Exam 1 - PUD and Gastric Cancer Flashcards by Kelsey Peiser

What is the function of the parietal cells in the stomach?

Produce HCL and intrinsic factor

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What is the function of the chief cells in the stomach?

Secrete pepsinogen

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What is the function of the mucus neck cells in the stomach?

Secrete a thin, acidic mucus

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What is the function of the enteroendocrine cells in stomach?

Secrete various hormones. Enteroendocrine G cells secrete gastrin

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What are 4 protective features of the stomach mucosa?

bicarbonate-rich mucus
tight junctions
Stem cells
prostaglandins

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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

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What is the most common cause of PUD worldwide?

H. pylori

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What does H. pylori predispose individuals to?

Gastric cancer

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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

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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

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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

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What is the common clinical presentation of PUD?

Majority are asymptomatic

- Upper abdominal pain/discomfort in those who are sympatomatic

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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

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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

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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

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What is the most common complication of PUD?

Hemorrhage

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What are some possible complications one can experience from PUD?

Hemorrhage
Perforation
Penetration
Gastric outlet obstruction

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What is the clinical presentation associated with hemorrhage from PUD?

Melena
Hematemesis
Hematochezia

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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