Gastric Disorders Flashcards
What does the stomach secrete in response to its expansion during digestion?
hydrochloric acid, pepsin, gastrin
Why do you need the stomach to have a low pH
kill ingested bacteria and promote proteolysis and activation of pepsin
What type of cell does gastrin originate from
G cells
What are the 2 purposes of gastrin
stimulate gastric juice (acidic - -.9-1.5) (hydrochloric acid, pepsin, and intrinsic factor
stimulate stomach motor function
what is the pathway that leads to gastrin and its effect?
When food enters the stomach, the protein component stimulates G cells situated in the antral region of the stomach to release the hormone gastrin, which stimulates the cells to release histamine and stimulates parietal cells to secrete acid.
As the acidity of the stomach and duodenum increases, protective feedback pathways are activated to inhibit further___ ___________.
acid secretion
The release of what is a mechanism of acid-mediated inhibitory control
somatostatin by D cells
Gastritis and gastritis related disease (gastric bcell lymphoma, peptic ulcer disease, and stomach cancer) are associated with what?
H. pylori
when are you most likely to acquire H pylori
in childhood
How do you contract H pylori
transmission via fecal/oral or oral/oral routes
H pylori burrows and attaches to the gastric epithelium where pH is closer to what
4.5 to 6.5
H pylori burrowing through mucus layer to gastric epithelium leads to inflammation resulting in histologic changes. This makes this cascade the _____ leading cause of cancer death worldwide
fifth
Gold standard testing for H pylori
endoscopy with 4 biopsies along the stomach lining
3 non invasive testing for H pylori
antibody test - not helpful in acute cases
Urea breath test - most widely used
Fecal antigen test
How many times do you get a urea breath test
1st time: + –> treat –> 2nd time –> improvement?
Symptoms of gastritis/dyspepsia
epigastric pain, discomfort, burning
causes of acute gastritis
NSAIDs/Aspirin
Smoking and alcohol use
Physiological stress (burns, trauma, shock)
Types of Chronic Gastritis
A (fundal) - autoimmune (atrophic gastritis or pernicious anemia)
B (astral) - helicobacter pylori infection
What type of eating disorder can you often see gastritis with
Bulimia due to chronic vomiting
What else besides vomiting can trigger gastritis
Excessive alcohol use and anti-inflammatory drugs
What 4 things are most gastric and duodenal ulcers attributed
H pylori
NSAIDs
Severe physiologic stress
Hypersecretory conditions (Zollinger-Ellison)
Why are NSAIDs implicated with Gastritis
They decrease prostaglandins which decreases mucus production resulting in gastric ulcers
Patients with gastritis due to hypersecretory conditions present typically have what? and what do labs reveal?
a gastroma located in the pancreas or duodenum
present with diarrhea
labs reveal increased gastrin level
What are gastronomas (gastrin secreting neuroendocrine tumor) associated with besides gastritis
Multiple endocrine neoplasia (MEN) type 1
Treatment of Gastritis
PPI and removal of tumor
What two mechanisms contribute to the pathophysiology of gastritis?
H pylori
Decrease in number of somatostatin secreting astral D cells
Is H pylori gram positive or gram negative
Gram negative
What does H pylori Produce
Ammonia which is toxic to epithelial cells, causing gastritis
How do you differentiate gastritis from peptic ulcer disease with patient presentations
patients with peptic ulcer disease tend to have symptoms more pronounced with food intake
What must you rule out on physical examination to make sure patient is not having complications (perforation) of peptic ulcer disease
rigid abdomen, rebound tenderness, or guarding
What type of patient presentations would you consider GERD until proven otherwise
complaint of heart burn or abdominal pain with heartburn more than once per week
If patient has any symptoms of dyspnea or chest pressure what should that make you think
cardiac etiology
Where does biliary pain often radiate and what type of food is it associated with
right shoulder
fatty/greasy foods
If a patient describes a severe boring type of pain in epigastrium that is relieved when they bend over what should you be thinking?
