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Julie W: Module 9 - GI > GI Conditions - D/O of Stomach & Duodenum - Dr. Handler > Flashcards

GI Conditions - D/O of Stomach & Duodenum - Dr. Handler Flashcards

1
Q

Dyspepsia

Common GI Symptom

A
  • Acute, chronic, or recurrent pain/discomfort
  • Centered in upper abdomen
  • Characterized by:
    • Fullness
    • Bloating
    • Burning
    • Nausea
    • Anorexia
  • “Indigestion”
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2
Q

Peptic Ulcer Disease

A

A Break in the Gastric or Duodenal Mucosa

Result of:

  • Impaired normal mucosal defense factors
  • Defensive factors overwhelmed by agressive luminal facors
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3
Q

Peptic Ulcer Disease

Location

A
  • Duodenal bulb
  • Pyloris
  • Stomach
  • Duodenal ulcers 5x more common than gastric
    • Gastric antrum (60%)
    • Lesser curvature (25%)
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4
Q

Peptic Ulcer Disease

Epidemiology

A
  • 500,000 new cases/year in US
  • 10-20% lifetime occurance (adults)
    • Decreasing incidence since 1970s:
      • Correlates with decrease H. pylori infection/successful treatment &
      • Development of anti-secretory drugs
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5
Q

Peptic Ulcer Disease

Epidemiology

A
  • 500,000 new cases/year in US
  • 10-20% lifetime occurance (adults)
    • Decreasing incidence since 1970s:
      • Correlates with decrease H. pylori infection/successful treatment &
      • Development of anti-secretory drugs
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6
Q

Peptic Ulcer Disease

Pathology

A
  • NSAIDS:
    • Ulcers/gastritis assc. w/ long-term use
  • Helicobacter pylori infection:
    • Duodenal & Gastric ulcers
  • Idiopathic:
    • H. pylori negative & no NSAID use
    • 5-10% of all ulcers
  • Hypersecretory State
  • Smoking
    • ​Big risk in all ulcer formation
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7
Q

Peptic Ulcer Disease

Pathology

Duodenal Ulcer (DU)

A
  • H. pylori infection
    • Increases Acid
      • Gastric Metaplasia in duodenal bulb
        • More H. pylori infxn
          • Duodenitis
            • Mucosal breakdown
              • DU
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8
Q

Peptic Ulcer Disease

Pathology

Gastric Ulcer (GU) & H. pylori

A
  • H. pylori infection of stomach
    • Gastritis w/ chronic inflammation =
    • defenses overwhelmed
      • Mucosal breakdown
        • GU
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9
Q

Peptic Ulcer Disease

What is a necessary Co-Factor of Duodenal Ulcers & Gastric Ulcers?

A
  • Helicobacter pylori
    • (Not associated w/ NSAID ulcers)
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10
Q

Peptic Ulcer Disease

Helicobacter pylori

A
  • “Hearty” bacteria
    • Sprial, gram - rod
  • Urease production
  • Person-to-Person Spread
    • Transmission…. unknown
  • Incidence:
    • Correlates w/ socioeconomic status
      • ~25-30% US adults
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11
Q

Peptic Ulcer Disease

Helicobacter pylori

Associated with….

A
  • Assc. w/ acute infectious syndrome
    • Gastroenteritis
    • Nausea, abd pain
  • Chronic Local Infection:
    • Diffuse superficial mucosal infxn
      • w/ polyps & lymphocytes
    • Majority of patients asymptomatic
      • 15% develop PUD
  • Eradication = CRUCIAL
    • Prevent Ulcer recurrance
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12
Q

Peptic Ulcer Disease

Pelvic Ulcer Disease (PUD)

Signs & Symptoms, 1

A
  • Epigastric pain common (80-90%)
  • Burning, gnawing, aching
  • “hunger-like”
    • NOT DIAGNOSTIC
  • 50% pain relief when eating +/- antacids
    • Pain returns in ~2-4 hours
  • Nocturnal awakening w/pain
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13
Q

Peptic Ulcer Disease

Pelvic Ulcer Disease (PUD)

Signs & Symptoms, 2

A
  • Change in pain pattern
    • Penetration or Perforation
      • CAUTION!
  • Gastric Ulcers:
    • Nausea/Anorexia
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14
Q

Peptic Ulcer Disease

Pelvic Ulcer Disease (PUD)

Physical Exam

A
  • PE
    • Often Unremarkable
  • Rectal for Occult Blood
    • Usually negative
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15
Q

