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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
Diagnosis of perforation
CXR, 2 views abdominal xrays: upright and supine UGI with barium contraindicated
26
Treatment for perforation
IV fluids, PPIs, abx NG tube, NG suction for gastric decompression Surgery
27
Penetration presentation
Change in symptoms related to other affected structures→ pain without meal association, more intense pain, pain in back
28
Diagnosis of penetration
UGI, CT scan
29
Symptoms of gastric outlet obstruction
``` Vomiting early satiety bloating anorexia/weight loss epigastric pain ```
30
Diagnosis of gastric outlet obstruction
CT scan, imaging | Show dilated stomach
31
Gastric outlet obstruction tx
Stabilize with IV fluids and PPIs NG tube and gastric decompression Failing medical tx→ +/- EGD with endoscopic balloon dilatation or surgery
32
Most sensitive and specific test for ulcer diagnosis
EGD
33
Vital signs of a patient with an ulcer
Hypotension, tachycardia
34
Rectal exam finding for ulcers
Melena in rectal vault Positive hem-occult Bright red blood per rectum
35
Succession splash
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
Abdominal exam findings indicative of ulcers
Epigastric tenderness RUQ tenderness peritoneal signs
37
What does an ulcer look like on EGD?
Clean white base in ulcer crater | +/- evidence of active bleeding
38
What does an ulcer look like on Upper GI imaging?
Small ulcer crater with smooth folds radiating into center of the ulcer
39
Urea breath testing
Identifies active infection, can determine eradication | Drink radioactively labelled urea→ urease splits into NH3 and CO2→ test measures labelled CO2 in breath
40
Fecal antigen test
Identifies active infection, can determine eradication | Identifies H pylori antigen in feces
41
Serology for H pylori
IgG antibodies (memory) → high false positives/negatives→ not recommended
42
Most sensitive and specific diagnosis of H pylori
biopsy during EGD
43
Before the urea breath test or fecal antigen test....
Discontinue PPI use 2 weeks prior and bismuth/abx 4 weeks prior
44
1st line to eradicate H pylori
``` Bismuth Quadruple Therapy x 14 days PPI BID Bismuth 524 mg QID Tetracycline 500 mg QID Metronidazole 250 mg QID ```
45
4 weeks after treatment for H pylori
Confirm eradication
46
To treat an ulcer that wasn't caused by H pylori
PPI 4-8 weeks
47
If symptoms persist after bismuth quadruple therapy...
PPI 4-8 weeks
48
If symptoms persist after PPI therapy
TCA 8-12 weeks
49
If symptoms persist after TCA therapy
Prokinetic 4 weeks
50
If symptoms persist after prokinetic therapy
EGD (if not done previously)
51
Ulcer tx order:
``` Bismuth quadruple therapy (h pylori) PPI (non-h pylori or refractory) TCA Prokinetic EGD ```
52
Zollinger-Ellison syndrome
Duodenal or pancreatic gastrinomas→ gastrin hypersecretion→ increased HCl from parietal cells, gastric motility
53
Increased likelihood of Zollinger-Ellison syndrome
``` MEN1 gene (20% of cases) M>F ```
54
Zollinger-Ellison syndrome presentation
Recurrent peptic ulcer disease, often distal to duodenal bulb Abdominal pain Diarrhea/steatorrhea
55
Zollinger-Ellison syndrome treatment
PPIs or H2 blockers
56
Diagnosis of Zollinger-Ellison syndrome
*Fasting serum gastrin >1000 pg/mL* Gastric pH <2 Secretion stimulation test→ normally suppresses gastrin release by (-) feedback CT abdomen→ locate tumor
57
Risk factors for gastric cancer
``` Gastric ulcers adenomatous polyps intestinal metaplasia Nitroso compounds high-salt diet with few vegetables Alcohol tobacco ```
58
Early signs of gastric cancer
none--asymptomatic
59
Presentation gastric cancer
``` Weight loss persistent abdominal pain early satiety nausea anorexia dysphagia occult GI bleeding gastric ulcer history (25%) ```
60
Late signs of gastric cancer
palpable stomach mass succussion splash paraneoplastic syndromes
61
Imaging for gastric cancer
1st line EGD→ histologic grading and differentiation of gastric vs esophageal cancer 2nd line: UGI
62
90-95% of gastric cancers are _____
adenocarcinomas
63
Gastric cancer may appear as ______ on EGD
``` subtle polypoid protrusion superficial plaque mucosal discoloration depression ulcer ```
64
left supraclavicular node
Virchow’s node (most common) | LAD of gastric cancer
65
periumbilical node
Sister Mary Joseph’s node/nodule | LAD of gastric cancer
66
Left axillary node
Irish node | LAD of gastric cancer
67
Early Gastric Cancer (rare) treatment
Endoscopic mucosal resection
68
Advanced gastric cancers treatment
total/partial gastrectomy
69
Unresectable gastric cancers
chemotherapy or chemoradiotherapy
70
Dyspepsia aka
indigestion
71
Dyspepsia definition
abdominal discomfort accompanied by bloating, belching, or abdominal distention
72
Workup for dyspepsia if >60 years
EGD with biopsy on all patients: Peptic ulcer disease→ treat No organic disease→ “functional dyspepsia”, test for H. pylori, treat as necessary
73
Dyspepsia alarm features
``` Unintentional weight loss Progressive dysphagia Odynophagia Unexplained iron deficiency anemia Persistent vomiting Palpable mass or LAD Family history of upper GI cancer ```
74
When to do an EGD for dyspepsia on a patient <60 years
rapidly progressing alarm features | 2 or more alarm features

Unit 1 Clin Med III (7 decks)

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