Peptic Ulcer Disease and Gastric Cancer Flashcards
1
Q
3 layer of stomach wall
A
Mucosa
Submucosa
Muscularis
2
Q
increases stomach motility and increases acid production
what hormone
A
gastrin
3
Q
inhibits stomach motility
decreases bile secretion
increases enzyme flow
A
secretin
4
Q
increases bile secretion
increases enzyme flow
A
CCK release
5
Q
CCK: stimulatory or inhibitory
A
stim
6
Q
secretin: stimulatory or inhibitory
A
inhib
7
Q
what causes gastrin to be released
A
food in lower stomach
8
Q
acid and food in duodenum causes what to be released
A
secretin
9
Q
fatty food and amino acids in duodenum causes what to be released
A
CCK
10
Q
peptic ulcers must extend through what
A
muscularis mucosa
11
Q
peptic ulcers can be in what two locations
A
gastric or duodenal mucosa
12
Q
2 PUD etiology
A
H. pylori
NSAIDS
13
Q
Can PUD be caused by stress, etoh, spicy foods, caffeine, or tobacco?
A
NO - they can make them worse and more difficult to heal, however
14
Q
most common cause of PUD
A
H. pylori
15
Q
describe h. pylori as an organism
A
Gram(-) rod
Motile flagella used to attach to gastric mucosa
Oral-oral or oral-fecal route
Disrupts protective properties by decreasing gastric mucus and mucosal bicarb secretion
16
Q
what does h. pylori do to the stomavh
A
decreases gastric mucus and mucosal bicarb secretion so stomach is not as protected
17
Q
5 factors that increase risk of PUD with use of NSAIDS
A
previous hx of PUD/ulcer complications
presence of h. pylori infection
over 75
increased dose, time, duration of use
concomitant use of steroids, NSAIDS, anticoags, low dose aspirin, SSRI, alendronate
18
Q
most common presentation of SYMPTOMATIC pts with PUD (30% will be symptomatic and 70% will be asymptomatic)
A
abdominal pain/discomfort
19
Q
most common clinical presentation of PUD (70%)
A
asymptomatic
20
Q
symptoms of dyspepsia
A
belching
bloating
distention
21
Q
symptoms of PUD complications
A
hematemesis
melena
fatigue
dyspnea
22
Q
gastric or duodenal ulcer:
pain worse after meals
pain worse 30 min to one hour after meals
A
gastric
23
Q
gastric or duodenal ulcer:
vomiting common
A
gastric
24
Q
gastric or duodenal ulcer:
more likely to hemorrhage; manifests as hematemesis
A
gastric
25
gastric or duodenal ulcer
weight loss/anorexia
gastric
26
gastric or duodenal ulcer:
pain relieved by meals
pain occurs 2-3 hours after a meal
duodenal
27
gastric or duodenal ulcer
vomiting uncommon
duodenal
28
gastric or duodenal ulcer
less likely to hemorrhage, but if it does - melena
duodenal
29
gastric or duodenal ulcer
weight gain
duodenal
30
PUD alarm symptoms
bleeding
unexplained iron def anemia
early satiety
unintentional weight loss
progress dyspagia/odynophagia
acute onset of intense upper abdominal pain
persistent vomiting
family hx of upper GI cancer
31
most common complication of PUD (+ others)
bleeding
**others include perforation, penetation, gastric outlet obstruction (rare)
32
how can bleeding from PUD present
hematemesis, melena, or hematochezia
33
dx for PUD
1. stabilize with IV fluids or packed red blood cells
2. start IV PPI
3. perform EGD - EGD is diagnostic and allows for therapeutic interventions
THESE ARE ALL PART OF DX
34
tx of PUD complication: bleeding
thermal coagulation, hemoclip placement, injection tx
35
if you suspect someone has PUD and a perforation (a complication of PUD), what do you NOT do
UGI with barium
36
someone presents with severe, diffuse, abdominal pain, tachycardia, weak pulse, N/V
these symptoms may progress to "board like abdominal rigidity"
what dx test should you NOT do?
