GI Conditions: D/O of Stomach - Porth, Chpt. 29 Flashcards
Disorders of the Stomach
Include
- Gastritis
- Peptic Ulcer
- Gastric Carcinoma
Gastric Mucosal Barrier
- Stomach lining, usually impermeable to its acid
What protects it?
- Impermeable epithelial cell surface
- coupled secretion of H+ and HCO3-
- Gastric Mucus
Gastric Mucosal Barrier
How Aspirin jeporadizes this barrier
- Rapid diffusion across lipid layer of barrier
- Increases Mucosal Permability
- Damages Epithelial Cells
Gastric Irritation & Occult Bleeding results.
Gastric Mucosal Barrier
When Aspirin & _______ are taken together, there is increased risk of gastric irritation.
Alcohol
Gastric Mucosal Barrier
Whenfrom the Duodenum are Refluxed into the stomach, gastric irritation can also occur.
Bile Acids
Gastric Mucosal Barrier
For every H+ secreted by the stomach, a _________ should also be secreted…. Otherwise, mucosal injury can occur.
HCO3-
Hydrogen & Bicarbonate secretion should be “in sync”
Gastric Mucosal Barrier
How do Prostaglandins protect the gastric mucosa?
- Improve mucosal blood flow
- Decrease acid secretion
- Increase bicarb secretion
- Enhance mucus production
NSAIDs inhibit PG synthesis =’s may contribute to gastric irritation
Gastritis
- Inflammation of the Gastric Mucosa
- Acute
- Chronic
Gastritis
Acute Gastritis
- Acute mucosal inflammatory process
- may include some hemorrhaging
- Assc. w/:
- NSAIDs
- ETOH
- Bacterial Toxins
-
Self-limiting!
- Regeneration & Healing w/in days
Gastritis
Acute Gastritis
& Stress
“Stress Ulcers”
- Due to Serious illness or Trauma accompanied by profound physiologic stress
- Vulnerable gastric mucosa
Gastritis
Acute Gastritis
Presentation/Complaints
- Vary
- Asymptomatch
- Heartburn/Sour Stomach
Gastritis
Acute Gastritis
W/ Excessive Alcohol Consumption
- W/ Excessive Alcohol:
- Gastric Distress
- Vomiting
- possibly Bleeding & Hematemesis
- Gastric Distress
Gastritis
Acute Gastritis
Infectious Organism Toxins
- Abrupt & Violent onset
- Gastric Distress
- Vomiting
- ~5 hours post-eating bad food!
Gastritis
Chronic Gastritis
A Separate Entity
- Absence of grossly visible erosions
- Presence of Chronic Inflammatory Changes
- Leads to: Atrophy of Glandular Epithelium of Stomach
Gastritis
Chronic Gastritis
3 MAJOR Types
- H. pylori
- Autoimmune
- Chemical gastropathy
Gastritis
Chronic Gastritis
H. pylori Gastritis
- Antrum & Body of stomach
- MCC of Chronic Gastritis in US & infects >1/2 world’s population!
Gram Negative buggers that colonize mucus-secreting cells of stomach
Gastritis
Chronic Gastritis
H. pylori Gastritis
Characteristics
- Transmission: Unsure
- Oral-Oral? Fecal-Oral?
- Secrete Urease
- =’s produces ammonia to buffer acidity of immediate environment
- Has enzymes & toxins that interfere w/ mucosa protection & constant inflammatory response!
Gastritis
Chronic Gastritis
H. pylori Gastritis
Inflammatory Response
- Results in varying degrees of Atrophy & Metaplasia
- Gastric Epithelium turns into Intestinal-type Epithelium
Gastritis
Chronic Gastritis
H. pylori Gastritis
Cinical Course
- Can be Acute
- Couple days of discomfort + then, Asymptomatic Infxn
- Can be Chronic
- Gastric Atrophy
- Peptic Ulcer
- Accs. w/ Gastric Adenocarcinoma
Gastritis
Chronic Gastritis
H. pylori Gastritis
Detection!
- Carbon (C) urea breath test
- Stool Antigen Test
- Endoscopic Biopsy
- all detect Urease
- Serology for antibodies
Gastritis
Chronic Gastritis
H. pylori Gastritis
Treatment
- Goal: ELIMINATE ORGANISM!!!
