Stomach Flashcards
caused by
Medications (NSAIDs)
Alcohol
Stress from severe surgical/medical illness
Portal HTN
– no inflammation, but damage is present
erosive + hemorrhagic gastropathy
Usually asymptomatic or
Anorexia, epigastric pain, nausea, vomiting, no improvement or worsening w eating
Most common = upper GI bleeding (coffee ground emesis)
erosive + hemorrhagic gastritis
Vs PUD also has better or worse symptoms w eating
common with
Mechanical ventilation, coagulopathy, trauma, burns, shock, sepsis, CNS injury, liver failure, kidney disease, multiorgan failure, portal HTN
– alcoholics or critically ill patients
erosive + hemorrhagic gastritis
What is prophylaxis for stress erosive/hemorrhagic gastritis
early enteral feeding (like while critically ill), H2 receptor antagonist or PPI
What are alarm symptoms for erosive/hemorrhagic gastritis?
(severe pain, weight loss, vomiting, GI bleeding, anemia) → upper endoscopy
How do you treat erosive/hemorrhagic gastritis?
Stress → Tx: continuous PPI infusion (esomeprazole or pantoprazole) + sucralfate suspension, look for cause
NSAID → selective NSAIDs (celecoxib, etodolac, meloxicam) have less risk
Discontinue agent, reduce to lowest effective dose, take with food and PPI
Alcoholic → H2 receptor antagonists, PPIs, sucralfate
Portal HTN → propranolol or nadolol, decompressive procedures
What are the different types of histologic gastritis?
Pernicious anemia
- Decreased B12, decreased iron
Eosinophilic
Infectious
- From acute bacterial infection, viral from CMV, fungal. H pylori
H. pylori →
Acute = transient nausea + abdominal pain lasting for several days
Symptoms resolve then progress to chronic
Chronic = duodenal or gastric ulcers, gastric cancer, low-grade B cell gastric lymphoma
Pernicious anemia → associated with other autoimmune disorders, B12 deficiency, psychiatric changes, glossitis, anemia
Eosinophilic → anemia, abdominal pain, early satiety, postprandial vomiting
histologic gastritis
In who is h. pylori gastritis common
non whites + immigrants
anti-intrinsic factor and anti-parietal cell antibodies w/ elevated fasting gastrin levels supports —–
diagnosis for histologic pernicious anemia gastritis
H. pylori testing indicated w/
Active or past history of documented PUD
Gastric metaplasia
Gastric MALToma
Personal family history of gastric cancer
→ stool PCR (stop PPIs for 14 days and 28 days for abx)
→ endoscopy for biopsy
autoimmune biopsy in gastritis if
pernicious anemia at time of diagnosis
Every 3 years with advanced atrophic gastritis
How do you treat histologic gastritis?
H. pylori – eradication w/ antibiotics
eosinophilic – steroids
Postprandial nausea, vomiting, belching, early satiety, bloating, discomfort, pain
Reflux symptoms common
Chronic = weight loss +/- electrolyte disturbances
Nutritional + vitamin deficiencies
gastroperesis
Delayed gastric emptying not associated w/ obstructing structural lesion
– idiopathic, diabetic, postsurgical
gastroperesis
Succussion splash when auscultating while shaking abdomen from side to side for 1+ hour after eating
→ GCSI assesses severity
Imaging, upper endoscopy: rule out causes
Scintigraphy best
gastroperesis
What’s treatment for gastroperesis
Correct dehydration, malnutrition, nutritional deficiencies
Dietary modification (frequent, smaller, meals)
Pharmacologic motility: prokinetics, antiemetics, pain management
Treat underlying cause
Epigastric pain is hallmark - relieved with food or antacids
Nocturnal pain, nausea, anorexia
Dyspepsia “hunger-like” epigastric pain
– duodenal = relieved with food, antacids, acid suppressants, and worse before meals or 2-5 hours after, worse at night, awakening from sleep
– gastric = food-provoked
Vomiting and weight loss UNUSUAL
Most common cause of upper GI bleed
peptic ulcer disease
What are average ages for PUD?