Peptic Ulcer Disease

Pelvic Ulcer Disease (PUD)

Investigate/Diagnostics

A
  • Hgb/Hct for anemia
    • +/- Amylase
  • Best Diagnostic Tool:
    • ​Endoscopy! (EGD)
      • ​visualize ulcer, biopsy, can test for H. pylori via histology
  • Imaging:
    • Barium UGI
      • Screening tool for dyspepsia
      • Helpful, limited!
      • Cannot determine benign v. malignant
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16
Q

Peptic Ulcer Disease

Non-Invasive H. pylori testing

A
  • Fecal antigen test (95% s/s):
    • ​Indicates active infxn
  • <strong>13</strong>C-urea breath test (95% s/s):
    • ​Indicates active infxn
  • Serologic blood tests
    • NO LONGER RECOMMENDED
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17
Q

Peptic Ulcer Disease

Gastric v. Duodenal Ulcer

A
  • Major Difference:
    • ​Gastric ulcers may be malignant (3-5%)
      • Biopsy! is essential
  • Gastric ulcers often take longer to heal than duodenal
    • Require longer treatment
    • Not healing GU =
      • Repeat endoscopy & biopsy (malignant?)
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18
Q

Peptic Ulcer Disease

Treatment

A
  • Acid-antisecretory agents
  • H. pylori eradication
  • Enhanced mucosal defense agents
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19
Q

Peptic Ulcer Disease

Treatment

  • Acid-Antisecretory Agents*
  • *Healing Time**
A
  • >90% of DU heal in 4wks
  • >90% GU heal in 8 weeks
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20
Q

Peptic Ulcer Disease

Treatment

Acid-Antisecretory Agents

A
  • Proton Pump Inhibitors (PPI):
    • ​Inactive the H+-K+ ATPase (proton) pump in the stomach
    • Short 1/2 life
      • 24hr pump inactivation allows 1-2x daily Rx
    • oral agents
    • Inhibit>90% acid secretion

PPIs are preferred Rx for PUD

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21
Q

Peptic Ulcer Disease

Treatment

  • Acid-Antisecretory Agents*
  • Characteristics*
A
  • Safe, low side effect profile
    • Minor GI/CNS SEs
  • Ex:
    • Omeprazole, Lansoprazole
  • 2x BID while eradicating H. pylori, then QID

Ulcers likely to recur unless ERADICATE H. pylori

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22
Q

Peptic Ulcer Disease

Treatment

  • Other Acid-Antisecretory Agents:*
  • H2 receptor antagonists*
A
  • H2 receptor antagonists
    • Inhibit histamine mediated gastric acid secretion
    • Suppress nocturnal >waking/post-meal acid secretion
    • Less effective than PPI, but most ulcers heal (85-90% efficacy) over 6-8 weeks
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23
Q

Peptic Ulcer Disease

Treatment

  • Other Acid-Antisecretory Agents:*
  • H2 receptor antagonists*
A
  • Ranitidine, Famotidine
    • ​& others (all OTC)
  • Safe
  • Taken as single, large PO dose at night
  • Available in IV form for gastritis prophylaxis
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24
Q