- Combo therapy:
- 3 to 4-drug regimens
- 10-14 days
Abx: Clarithromycin, Metronidazole, Amoxicillin, Tetracycline
Gastritis
Chronic Gastritis
Chronic Autoimmune Gastritis
- <10% of cases
- Assc. w/ other D/Os: DM, Addison’s…
Characterized by:
- Autoantibodies to gastric parietal cells & intrinsic factor
- Defective gastric acid secretion
- & B12 deficiency
Spares the antrum (vs. H. pylori)
Gastritis
Chronic Gastritis
Chronic Autoimmune Gastritis
Complications
- Atrophy of fundic pyloric & chief cells
- Development of gastric adenocarcinoma
- Absence of acid production =’s gastrin release
- Hyperplasia of cells & hypergastrinemia
- May lead to tumor formation
- Hyperplasia of cells & hypergastrinemia
- Lack of intrinsic factor
- B12 deficiency –> Megoblastic anemia
Gastritis
Chronic Gastritis
Chronic Autoimmune Gastritis
Note-worthy for:
- Slow onset & variable progression
- Several decades to atrophy
- May have for several years before even being diagnosed
Gastritis
Chronic Gastritis
Chronic Autoimmune Gastritis
Clinical Presentation
- Related to Anemia
- <vit.>
<li>Malabsorptive Diarrhea</li>
<li>Neuropathies
<ul>
<li>Parasthesias & Numbness</li>
</ul>
</li>
<li>Cerebral Manifestations
<ul>
<li>Personality change, memory loss</li>
</ul>
</li>
</vit.>
- <vit.>
Gastritis
Chronic Gastritis
Chemical Gastropathy
- Effects of chronic gastric injury
- Result of reflux of
- alkaline duodenal contents
- pancreatic secretions
- bile
- Result of reflux of
- Cause - Surgeries
- Gastroduodenostomy
- Gastrojejunostomy
Peptic Ulcer Disease
Ulcerative D/Os in upper GI tract that are exposed to acid-pepsin secretions
Most common forms: Gastric & Duodenal
Peptic Ulcer Disease
A Chronic Health Problem!
- ~10% of population Have or Will Have one!
Peptic Ulcer Disease
Quick Details
- Can affect all or 1 layer of stomach
- May extend into smooth muscle layers
- May penetrate outer wall
- Damaged muscle layers are replaced by scar tissue
Peptic Ulcer Disease
2 Most Important Risk Factors
- H. pylori
- Aspirin & other NSAIDs
- Aspirin = most ulcerogenic
Peptic Ulcer Disease
NSAID-Induced Gastric Injury
- Often asymptomatic!
- can lead to life-threatening conditions
Peptic Ulcer Disease
COX-2-selective NSAIDs
- Less gastric irritation assc. w/ these
Peptic Ulcer Disease
Independent Factors that augment effects
- Advancing age
- Prior peptic ulcer
- multiple NSAID use
- concurrent use of
- Warfarin
- Corticosteroids
- Smoking - Impairs healing
Peptic Ulcer Disease
Clinical Manifestations
- Discomfort
-
Pain
- Burning
- Gnawing
- Cramp-like
- Most often when Stomach is EMPTY!
Pain is relieved by food or antacids.
Peptic Ulcer Disease
Clinical Manifestations
Additional Characteristic of Ulcer Pain
-
Periodicity
- Recurs @ intervals of weeks to months
Peptic Ulcer Disease
Complications
- Hemorrhage
- Perforation
- Penetration
- Gastric Outlet Obstruction
Peptic Ulcer Disease
Complications
Hemorrhage, pt. 1
- ~20% of persons w/ peptic ulcer
- Hematemesis or Melena
- May be sudden or insidious
- Same may have no symptoms of Pain assc.
- esp if NSAID-induced
Peptic Ulcer Disease
Complications
Hemorrhage, pt. 2
Acute:
- Weakness
- Dizziness
- Thirst
- Cold
- Passage of Loose, Tarry or even red stool
- Coffee-ground emesis
Look out for signs of shock!
Peptic Ulcer Disease
Complications
Perforation
- Ulcer erodes all the way through the wall
- 5% of persons
- Usually Anterior Wall…
- GI Contents enter peritoneum & cause
- Peritonitis!
