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Unit 1 Clin Med III > L4: Peptic Ulcer Disease and Gastric Cancer > Flashcards

L4: Peptic Ulcer Disease and Gastric Cancer Flashcards

1
Q

Definition of peptic ulcer disease

A

defect in the gastric or duodenal mucosa that extends through the muscularis mucosa into deeper layers of the wall→ gastric and duodenal

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2
Q

Rate of ulcers increases with ___

A

age

M=F

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3
Q

3 main causes of ulcers

A
  1. H pylori (most common)
  2. NSAIDs
  3. Non-H pylori, Non-NSAID
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4
Q

Why is H pylori declining in developed countries?

A

hygiene
decreased oral-fecal or oral-oral transmission
increased eradication

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5
Q

H pylori morphology and virulence factors

A

G- rod
Disrupts protective properties by decreasing gastric mucus amd mucosal bicarbonate secretion
Flagella→ attach to gastric mucosa, burrow into mucus to less acidic epithelial cells

Urease→ hydrolyzes urea to ammonia→ neutralize acid→ aids mucus penetration

Adhesins→ adhere to epithelial cells

Inflammation→ G cells in antrum to secrete gastrin→ increased HCl

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6
Q

NSAIDs have an increased incidence of ulcers when taken

A

IM/IV

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7
Q

Why do NSAIDs cause ulcers?

A

Inhibit COX 1 + 2 → decreased prostaglandins
PGE2 maintains gastric health, increases mucin and epithelial cell proliferation, decreases GI release of gastrin (less HCl)

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8
Q

_____ + NSAIDs= increased risk of ulcers

A

History of ulcers
H pylori infection
>75 years
increased dose/duration of use

Concomitant use of: 
Steroids
other NSAIDs
anticoagulants
low dose ASA
SSRI
alendronate
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9
Q

Ulcers are not caused by ______, but they can make ulcers worse or more difficult to heal

A 
stress
alcohol
spicy foods
caffeine
tobacco
*may cause dyspepsia but not ulcer disease*
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10
Q

Ulcer presentation

A

Asymptomatic (70%)
Abdominal pain/discomfort (most common if symptomatic)
Dyspepsia→ belching, bloating, distention
N/V
early satiety

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11
Q

Possible complications of ulcers

A

Hematemesis
Melena
Fatigue
Dyspnea

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12
Q

Ulcer Alarm symptoms

A 
Bleeding
Unexplained iron deficiency anemia
Early satiety
Unintentional weight loss
Progressive dysphagia/odynophagia
Acute onset of intense upper abdominal pain
Persistent vomiting
Family history of upper GI cancer
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13
Q

Gastric vs duodenal ulcers: pain

A

Gastric ulcers: worse 30 mins-1 hour after meals

Duodenal ulcers: relieved by meals, but worse 2-3 hours after meal

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14
Q

Gastric vs duodenal ulcers: vomiting

A

Gastric ulcers: vomiting

Duodenal ulcers: no vomiting

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15
Q

Gastric vs duodenal ulcers: hemorrhage

A

Gastric ulcers: more likely, hematemesis

Duodenal ulcers: less likely, melena

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16
Q

Gastric vs duodenal ulcers: weight changes

A

Gastric ulcers: weight loss, anorexia

Duodenal ulcers: weight gain

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17
Q

The most common complication of ulcers

A

Hemorrhage

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18
Q

Penetration of an ulcer…

A

Penetration of the ulcer through the bowel wall without free perforation→ leakage of luminal contents into peritoneal cavity

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19
Q

Gastric outlet obstruction

A

Complication of an ulcer caused by scarring/fibrosis or inflammation/edema in pyloric channel

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20
Q

Organ most commonly affected by a penetrating ulcer

A

Pancreas

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21
Q

Symptoms of bleeding

A

Melena
Hematemesis
Hematochezia

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22
Q

Diagnosis of bleeding

A

EGD→ diagnostic and therapeutic

Thermal coagulation/hemoclip/ injection therapy

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23
Q

IV meds for bleeding

A

IV fluids/packed RBCS

IV PPIs

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24
Q

Presentation of perforation

A

Severe, diffuse abdominal pain, N/V
+/- progress to “board-like” abdominal rigidity
Tachycardia, weak pulse

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25
Q

Diagnosis of perforation

A

CXR, 2 views
abdominal xrays: upright and supine
UGI with barium contraindicated

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26
Q

Treatment for perforation

A

IV fluids, PPIs, abx
NG tube, NG suction for gastric decompression
Surgery

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27
Q

Penetration presentation

A

Change in symptoms related to other affected structures→ pain without meal association, more intense pain, pain in back

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28
Q

Diagnosis of penetration

A

UGI, CT scan

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29
Q

Symptoms of gastric outlet obstruction

A 
Vomiting
early satiety
bloating
anorexia/weight loss
epigastric pain
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30
Q

Diagnosis of gastric outlet obstruction

A

CT scan, imaging

Show dilated stomach

31
Q

Gastric outlet obstruction tx

A

Stabilize with IV fluids and PPIs

NG tube and gastric decompression

Failing medical tx→ +/- EGD with endoscopic balloon dilatation or surgery

32
Q

Most sensitive and specific test for ulcer diagnosis

A

EGD

33
Q

Vital signs of a patient with an ulcer

A

Hypotension, tachycardia

34
Q

Rectal exam finding for ulcers

A

Melena in rectal vault
Positive hem-occult
Bright red blood per rectum

35
Q

Succession splash

A

Specialized abdominal exam for ulcers:

place stethoscope over upper abdomen→ rock pt back and forth at hips→ retained gastric material >3 hours after a meal→ hollow viscus filled with fluid and gas→ splashing sound

36
Q

Abdominal exam findings indicative of ulcers

A

Epigastric tenderness
RUQ tenderness
peritoneal signs

37
Q

What does an ulcer look like on EGD?

