stomach and duodenum - peptic ulcer Flashcards
what is upper area of stomach called
fundus
where is food broken up in the stomach
body and antrum
what are the 3 layer of the stomach
- outer longitudinal
- inner circular
- innermost oblique layers
what is the pyloric sphincter made up of
thickening of the circular muscle layer
what does the mucosa of the upper two thirds of the stomach contain
- parietal cells
- chief cells
what do parietal cells secrete
hydrochloric acid
what do chief cells secrete
pepsinogen
what does the antral mucosa secrete
bicarbonate
what do G cells secrete
gastrin
what is somatostatin
a suppressant of acid secretion
produced by D cells
what is the mucus made up of
glycoproteins called mucin
do prostaglandins stimulate or inhibit secretion of mucus
stimulate
what inhibit prostaglandins
- aspirin
- NSAIDs
is acid essential for digestion
no
but it prevents some food-borne infections
what do acetylcholine and gastrin release
histamine via enterochromaffin cells
what does somatostatin inhibit
histamine and gastrin release
what are the 3 phases of acid secretion
- cephalic
- gastric
- intestinal
what is cephalic phase
thought, sight and smell of food stimulate the vagus, producing acetylcholine
what is gastric phase
distension of food directly stimulates secretory cells and gastrin release
what is intestinal phase
passage of food into duodenum stimulates GI hormone release
what do osmoreceptors in duodenal mucosa control
gastric emptying by local reflexes and release of gut hormones
what does intraduodenal fat do to gastric emptying
delays it
by negative feedback
what is gastritis
inflammation associated mucosal injury
what does gastropathy indicate
epithelial cell damage and regeneration without inflammation
what is most common cause of gastritis
H.pylori
what can chronic inflammation due to H.pylori lead to
gastric intestinal metaplasia, precursor to gastric cancer
where does autoimmune gastritis affect in the stomach
fundus and body
what does autoimmune cause loss of
parietal cells
what is gastropathy caused by
- irritants
- bile reflux
- chronic congestion
what is helicobacter pylori
gram-negative
what does H.pylori play a major role in
- gastritis
- peptic ulcers
where is H.pylori found
in gastric pits
when is H.pylori usually acquired
childhood
what factors increase duodenal ulceration
- increased gastrin secretion
- smoking
- bacterial virulence
- genetic susceptibility
what are gastric ulcers associated with
gastritis
what does gastritis cause loss of
- parietal cells
- acid production
what is a peptic ulcer
break in the superficial epithelial cells penetrating down to the muscular mucosa
where can peptic ulcers occur
stomach or duodenum
what are characteristics of peptic ulcer
- fibrous base
- increase in inflammatory cells
what are erosions
superficial breaks in mucosa alone
where are duodenal ulcers usually found
in duodenal cap
where are gastric ulcers usually found
lesser curve near incisura
what are more common duodenal ulcer or gastric ulcers
duodenal
who are common to get peptic ulcers
elderly
symptoms of peptic ulcer
- recurrent, burning epigastric pain
- nausea
- vomiting
- anorexia
- weight loss
when does duodenal pain occur
at night - worse when hungry
how is pain for peptic ulcers relieved
by antacids
what does back pain with peptic ulcers suggest
penetrating posterior ulcer
how to diagnose H.pylori
- serological tests
- C-urea breath test
- stool antigen
- biopsy urease test
- histology
- culture
what does serological test for H.pylori detect
IgG antibodies
- can be found in saliva
what is the most reliable test for H.pylori
urea-breath test
what happens if H.pylori is present what happens
the urease enzyme that the bacteria produce splits the urea to release ammonia
what must you rule out first in patients with peptic ulcers in older people
you must exclude cancer before starting eradication therapy
what is the treatment for peptic ulcer
H.pylori eradication
what are the H.pylori eradication medications
- omeprazole + clarithromycin + amoxicillin
- omeprazole + metronidazole + clarithromycin
how long is treatment for H.pylori eradication
2 weeks
what should be used for clarithromycin resistance
bismuth chelate
metronidazole
tetracycline
PPI
what should be done to check for eradication
breath or stool test should be performed
6 weeks after end of treatment
what should strongly be encouraged to be stopped for a peptic ulcer
smoking
how does smoking have a negative effect on peptic ulcer healing
it slows mucosal healing
what perforates more duodenal or gastric ulcers
duodenal
what is usually performed to close perforations
laparoscopic surgery
what are 2 other H.pylori associated diseases
- gastric adenocarcinoma
- gastric B-cell lymphoma
what is another name for gastric B-cell lymphoma
MALT
who is more likely to get adenocarcinoma women or men
men
what is the flow chart for H.pylori infection to gastric carcinoma
- H.pylori infection
