Peptic disease

Question 1

If all peptic ulcers were biopsied, 70% would reveal:

Answer 1

H. pylori

(Spiral shaped, gram -)

Question 2

A patient presents with epigastric pain that worsens with meals. Biopsy of the body of the stomach would reveal:

Answer 2

Normal histology!

(H. pylori resides in antrum only; this presentation suggests gastric ulcer)

Question 3

What substances are elevated in duodenal ulcer patients compared with normal patients? Reduced?

Answer 3

Basal and peak acid output and [gastrin] elevated

Basal and acid-induced HCO3- secretion from mucus cells reduced

Question 4

Chronic diseases associated with PUD

Answer 4

1. ICU patients on ventilators (think stress ulcer due to hypoperfusion)
2. Cirrhosis
3. COPD
4. Organ transplantation

Question 5

Dx of this stomach biopsy?

Answer 5

Chronic gastritis with metaplasia

(Notice the appearance of intestinal epithelium with goblet cells + inflammatory cells in lamina propria)

Question 6

Dx?

Answer 6

Alcoholic hemorrhagic gastritis

(Multiple subepithelial hemorrhages without breaks in mucosa)

Question 7

Epigastric pain relieved by eating

Answer 7

Duodenal ulcer

(Duodenum begins secreting protective factors against the acid load it would receive from stomach)

Question 8

Epigastric pain worse with eating

Answer 8

Gastric ulcer

(Stomach produces HCl)

Question 9

A patient presents with N/V and a succussion splash. Barium x ray yields this results. What is the cause of this in a patient with an acute vs chronic ulcer?

Answer 9

Gastric outlet obstruction due to edema (acute) or fibrosis (chronic)

Question 10

A patient with known duodenal ulcer presents with the sudden onset of severe abdominal pain radiating to the back and N/V. CT scan is below. What is the cause of his symptoms?

Answer 10

Perforated posterior duodenal ulcer causing acute pancreatitis due to activation of pancreatic enzymes

Question 11

G cell hyperplasia

Answer 11

Autoimmune chronic gastritis

(ABs against parietal cells = no HCl = gastrin trying to stimulate HCl production so G cells increase in number)

Question 12

How can H. pylori lead to gastric adenocarcinoma?

Answer 12

CagA protein causes degradation of p53 which leads to cell proliferation and altered cellular polarization

Question 13

The symptoms of the patient from whom this immunoflourescence with anti-parietal cell antibodies was taken would have been:

Answer 13

Abd pain, N/V, hematemesis due to gastritis caused by achlorhydria

Fatigue, parasthesias, weakness due to pernicious anemia caused by lack of intrinsic factor for B12 absorption in ileum

(Autoimmune gastritis)

Question 14

Biopsy of the lamina propria of the antrum of the stomach in H. pylori infection would reveal:

Answer 14

Primarily PMNs but NOT THE BUG!!

(H. pylori doesn’t invade but release chemotactic peptide + LPS)

Question 15

What are some causes of acute gastritis?

Answer 15

NSAIDs, alcohol, bile reflux, Cushing ulcer, Curling ulcer, chemo/radiation, shock/stress, ingesting corrosives

(Anything that increases acid or decreases mucosal barrier)

Question 16

Curling vs. Cushing ulcer

Answer 16

Curling = severe burn causes hypovolemia which reduces blood flow to gastric mucosa, reducing protective barrier

Cushing = increased intracranial pressure causes vagal stimulation which increases ACh which increases HCl production)

Question 17

Dx?

Answer 17

Chronic lymphocytic gastritis secondary to H. pylori

(Notice the germinal centers)

Question 18

List 4 ways to diagnose H. pylori

Answer 18

1. Urea breath test
2. Fecal antigen test
3. Serological testing
4. Biopsy of gastric ulcers (urea tests, histological tests)

Question 19

Which artery is the most common culprit in bleeding from a gastric ulcer? From a duodenal ulcer?

Answer 19

Left gastric artery (runs along lesser curvature of stomach where most gastric ulcers are)

Gastroduodenal ulcer (if duodenal ulcer is posterior)

Question 20

Dx?

Answer 20

Endoscopic gastritis

(Radial streaks of erythema)

Question 21

Describe the pathogenesis of H. pylori-induced peptic ulcers

Answer 21

1. H. pylori resides in proximal duodenum &/or antrum of stomach
2. H. pylori produces LPS and a peptide
3. LPS and peptide are chemotactic
4. Inflammatory cells release IL-1, TNF, ROS, and prostaglandins that promote further inflammation
5. Defect in mucosa extending through muscularis mucosa

Question 22

Histology of a chronic peptic ulcer reveals:

Answer 22

Necrosis

Inflammation (mostly PMNs)

Granulation tissue

Scar (fibrosis)

Question 23

What are some causes of chronic gastritis?

Answer 23

H. pylori, autoimmune disease, bile reflux

(AI = ABs against parietal cells)

Question 24

List the 3 ways in which NSAIDs cause peptic ulcers

Answer 24

1. Decrease PG inhibition of HCl production
2. Decrease HCO3- and mucin production
3. Decrease glutathione (free radical scavenger) production

Question 25

A patient with a history of duodenal ulcer presents with sudden onset of severe abdominal pain and left shoulder pain. What do you expect to see on x ray?

Answer 25

Air under diaphragm

(Presentation is classic for perforated duodenal ulcer, which will leak air into the peritoneal cavity)

Question 26

Dx?

Answer 26

Benign gastric ulcer

(Protrudes away from lumen, no mass effect)

Question 27

Which H. pylori test should not be used to monitor recurrence?

Answer 27

Serology; only tells you if you have ever had H. pylori

Question 28

Biopsy of this stomach would reveal:

Answer 28

PMNs infiltrating the gastric mucosa

Question 29

What is T4SS?

Answer 29

Type 4 secretion system of H. pylori that injects CagA protein into cells

Question 30

How could a peptic ulcer be present two feet distal to the iliocecal valve?

Answer 30

Meckel’s diverticulum containing ectopic gastric mucosa

(Remember Meckel’s diverticulum is generally 2 feet from iliocecal valve)

Question 31

How could a peptic ulcer be present in the jejunum?

Answer 31

ZE syndrome

(Also suggested by multiple ulcers)

Question 33

Benign or malignant?

Answer 33

Benign

(Round, small, flat margins)

Question 34

Benign or malignant?

Answer 34

Malignant

(Heaped up border, irregular shape, very large, necrotic)

Question 35

A patient presents to your office complaining of headache and abdominal pain. He hit a tree while skiing about a week ago but felt fine so did not seek medical attention. He reports throwing up what looked like blood. Explain the etiology of these findings.

Answer 35

Cushing ulcer (stress ulcers)

May have concussion/intracranial bleed (cause of HA)= increased ICP = increased vagal stimulation = increased ACh = increased HCl production = stress ulcers (usually hemorrhagic = cause of hematemesis)