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General Surgery > Peptic Ulcer Disease > Flashcards

Peptic Ulcer Disease Flashcards

1
Q

What are the most common cause/s of duodenal and gastric ulcers?

A

H. pylori infection and/or NSAID use.

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2
Q

What are the causes of duodenal and gastric ulcers?

A 
1 - ZES (gastrinoma).
2 - Antral G-cell hyperfunction and/or hyperplasia.
3 - Systemic mastocytosis.
4 - Trauma.
5 - Burns.
6 - Major physiologic stress.
7 - All NSAIDs.
8 - Aspirin.
9 - Cocaine.
10 - Smoking.
11 - Psychologic stress.
12- H. pylori infection.
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3
Q

How does H. pylori is uniquely equipped for survival in the hostile environment of the stomach ?

A

By having specialized flagella and a rich supply of urease

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4
Q

What are the causes of chronic gastritis ?

A
  • H. pylori (most common).
  • Alcohol.
  • NSAIDs.
  • Crohn’s disease.
  • Tuberculosis.
  • Bile reflux (primary or secondary).
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5
Q

What is the most common type of gastric ulcers?

A

Johnson type I gastric ulcer, is typically located near the angularis incisura on the lesser curvature, close to the border between antral and corpus mucosa.

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6
Q

What is the modified Johnson classification ?

A

I. Lesser curve, incisura.

II. Body of stomach, incisura + duodenal ulcer (active or healed).

III. Prepyloric.

IV. High on lesser curve, near gastroesophageal junction.

V. Medication-induced (NSAID/ acetylsalicylic acid), anywhere in stoma

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7
Q

What are the risks of chronic use of NSAIDs (including aspirin) ?

A

increases the risk of:

  • Peptic ulcer disease about 5-fold.
  • Upper GI bleeding about 4-fold.
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8
Q

What are the factors that clearly put patients at increased risk for NSAID-induced GI complications and the need of having acid suppressing medication?

A
  • Age over 60
  • History of acid/peptic disease
  • Concurrent steroid intake
  • Concurrent anticoagulant intake
  • High-dose NSAID or acetylsalicylic acid
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9
Q

How does smoking is associated with PUD?

A
  • Increases gastric acid secretion and duodenogastric reflux.
  • Decreases both gastroduodenal prostaglandin production and pancreaticoduodenal bicarbonate production.
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10
Q

What are the symptoms and signs of PUD?

A 
- Nonradiating pain, burning in quality, and
located in the epigastrium.
- Nausea.
- Bloating.
- Weight loss.
- Stool positive for occult blood.
- Anemia
- Dyspepsia
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11
Q

What are the Alarm symptoms that indicate the need for upper endoscopy ?

A
  • Weight loss
  • Recurrent vomiting
  • Dysphagia
  • Bleeding
  • Anemia
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12
Q

What are the Indications for diagnosis and treatment of Helicobacter pylori ?

A

Established
- Active peptic ulcer disease (gastric or duodenal ulcer)
- Confirmed history of peptic ulcer disease (not previously treated for H. pylori)
- Gastric mucosa-associated lymphoid tissue lymphoma (low grade).
- After endoscopic resection of early gastric cancer
- Uninvestigated dyspepsia (depending on H. pylori prevalence).
Controversial
- Nonulcer dyspepsia
- Gastroesophageal reflux disease
- Persons using NSAIDs
- Unexplained iron deficiency anemia
- Populations at higher risk for gastric cancer

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13
Q

What are the most common complications of PUD?

A
  • Bleeding.
  • Perforation.
  • Obstruction.
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14
Q

What are the two widely used risk stratification tools in predicting rebleeding and death in bleeding PUD?

A
  • Blatchford Score.

- Rockall Score.

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15
Q

What are the most common endoscopic hemostatic modalities used in bleeding PUD ?

A
  • Injection with epinephrine.

- Electrocautery

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16
Q

What is the initial management of perforated peptic ulcer?

A
  • History: patient can give exact time of onset of the
    excruciating abdominal pain.
  • On Ex: obvious distress, peritoneal signs. Usually, marked involuntary guarding and rebound
    tenderness.
  • Radiology: Upright CXR shows free air in about 80% of patients.
  • Initial Mx: analgesia and antibiotics, resuscitated with isotonic fluid, and taken to the operating room.
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17
Q

What is the clinical manifestation of Gastric outlet obstruction?

A
  • Nonbilious vomiting.
  • Profound hypokalemic hypochloremic metabolic alkalosis.
  • Pain or discomfort is common.
  • Weight loss
18
Q

What is the initial treatment of gastric obstruction ?

A
  • Nasogastric suction.
  • IV hydration.
  • Electrolyte repletion and cid suppression.
19
Q

How to confirm Dx of gastric obstruction ?

A

Diagnosis is confirmed by endoscopy

20
Q

What is the medical Treatment of peptic Ulcer Disease ?

A
  • PPIs are the mainstay of medical therapy.
  • High dose of H2RAs and sucralfate are also effective.
  • Stop smoking.
  • Avoid alcohol and NSAIDs (including aspirin).
21
Q

What are the initial regimens of treating Helicobacter pylori?

