Peptic Ulcer Disease and Gastritis Flashcards
What are the 3 primary causes of peptic ulcer disease and what are the major risk factors for developing PUD?
3 primary causes of PUD: H. pylori infection, NSAID abuse, use and stress related gastric mucosal damage (shock, hypotension)
What are the risk factors for PUD?
- H. pylori infection
- NSAID use
- Gastric acid hypersecretion
- EtOH (increased susp. to HP)
- Smoking (alters gastric motility; increased oxygen free radicals)
- Ischemia
- Stress (sepsis, shock, mechanical ventilation)
What tests can be used to determine the presence of gastritis, H. pylori infection and other causes of PUD?
EGD (upper endoscopy) is the best single evaluation to establish gastritis (and PUD), H. pylori by biopsy! Stool antigen before and after treatment, antibody before, urea breath test before and after
Where do most H. pylori ulcers predominantly occur?
Most common place for ulcer is duodenum
What is the “gold standard” for diagnosing H. pylori and what other tests can be used to confirm this diagnosis?
x
How can its eradication be confirmed?
x
x
H. pylori - Resides primarily in antrum (is the initial portion of the pyloric part of the stomach. It is near the bottom of the stomach, proximal to the pyloric sphincter, which separates the stomach and the duodenum.), but can migrate proximally. Generally does not invade the epithelial cells. Cause 90% of duodenal ulcers and up to 80% of gastric ulcers. Only 15% of H.pylori infected pts develop PUD.
x
- Endoscopy: > 90% sensitivity
- Upper GI series 60-90% sensitivity
- H. pylori testing (endoscopic bx, serologic antibody, stool antigen testing) - A serum H pylori antibody would not be a good test with a peptic ulcer bc they might have had it before and they will still have the antibody
- Empiric trial of acid suppression for 2-4 wks and H.pylori testing ?
x
H. pylori testing
- HP antibody serology (previous or current infection)
- Histologically on biopsy
- Stool antigen test (sens./specificiy >90%)
- Urea breath test
- Re-test 4-6 weeks after Rx (prescription) for eradication
What treatments are available for the eradication of H. pylori as well as treatment of symptomatic gastritis? – don’t need to know doses
Helidac = metronidazole, tetracycline, bismuth subsalicylate +h2-antagonist (beta lactam allergic) or prevpac = lansoproazole (PPI), biaxin (clarithromycin) and amoxicillin
Treat H. pylori:
- Proton pump inhibitor bid + Amoxacillin 1.0 gm bid + clarithromycin 500 mg bid x 14 days (80-95% efficacy)
OR - Omeprazole 20 mg bid + Bismuth 2 tabs qid + tetracycline 500 mg qid + metronidazole 500 mg tid x 14 days (90-95% efficacy)
PUD treatment:
- Discontinue NSAIDS
- Treat for H. pylori if present
- Acid suppression
- Re-endoscope gastric ulcers to assess healing and r/o malignancy; duodenal ulcers do not need repeat endoscopy
- Quit smoking/drinking
- Surgery rarely needed
PUD Medical Therapies:
CHART
What are the major causes of gastritis?
H. pylori, NSAID abuse and stress related gastric mucosal damage, autoimmune gastritis, lymphocytic/eosinophilic gastritis, CMV
What are the 2 types of gastritis?
Type A – Atrophic Gastritis & Type B – Nonatrophic Gastritis
What type of vitamin deficiency can be caused by gastritis and where do they predominantly occur?
Macrocytic anemia with a vitamin b12 deficiency
Type A – Atrophic Gastritis
- Can be autoimmune vs multifocal gastritis
- Less common
- Can be associated with pernicious anemia
- Primarily involves fundus and body
- Spares antrum
- Can be associated with H.pylori, but not common
Type B – Nonatrophic Gastritis
- More common
- Generally associated with H.pylori
- Antral-predominant gastritis
- Can expand to involve entire stomach
Gastritis can be caused by irritation due to excessive alcohol use, chronic vomiting, stress, or the use of certain medications such as aspirin or other anti-inflammatory drugs. It may also be caused by any of the following:
Helicobacter pylori (H. pylori): A bacteria that lives in the mucous lining of the stomach. Without treatment the infection can lead to ulcers, and in some people,stomach cancer.
Pernicious anemia: A form of anemia that occurs when the stomach lacks a naturally occurring substance needed to properly absorb and digest vitamin B12.
Bile reflux: A backflow of bile into the stomach from the bile tract (that connects to the liver and gallbladder).
Infections caused by bacteria and viruses.
Treatment for gastritis usually involves:
Taking antacids and other drugs to reduce stomach acid, which causes further irritation to inflamed areas.
Avoiding hot and spicy foods.
For gastritis caused by H. pylori infection, your doctor will prescribe a regimen of several antibiotics plus an acid blocking drug (used for heartburn).
If the gastritis is caused by pernicious anemia, B12 vitamin shots will be given.
Eliminating irritating foods from your diet such as lactose from dairy or gluten from wheat.
Once the underlying problem disappears, the gastritis usually does, too.
What rare type of gastric cancer is associated with H. pylori infection that generally goes into remission with eradication of the organism?
MALT lymphoma (abnormal proliferation of B-lymphocytes)
Associated with gastric cancer
– Adenocarcinoma
– MALToma (Mucosa Associated Lymphoid Tissue-oma) – goes into remission with eradication H. pylori
What is PUD?
Imbalance between aggressive and defensive factors in the gastroduodenal mucosa.
Factors:
H. pylori, NSAIDS, acid secretory abnormalities
How does a patient present with PUD?
- Deep, gnawing or burning pain in the epigastric region.
- Onset 1-3 hours after eating, awaken at night
- Relief with food
- Nausea with or without vomiting
What are the physical exam findings of a patient with PUD?
- Tenderness in RUQ/epigastrium
- Maybe peritoneal signs
How do we diagnose PUD?
- H. pylori testing (Breath test)
- CBC
- EGD with biopsy
What is the treatment for PUD?
- Lifestyle changes
- H. pylori therapy: Bismuth, metronidazole, tetracycline or amoxicillin, and omeprazole
- Antacids
- H2 blockers
- Proton pump inhibitors
Triple therapy: PPI or bismuth with two of the above antibiotics for 7-14 days.
What is Zollinger-Ellison Syndrome?
A gastrin producing tumor leads to refractory PUD
What are the clinical manifestations of Zollinger-Ellison Syndrome?
Same symptoms as with PUD
What are the expected significant lab results for Zollinger-Ellison Syndrome?
Labs
Elevated gastrin level
EGD: multiple ulcers
What is the treatment for Zollinger-Ellison Syndrome?
Proton pump inhibitors
Surgical resection
Gastric Neoplasms
Adenocarcinoma: Men > women, Never younger than 40 year old
Lymphoma:
- Stomach is common site for non-Hodgkin’s lymphoma
- Increase risk with H. pylori infection
What are the clinical manifestations of gastric neoplasms?
Dyspepsia, weight loss, occult bleeding, progressive dysphagia, postprandial vomiting
What is the treatment for gastric neoplasms?
- Surgery
- Chemotherapy
- Radiation therapy
