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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
Q

Peptic Ulcer Disease

H. pylori eradication!

A
  • Difficult!
  • Requires “triple” Rx or more!
  • 2/3 abx** + PPI +/- bismuth
    • Regimens!
  • 10-14 day course
  • **Antibiotics:
    • Resistant strains common
26
Q

Peptic Ulcer Disease

H. pylori eradication

Regimen Example

A
  • PPI BID
    • Omeprazole 40mg
  • Clarithromycin BID
    • 500mg
  • Amoxicillin BID
    • 1g

~70-75% successful eradication rate

27
Q

Peptic Ulcer Disease

H. pylori eradication

Other Regimens…

A
  • Quadruple Rx w/ Bismuth
    • 10-14 day course
  • Quadruple Rx & 3 Antibiotics
    • 10 day course

These regimens= 90% successful eradication rate

28
Q

Peptic Ulcer Disease

Post H. pylori Rx

A
  • 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
Q

Peptic Ulcer Disease

Post H. pylori Rx

Must confirm Eradication of H. pylori!!!

A
  • C-urea breath test, or
  • Fecal Antigen Test
    • >4wk post-completion of abx regimen,
    • >2wk post-discontinuation of PPI
30
Q

Peptic Ulcer Disease

NSAID Ulcers

A
  • 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
Q

Peptic Ulcer Disease

NSAID Ulcers

Complications

A
  • 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
Q

Peptic Ulcer Disease

NSAID Ulcers

  • Complications*
  • & Treatment*
A
  • PPI or H2 blocker 4wks (DU), 8wks (GU)
  • DISCONTINUE NSAID
  • Eradicate H. pylori, if present
33
Q

Peptic Ulcer Disease

Prevention & Prophylaxis

A
  • 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
Q

Peptic Ulcer Disease

Prevention & Prophylaxis

Other option

A
  • 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
Q

Peptic Ulcer Disease

Refractory Ulcers

A
  • 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
Q

Peptic Ulcer Disease

Ulcer complications

A
  • Bleeding
  • Penetration/Perforation
  • Gastric Outlet Obstruction
37
Q

Peptic Ulcer Disease

Bleeding Ulcers

A
  • Common
    • ​10-20% of pts. w/ PUD
    • 6-10% mortality
  • 50% of UGI is from ulcers
  • 80% stop spontaneously
38
Q

Peptic Ulcer Disease

Bleeding Ulcers

Presentation

A
  • Hematemesis and/or melena

​

  • Hematochezia = unusual unless massive bleeding
39
Q

Peptic Ulcer Disease

Bleeding Ulcers

Presentation & Work-up

A
  • Gastric Lavage/emesis:
    • BRB v. ‘coffee grounds’
  • PE:
    • Vitals
    • Postural changes
    • Pallor
      • Dependent on amount of blood loss

​

40
Q

Peptic Ulcer Disease

Bleeding Ulcers

Labs

A
  • 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
Q

Peptic Ulcer Disease

Bleeding Ulcers

Treatment 1

A
  • 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
Q

Peptic Ulcer Disease

Bleeding Ulcers

Treatment 2

A
  • 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
Q

Peptic Ulcer Disease

Bleeding Ulcers

Treatment 3

A
  • H. pylori eradicated (if present)
  • Surgery for re-bleeding/refractory bleeding in selected patients

​

44
Q

Peptic Ulcer Disease

Ulcer Perforation

A
  • 5% incidence in ulcer cases​
  • Location
    • Anterior wall of stomach or duodenum
45
Q

Peptic Ulcer Disease

Ulcer Perforation

A
  • Results in chemical peritonitis
    • Severe generalized abdominal pain
    • Rigid abdominal rebound
    • Increase WBC
    • Free air on KUB/upright
  • Intensive Medical Rx required

​

46
Q

Peptic Ulcer Disease

Ulcer Perforation

A
  • Results in chemical peritonitis
    • Severe generalized abdominal pain
    • Rigid abdominal rebound
    • Increase WBC
    • Free air on KUB/upright
  • Intensive Medical Rx required

​

47
Q

Gastritis

Erosive & Hemorrhagic Gastritis

Etiology/Causes

A
  • ​ETOH
  • NSAIDS
  • Stress from underlying severe med/surg dz

​

48
Q

Gastritis

Erosive & Hemorrhagic Gastritis

Symptoms

A
  • Often asymptomatic
  • Anorexia
  • N/V
  • Dyspepsia
  • May present as GI Bleeeding

​

49
Q

Gastritis

Stress Gastritis/Ulcers

A
  • 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
Q

Gastritis

Stress Gastritis/Ulcers

Risk Factors

A
  • Respiratory Failure/Mechanical Ventilation
  • Coagulation Problems
  • Trauma
  • Burns
  • Sepsis
  • Shock
  • Hypotension
  • ARF
  • CNS injury

​

51
Q

Gastritis

Stress Gastritis/Ulcers

Prophylaxis - High Risk Patient

A
  • IV H2 Blockers
    • Decrease bleeding incidence by 50%
  • PPI - Oral/NG or IV
    • Better than H2 blocker!
    • Decrease bleeding
  • Improve hemodynamics when possible

​

52
Q

Gastritis

NSAID Gastritis

A
  • 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
Q

Gastritis

Alcohol Gastritis

A
  • Excessive ETOH Intake
    • Nausea, dyspepsia, emesis, hematemesis
    • minor UGI Bleeding
  • Responds to:
    • H2 receptor blocker
    • PPI
    • sucralfate Rx

​

54
Q

Gastritis

Alcohol Gastritis

DDX

A
  • PUD
  • Esophageal varices from Portal HTN

​

55
Q

Gastritis

H. pylori Gastritis

A
  • Non-erosive, non-specific picture
  • Usually asymptomatic
    • Unlikely cause of dyspepsia/nausea
  • Co-factor for PUD

​

56
Q

Gastritis

  • H. pylori* Gastritis
  • Associations*
A
    1. Gastric Adenocarcinoma
      * Find early b/c Fatal!
    1. B-cell gastric lymphoma
      * MALToma

​

57
Q

Gastritis

Zollinger-Ellison Syndrome

A
  • Hypersecretory state from a gastrin secreting tumor
  • Tumor found in:
    • Duodenum
    • Lymph nodes
  • 2/3 Malignant
    • Metastasize to liver
    • Slow growth

​

58
Q

Gastritis

Zollinger-Ellison Syndrome

A
  • Excess acid secretion leads to Recurrent or Refractory Duodenal Ulcers
    • ​Non-healing, slow growth
    • ​Assc. symptoms: GERD, diarrhea
  • Leads to: Malabsorption, weight loss
59
Q

Gastritis

Zollinger-Ellison Syndrome

Testing

A
  • Secretes Gastrin! ​
    • Get Gastrin levels!
  • Testing: Increased Serum Gastrin levels (>500pg/mL)
    • ​+ document gastric pH <3 (low pH)
60
Q

Gastritis

Zollinger-Ellison Syndrome

Imaging

A
  • ​Special imaging required to finding tumor/metastasis:
    • ​Somatostatin receptor scintigraphy

Endoscopic ultrasonograpy

61
Q

Gastritis

Zollinger-Ellison Syndrome

Treatment

A
  • If Isolated Primary Tumor:
    • PPI + Resection
  • If metastasis:
    • PPI in high dose
      • Decrease basal acid output
  • Prognosis: Good… if isolated tumor!
62
Q

Review

Duodenal v. Gastric Ulcer

A
  • Duodenal Ulcer
    • Better with food
  • Gastric Ulcer
    • Worse with food

Julie W: Module 9 - GI (8 decks)

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