GI Conditions - D/O of Stomach & Duodenum - Dr. Handler Flashcards
Dyspepsia
Common GI Symptom
- Acute, chronic, or recurrent pain/discomfort
- Centered in upper abdomen
- Characterized by:
- Fullness
- Bloating
- Burning
- Nausea
- Anorexia
- “Indigestion”
Peptic Ulcer Disease
A Break in the Gastric or Duodenal Mucosa
Result of:
- Impaired normal mucosal defense factors
- Defensive factors overwhelmed by agressive luminal facors

Peptic Ulcer Disease
Location
- Duodenal bulb
- Pyloris
- Stomach
- Duodenal ulcers 5x more common than gastric
- Gastric antrum (60%)
- Lesser curvature (25%)

Peptic Ulcer Disease
Epidemiology
- 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
- Decreasing incidence since 1970s:
Peptic Ulcer Disease
Epidemiology
- 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
- Decreasing incidence since 1970s:
Peptic Ulcer Disease
Pathology
-
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
Peptic Ulcer Disease
Pathology
Duodenal Ulcer (DU)
-
H. pylori infection
- Increases Acid
- Gastric Metaplasia in duodenal bulb
- More H. pylori infxn
- Duodenitis
- Mucosal breakdown
- DU
- Mucosal breakdown
- Duodenitis
- More H. pylori infxn
- Gastric Metaplasia in duodenal bulb
- Increases Acid
Peptic Ulcer Disease
Pathology
Gastric Ulcer (GU) & H. pylori
-
H. pylori infection of stomach
- Gastritis w/ chronic inflammation =
- defenses overwhelmed
- Mucosal breakdown
- GU
- Mucosal breakdown
Peptic Ulcer Disease
What is a necessary Co-Factor of Duodenal Ulcers & Gastric Ulcers?
- Helicobacter pylori
- (Not associated w/ NSAID ulcers)
Peptic Ulcer Disease
Helicobacter pylori
- “Hearty” bacteria
- Sprial, gram - rod
- Urease production
- Person-to-Person Spread
- Transmission…. unknown
- Incidence:
- Correlates w/ socioeconomic status
- ~25-30% US adults
- Correlates w/ socioeconomic status
Peptic Ulcer Disease
Helicobacter pylori
Associated with….
- 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
- Diffuse superficial mucosal infxn
-
Eradication = CRUCIAL
- Prevent Ulcer recurrance
Peptic Ulcer Disease
Pelvic Ulcer Disease (PUD)
Signs & Symptoms, 1
- 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

Peptic Ulcer Disease
Pelvic Ulcer Disease (PUD)
Signs & Symptoms, 2
- Change in pain pattern
- Penetration or Perforation
- CAUTION!
- Penetration or Perforation
- Gastric Ulcers:
- Nausea/Anorexia

Peptic Ulcer Disease
Pelvic Ulcer Disease (PUD)
Physical Exam
- PE
- Often Unremarkable
- Rectal for Occult Blood
- Usually negative
Peptic Ulcer Disease
Pelvic Ulcer Disease (PUD)
Investigate/Diagnostics
- Hgb/Hct for anemia
- +/- Amylase
-
Best Diagnostic Tool:
-
Endoscopy! (EGD)
- visualize ulcer, biopsy, can test for H. pylori via histology
-
Endoscopy! (EGD)
- Imaging:
- Barium UGI
- Screening tool for dyspepsia
- Helpful, limited!
- Cannot determine benign v. malignant
- Barium UGI

Peptic Ulcer Disease
Non-Invasive H. pylori testing
-
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
Peptic Ulcer Disease
Gastric v. Duodenal Ulcer
-
Major Difference:
-
Gastric ulcers may be malignant (3-5%)
- Biopsy! is essential
-
Gastric ulcers may be malignant (3-5%)
- Gastric ulcers often take longer to heal than duodenal
- Require longer treatment
- Not healing GU =
- Repeat endoscopy & biopsy (malignant?)