Peptic Ulcer Disease

Treatment

Mucosal Defense Agents

A
  • 2nd line or adjunct Rx of PUD
    • 1st line: Antisecretory Agents
  • Antacids
    • buffer acid
    • rapid
    • symptom relief
    • supplemental Rx
  • Sucralfate
    • ​Adheres to ulcer craters & protects cells
    • Allows healing
  • Bismuth ​
    • ​Anti-bacterial v. H. pylori
    • Enhances mucosal defenses
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25
**Peptic Ulcer Disease** *H. pylori eradication!*
* Difficult! * Requires "triple" Rx or more! * 2/3 abx\*\* + PPI +/- bismuth * Regimens! * 10-14 day course * \*\*Antibiotics: * Resistant strains common
26
**Peptic Ulcer Disease** *H. pylori eradication* Regimen Example
* PPI BID * Omeprazole 40mg * Clarithromycin BID * 500mg * Amoxicillin BID * 1g *~70-75% successful eradication rate*
27
**Peptic Ulcer Disease** *H. pylori eradication* Other Regimens...
* Quadruple Rx w/ Bismuth * 10-14 day course * Quadruple Rx & 3 Antibiotics * 10 day course *These regimens= 90% successful eradication rate*
28
**Peptic Ulcer Disease** Post *H. pylori* Rx
* If ulcer \>1cm * No further Rx * If ulcer large or complication (bleeding, etc...) * Duodenal Ulcer * PPI QID for 2-4wks * Gastric Ulcer * PPI QID for 4-6wks
29
**Peptic Ulcer Disease** Post *H. pylori* Rx **Must confirm Eradication of *H. pylori!!!***
* C-urea breath test, or * Fecal Antigen Test * \>4wk post-completion of abx regimen, * \>2wk post-discontinuation of PPI
30
**Peptic Ulcer Disease** NSAID Ulcers
* **Long term use of NSAIDS increases risk of ulcers, gastritis & complications** * Inhibit COX 1 & 2 * Inhibition of gastric COX-1: * Decrease PG synthesis * Impairs gastric mucus/HCO3 secretion (+ other protective mechanisms) * Selective COX-2 agents * Decrease risk of ulcers/gastritis * *assc. w/ CV complications (stoke, MI, death)*
31
**Peptic Ulcer Disease** NSAID Ulcers *Complications*
* **Bleeding** & Perforation occur in 1-2% patients w/ NSAID ulcers * Risk factors: * hx PUD or complications * corticosteroids * anticoagulants or ASA * age \>60 * underlying medical illness
32
**Peptic Ulcer Disease** NSAID Ulcers * Complications* * & Treatment*
* **PPI** or H2 blocker 4wks (DU), 8wks (GU) * DISCONTINUE NSAID * Eradicate *H. pylori,* if present
33
**Peptic Ulcer Disease** Prevention & Prophylaxis
* **Reserve for high-risk patients** * Prevent ulcer complications * **PPI Prophylaxis!!!!** * **​**Omprezole 20mg daily (while on NSAID) * Misoprostol for prophylaxis vs. NSAID induced ulcer or gastritis * PG analog - stimulates gastric mucus + HCO3 secretion. SE: Diarrhea. $$$ * *Infrequently used*
34
**Peptic Ulcer Disease** Prevention & Prophylaxis *Other option*
* **Cox-2 NSAID as alternative to non-selective NSAID** * **​**Decrease ulcer complications, but increases MI events * Low dose Celecoxib & Short duration of use = low risk of Med SEs
35
**Peptic Ulcer Disease** Refractory Ulcers
* **Non-healing** * **​**uncommon * Lack of compliance with Meds = _major cause_ * Other factors: * Smoking cigs * NSAIDS (low dose ASA, too) * _Failure to eradicate *H. pylori*_ * Malignancy may be present, too!
36
**Peptic Ulcer Disease** Ulcer complications
* **Bleeding** * **Penetration/Perforation** * **Gastric Outlet Obstruction**
37
**Peptic Ulcer Disease** Bleeding Ulcers
* **Common** * **​**10-20% of pts. w/ PUD * 6-10% mortality * **50% of UGI is from ulcers** * **80% stop spontaneously**
38
**Peptic Ulcer Disease** Bleeding Ulcers *Presentation*
* **Hematemesis and/or melena** **​** * Hematochezia = unusual unless massive bleeding
39
**Peptic Ulcer Disease** Bleeding Ulcers *Presentation & Work-up*
* Gastric Lavage/emesis: * BRB v. 'coffee grounds' * PE: * Vitals * Postural changes * Pallor * *Dependent on amount of blood loss* **​**
40
**Peptic Ulcer Disease** Bleeding Ulcers *Labs*
* Decrease **Hgb, Hct** * **​**will drop further w/ volume expansion * initally H+H may not be too low, but be aware it may drop more!! * Check PTT, INR & platelets * BUN may be increased * due to blood digested in intestine **​**
41
**Peptic Ulcer Disease** Bleeding Ulcers *Treatment 1*
* Decrease **Hgb, Hct** * **​**will drop further w/ volume expansion * initally H+H may not be too low, but be aware it may drop more!! * Check PTT, INR & platelets * BUN may be increased * due to blood digested in intestine **​**