Duodenum in bulb or pyloric channel in 30-55 years
Stomach in antrum or junction in 55-70 years
Break in gastric or duodenal mucosa
NSAIDs = gastric
Generally w/n first 3 months of therapy, >60, prior hx (lowering PROTECTION) worse with meals, 1-2 hrs
MC in old
Chronic H. pylori infection = duodenal (increasing DAMAGE)
Better with meals, worse 2-5 hours after
MC in young
Or CMV, acid hypersecretory, crohn’s, lymphoma, meds
peptic ulcer disease
a break in the gastric mucosa can be caused by –
NSAIDs
lowering PROTECTION
gastric ulcers are worse with –
meals, 1-2 hours after eating
more common in older patients
a break in the duodenum can be caused by –
h. pylori infection
increasing DAMAGE
Duodenal ulcers are better with –
meals, worse 2-5 hours after eating
more common in young
gold standard diagnosis for PUD is
upper endoscopy
duodenal ulcers are not —, while gastric ulcers need a biopsy
malignant
tests for h. pylori
fecal antigen or PCR w/ Hx of PUD (hold PPIs)
What does sudden onset diffuse abdominal pain, tachycardia, and abdominal rigidity in PUD indicate?
perforation
PE: normal or mild, localized epigastric tenderness to deep palpation
FOBT or FIT + in ⅓
Labs: ordered to exclude other causes
PUD
How do you treat gastric ulcers (NSAID made)
NSAID acid-antisecretory agents – PPIs (-prazole) or H2 receptor antagonists (-tidine)
Mucosal enhancers PRN to supplement antisecretory agents during first few days
How do you treat an active gastric ulcer?
Active ulcer = discontinue offending agent + start PPI therapy, test for h. Pylori
Consider risks and prevent! Oral PPI once daily when taking NSAIDs, lowest dose/time
How do you treat a duodenal ulcer?
Bismuth, tetracycline, PPI, metronidazole
need 2-3 antibiotics w/ PPI or bismuth w/ antibiotic susceptibility testing
How do you treat a duodenal PUD with an active ulcer?
Active ulcer = 14 days w/ eradication regimen followed by antisecretory agent (PPI or H2RA) for 2-4 weeks (d) or 4-6 weeks (g)
confirm eradication >4 weeks after completion w/ non invasive tests
Prevent recurrence w/ PPI
Projectile postprandial vomiting (2-4 weeks of age), blood streaked
Infants are hungry
Abdominal distention after feeding
pyloric stenosis
What predisposes someone to pyloric stenosis?
Babies – males
Erythromycin (macrolides)
First 3-12 weeks of life
Thickening of pyloric sphincter, hypertrophy and hyperplasia of pyloric muscles
pyloric stenosis
Oval mass in RUQ “olive sign”
Lab: hypochloremic alkalosis w/ potassium depletion
Dehydration = Hgb and Hct
US = hypoechoic muscle ring >4mm thickness w/ hyperdense center
Barium upper GI = retention of contrast; “string sign”
pyloric stenosis
How do you treat pyloric stenosis?