A
  1. PPI + clarithromycin 500 mg bid + amoxicillin 1000 mg BID for 10–14 d.
  2. PPI + clarithromycin 500 bid + metronidazole 500 bid for 10–14 d.
  3. PPI + amoxicillin 1000 mg bid for 5 d , then
    PPI + clarithromycin 500 mg bid + Tinidazole 500 mg bid for 5 d.
22
Q

What are the Salvage regimens for patients who fail one of the initial regimens treating H.pylori ?

A
  1. Bismuth subsalicylate 525 mg qid + metronidazole 250 mg qid + tetracycline 500 mg qid + PPI for 10-14 d.
  2. PPI + amoxicillin 1000 mg bid + levofloxacin 500 mg daily for 10 days.
23
Q

What are the indications for surgery in PUD in general ?

A
  • Bleeding.
  • Perforation.
  • Obstruction.
  • Intractability or nonhealing.
24
Q

What are the basic operations for peptic ulcers

treatment ?

A
  1. Parietal cell vagotomy (highly selective vagotomy HSV ) (proximal gastric vagotomy).
  2. Vagotomy and drainage (V+D).
  3. vVgotomy and distal gastrectomy.
25
Q

What is the potentially lethal complication during truncal vagotomy?

A

Esophagus perforation.

26
Q

What is the most commonly performed pyloroplasty in PUD?

A

The Heineke-Mikulicz type.

27
Q

What is the procedure of choice for type I gastric ulcer?

A

Distal gastrectomy without vagotomy (usually about a

50% gastrectomy to include the ulcer) .

28
Q

What are the surgical options in the treatment of duodenal and gastric ulcer if the indication for surgery was bleeding?

A

Duodenal :

  1. Oversewa
  2. Oversew, V + D
  3. V + A

Gastric:

  1. Oversew and biopsy
  2. Oversew, biopsy, V + D
  3. Distal gastrectomy.
29
Q

What are the surgical options in the treatment of duodenal and gastric ulcer if the indication for surgery was perforation?

A

Duodenal :

  1. Patcha
  2. Patch, HSV
  3. Patch, V + D

Gastric:

  1. Biopsy and patch.
  2. Wedge excision, V + D
  3. Distal gastrectomy.
30
Q

What are the surgical options in the treatment of duodenal and gastric ulcer if the indication for surgery was Intractability/nonhealing ?

A

Duodenal :

  1. HSV
  2. V + D
  3. V + A

Gastric:

  1. HSV and wedge excision
  2. Distal gastrectomy.
31
Q

What are the surgical options in the treatment of duodenal and gastric ulcer if the indication for surgery was obstruction?

A

Duodenal:

  1. HSV + GJ
  2. V + A

Gastric:

  1. Biopsy; HSV + GJ
  2. Distal gastrectomy.
32
Q

What is the DDx of intractability or nonhealing

peptic ulcer disease?

A
  1. Cancer
    - Gastric
    - Pancreatic
    - Duodenal
  2. Persistent Helicobacter pylori infection
    - Tests may be false-negative
    - Consider empiric treatment
  3. Noncompliant patient
    - Failure to take prescribed medication
    - Surreptitious use of NSAIDs
  4. Motility disorder
  5. Zollinger-Ellison syndrome
33
Q

Type IV gastric ulcers may be difficult to resect as part of a distal gastrectomy, and a variety of surgical techniques have been described to treat these more proximal lesions. Name them.

A 
1 - Ulcer excision.
2- Antrectomy.
3 - Pauchet procedure.
4 - Kelling-Madlener procedure.
5 - Subtotal gastrectomy Roux-en-Y esophagogastrojejunostomy.
6 - Csendes procedure.
34
Q

What is Zollinger-Ellison Syndrome?

A

Uncontrolled secretion of abnormal amounts of gastrin by a duodenal or pancreatic neuroendocrine tumor (i.e., gastrinoma).

35
Q

What is MEN I?

A

multiple endocrine neoplasia type I (MEN I), which is an autosomal dominant disorder , consists of:

  • Parathyroid
  • Anterior Pituitary.
  • Pancreatic (or duodenal) tumors.
36
Q

What is the most common symptoms of ZES (Zollinger-Ellison Syndrome) ?

A
  • Epigastric pain.
  • GERD.
  • Diarrhea.
37
Q

How to diagnose Zollinger-Ellison Syndrome?

A

By the secretin stimulation test.
An IV bolus of secretin (2 U/kg) is given and gastrin levels are checked before and after injection.
An increase in serum gastrin of 200 pg/mL or greater suggests the presence of gastrinoma.

38
Q

What is Gastrinoma triangle/ Passaro’s triangle ?

A

Passaro’s triangle or Gastrinoma triangle is a presumptive region in the abdomen between three points: Superior- Body of Gallbladder (Earlier-confluence of the cystic and common bile duct), Inferior-junction of the second and third portion of duodenum, and. Medial- junction of the neck and body of the pancreas.

39
Q

What is the study of choice for gastrinoma?

A

Somatostatin receptor scintigraphy

the octreotide scan

40
Q

What is the difference of gastric ulcer pain and duodenal ulcer pain?

A

-Duodenal ulcer often experience pain 2 to 3 hours
after a meal and at night.
- Gastric ulcer more commonly occurs with eating and is
less likely to awaken the patient at night.

General Surgery (11 decks)

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