- acute gastritis
- chronic active gastritis
- atrophic gastritis
- intestinal metaplasia
- dysplasia
- advanced gastric cancer
is smoking associated with increased stomach cancer
yes
what is a risk factor for gastric carcinoma
anaemia
where is early gastric cancer confined to
mucosa or submucosa
what are the 2 major types of gastric cancer
- intestinal
- diffuse
is intestinal differentiated or undifferentiated
differentiated
- well formed glandular structures
what do intestinal cancer look like
polypoid or ulcerating lesions with heaped-up rolled edges
what patients usually get intestinal gastric cancer
patents with atrophic gastritis
is diffuse gastric cancer differentiated or undifferentiated
undifferentiated
what has a worse prognosis intestinal or diffuse
diffuse
symptoms of gastric cancer
- epigastric pain (similar to that of a peptic ulcer)
- nausea
- anorexia
- weight loss
- vomiting
- anaemia
when does dysphagia occur in gastric carcinoma
when it involves the fundus
where can gastric carcinoma metastases to
- bone
- brain
- lung
diagnosis of gastric carcinoma
- gastroscopy
- CT
- endoscopic ultrasound
- PET
what does gastric carcinoma look like on gastroscopy
- allows biopsies
- diffuse type gastric caner infiltrates submucosa and muscular propria so can be undetected
CT scan of gastric carcinoma shows
- gastric wall thickening
- lymphadenopathy
- lung and liver secondaries
endoscopic ultrasound of gastric carcinoma
- staging
- depth of penetration of the cancer through the gastric wall
- extension into local lymph nodes
is not needed to confirm
what classification is used for gastric carcinoma
TNM staging
what is TNM staging
T = tumour N = nodes M = metastases
staged 0-4
what kind of survival do the following have
T1N0M0, T1N1M0 or T2N0M0
88% 5 year
what kind of survival do the following have:
T1N2M0, T2N1M0 or T3N0M0
65% 5 year
what kind of survival do the following have:
T2N2M0, T3N1M0 or T4N0M0, T3N2M0
35% 5 year
what kind of survival do the following have:
T4N1–3M0, TxN3M0 or TxNxM1
5% 5 year
what is treatment for early stage gastric carcinoma
non-ulcerated mucosal lesions can be removed endoscopically
what is the most effective treatment for gastric carcinoma
surgery
what is given for advanced gastric carcinoma
surgery combined chemoradiotherapy
what are the symptoms of GIST
- usually asymptomatic
but can ulcerate and bleed
what age does GIST usually affect
55-65
where do truly benign leiomyomas occur
mainly oesophagus
what kind of tumour is GIST
mesenchymal tumour
what is the origin of GIST
stromal
what do GIST share a common ancestor with
interstitial cells of Cajal
what mutations cause GIST
- proto-oncogene KIT
- platelet-derived growth factor receptor-alpha
what is preferred treatment for GIST
surgery
what drug is given for GIST
imatinib
what is imatinib
tyrosine kinase inhibitor
what is a primary gastric lymphoma
mucosa-associated lymphatic tissue (MALT)
what type of lymphoma are MALT
B-cell marginal zone lymphomas
what is primary site of MALT
lymph nodes
what are MALT due to
H.pylori
what age are people usually diagnosed with MALT
60
symptoms of MALT
- stomach pain
- ulcers
- localised symptoms
rarely have systemic complications
what is first treatment for MALT
H.pylori eradication
is prognosis good for MALT
yes
what can large polyps result in
anaemia or haematemesis
how to diagnose gastric polyps
endoscopic biopsies
what is treatment for gastric polyps
polypectomy
what is most common type of poly
hyperplastic polyp
what do cystic gland polyps contain
microcysts that are lined by fundic type parietal and chief cells
what cells secrete HCl
parietal cells
what secrete alkaline fluid
mucosal cells
who is most likely to get peptic ulcer men or women
men (middle-aged)
risk factors of peptic ulcer
- NSAIDs
- H.pylori infection
- smoking
- Zollinger-Ellison syndrome
what does dyspepsia describe
- epigastric comfort
- nausea and vomiting
- bloating and burping
what diseases is dyspepsia seen in
- peptic ulcer
- GORD
- gastric cancer
characteristics of pain in gastric ulcers
epigastric pain worsened by eating
how is the pain eased in gastric ulcer
by antacids and lying flat
how would rupture present in gastric ulcer
haematemesis
what is gastric ulcer associated with
gastric malignancy
characteristic of pain in duodenal ulcer
epigastric pain relieved by eating
how would rupture present in duodenal ulcer
rectal bleeding / malaena
what happens if ulcer perforates into abdomen
widespread peritonism (really bad)
if patient present with dyspepsia what alarm symptoms must ask about
- abdominal mass ?
- haematemesis ?
- rectal bleeding ?
- weight loss ?
what do you do if patient has alarm symptoms
scope and endoscopy
what are patients tested for one month after uncomplicated dyspepsia
H.pylori
how do you test for H.pylori
- breath test
- stool antigen
how is H.pylori treatment done
triple therapy
management of ruptured peptic ulcer
ABCDE
- admit for surgical management