pancreatitis
What are the alarm signs of dyspepsia
> 55 y/o
bleeding
anemia
unintentional weight loss
dysphagia
odynophagia
early satiety
previous malignancy
Lymphadenopathy
abdominal mass
previous ulcer
What alarm signs should be recognized in patients > 55 yo
unintended weight loss
progressive dysphagia
persistent vomiting
evidence of GI bleeding
family Hx of cancer
What 2 signs are patients with gastro ulcers always going to present with
dyspepsia and abdominal pain
What are other symptoms of gastro ulcers
pain in upper belly
feeling bloated or early satiety
decreased appetite
nausea/vomiting
vomiting blood or black colored stool
more tired than usual - anemia
What is the most common cause of upper GI bleed
peptic ulcer disease
What will you see with Duodenal Ulcers
most common
well nourished
Pain 2-3 hours after meals
EATING DECREASES PAIN
What will you see with Gastric Ulcers
Weight loss
Pain 30 min-1hr after eating
vomiting
EATING INCREASES PAIN
How do you approach treatment and diagnosis for Peptic Ulcer Disease
Test then Treat (H Pylori Prevalence High)
OR
Empiric (H Pylori Prevalence Low)
How are you going to treat PUD if H Pylori prevalence is low
Empirically - PPI for 4-8 WEEKS
no improvement? test for H Pylori
How are you going to treat PUD if H Pylori prevalence is high
Test for H Pylori then Treat
Triple therapy (first line) - PPI, clarithromycin, amoxicillin for 14 d
Quadruple Therapy (2nd line) - PPI, Bismuth, tetracycline, metronidazole
What are the most significant complications of PUD
gastric bleeding, perforation, or outlet obstruction
What is the most common cause of death in patients with PUD
Gastrointestinal bleeding… usually artery so bright red
What percentage of peptic ulcers cause perforation?
5%
Where does perforation due to peptic ulcers usually occur
anteriorly through the duodenum or lesser curve of the stomach
How will patients present if they have a perforation due to peptic ulcer
fever, tachy, dehydration… the thorax will appear distended, tight, hyper resonant, and the patient does not want to be touched
What may you see on CXRay
Pneumoperitoneum
free air under the diaphragm
What is another acute or chronic complication you can see with PUD
Gastric Outlet Obstruction
How will patients present with a Gastric Outlet Obstruction
Severe hypochloremic hypokalemic alkalosis
this must be corrected prior to sx
motility disorder characterized by heartburn and caused by the reflux of gastric contents into the esophagus
Gastroesophageal reflux disease (GERD)
Patient presents with heartburn, generally worse after meals or lying down. Often already taken antacids … they may also have regurgitation and dysphagia
what are you thinking?
GERD
What is GERD caused by?
LES not closing allowing for reflux of gastric contents into esophagus causing burning pain
If you hear these 3 words in a vinet I immediately want you to think what
Heartburn, dysphagia, regurgitation
GERD!!!!!
Exacerbating factors
Obesity or increased weight
Fatty foods
caffeine
carbonated beverages
ETOH
tobacco
drugs
peppermints
chocolate
How do you diagnose GERD
You can diagnose it with history alone usually
What will you hear in clinic from GERD patients
nongastro symptoms
wheezing
asthma exacerbation
nocturnal cough or choking
hoarseness
Anemia
enamel erosion
halitosis
What must you also exclude if patient has chest pain before gastro evaluation
cardiac causes
If patient has ALARM symptoms or if they haven’t improved on PPIs, what are you going to do
Endoscopy
What are you going to start GERD patients on
PPI
What are lifestyle modifications you can recommend to GERD patients
stop smoking
lose weight
avoid fatty foods, alcohol, coffee, chocolate
elevate head of bed
dont lie down after meal
What are pharmacological treatment options
PPI
H2 blockers (tidine)
Vitamin B12 and calcium supplementations if taking PPIs prolonged
What is the surgery option for treatment of GERD
Fundoplication
How should you treat GERD in pregnancy
antacid therapy, lifestyle modification, or sucralfate
History of chronic GERD which causes metaplastic change in the lining of the distal esophagus
Barrett Esophagus
What is Barrett esophagus associated with a risk for
adenocarcinoma of the esophagus
What population is Barrett Esophagus predominantly found in?
Middle aged white males
What are the risk factors for Barrett esophagus
long standing frequent reflux, smoking, male, older, central obesity
What do almost all Barrett Esophagus patients have
hiatal hernia
What is diagnostics for Barrett Esophagus
endoscopy
Treatment for Barrett Esophagus
PPIs, lifestyle modifications
Management of Barrett Esophagus with no Dysplasia and cancer risk
upper endoscopy every 3-5 years
0.2% per year
Management of Barrett Esophagus with LOW grade dysplasia and cancer risk
upper endoscopy annually OR endoscopic treatment with radio frequency ablation
0.7% per year, but may be as high as 8%
Management of Barrett Esophagus with HIGH grade dysplasia and cancer risk
radio frequency ablation
7-19% per year
What is the most common cancer/ gastric neoplasm of the stomach?
ADENOCARCINOMA
patient present with weight loss, early safety abdominal pain/fullness and dyspepsia
what are you thinking
Adenocarcinoma of stomach
Are adenocarcinoma of the stomach patients usually asymptomatic
yes
Are males or females more likely to get adenocarcinoma
2x more common in males
What is the most important risk factor for gastric neoplasms
H pylori
you may also see Virchow’s node (above clavicle) or sister Mary joseph’s node (belly button)
Projectile vomiting that occurs shortly after feeding an infant <3mo old
Pyloric Stenosis
What is the buzz word for the PANCE with Pyloric Stenosis
Olive like mass
Diagnostics for pyloric stenosis
ultrasound and/or barium studies
