Lecture 80 -- Disease of the stomach Flashcards
Peptic Ulcer Disease:
Erosion vs Ulcer
Erosion – a break in the mucosal lining
Ulcer -a break with depth into the submucosa
Peptic Ulcer Disease: causes
Causes: “PH, HP, nough SAID”
pH, H. Pylori, NSAID – 90%
Peptic Ulcer Disease:
pathogenesis
Pathogenesis:
1) Injurants to the lining –
Gastric acid or bile acid
NSAIDs
2) Impaired mucosal Defenses: Impaired mucus and bicarbonate secretion Poor Blood Flow
what are Stress Ulcers ?
who get’s them?
what’s a Cushing’s ulcer?
what’s a Curling ulcer?
Stress Ulcers – -occur with severe physiological distress
ICU Patients, Intubated Patients, Post Trauma Patients,
Cushing's Ulcer = patients with increased Intra cranial pressure
Curling Ulcer — in burn patients
4 complications of Ulcers?
which is the most common?
why is incidence decreasing?
Perforations – non sterile contents of the GI lumen break open into the peritoneal cavity
Bleeding - the most common complication
Penetration – ulcer breaks into adjacent organ
Obstruction – such as with an ulcer situated at the pyloric outlet
have largely been resolved with the use of PPIs
H. Pylori –
where will the ulcers be?
course of the infection ?
Gastric + Duodenal Ulcers
90% of Duodenal Ulcers; 80% of Gastric Ulcers are H pylori associated?
Initial Infection —>
Almost everyone will get chronic gastritis
10% Gastric or Duodenal Ulcers
Atrophic Gastritis – precursor for gastric cancer
Lymphoproliferative MALT Lymphoma (MALToma)
H. Pylori –
diagnostic techniques
serum antibody – this can be used for initial detection, but not thereafter as it will always be positive
stool antigen
Breath test – H pylori is urease producing; therefore give patient radiolabelled Urea, and detect if CO2 on exhalation is also radiolabelled; indicates presence of urease
Biopsy – spiral shaped bacteria in the mucosa
Giemsa, Genta or Silver Stains
CloTest – bx of the stomach and put in on an assay
If urease is present it will be positive
H. Pylori –treatment
Treatment – 2 antibotics + PPI
Amoxcillin, tetracyclin, metronidazole, clarithromycin
If you eradicate the organism, risk of recurrent ulcer decreases
NSAIDs and Gastric Ulcers
pathogenesis?
NSAIDS = COX inhibition
therefore there is less: prostaglandins, thromboxane and prostacyclin
These are very important for protection of the gastric Mucosa
NSAID Ulcers: Risk factors:
concurrnet use of what drug is bad?
> 60 yo, past hx of ulcer, high doses of NSAID
Concomitant Steroid Use
NSAID Ulcers:
treatment and prevention
Prevention:
Avoid NSAIDs, Use COX2 selective NSAIDs (Celebrex)
Concomitant use of H2 blockers or PPI –
Misoprostol – PGE1 analog
Treatment: Stop NSAID, start PPI
Zollinger Ellison Syndrome and Ulcers
what is ZE?
Prevalence in the US?
what % have Multiple endocrine neoplasia?
What is it? Gastrin secreting non beta cell tumor of the pancreas (Gastrinoma); which constitutively secretes Gastrin (loss of negative feedback from low pH), leading to gastric acid hypersecretion from parietal cells
25% of ZE patients have MEN
1 in a million Americans have ZE
Manifestations of ZE
Gastric and Small intestinal ulcers,
Diarrhea (due to the volume of the extra acid and malabsorption from inhibition of pancreatic enzymes),
Severe GERD
Diagnosis of ZE
hypergastrinemia in the setting of Low pH
Secretin Provocation Test (normally secretin inhibits gastrin release)
Localizing the Tumor:
Ocreotide
Treatment of ZE
Treatment:
Resection
High Dose PPI
Ocreotide – somatostatin analog
Acute Gastritis –
What is it:
Causes
What is it: gastritis is inflammation without breaks, but it can be erosive or hemorrhagic
Causes: Toxins and drugs: EtOhH, Aspirin, NSAIDs, Chemo Physical Agents: Radiation Vascular: Ischemia, Vasculitis --- patients who are hypotensive Gastro-Duodenal Reflux - post gastrectomy (as part of Whipple?)--- bile reflux gastritis Stress Gastritis
Describe the normal metabolism of B12?
what cells secrete intrinsic factor?
what is pernicious anemia?
