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X Clin Med III Exam I > Peptic Ulcers and Gastric Cancer > Flashcards

Peptic Ulcers and Gastric Cancer Flashcards

1
Q

Where does gastrin come from?

A

G cells in the antrum

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2
Q

What does gastrin do?

A

Act on parietal cells to increase acid and pepsinogen and also increases motility
Stimulated by distention and peptides and amino acid in the stomach
Inhibited by decreased pH (<2) and PGs

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3
Q

What is a peptic ulcer?

A

Defect in the gastric or duodenal mucosa that extends through the muscularis mucosa into the deeper layers of the wall

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4
Q

1 cause of GI bleed

A

Peptic ulcers

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5
Q

Etiology of PUD

A 
#1 is helicobacter pylori
#2 is NSAIDs
Also non-NSAID and non-H pylori
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6
Q

What factors do not cause ulcers but can make them more difficult to heal?

A

Emotional stress, alcohol, spicy foods, caffeine and tobacco

some foods may cause dyspepsia but do not cause ulcer disease

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7
Q

What might a pt with h pylori be predisposed to?

A

Gastric cancer

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8
Q

Why is h pylori decreasing in developed countries?

A

Improved hygiene and decreased transmission
Correlates with decline in PUD
Increased rates of eradication

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9
Q

What does h pylori look like?

A

Gram negative rod
Motile flagella used to attach to mucosa
-disrupts protective properties by decreasing gastric mucus and mucosal bicarbonate secretion

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10
Q

Virulence factors of H pylori

A

Flagella
Urease (hydrolyze gastric urea to form ammonia to neutralize acid to penetrate)
Adhesins
Causes inflammation (cause G cells to secrete gastrin and increase HCl)

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11
Q

How is h pylori transmitted?

A

Oral-oral or fecal-oral to get to stomach

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12
Q

Why are NSAIDs not good for PUD?

A

They inhibit COX1 and 2 so there is no production of PGE2 which is important for a good environment in the stomach (stimulates mucin and inhibits gastrin to promote epithelial cell proliferation)

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13
Q

Factors that increase risk of PUD with use of NSAIDs

A 
Prior history of PUD/ulcer complications
Presence of H pylori infection
Age >75
Increased dose, time and duration
Concomitant use of steroids, other NSAIDs, anticoagulants, low dose ASA, SSRI and alendronate
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14
Q

Build up of what leads to formation of peptic ulcers?

A

H pylori
Gastric acid
Pepsin
NSAIDs

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15
Q

What are some protective factors of gastric mucosa?

A

Bicarbonate
PGs
Mucus production
Blood flow to mucosa

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16
Q

Most common sxs of PUD

A

Most are asymptomatic and of those that are symptomatic, they will have abdominal pain/ discomfort (burning/gnawing pain)

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17
Q

Other sxs of PUD

A

Belching, bloating, distention (dyspepsia-indigestion)
N/v, early satiety
Complications that cause hematemesis, melena, fatigue, dyspnea

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18
Q

Classic sxs of gastric ulcers

A

Pain worse after meals (30 min-1 hr)
Vomiting common
More likely to hemorrhage and cause hematemesis
Weight loss/ anorexia

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19
Q

Classic sxs of duodenal ulcers

A

Pain relieved by meals and worse 2-3 hrs after meal
Vomiting is uncommon
Less likely to hemorrhage but if does then melena
Weight gain

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20
Q

Alarm sxs of PUD

A 
Bleeding (hematochezia is bad b/c these are upper and bleeding so fast that can't be digested)
Unexplained iron deficiency anemia
Early satiety
Unintentional weight loss
Progressive dysphagia/odynophagia
Acute onset of intense upper abd pain
Persistent vomiting
Family hx of upper GI cancer
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21
Q

Most common complication of PUD

A

Bleeding/ hemorrhage

others are perforation, penetration and gastric outlet obstruction

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22
Q

Tx for bleeding due to PUD

A

Stabilize with IV fluids or PRBCs, start IV PPI and perform upper endoscopy/EGD (first thing you do after stabilize)

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23
Q

Standard tx to stop bleeding in PUD

A

Thermal coagulation
Hemoclip placement
Injection therapy

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24
Q

Presentation of perforation from PUD

A

Severe, diffuse, abdominal pain, tachycardia, weak pulse and n/v (may become board-like abd rigidity)

