Stomach Flashcards
GERD definition
Reflux of gastric content into esophagus- can be acidic or basic
Tx of GERD
PPI- makes the refluxate less acidic. Reglan- decreases episodes of reflux
What is LES comprised of and what is function?
LES- comprised of the circular esophageal muscles at the base of the esophagus- held in a state of tonic contraction until person swallows, and then open to allow contents to go from esophagus to stomach
Pathologic reflux is defined by…
SYMPTOMS- more than 2-3 episodes of heartburn requiring medicine a week, and DIAGNOSTIC TESTING- DeMeester score above 14.7 on pH probe testing
GERD often associated with…
hiatal hernia
Most common symptom of GERD
heartburn
Regurgitation of undigested food characteristic in..
Zenker’s or achalasia
Patient presents with heartburn, epigastric, substernal pain, a burning/stinging sensation. Regurgitation of digested food. Pain does not radiate to back. Patient describes symptoms as “water brash.” Other symptoms include coughing, aspiration, and occasionally wheezing. Likely diagnosis?
GERD
Water brash
Excessive salivation accompanying episodes of reflux
3 types of hiatal hernia
Type I (sliding), Type II (rolling or paraesophageal), Type III (mixed)
HH Type I
Ge junction is intrathoracic
HH Type II
GE junction is intra-abdominal, but viscera can herniate into the thorax
HH Type III
GE junction and viscera are displaced
Questions about dysphagia to ask to patient with GERD
Difficulty with swallowing solid vs. liquid. Often dysphagia to solid comes first, with mechanical obstruction.
Patient with GERD that has dysphagia to liquids and solids equally often associated with…
neuromuscular disorder
Cause of obstruction in patients with GERD
peptic stricture
GI disorder that is a common cause of asthma in adults
GERD
Test recommended to all patients over 40 with GERD or in anyone who does not respond to therapy
EGD
Tx for hiatal hernia and GERD
double dose PPI for 6 weeks, follow up, check for anemia, lifestyle modification
If GERD patient with no response to PPI, …
evaluate for other causes of pain- angina, cholelithiasis, PUD
Major cause of duodenal and gastric ulcers
H. pylori
How does H. pylori protect itself form acidic stomach environment
Lives in submucosa of stomach- protection from acid and antibiotics. Also, produces urease, which cleaves urea into bicarbonate and ammonia, producing an alkaline environment for itself.
Non invasive vs. invasive diagnostic tests for H. pylori
Noninvasive- Urea breath test, fecal antigen, H. pylori serology. Invasive- rapid urease assay and H. pylori histology
Gold standard for determining if H. pylori present
H. pylori histology- tissue biopsy during EGD
Effect of H. pylori
Damage to stomach- inflammation- increased gastrin levels, increased acid- ulceration or neoplasm
Tx for H. pylori infection
Prevpac- Prevacid, Biaxin, amoxicillin or alternate regimens- 4 agents taken Q1D
Common causes of gastritis
most common-NSAIDS, H. pylori, alcohol. less often- viral infection, auto immune disorder, bile reflux, cocaine, poisons
Chronic gastritis is a risk factor for ..
gastric cancer
Gastritis has strong association with…
ulcer disease
Patient presents with nausea, loss of appetite, upper abdominal pain, melena, coffee ground emesis, fatigue. Dx?
Gastritis
You suspect gastritis..what to order in workup?
CBC, EGD to examine and biopsy mucosa, H. pylori testing to see if that is the cause, hemoccult testing
Gastritis tx
remove offending agent, treat infection, suppress the acid
Tx of stress gastritis
fluid resuscitation, replacement of blood, treatment of underlying condition, NG placement, PPI
Prophylaxis tx in stress gastritis
Double dose IV PPI’s, sucralfate 1 g q 6 hours per NG
Hypertrophic gastritis aka
Menetrier’s disease
hypertrophic gastritis associated with what other disorders
CMV infection in children and H. pylori infection in adults
Tx in hypertrophic gastritis
anticholinergics, acid suppression, H. pylori eradication, octreotide
Gastric ulcer and duodenal ulcer diagnosis
UGI, EGD, CBC
Patient presents with upper abdominal pain, which is often RELIEVED by food. Also has nausea/anorexia. Fatigue. History of NSAID use, alcohol use, and H. Pylori infection.