Peptic Ulcer Disease
Complications
Perforation
Signs & Symptoms
- Radiation of pain to Back
- Night distress
- Inadequate pain relief from eating/antacids
Peptic Ulcer Disease
Complications
Penetration
- Similar to Perforation
- But
- Ulcer crater erodes into Adjacent Organs!
- But
- Subtle presentation:
- Gradual increase in severity & frequency of pain
Peptic Ulcer Disease
Complications
Penetration
- Similar to Perforation
- But
- Ulcer crater erodes into Adjacent Organs!
- But
- Subtle presentation:
- Gradual increase in severity & frequency of pain
Peptic Ulcer Disease
Complications
Outlet Obstruction
- Caused by:
- Edema
- Spasm
- Contraction of Scar Tissue
- & Interference w/ free passage of gastric contents through pylorus/adjacent areas
- Insidious presentation
- Early satiety
- Feeling of fullness/heaviness post-meals
- GERD
- Weight loss, pain
- Severe = vomiting of undigested food
Peptic Ulcer Disease
Diagnosis
- Hx taking
- Aspirin? NSAIDs?
- Labs
- Anemia?
- Radiology
- XR w/ Barium - detects ulcer crater
- Endoscopy
- Visualize area & Biopsy!
- Is H. pylori present?
Peptic Ulcer Disease
Treatment
- Goal: ERADICATE THE CAUSE & permanent cure
- Avoid triggers/irritants
- Neutralize & Inhibit Gastric Acid
- Promote Mucosal Protection
- Surgery when needed
Peptic Ulcer Disease
Treatment
- Goal: ERADICATE THE CAUSE & permanent cure
- Avoid triggers/irritants
- Neutralize & Inhibit Gastric Acid
- Promote Mucosal Protection
- Surgery when needed
Peptic Ulcer Disease
Zollinger-Ellison Syndrome
- Rare condition
- Caused by: Gastrinomas
- found in small intestine & pancreas
- SO MUCH Gastrin Secretion due to these tumors that Ulcers form
- Caused by: Gastrinomas
- >2/3 are malignant!
- Symptoms = like peptic ulcer
- 25% are due to Multiple Endocrine Neoplasia Type 1
Peptic Ulcer Disease
Zollinger-Ellison Syndrome
Diagnosis
- Elevated Serum Gastrin & Basal Gastric Acid Levels
- CT
- Abd US
- Selective angiography
- Localize & stage
Peptic Ulcer Disease
Zollinger-Ellison Syndrome
Treatment
- Control Gastric Acid secretion by PPIs
- Malignant + Not Metastasized? Surgery!
Peptic Ulcer Disease
Stress Ulcers
aka “Curling ulcers”
- Develop due to Physiologic Stress
- Large burns, trauma, sepsis, ARDS, Liver failure…
- Result from:
- Ischemia
- Tissue Acidosis
- Bile Salts
- esp if decreased GI tract motility
- High risk in ICUs!
Peptic Ulcer Disease
Stress Ulcers
Prevention & Treatment
- H2 Receptor Antagonists
- PPIs
Cancer
of the
Stomach
- Decreasing in Incidence in US
- But huge cause of deaths
- More common in :
- Lower socioeconomic groups
- Male-to-Female 2:1
Cancer of the Stomach
Risk Factors
- Genetics
- Carcinogenic (in the diet)
- Smoked/Preserved foods
- Autoimmune Gastritis
- Gastric Adenomas or Polyps
- Chronic H. pylori = co-factor (not commonly)
Cancer of the Stomach
Appearance
- Bulky
- Irregular shape
- Firm, jagged edges
(versus smooth margins of gastric ulcers)
Cancer of the Stomach
Symptoms
- Bad: Asymptomatic until late in course
- Vague sxs
- Indigestion
- Anorexia
- Weight Loss
- Vague epigastric pain
- Vomiting
- Abdominal Mass
- Vague sxs
Cancer of the Stomach
Diagnosis
- Barium XR Studies
- Endoscopic Studies w/ Bx
- Cytologic Studies (pap smear) of gastric secretions
- Cytologic tests = useful for routine screening
- Endoscopic US + CT = staging/spread
Cancer of the Stomach
Treatment
- Depends on Location & Extent
- Surgery:
- Radical Subtotal Gastrectomy
- Irradiation & Chemo = not very useful; more-so palliative