Pyloromyotomy
Treat dehydration + electrolyte imbalance
Post-op vomiting is common because of gastritis, esophagitis, reflux
90% will develop PUD - solitary and located in duodenal bulb
GERD symptoms
Diarrhea, steatorrhea, weight loss (nasogastric aspiration of stomach acid stops diarrhea), abdominal pain, heartburn
Zollinger-Ellison syndrome
fasting gastrin levels should be obtained in zollinger-ellison syndrome if
Ulcers refractory to standard therapy
Giant ulcers >2cm
Ulcers located distal to duodenal bulb
Multiple duodenal ulcers
Frequent recurrence
Associated w/ diarrhea
After surgery
Complications
H.pylori neg and not taking NSAIDs
Gastrin-secreting gut neuroendocrine tumors → hypergastrinemia + acid hypersecretion
In pancreas, duodenal wall (MC), lymph nodes, elsewhere
80% within “gastrinoma triangle”
25% associated w MEN 1 syndrome
zollinger-ellison syndrome
Elevated fasting serum gastrin (>150)
Discontinue meds before hand (H2 receptor antag for 24 hours, and PPI for 6 days)
Only if patient is stable + free from disease
IF elevated – measure gastric pH
FSG > 10x normal AND gastric pH<2 = confirm
→ secretion stimulation test can distinguish from other causes
zollinger-ellison syndrome
FSG ___ upper limit of normal and gastric pH ___ confirms diagnosis of Zollinger-Ellison syndrome
FSG >10x and pH<2
FSG <— rules out zollinger-ellison diagnosis
<100 pg/mL
When you confirm zollinger-ellison syndrome, what’s next?
Imaging to localize tumor – CT and MRI scans, full body gallium 68 PET/CT to find small ones
If negative → US
How do you treat metastatic zollinger-ellison syndrome?
If multiple metastases → initial therapy to control hypersecretion → oral PPI
Isolated hepatic metastases → surgical resection or cryoablation
Systemic therapy if metastatic = octreotide, tyrosine kinase inhibitors, peptide receptor radionuclide therapy
How do you treat localized zollinger-ellison syndrome?
Resect prior to hepatic spread!
Laparotomy to verify no metastasis
Surgery not recommended with MEN 1
Asymptomatic until advanced – dyspepsia, vague epigastric pain, anorexia, early satiety, weight loss
Ulcerating lesions = acute GI bleeding
Pyloric obstruction = postprandial vomiting
Lower esophageal obstruction = progressive dysphagia
gastric adenocarcinoma
What are RFs for gastric adenocarcinoma
Increasing age
Male sex
Non-white race
Smoking
H. pylori infection
intestinal gastric adenocarcinoma is more/less common
more – forms glandular structures and common in men, older people, from H. pylori infections
diffuse type gastric adenocarcinoma is common in
men and women and younger, worser prognosis and not as associated w/ h. Pylori, may be due to genetics
Lab:
Iron deficiency anemia
+ occult blood
Elevated AST if in liver
Circulating tumor markers (monitor treatment)
After diagnosis - preop eval with contrast CT of chest, abdomen, pelvis and EUS to delineate extent of tumor
→ PET or PET-CT for distant mets
gastric adenocarcinoma
Get an endoscopy –
Obtain in >60 years w/ new onset epigastric symptoms
Young patients with “alarm” symptoms
Biopsy needed - vertical
What are signs of metastatic spread of gastric adenocarcinoma
Left supraclavicular lymph node (Virchow)
Umbilical nodule (Sister Mary Joseph)
Rigid rectal shelf (Blumer)
Ovarian metastasis (Krukenberg)
How do you treat gastric adenocarcinoma
Surgical resection
Systemic chemo
Radiotherapy
Immunotherapy
Targeted therapy
Abdominal pain, weight loss, bleeding
Systemic symptoms
Diffuse gastric lymphoma
Systemic symptoms distinguish it from adenocarcinoma and localized lymphoma
Primary (gastric mucosa) - 95% being non-Hodgkin B cell lymphoma - or secondary (advanced nodal lymphomas
gastric lymphoma
Endoscopy → horizontal infiltration
Diagnosis established with biopsy
Test for h.pylori and EUS for depth
All need staging with CT of chest, abdomen and pelvis
gastric lymphoma
how do you treat gastric lymphoma
MALT-Type lymphoma
H. pylori eradication, radiation
Diffuse large b-cell lymphoma
Chemo, radiation (CHOP or r-CHOP)
What is gold standard for pyloric stenosis?
US