42
**Peptic Ulcer Disease** Bleeding Ulcers *Treatment 2*
* Volume expansion (isotonic fluids) * Transfuse when needed * _Endoscopy_ * _​_IDs site, stability of bleeding site * & Stops bleeding, when necessary * IV PPI or high dose oral PPI * Decrease re-bledding, Need for transfusion, Re-interventions, including surgery * *80% of the time...bleeding stops spontaneously* **​**
43
**Peptic Ulcer Disease** Bleeding Ulcers *Treatment 3*
* *H. pylori* eradicated (if present) * Surgery for re-bleeding/refractory bleeding in selected patients **​**
44
**Peptic Ulcer Disease** Ulcer Perforation
* 5% incidence in ulcer cases**​** * Location * Anterior wall of stomach or duodenum
45
**Peptic Ulcer Disease** Ulcer Perforation
* Results in chemical peritonitis * Severe generalized abdominal pain * Rigid abdominal rebound * Increase WBC * Free air on KUB/upright * Intensive Medical Rx required **​**
46
**Peptic Ulcer Disease** Ulcer Perforation
* Results in chemical peritonitis * Severe generalized abdominal pain * Rigid abdominal rebound * Increase WBC * Free air on KUB/upright * Intensive Medical Rx required **​**
47
**Gastritis** Erosive & Hemorrhagic Gastritis *Etiology/Causes*
* **​**ETOH * NSAIDS * Stress from underlying severe med/surg dz **​**
48
**Gastritis** Erosive & Hemorrhagic Gastritis *Symptoms*
* *Often asymptomatic* * Anorexia * N/V * Dyspepsia * May present as GI Bleeeding **​**
49
**Gastritis** Stress Gastritis/Ulcers
* Superficial erosions common & develop quickly in **Critically Ill/ICU Patients** * Bleeding in up to 6%w/ increased mortality * Pathophys: Decrease in gastric mucosal blood flow **​**
50
**Gastritis** Stress Gastritis/Ulcers *Risk Factors*
* **Respiratory Failure/Mechanical Ventilation** * **Coagulation Problems** * Trauma * Burns * Sepsis * Shock * Hypotension * ARF * CNS injury **​**
51
**Gastritis** Stress Gastritis/Ulcers *Prophylaxis - High Risk Patient*
* IV H2 Blockers * Decrease bleeding incidence by 50% * **PPI -** Oral/NG or IV * Better than H2 blocker! * Decrease bleeding * Improve hemodynamics when possible **​**
52
**Gastritis** NSAID Gastritis
* Very common in patients on chronic NSAIDs * **Most _Unrecognized_ b/c NO Symptoms!** * Dyspepsia in 5-10% of patients * **Empiric Rx is reasonable:** * D/C NSAID * PPI for 2-4 weeks (high dose not needed) * Symptoms persistent/worsening? * Endoscopy (EGD) * PPI 2-4 weeks **​**
53
**Gastritis** Alcohol Gastritis
* Excessive ETOH Intake * Nausea, dyspepsia, emesis, hematemesis * *minor UGI Bleeding* * Responds to: * H2 receptor blocker * PPI * sucralfate Rx **​**
54
**Gastritis** Alcohol Gastritis *DDX*
* PUD * Esophageal varices from Portal HTN **​**
55
**Gastritis** *H. pylori* Gastritis
* Non-erosive, non-specific picture * _Usually asymptomatic_ * Unlikely cause of dyspepsia/nausea * Co-factor for PUD **​**
56
**Gastritis** * H. pylori* Gastritis * Associations*
* 1. Gastric Adenocarcinoma * Find early b/c Fatal! * 2. B-cell gastric lymphoma * MALToma **​**
57
**Gastritis** Zollinger-Ellison Syndrome
* Hypersecretory state from a gastrin secreting tumor * Tumor found in: * Duodenum * Lymph nodes * 2/3 Malignant * Metastasize to liver * Slow growth **​**
58
**Gastritis** Zollinger-Ellison Syndrome
* Excess acid secretion leads to **Recurrent or Refractory Duodenal Ulcers** * **​**Non-healing, slow growth * **​**Assc. symptoms: GERD, diarrhea * Leads to: Malabsorption, weight loss
59
**Gastritis** Zollinger-Ellison Syndrome *Testing*
* Secretes Gastrin! ​ * Get Gastrin levels! * Testing: Increased Serum Gastrin levels (\>500pg/mL) * ​+ document gastric pH \<3 (low pH)
60
**Gastritis** Zollinger-Ellison Syndrome *Imaging*
* ​Special imaging required to finding tumor/metastasis: * ​Somatostatin receptor scintigraphy Endoscopic ultrasonograpy
61
**Gastritis** Zollinger-Ellison Syndrome *Treatment*
* If Isolated Primary Tumor: * PPI + Resection * If metastasis: * PPI in high dose * Decrease basal acid output * Prognosis: Good... if isolated tumor!
62
**Review** Duodenal v. Gastric Ulcer
* _Duodenal Ulcer_ * Better with food * _Gastric Ulcer_ * Worse with food

Julie W: Module 9 - GI (8 decks)

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