what should you do instead
do not do UGI with barium
you can do upright chest and abdominal x-rays with MAYBE a CT scan to localize perforation
37
how to dx perforation complication of PUD
stabilize with IV fluids
NG tube
NG suction of gastric decompression
IV PPI
broad spectrum antibx
surgery
38
what will you see on chest xray to indicate perforation
free air under diaphragms (crescents)
39
what does PUD penetration complication mean
penetration of the ulcer through the bowel wall without free perforation and leakage of luminal contents into peritoneal cavity
40
what is the most common structure affected in penetration
pancreas
41
clinical presentation of penetration (PUD complication)
symptoms change due to what adjacent structure is involved BUT symptoms are usually pain without meal assoc, more intense pain and pain referral to back
42
gastric outlet obstruction (PUD complication) causes
scarring, fibrosis or inflammation/edema in pyloric channel
43
gastric outlet obstruction (PUD complication) clinical presentation
vomiting
early satiety
bloating
epigastric pain
weight loss
anorexia
44
dx and tx with gastric outlet obstruction (PUD complication)
imaging shows dilated stomach
stabilize with IV fluids, NG tube, gastric decompression, and IV PPIs
45
what happens if gastric outlet obstruction is not treated effectively with IV fluids, NG tube, gastric decompression, and IV PPI
EGD with endoscopic balloon dilation
or
surgery
46
PUD abdominal physical exam
epigastric tenderness
RUQ tenderness
peritoneal signs
succussion splash
47
PUD vital signs physical exam
hypotension
tachycardia
48
PUD rectal exam on physical exam
melena (in rectal vault)
hemoccult positive stool
bright red blood per rectum
49
what is succussion splash
it is elicited by placing stethoscope over upper abdomen and rocking the pt back and forth at the hips. Retained gastric material greater than 3 hours after a meal will generate a splash sound and indicate prescence of a hollow viscus filled with both fluid and gas
50
__________ is elicited by placing stethoscope over upper abdomen and rocking the pt back and forth at the hips. Retained gastric material greater than 3 hours after a meal will generate a splash sound and indicate prescence of a hollow viscus filled with both fluid and gas
succussion splash
51
gold standard for PUD dx
EDG - looking for clean white base in ulcer crater with NO evidence of active bleeding
52
other imaging for PUD dx
upper GI - small ulcer crater with smooth folds radiating into center of ulcer
53
what can be done to see if PUD is caused by h. pylori
urea breath test
fecal antigen test
serology
biopsy during EGD
54
most specific and sensitive H. pylori dx test
biopsy during EDG
55
succision splash indicates what
GASTRIC OUTLET OBSTRUCTION
56
h. pylori virulence factors
flagells
urease
adhesins
inflammation causing
57
what does urease do for h. pylori
hydrolyzes gastric urea to form ammonia that helps neutralize gastric acid, enabling it to penetrate gastric mucus layer
58
flagella does what for h. pylori
used to burrow into stomach mucus to reach epithelial cells where it is less acidic
59
adhesins do what for h. pylori
adhere to epithelial cells
60
why does h. pylori cause inflammation
inflammation causes G cells in antrum to secrete gastrin and therefore HCl increases
61
what prostaglandin is assoc with stomach
PGE2
62
how do NSAIDS lead to PUD
NSAIDS block COX 1 and 2 which prevents PGE2 synthesis
PGE2 stimulates mucin, inhibits gastrin, and leads to peptic ulcer formation due to change in environment
63
PGE2:
increase or decreases mucin
increases or decreases gastrin
increases mucin
decreases gastrin (decreased acid)
SO without PGE2, there is decreased mucus (hostile environ) and increased gastrin which leads to increased acid
64
3 symptoms of dyspepsia
belching
bloating
distention
65
4 symptoms of PUD complicagtions
hematemesis
melena
fatigue
dyspnea
66
what dx test is contraindicated if you suspect perforation (severe, diffuse abdominal pain, tachycardia, weak pulse, N/V)
what do you do instead?
