Stomach Disease Flashcards
1
Q
What is Peptic Ulcer Disease?
A
- Break in the lining of the gastrointestinal tract, extending through muscular layer of the bowel wall. May technically appear anywhere in the GI tract.
- Most often located on:
- Lesser curvature of the Proximal Stomach
- First part of Duodenum
2
Q
What is the pathophysiology of Peptic Ulcer Disease?
A
Ulceration happens when there is an overwhelming presence of a noxious substance or when natural barriers are impaired. This is due to presence of:
- H.Pylori
- NSAIDS
- High alcohol intake
- Steroid use
- Foreign body ingestion e.g batteries or Zollinger-Ellison syndrome
3
Q
What are clinical features of Peptic Ulcer Disease?
A
- Epigastric Pain
- Nausea
- Hisotry of NSAID use
- Gastric ulcer present with epigastric pain exacerbated by eating, nausea/vomiting and weight loss
- Duodenal ulcer may present with epigastric pain that is worse hours after eating or when fasting and often relieved by eating
- Some patient may present with complications such as bleeding, perforation, or gastric outlet obstruction.
4
Q
How can peptic ulceration result in Malaena?
A
- Ulceration can result in erosion into the blood vessels supplying the upper GI tract.
- More severe if ulcer erodes through posterior gastric wall into the gastroduodenal artery. Blood occurs with any artery.
5
Q
What are investigations undertaken for Peptic Ulcer Disease?
A
- OGD can identify peptic ulceration and also allow for biopsies to be taken which are sent for histology and rapid urease CLO test.
- Full blood count is often warranted in suspected cases to assess anaemia
- For patient not requiring OGD but not responding to initial conservative management, non-invasive H. Pylori testing, after patients stop treatment 2 weeks prior to investigation, required which will be either
- Carbon-13 urea breath test
- Serum antibodies to H. Pylori
- Stool antigen
6
Q
What is the medical management of Peptic Ulcer Disease?
A
- Conservative
- Lifestyle advice to reduce symptoms such as smoking cessation, weight loss and reduction in alcohol consumption.
- