Gastritis, ulcer, non-ulcer dyspepsia Flashcards
gastritis - defnition
inflammation or erosion of the gastric lining that is sometimes called gastropathy
gastritis - is caused by
- alcohol 2. NSAID 3. H. pylori 4. Porta hypertension
5. Stress (burns, trauma, sepsis, multiorgan failure, uremia)
atrophiuc gastritis is associated with
vit B12 deficiency
gastritis often presents with
GI bleeding without pain. Severe erosive gastritis can present with epigastric pan
- NSAID or alcoholsim in the history is a clue
gastritis - physical findings
there are no unique physical findings for gastritis
gastritis - bleeding
almost any degree: from mild cofee-graound emesis to large vomiting to red blood , to black stool (melena)
corellation of manifestations with volume of bleeding
cofee-ground emesis: 5-10 ml
heme (quaic) positive stool: 5-10 ml
melena: 50-100 ml
Gastritis - definitive diagnosis
only with upper endoscopy
Gastritis - anemia - diagnosis
no specific blood tests
Gastritis - radiologic studies
such as uppe GI series are NOT SPECIFIC ENOUGH
gastritis - capsule endoscopy
not appropriate for upper GI bleeding if endoscopy is one of the choices
in gastritis, also test fo
H. pylori –> this organism should be treated if it is associated with gastritis
tests for H. pylori - types (which is the most accurate)
- endoscopic biopsy (The most accurate)
- serology
- Urea C13 or C14 breath testing
- H. pylori stool antigen
If endoscopy, there is no point in doing other test
H. pylori - endocopic biopsy - advantages
The most accurate test for H. pylori
H. pylori - endocopic biopsy - disadvantages
invasive
H. pylori - serology - advantages
- low cost
- easily excludes infection if it is negative
- no complications ore procedures required
H. pylori - serology - disadvantages
Low specificity –> a (+) test does not easily tell difference between current and previous infection
H. pylori - Urea C13 or C14 breath - advantages
- (+) only in active infection
2. non-invasive
H. pylori - Urea C13 or C14 breath - disadvantages
requires expensive equipment in office
H. pylori - stool antigen - advantages
- (+) only in active infection
2. non-invasive
H. pylori - stool antigen - disadvantages
Requires stool sample
gastritis - treatment
treat with PPI
H2 blockers, sucralfate and liquid anntiacids are not as effective
Sucralfate inert substance (aluminium hydroxide complex) that coats stomach
inert substance (aluminium hydroxide complex) that coats stomach NEVER CORRECT
stress ulcer prophylaxis is indicated in
- mechanical ventilation
- Burns
- Head trauma
- Coagulopathy
how to distinguish definitely gastric and duodenal ulcers
no way wothout endoscopy
Peptic ulcer disease (PUD) is most commonly caused by
H. pylori
2nd MCC of PUD
NSAID: inhibition of the production of the protective mucus barrier in the stomach
(inhibit prostagladins which produce mucus)
Less common causes of PUD
- Burns
- Head trauma
- CROHN DISEASE
- gastric cancer
- Gastrinoma (Zollinger-Ellison syndrome)
alcohol and tobacco - PUD
they do not cause –> but they delay the healing
PUD - presentation
- recurrent episodes of epigastric pain hat is described as dull, sore, gnawing
- Bleeding
- tenderness and vomiting are UNUSUAL
CANNOT ANSWER PUD BASED ONLY ON SYMPTOMS
PUD - bleeding?
although is the MCC of upper GI bleeding, the majority of ulcers do not bleed
PUD - tenderness and vomiting
unusual
duodenal vs gastric ulcers regarding sympoms
- duodenal is more often improved with eating
- gastric is more often worsened by eating
YOU CANNOT definitively distinguish duodenal, gastric and non ulcer dysplasia without endoscopy
PUD - diagnosis
there is no way to diagnose withou endoscopy or barium studies
PUD - most accurate tests
Upper endoscopy
PUD - radiologic testing such as Upper GI series
can detect ulcers, but cannot detect the presence of either cancer or H. pylori
PUD - cancer: epidemiology / diagnosis
cancer is present in 4% of thise with gastric ulcer but none o thise with Duodenal ucler
The only method to diagnose gastric ca is endoscopy
duodenal vs gastric ulcer regarding H. pylori
Duodenal: 80-90%
gastric: 50-70%
PPIs in PUD
responds in 95% of cases, but will ecure unless H. pylori is eradicated in those who are infected
H. pylori eradication (treatment)
PPIs in combination with 2 antibiotics
1. best initial: PPIs with clarythromycin and amoxicillin (or metronidazole in allergy)
2. if no respinse: metronidazole and tetracycline
Adding bismuth to a change of antibiotics may aid in resolution of treatment-resistant ulcer
H. pylori eradication (treatment) - best initial
PPIs + clarythromycin + amoxicillin (or metronidazole in allergy)
H. pylori - confirmation of the eradication
1-2 months post-therapy –> retest with stool antigen or breath test
patient with epigastric pain from confirmed ulcer that is not responded to antibiotics - next step
if duodenal –> confirm the persistence of the active infection (Urea, stool or endoscopy) –> switch antibiotics
if gastric –> repeat endoscopy to exclude cancer
PUD - treatment of failure most often stems from
- nonadherence to medications
- alcohol
- tobacco
- NSAID
differences between duodenal and gastric ulcer
- Gastric is more often worsened by food
- gastric is routinely biopsed (4% cancer)
- routinely repeating the endoscopy to confirm healing is standard to gastric ulcer
non-ulcer dyspepsia - definition
epigastric pain that has no identified etiology
with a normal endoscopy
non-ulcer dyspepsia - diagnosis
only by endoscopy
non-ulcer dyspepsia - pain is identical to
gastritis, PUD, gastric cancer, reflex
non-ulcer dyspepsia - management
if under 45 –> treat empirically with PPIs and scope only if do not resolve
If over 55 –> endoscopy
45-55 –> unclear
scope dyspepsia if
- over 55 age
2. alarm symproms
alarm symptoms of dyspesia
dysphagia, weight loss, anemia
non ulcer dyspepsia - etiology / best initiatl therapy
unknown
best initial therapy: PPIs
MCC of epigastric pain
non ulcer dyspepsia
non ulcer dyspepsia - H. pylori
No association
however, if symptoms not resolve, with initial therapy and H. pylori is present, you should try to treat it
no definite benefit to treating non ulcer dyspepsia with antibiotics to eradicate H. pyori
only 10% will expericne an improvement of symptoms after this
when to suspect gastrinoma
patients with ulcers that are
1. large (more than 1-2cm), 2. recurrent after H. pylori eradication 3. distal in theduodenum 4. multiple
gastrinoma - presntation
diarrhea because acid inactivates lipase
gastrinoma - the most accurate test
once endoscopy confirms the presence of an ulcer, the most accurate test is by gastrin levels
gastrinoma - gastrin levels
- high gastrin levels off antisecretory therapy (PPIs or H2 blockers) with high gastric acidity
- high despite a high gastric acid output
- persistent high gastrin levels despite injecting secretin
any one of these 3 can be used to confirm the diagnosis –> the single most accurate test is always a functional test such as looking at the response of secretin
gastrinoma - imaging - importance
once a diagnosis of gastrinoma is confirmed, the most important issue is to exclude metastatic disease
gastrinoma - types
- CT
- MRI
- Somatostatin receptor scintigraphy (nuclear octreotide scan combined with endoscopic US
gastrinoma - CT / MRI
poor sensitivity but are done first –> (-) does not exclude metastases
gastrinoma - Somatostatin receptor scintigraphy (nuclear octreotide scan combined with endoscopic US
do these CT and MRI are normal –> to exclude metastasis
gastrinoma is associated wit ha massive increase of somatostatin receptors in the abdomen
gastrinoma is aka
Zollinger- Ellison syndrome
gastrinoma - treatment
local disease –> removed surgically
metastatic –> udresectable –> lifelong PPI to block acid production
gastrinoma - MEN
MEN 1 (menin) : - pituitary tumors (prolactin or GH)
- pancreatic endocrine tumors
- parathyroid adenoma
MEN 2A
- Parathyroid huperplasia
- medullary thyroid ca
- pheochromocytoma
MEN 2B
- medullary thyroid ca
- pheochromocytoma
- mucosal neuromas (oral/intestinal ganglioneuromatosis)
- marfanoid habitus
diabetic gastroparesis - definition
long standing iabetes leads to gastric dysmotility
the most important stimulant of GI motility
distention of the stomach and the intestines
Gastroparesis?
autonomic neuroapty leading to dysmotility
dysmotility?
from the inability to sense stretch in the GI
diabetic gastroparesis - look for patient with … (symptoms)
- diabetis with chronic abdominal discomfort, bloating, and constipation
- also anorexia, nausea, vomiting, early satiety
the most accurate test for diabetic gastroparesis
nuclear gastric emptying study (rarely needed)
diabetic gastroparesis - treatment
erythromycin and metoclopramide –> increase GI motility
diabetic gastroparesis - if it is clear diagnosis from the clinical picture
no need to do diagnostic testing, unless failure of therapy