Peptic Ulcer Disease
Treatment
- Acid-antisecretory agents
- H. pylori eradication
- Enhanced mucosal defense agents
Peptic Ulcer Disease
Treatment
- Acid-Antisecretory Agents*
- *Healing Time**
- >90% of DU heal in 4wks
- >90% GU heal in 8 weeks
Peptic Ulcer Disease
Treatment
Acid-Antisecretory Agents
-
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
Peptic Ulcer Disease
Treatment
- Acid-Antisecretory Agents*
- Characteristics*
- 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
Peptic Ulcer Disease
Treatment
- Other Acid-Antisecretory Agents:*
- H2 receptor antagonists*
- 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
Peptic Ulcer Disease
Treatment
- Other Acid-Antisecretory Agents:*
- H2 receptor antagonists*
-
Ranitidine, Famotidine
- & others (all OTC)
- Safe
- Taken as single, large PO dose at night
- Available in IV form for gastritis prophylaxis
Peptic Ulcer Disease
Treatment
Mucosal Defense Agents
-
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
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
Peptic Ulcer Disease
H. pylori eradication
Regimen Example
- PPI BID
- Omeprazole 40mg
- Clarithromycin BID
- 500mg
- Amoxicillin BID
- 1g
~70-75% successful eradication rate
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
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
- Duodenal Ulcer
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
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)
- Inhibition of gastric COX-1:
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
- Risk factors:
Peptic Ulcer Disease
NSAID Ulcers
- Complications*
- & Treatment*
- PPI or H2 blocker 4wks (DU), 8wks (GU)
- DISCONTINUE NSAID
- Eradicate H. pylori, if present
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
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
-
Decrease ulcer complications, but increases MI events
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!
Peptic Ulcer Disease
Ulcer complications
- Bleeding
- Penetration/Perforation
- Gastric Outlet Obstruction
Peptic Ulcer Disease
Bleeding Ulcers
-
Common
- 10-20% of pts. w/ PUD
- 6-10% mortality
- 50% of UGI is from ulcers
- 80% stop spontaneously
Peptic Ulcer Disease
Bleeding Ulcers
Presentation
- Hematemesis and/or melena
- Hematochezia = unusual unless massive bleeding

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
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
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
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
Peptic Ulcer Disease
Bleeding Ulcers
Treatment 3
- H. pylori eradicated (if present)
- Surgery for re-bleeding/refractory bleeding in selected patients
Peptic Ulcer Disease
Ulcer Perforation

- 5% incidence in ulcer cases
- Location
- Anterior wall of stomach or duodenum
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
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
Gastritis
Erosive & Hemorrhagic Gastritis
Etiology/Causes
- ETOH
- NSAIDS
- Stress from underlying severe med/surg dz
Gastritis
Erosive & Hemorrhagic Gastritis
Symptoms
- Often asymptomatic
- Anorexia
- N/V
- Dyspepsia
- May present as GI Bleeeding

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
Gastritis
Stress Gastritis/Ulcers
Risk Factors
- Respiratory Failure/Mechanical Ventilation
- Coagulation Problems
- Trauma
- Burns
- Sepsis
- Shock
- Hypotension
- ARF
- CNS injury
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
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
Gastritis
Alcohol Gastritis
- Excessive ETOH Intake
- Nausea, dyspepsia, emesis, hematemesis
- minor UGI Bleeding
- Responds to:
- H2 receptor blocker
- PPI
- sucralfate Rx
Gastritis
Alcohol Gastritis
DDX
- PUD
- Esophageal varices from Portal HTN
Gastritis
H. pylori Gastritis
- Non-erosive, non-specific picture
-
Usually asymptomatic
- Unlikely cause of dyspepsia/nausea
- Co-factor for PUD
Gastritis
- H. pylori* Gastritis
- Associations*
- Gastric Adenocarcinoma
* Find early b/c Fatal!
- Gastric Adenocarcinoma
- B-cell gastric lymphoma
* MALToma
- B-cell gastric lymphoma
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
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
Gastritis
Zollinger-Ellison Syndrome
Testing
- Secretes Gastrin!
- Get Gastrin levels!
- Testing: Increased Serum Gastrin levels (>500pg/mL)
- + document gastric pH <3 (low pH)
Gastritis
Zollinger-Ellison Syndrome
Imaging
- Special imaging required to finding tumor/metastasis:
- Somatostatin receptor scintigraphy
Endoscopic ultrasonograpy
Gastritis
Zollinger-Ellison Syndrome
Treatment
- If Isolated Primary Tumor:
- PPI + Resection
- If metastasis:
- PPI in high dose
- Decrease basal acid output
- PPI in high dose
- Prognosis: Good… if isolated tumor!
Review
Duodenal v. Gastric Ulcer
-
Duodenal Ulcer
- Better with food
-
Gastric Ulcer
- Worse with food