Stomach and Duodenum Disease

Question 0

Gastric ulcer

Answer 0

Aggravated by eating

Nausea and weight loss

Question 1

H. pylori

Answer 1

Dx: Breath test, Fecal antigen test, Upper endoscopy (best method)- biopsy urease test/ histologic identification of organisms (gold standard)

Question 2

Duodenal ulcer

Answer 2

Pain relieved by eating
Pain returns 90mins- 3hrs after eating
Associated with weight gain
Interrupts sleep (at night)

Question 3

Types of Gastric ulcer

Answer 3

Type1- located at the body of the stomach
Type2- gastric + duodenal ulcer
Type3- pre-pyloric area
Type4- located near the area of the cardia

Question 4

Management of PUD

Answer 4

Stop NSAIDs use (if ulcer is >5mm, add PPI. otherwise, lower the dose of NSAIDs)- (prophylaxis of NSAIDs induced PUD- Omeprazole/ Misoprostol)
Acid neutralization- Antacids, H2 antagonist, PPI, Mucosal protective agents (Sucralfate)
H. pylori eradication- PPI + Clarithromycin + Amoxicillin/ Metronidazole

Question 5

Predictors for adverse outcome of Bleeding PUD

Answer 5

• Hemodynamic instability on presentation
• Hematochezia
• Bright red blood in nasogastric tube
• > 60yo
• ongoing transfusion requirements
• underlying medical illnesses

Question 6

Gastric Outlet Obstruction (GOO)

Answer 6

Prolonged vomiting-> loss of chloride and sodium-> Hypokalemic hypochloremic metabolic alkalosis-> Intracellular K+ shifts to extracellular thus serum K+ is increased factitiously.

Surgical options

• Billroth1 (gastroduodenostomy)
• Billroth2 (gastrojejunostomy)

Question 7

Perforation of PUD

Answer 7

“Board-like” abdomen
Pneumoperitoneum on upright CXR

Tx: Omental patching

Question 8

Classification of Chronic Gastritis by SITE

Answer 8

TypeA- autoimmune gastritis; fundus and body-predominant (antral sparing). Associated with pernicious anemia
TypeB- H. pylori related (more common); antral-redominant (may lead to pangastritis)

Question 9

Classification of Chronic Gastritis by Histology

Answer 9

Superficial gastritis- inflammatory cells up to lamina propria, intact gastric glands
Atrophic gastritis- infiltrates deeper to the mucosa with glandular distortion/ destruction. Paucity of inflammatory cells. Thin mucosa (blood vessels are visible)

Question 10

Gastritis

Answer 10

Made worse by meal.
Tx: Antacids, H2 Blockers, PPI, Stop NSAIDs.
-Treatment for H. pylori is not routinely recommended unless PUD is present.

Question 11

Stress Related Gastric Mucosal Damage

Answer 11

Prophylaxis required with following conditions present..

• Coagulopathy
• Mechanical ventilation > 48hrs
• CNS trauma
• Significant burns
• Organ transplantation

Prophylaxis- Continuous drip H2 blocker, titrate the intra-gastric pH to 4.

• History of PUD
• Multi-organ failure
• Major trauma
• Major surgery

Question 12

Zollinger-Ellison syndrome

Answer 12

-recurrent PUD, who are negative for H. pylori and who dont take NSAIDs.
Dx- serum gastrin level- fasting >1000pg/ml
Best imaging technique- Somatostatin receptor scintigraphy or Endoscopic ultrasonography

Question 13

Gastrinoma Triangle (ZE syndrome)

Answer 13

Bordered by the junction of the cystic duct and the CBD, the junction of the 2-3rd portion of the duodenum, and the body of the pancreas.
-most likely area the gastrinoma is found.

Question 14

Delayed Gastric Emptying

Answer 14

Most important cause is diabetic gastroparesis.

Tx: Dietary (more liquids than solids), Metoclopramide, Surgical, Gastric pacemaker.

Question 15

Gastric adenocarcinomas

Answer 15

Intestinal type: glandular structures, hematogenous spread,

Diffuse type: poorly differentiated, transmural/lymphatic spread, linitis plastica (worse prognosis),

Dx: CBC (to identify anemia), Electrolyte panels and liver function tests.

Tx: Gastrectomy (5cm surgical margin proximally and distally to the primary lesion is made)