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25
Diagnosis for perforation
H & P | Upright chest and abd x-rays (maybe CT scan to localize)
26
Tx for perforation
``` Stabilize with IV fluids NG tube or NG suction for gastric decompression IV PPI Broad spectrum abx Surgery is definitive ```
27
What is contraindicated if you suspect a perforation?
UGI with barium
28
What will be seen on CXR with perforation?
Free air under diaphragm
29
What is a penetration related to PUD?
Penetration of ulcer through bowel wall without free perforation and leakage of luminal contents into peritoneal cavity (goes into surrounding structure)
30
Most common adjacent structure penetrated
Pancreas
31
Presentation of PUD penetration
Sxs change due to involvement of other affected structures | -Pain without meal association, more intense pain, pain referral to back
32
What causes gastric outlet obstruction?
Scarring/ fibrosis or inflammation/edema in pyloric channel
33
Presentation of gastric outlet obstruction
Vomiting, early satiety, bloating, epigastric pain, weight loss, anorexia
34
Tx for gastric outlet obstruction
See dilated stomach on imaging | Stabilize with IV fluids, NG tube, gastric decompression, IV PPI
35
What to do if failure of medical tx for gastric outlet obstruction?
Consider EGD with endoscopic balloon dilatation or surgery
36
What might be seen on the abd exam for PUD?
Epigastric tenderness RUQ tenderness Peritoneal signs Succussion splash
37
Vital signs that might be seen in PUD
Hypotension and tachycardia
38
Rectal exam in PUD
Melena in rectal vault Hemoccult positive stool Bright red blood per rectum
39
What is succession splash? | What does it test for?
Stethoscope on upper abdomen and rock hips of pt--the retained gastric material creates a splash sound (when it is greater than 3 hrs after a meal) and indicated hollow viscous full of fluid and gas Shows gastric outlet obstruction
40
Gold standard to diagnose PUD
EGD (clean white base in ulcer crater with no bleeding) | -other option is upper GI
41
Options for diagnostic testing of H pylori
Urea breath test* Fecal antigen test* Serology Biopsy during EGD (most sensitive and specific
42
What is urea breath testing?
Identifies h pylori bacteria in the stomach to show an active infection or to determine eradication Pt drinks radioactively labeled urea (urease is produce by bacteria so it splits urea in CO2 and NH3) and then measure labled CO2 on breath
43
What is the fecal antigen test?
Identifies antigen in feces to show active infection and can determine H pylori eradication
44
What must the pt do before urea breath test or fecal antigen test?
Discontinue PPI 2 wks prior and bismuth/abx 4 wks prior
45
How does serology work for PUD?
Identifies IgG antibodies to H pylori bacteria High false positive due to seeing anything from a prior infection Not recommended
46
Steps for PUD tx
Stop exacerbating stuff obvi 1- eradicate h pylori if present and confirm eradication 4 wks after 2- if h pylori is absent or sxs persist after step 1, treat with PPI for 4-8 wks 3- if still sxs, tricyclic antidepressant for 8-12 wks 4- if still sxs, 4 wks of prokinetic 5- if still sxs, perform an EGD
47
Standard h pylori tx in US
Bismuth quadruple therapy x 14 days (PPI, bismuth, tetracycline and metronidazole)
48
What is zollinger-ellison syndrome?
Gastrinomas in duodenum or pancreas hypersecrete gastrin
49
When is ZES seen more?
Sporadically mostly but can be part of MEN1 | More in men
50
Presentation of ZES
``` Recurrent PUD (often distal to duodenal bulb) Abd pain and diarrhea (steatorrhea) ```
51
How to diagnose ZES
Fasting serum gastrin >1000 pg/ml Gastric pH <2 Secretin stimulation test CT abdomen to localize tumor
52
Tx of ZES
PPIs or H2 blockers
53
Risk factors of gastric cancer
GASTRIC ULCERS, polyps and intestinal metaplasia Dietary (high salt with few veggies) Alcohol and tobacco CHRONIC h pylori infection
54
Presentation of gastric cancer
Asymptomatic early on Weight loss, persistent abd pain, early satiety, nausea, anorexia, dysphagia, gastric ulcer history, occult GI bleeding Late: palpable stomach mass, succession splash, paraneoplastic syndromes
55
Diagnostics for gastric cancer
EGD (grading and differentate stomach and esophageal) | UGI second
56
Most common type of gastric cancer
Adenocarcinoma
57
How might you see early gastric cancer on EGD?
Subtle polypoid protrusion, superficial plaque, mucosal discoloration, depression or ulcer
58
How do you stage stomch cancer?
``` 0 is just in mucosa 1 goes to submucosa 2 goes into muscle 3 is deeper 4 goes all the way through serosa and out ```
59
What is virchow's node?
Most specific sign for gastric cancer metastasis | Left supraclavicular lympn node
60
What are 2 other signs of metastatic gastric cancer?
Sister mary josephs node (periumbilical) | Left axillary node (irish)
61
Tx for early gastric cancer
Endoscopic mucosal resection (this is very rare though because most are found when advanced)
62
Tx for more advanced gastric cancer
Total or partial gastrectomy if resection is possible
63
Tx for unresectable gastric cancer
Chemo or chemoradiotherapy

X Clin Med III Exam I (5 decks)

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