Gastric ulcer
Peptic ulcer disease can be either…
gastric or duodenal
What are the 2 requirements of duodenal ulcers?
Secretion of acid and pepsin, and H. Pylori infection OR NSAID ingestion
Tx of gastic ulcer and duodenal ulcer
Removal of offending agent, tx of infection, acid suppression, surgery if recurrent or complicated disease
3 criteria of ZES
Gastric acid (HCl) hypersecretion by parietal cells, severe peptic ulcer disease, and non-beta islet cell tumor of pancreas (gastrinoma)
Where are gastrinomas often located
Duodenal wall, pancrease, or regional lymph nodes
Patient presents with steatorhea and diarrhea. Labs show increased gastrin levels and decreased secretin levels. Patient also has Multiple endocrine neoplasia. Diagnosis?
Zollinger-Ellison Syndrome
Why do you see steatorhea and diarrhea in ZES?
Increased HCl in ZES which causes inactivation of lipase so breakdown of fat not occuring leading to fatty stools- steatorrhea. Increased HCL also causes hyperperistalisis–>diarrhea
You have 2 patients with ZES. One has mass in duodenum, other does not. Tx in each case?
If mass, resect it. If no mass or metastatic disease, give ppi to reduce acid output to less than 10 mmol/hr. check acid suppression every 3 months.
Name benign gastric polyps. Which is most severe?
Fundic gland polyp, hyperplastic polyp, adenomatous polyp- can develop into adenocarcinoma
When should you remove adenomatous polyp
remove surgically when greater than 2 cm.
Benign gastric neoplasms
Gastric polyps and ectopic pancreas
95% of all MALIGNANT gastric neoplasms are…
adenocarcinomas
Linitis plastica
Type IV gastric adenocarcinoma- involves entire stomach
Boorman’s classification
Type I-5 gastric adenocarcinomas. Type I- polypoid. Type II- ulcerating with elevated borders. Type 3- ulcerating with infiltration. Type 4- diffusely infiltrating
Virchow’s node
supraclavicular lymph node, indicative of gastric adenocarcinoma
Sister Mary Joseph’s node
Periumbilical node, indicative of gastric adenocarcinoma
Blumer’s shelf
peritoneal metastasis in the pelvis palpable on rectal exam
Patient presents with weight loss, vomitting, indigestion, dysphagia. PE shows palpable abdominal mass, supraclavicular and preumbilical lymph nodes. Blumer’s shelf, hepatomegaly, jaundice, ascites, cachexia. Dx?
Gastric adenocarcinoma
What is the problem with double contrast UGI in diagnosing gastric adenocarcinomas?
very accurate, but cannot separate benign from malignant ulcers
Diagnosis of gastric adenocarcinoma made by…
biopsy taken during EGD
gastric lymphoma tx
Chemo includes CHOP- cyclophosphamide, hydroxydaunomycin, oncovin, prednisone and radiation
Where does gastric sarcoma arise from?
mesenchymal cells. a GIST.
Dieulafoy’s lesion
large tortuous vessel in the submucosa
In which disorder would you see Borchardt’s triad?
gastric volvulus
Patient presents with sudden constant, severe pain, recurrent retching with little emesis, and inability to pass an NG tube. Dx?
Borchadt’s triad indicating gastric volvulus
Patient has nausea, vomiting, upper abdominal pain, early satiety, bloating. Sx are worse with eating. There is slow gastric empyting due to denervation. What are you concerned about?
Gastroparesis
Diagnosis of gastroparesis
EGD, UGI, gastric emptying study
Tx of gastroparesis
prokinetics including Reglan and erythromycin and surgery (feeding tube)
Types of bezoars
phytobezoar and trichobezoar
Which bezoar has an underlying psychiatric disorder
trichobezoar
Which bezoar usually has some underlying gastric motility disorder?
phytobezoar