Salivary Complex — Haptocorrin (R factor) + B12
Pancreatic enzymes – cleave B12 from Haptocorrin
B12 binds to intrinsic factor (from the parietal cell)
B12 is then absorbed into the terminal ileum
Pernicious Anemia – lack of B12 leading to macrocytic anemia in the setting of antibody destruction of the GI
Cause: gastric atrophy and loss of IF production Autoimmune tendencies
diagnosis of pernicious anemia –
what features must be present ?
what test is rarely done (but commonly tested on boards) and what isit?
Low B12, macrocytic anemia, intrinsic factor/parietal cell antibodies
Achlorhydria – neutral pH
Schilling test (rarely done but commonly tested) – give high dose B12; and some radioactive B12;
If it appears in the urine -- indicative of dietary insufficiency; If it does NOT appear in the urine -- not just a dietary insufficiency given them IF with the radioactive B12, to prove it was due to IF deficiency \ could also give them pancreatic enzymes to see if the deficiency is there
Gastric Neoplasia:
benign lesions
Hyperplastic polyps – (do have pre-malignant potential, but along are totally benign)
Adenomatous polyps -- some can become adenocarcinoma Leiomyomas -- smooth muscle Lipomas - fatty
Gastric Neoplasia:
Malignant lesions
(GISTs are responsive to what therapy?)
Adenocarcinoma – most common (“gastric cancer”
Lymphoma –
GIST – Gastro-intestinal stromal tumors == responsive to Gleevac (imatinib) (anti BCR-ABL)
Carcinoid Tumors Kaposi Sarcomi
Gastric Adenomcarcinoma –
- if in the distal stomach … associated with?
- if in the proximal stomach.. associated with?
early and late symptoms
distal – a/w H pylori
PRoximal – not associated with H pylori
Early: No symptoms; often diagnosed late; not screened for
But is screened for in Asian countries
Late: Anorexia, early satiety, N/V, weight loss, melena, hematemesis
Gastric Adenomcarcinoma – physical exam findngs?
(common mets and their epynoyms)
-
epigastric mass, enlarged liver (from gastric mets)
Mets:
Hepatomegaly,
Left Supraclavicular Nodes – Virchow’s Node (common for gastric cancers)
Rectal Shelf Metastasis – Blumer’s Shelf
Umbilical Nodes – Sister Mary and Joseph Nodules
three vsacular lesions of Stomach…
which has the worst mortality with bleeding?
Angiodysplasia (aka Arteriovenous Malformation, AVM)
Watermelon Stomach / Gastric Antral Vascular Ectasia:
Gastric Varicies -- 30% mortality with active bleeder
Gastroparesis:
• What is it?
Cause
Diagnosis
- What is it?
* Delayed gastric emptying
* Disordered peristalsis
* Complicated process involving interaction of sympathetic, parasympathetic, plexi, smooth muscle cells
Cause: any diseases that affect the NS of the gut
• Diabetes is most common cause:
others include — slceroderma, Post viral, anti-cholinergis, anti-histamines, opiates
Gastroparesis
Treatment
side effects
- Metoclopramide – most common cause for litigation; good drug for gastric emptying but lots of bad side effects such as tardive dyskinesia which can be permanent
* Domperidone – not available in the US; can prolong QT interval; lactation
Miscellaneous gastric Diseases: Congenital Anatomical Menetrier's Disease Bezoar (name three kinds)
Congenital – Hypertrophic pyloric stenosis
Anatomical -- Diaphragmatic Hernia; Volvulus Menetrier's Disease -- Thickened folds of the stomach; gastric hyperplasia of mucosa.
Bezoar – conglomeration of indigestible materials
(phyto (vegetables), Tricho (hair), Pharmaco (eg ASA))
Upper gastrointestinal bleeding:
what is meant by “upper”
Hemetemesis: BRB vs COffee Ground
Melena
Hematochezia
Causes:
Upper = ligament of treitz (duo - jejunal junction)
Hematemesis –
BRB – brisk bleeding
coffee ground – oxidized
Melena -- dark tarry, foul smelling stool Hematochezia -- red blood through stool
Causes: i. Peptic ulcer ii. Gastritis iii. Esophagitis iv. Mallory Weiss Tear --- tearing with forceful v. Gastro esophageal Varices Dieulafoy Lesion
Treatment for GI bleeds:
Treatment for GI bleeds:
i. Stabilize patient
□ Two large bore IVs
□ Isotonic fluids
□ Blood products – type and crossed
ii. Check Labs – CBC, H&H, Liver tests, platelets, coags
iii. Start PPIs — blood clots better in neutral environment
iv. Nasogastric Lavage – what type of blood
v. Urgent Endoscopy
Endoscopic Therapy 1. Cautery 2. Hemoclips 3. Epinephrine Injection 4. Banding
