of NSAIDs?
- Prior hx of PUD/ulcer complications
- Presence of H. pylori infection
- Advanced age ( > 75 yo)
- Increased dose, time and duration of use
- Concomitant use of steroids, other NSAIDs, anticoagulants, aspirin, SSRI, alendronate
What is the common clinical presentation of PUD?
- Majority are asymptomatic
- Upper abdominal pain/discomfort in those who are sympatomatic
Are the following symptoms more correlated with a gastric or duodenal ulcer?
- Pain worse after meals; pain worse 30 minutes to 1 hour after meal
- Vomiting common
- More likely to hemorrhage which manifests as hematemesis
- Weight loss
Gastric ulcer
Are the following symptoms more correlated with a gastric or duodenal ulcer?
- Pain relieved by meals; pain worse 2-3 hours after meal
- Vomiting uncommon
- Less likely to hemorrhage, but manifests as melena
- Weight gain
Duodenal ulcer
What are some alarm symptoms for PUD?
- Bleeding
- Unexplained iron deficiency anemia
- Early satiety
- Unintentional weight loss
- Progressive dysphagia/odynophagia
- Acute onset of intense upper abdominal pain
- Persistent vomiting
- Family hx of upper GI cancer
What is the most common complication of PUD?
Hemorrhage
What are some possible complications one can experience from PUD?
- Hemorrhage
- Perforation
- Penetration
- Gastric outlet obstruction
What is the clinical presentation associated with hemorrhage from PUD?
- Melena
- Hematemesis
- Hematochezia
How is hemorrhage from PUD diagnosed?
EGD
What is the treatment for hemorrhage from PUD?
- IV fluids or PRBCs
- IV PPI
- Thermal coagulation
- Hemoclip
- Injection therapy
What is the clinical presentation associated with perforation from PUD?
- Severe, diffuse abdominal pain
- Tachycardia, weak pulse
- Nausea/Vomiting
How is perforation from PUD diagnosed?
Upright chest and 2-view abdominal x-rays (free air under diaphragm)
What is the treatment for a perforation from PUD?
- IV fluids
- IV PPI
- NG tube and suction
- Antibiotics
- Surgery
What is the most common adjacent structure affected due to penetration from PUD?
Pancreas
What is the clinical presentation associated with gastric outlet obstruction?
- Vomiting
- Early satiety
- Bloating
- Epigastric pain
- Anorexia/Weight loss
How is gastric outlet obstruction diagnosed?
- Dilated stomach on imaging
- Succussion splash on exam
What is the treatment for gastric outlet obstruction?
- IV fluids
- NG tube
- Gastric decompression
- IV PPI
- Endoscopic balloon dilatation or surgery if failure with medical treatment
How is H. pylori diagnosed?
- Urea breath test
- Stool Antigen test
- Serology
- Biopsy for histology during EGD
What is the most sensitive and specific testing method for H. pylori?
Biopsy for histology during EGD
What is the treatment for PUD due to H. pylori?
Clarithroymycin Triple Therapy x 14 days:
- PPI BID
- Clarithromycin 500 mg BID
- Amoxicillin 1000 mg BID
Bismuth Quadruple Therapy x 14 days
- PPI BID
- Bismuth subsalicylate 300 mg QID
- Metronidazole 250 mg QID
- Tetracycline 500 mg QID
- Confirmation eradication 4 weeks after completion of treatment
- Consider long-term acid suppression with daily PPI
- Discontinue exacerbating factors: NSAIDS, tobacco, alcohol
What is the treatment for PUD likely secondary to aspirin/NSAID usage?
- Discontinue aspirin/NSAID
- 6-8 weeks of PPI
- Consider long-term daily PPI
- Discontinue exacerbating factors: NSAIDS, tobacco, alcohol
What is the treatment for PUD if it is not due to H. pylori or aspirin/NSAID usage?
- Discontinue exacerbating factors: NSAIDS, tobacco, alcohol
- 4-8 weeks of PPI and evaluate for other etiologies
- Perform repeat EGD after initial PPI therapy
- Consider long-term daily PPI
What is Zollinger-Ellison Syndrome
Syndrome in which gastrinomas typically arising from the duodenum or pancreas hypersecrete gastrin, increasing HCL secretion and gastric motility
What is the clinical presentation associated with Zollinger-Ellison Syndrome?
- Recurrent PUD that is often distal to duodenal bulb
- Diarrhea (including steatorrhea)
- Upper abdominal pain
How is Zollinger-Ellison Syndrome diagnosed?
- Fasting serum gastrin > 1000 pg/mL + gastric pH < 2 ***
- Secretin stimulation test
- CT abdomen to localize tumor
What is the treatment for Zollinger-Ellison Syndrome?
PPIs and surgical resection if possible
What is the clinical presentation associated with gastric cancer?
- Most are asymptomatic
- Weight loss
- Persistent abdominal pain
- Gastric ulcer history
What is the clinical presentation if patient presents with late gastric cancer?
Palpable stomach mass, succussion splash, paraneoplastic syndromes
How is gastric cancer diagnosed?
EGD
What type of cancer are most gastric cancers?
Adenocarcinoma
What is the most common sign of metastatic disease with gastric cancer?
Virchow’s Node: left supraclavicular lymph node
What are some signs of metastatic disease with gastric cancer?
- Virchow’s Node: left supraclavicular lymph node
- Sister Mary Joseph’s Node: periumbilical nodule
- Left axillary node (Irish node)
What is the definition of dyspepsia?
Abdominal discomfort sometimes accompanied by bloating, belching or abdominal distention
What is the workup for a patient with dyspepsia who is 60 years or older?
- Perform EGD with biopsy in all patients
- If PUD present, treat
- If no evidence of organic disease, consider “functional dyspepsia” and test for H. pylori and treat as necessary
What is the workup for a patient with dyspepsia who is less than 60 years old?
Perform EGD if patients with ANY of the following:
- Clinically significant weight loss
- Overt GI bleeding
- 2 or more alarm features
- Rapidly progressive alarm features
What are some dyspepsia alarm features?
- Unintentional weight loss
- Progressive dysphagia
- Odynophagia
- Unexplained iron deficiency anemia
- Persistent vomiting
- Palpable mass or lymphadenopathy
- Family hx of upper GI cancer