UGI - barium swallow
upright chest and abdominal x-rays looking for free air under diaphragm
67
why can't you use serology to detest h. pylori
because it looks for IgG antibodies (so could indicate past or present infection)
68
what two tests can you do for h. pylori eradication testing
urea breath testing
fecal antigen test
69
what are instructions for urea breath and fecal antigen testing
stop PPI use 2 weeks prior and bismuth/antibx 4 weeks prior
70
PUD tx (5 steps if symptoms persist)
1. eradicate H. pylori and confirm eradication 4 weeks post-tx
2. if no H. pylori and symptoms persist, tx with 4-8 weeks of PPI
3. if symptoms persist, tx with 8-12 weeks of TCA
4. if symptoms persist, treat with 5 weeks of prokinetic
5. if symptoms persist, perform EGD
71
How to eradicate H. Pylori
bismuth quadruple therapy for fourteen days
PPI (BID)
Bismuth 524 mg (QID)
Tetracycline 500 mg (QID)
Metronidazole 250 mg (QID)
72
syndrome with gastrinomas
ZES
73
where do ZES gastrinomas arise from
duodenum or pancreas
74
pathophys of ZES
gastrin stimulates the secretion of gastric acid by the parietal cells of the stomach and aids in gastric motility
75
ZES more common in whom?
men
MEN1-assoc in 20% of cases
76
clinical presentation of ZES
recurrent PUD (often distal to duodenal bulb) OR multiple ulcers at once
abdominal pain
diarrhea (steatorrhea)
77
gold standard dx test of ZES
fasting serum gastrin over 1000 pg/mL
78
tx of ZES
PPIs or H2 blockers (usually PPIs)
79
risk factors for gastric cancer
gastric ulcers
ETOH/tobacco use
chronic H. pylori infection
diet high in salt/smoked meats
80
early gastric cancer signs
none - asymptomatic
81
gastric cancer signs not assoc with early or late gastric cancer
weight loss
persistent abdominal pain
early satiety
nausea
anorexia
dysphagia
gastric ulcer hx
occult GI bleeding
82
late gastric cancer clinical presentation
palpable stomach mass, succussion splash, paraneoplastic syndromes
83
dx test for gastric cancer
EGD - use for grading too
84
90-95% of gastric cancers are ____
adenocarcinomas
85
on EGD, how might gastric cancer appear
subtle polypod protrusion, superficial plaque, mucosal discoloration, depression, ulcer
86
stage 0 of stomach cancer
in mucosa
87
stage 1 of stomach cancer
to submucosa
88
stage 2 of stomach cancer
to muscle (considered a tumor)
89
stage 3 of stomach cancer
touches outer layer but not through
90
stage 4 of stomach cancer
goes through outer layer (serosa) and metastasizes
91
most common sign of metastatic disease with gastric cancer
Virchow's node (left supraclavicular lymph node)
92
other signs of metastatic disease of gastric cancer
sister mary joseph's node/nodeule - periumbilical nodule
left axillary node (irish node)
93
tx of early gastric cancer
endoscopic mucosal resection (very rare - doesn't usually get caught early)
94
tx of advanced gastric cancer
total or partial gastrectomy if resection possible
95
tx of unresectable cancers
chemo or chemoradiation but poor prognosis
96
55 y/o presents with abdominal discomfort, bloating, belching, and distention for 4 weeks.
NO: early satiety, weight loss, dysphagia, odynophagia, recurrent vomiting, hematemesis, melena, hematochezia, shortness of breath, palpations, fatigue
LABS ARE NORMAL
what are you thinking?
dyspepsia
97
abdominal discomfort sometimes accompanies by bloating, belching, or abdominal distention
defines what disorder
dyspepsia
98
1st thing to look at with dyspepsi
AGE
99
if 60+ y/p with dyspepsia, what do you do
EDG and biopsy
PUD present - tx accordingly
if no evidence of organic disease, test for H. pylori and tx as necessary
100
how do you proceed with a pt less than 60 with symptoms of dyspepsi
ONLY perform EDG IF:
- - sig weight loss
- - overt GI bleeding
- - 2+ alarm features
- - rapidly progressive alarm features (progressive dysphagia in 2 weeks)
101
Dyspepsia alarm features
unintentional weight loss
progressive dysphagia
odynophagia
unexplained iron def anemia
persistent vomiting
palpable mass or lymphadenopathy
family hx of upper GI cancer
(if pt less than 60, has 2+ of these symptoms OR rapidly progressing symptom, do EGD)
102
if pt is less than 60, no alarm features, how do you proceed
H. pylori testing as indicated
103
pt is less than 60, no alarm features, so you do H. pylori test and it is positive, what do you do?
you tx H. pylori with quadruple tx
then you do urea breath test to confirm eradication
if neg - then you tx with trial of PPI
if PPIs do not work and symptoms persist, consider EGD