A

Clean white base in ulcer crater

+/- evidence of active bleeding

38
Q

What does an ulcer look like on Upper GI imaging?

A

Small ulcer crater with smooth folds radiating into center of the ulcer

39
Q

Urea breath testing

A

Identifies active infection, can determine eradication

Drink radioactively labelled urea→ urease splits into NH3 and CO2→ test measures labelled CO2 in breath

40
Q

Fecal antigen test

A

Identifies active infection, can determine eradication

Identifies H pylori antigen in feces

41
Q

Serology for H pylori

A

IgG antibodies (memory) → high false positives/negatives→ not recommended

42
Q

Most sensitive and specific diagnosis of H pylori

A

biopsy during EGD

43
Q

Before the urea breath test or fecal antigen test….

A

Discontinue PPI use 2 weeks prior and bismuth/abx 4 weeks prior

44
Q

1st line to eradicate H pylori

A 
Bismuth Quadruple Therapy x 14 days
PPI BID
Bismuth 524 mg QID
Tetracycline 500 mg QID
Metronidazole 250 mg QID
45
Q

4 weeks after treatment for H pylori

A

Confirm eradication

46
Q

To treat an ulcer that wasn’t caused by H pylori

A

PPI 4-8 weeks

47
Q

If symptoms persist after bismuth quadruple therapy…

A

PPI 4-8 weeks

48
Q

If symptoms persist after PPI therapy

A

TCA 8-12 weeks

49
Q

If symptoms persist after TCA therapy

A

Prokinetic 4 weeks

50
Q

If symptoms persist after prokinetic therapy

A

EGD (if not done previously)

51
Q

Ulcer tx order:

A 
Bismuth quadruple therapy (h pylori)
PPI (non-h pylori or refractory) 
TCA
Prokinetic
EGD
52
Q

Zollinger-Ellison syndrome

A

Duodenal or pancreatic gastrinomas→ gastrin hypersecretion→ increased HCl from parietal cells, gastric motility

53
Q

Increased likelihood of Zollinger-Ellison syndrome

A 
MEN1 gene (20% of cases)
M>F
54
Q

Zollinger-Ellison syndrome presentation

A

Recurrent peptic ulcer disease, often distal to duodenal bulb
Abdominal pain
Diarrhea/steatorrhea

55
Q

Zollinger-Ellison syndrome treatment

A

PPIs or H2 blockers

56
Q

Diagnosis of Zollinger-Ellison syndrome

A

Fasting serum gastrin >1000 pg/mL
Gastric pH <2
Secretion stimulation test→ normally suppresses gastrin release by (-) feedback
CT abdomen→ locate tumor

57
Q

Risk factors for gastric cancer

A 
Gastric ulcers
adenomatous polyps
intestinal metaplasia
Nitroso compounds
high-salt diet with few vegetables
Alcohol 
tobacco
58
Q

Early signs of gastric cancer

A

none–asymptomatic

59
Q

Presentation gastric cancer

A 
Weight loss
persistent abdominal pain
early satiety
nausea
anorexia
dysphagia
occult GI bleeding
gastric ulcer history (25%)
60
Q

Late signs of gastric cancer

A

palpable stomach mass
succussion splash
paraneoplastic syndromes

61
Q

Imaging for gastric cancer

A

1st line EGD→ histologic grading and differentiation of gastric vs esophageal cancer
2nd line: UGI

62
Q

90-95% of gastric cancers are _____

A

adenocarcinomas

63
Q

Gastric cancer may appear as ______ on EGD

A 
subtle polypoid protrusion
superficial plaque
mucosal discoloration
depression
ulcer
64
Q

left supraclavicular node

A

Virchow’s node (most common)

LAD of gastric cancer

65
Q

periumbilical node

A

Sister Mary Joseph’s node/nodule

LAD of gastric cancer

66
Q

Left axillary node

A

Irish node

LAD of gastric cancer

67
Q

Early Gastric Cancer (rare) treatment

A

Endoscopic mucosal resection

68
Q

Advanced gastric cancers treatment

A

total/partial gastrectomy

69
Q

Unresectable gastric cancers

A

chemotherapy or chemoradiotherapy

70
Q

Dyspepsia aka

A

indigestion

71
Q

Dyspepsia definition

A

abdominal discomfort accompanied by bloating, belching, or abdominal distention

72
Q

Workup for dyspepsia if >60 years

A

EGD with biopsy on all patients:

Peptic ulcer disease→ treat

No organic disease→ “functional dyspepsia”, test for H. pylori, treat as necessary

73
Q

Dyspepsia alarm features

A 
Unintentional weight loss
Progressive dysphagia
Odynophagia
Unexplained iron deficiency anemia
Persistent vomiting
Palpable mass or LAD
Family history of upper GI cancer
74
Q

When to do an EGD for dyspepsia on a patient <60 years

A

rapidly progressing alarm features

2 or more alarm features

Unit 1 Clin Med III (7 decks)

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