Lecture 80 -- Disease of the stomach

Question 1

Peptic Ulcer Disease:

Erosion vs Ulcer

Answer 1

Erosion – a break in the mucosal lining

Ulcer -a break with depth into the submucosa

Question 2

Peptic Ulcer Disease: causes

Answer 2

Causes: “PH, HP, nough SAID”

pH, H. Pylori, NSAID – 90%

Question 3

Peptic Ulcer Disease:

pathogenesis

Answer 3

Pathogenesis:
1) Injurants to the lining –
Gastric acid or bile acid
NSAIDs

	2) Impaired mucosal Defenses: 
		Impaired mucus and bicarbonate secretion 
		Poor Blood Flow

Question 4

what are Stress Ulcers ?
who get’s them?

what’s a Cushing’s ulcer?
what’s a Curling ulcer?

Answer 4

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

Question 5

4 complications of Ulcers?
which is the most common?
why is incidence decreasing?

Answer 5

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

Question 6

H. Pylori –
where will the ulcers be?

course of the infection ?

Answer 6

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)

Question 7

H. Pylori –

diagnostic techniques

Answer 7

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

Question 8

H. Pylori –treatment

Answer 8

Treatment – 2 antibotics + PPI
Amoxcillin, tetracyclin, metronidazole, clarithromycin

					If you eradicate the organism, risk of recurrent ulcer decreases

Question 9

NSAIDs and Gastric Ulcers

pathogenesis?

Answer 9

NSAIDS = COX inhibition
therefore there is less: prostaglandins, thromboxane and prostacyclin
These are very important for protection of the gastric Mucosa

Question 10

NSAID Ulcers: Risk factors:

concurrnet use of what drug is bad?

Answer 10

> 60 yo, past hx of ulcer, high doses of NSAID

Concomitant Steroid Use

Question 11

NSAID Ulcers:

treatment and prevention

Answer 11

Prevention:
Avoid NSAIDs, Use COX2 selective NSAIDs (Celebrex)
Concomitant use of H2 blockers or PPI –
Misoprostol – PGE1 analog

	Treatment: Stop NSAID, start PPI

Question 12

Zollinger Ellison Syndrome and Ulcers

what is ZE?
Prevalence in the US?
what % have Multiple endocrine neoplasia?

Answer 12

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

Question 13

Manifestations of ZE

Answer 13

Gastric and Small intestinal ulcers,

Diarrhea (due to the volume of the extra acid and malabsorption from inhibition of pancreatic enzymes),

Severe GERD

Question 14

Diagnosis of ZE

Answer 14

hypergastrinemia in the setting of Low pH

Secretin Provocation Test (normally secretin inhibits gastrin release)

Localizing the Tumor:

Ocreotide

Question 15

Treatment of ZE

Answer 15

Treatment:
Resection
High Dose PPI
Ocreotide – somatostatin analog

Question 16

Acute Gastritis –
What is it:
Causes

Answer 16

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

Question 17

Describe the normal metabolism of B12?
what cells secrete intrinsic factor?
what is pernicious anemia?

Answer 17

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

Question 18

diagnosis of pernicious anemia –
what features must be present ?

what test is rarely done (but commonly tested on boards) and what isit?

Answer 18

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

Question 19

Gastric Neoplasia:

benign lesions

Answer 19

Hyperplastic polyps – (do have pre-malignant potential, but along are totally benign)

	Adenomatous polyps  -- some can become adenocarcinoma 

	Leiomyomas -- smooth muscle 

	Lipomas - fatty

Question 20

Gastric Neoplasia:
Malignant lesions

(GISTs are responsive to what therapy?)

Answer 20

Adenocarcinoma – most common (“gastric cancer”
Lymphoma –
GIST – Gastro-intestinal stromal tumors == responsive to Gleevac (imatinib) (anti BCR-ABL)

	Carcinoid Tumors
	Kaposi Sarcomi

Question 21

Gastric Adenomcarcinoma –

• if in the distal stomach … associated with?
• if in the proximal stomach.. associated with?

early and late symptoms

Answer 21

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

Question 22

Gastric Adenomcarcinoma – physical exam findngs?
(common mets and their epynoyms)
-

Answer 22

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

Question 23

three vsacular lesions of Stomach…

which has the worst mortality with bleeding?

Answer 23

Angiodysplasia (aka Arteriovenous Malformation, AVM)

Watermelon Stomach / Gastric Antral Vascular Ectasia:

Gastric Varicies --  30% mortality with active bleeder

Question 24

Gastroparesis:
• What is it?

Cause

Diagnosis

Answer 24

• 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

Question 25

Gastroparesis

Treatment

side effects

Answer 25

• 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

Question 26

Miscellaneous gastric Diseases: 
Congenital 
Anatomical 
Menetrier's Disease
Bezoar (name three kinds)

Answer 26

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))

Question 27

Upper gastrointestinal bleeding:
what is meant by “upper”

Hemetemesis: BRB vs COffee Ground

Melena

Hematochezia

Causes:

Answer 27

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

Question 28

Treatment for GI bleeds:

Answer 28

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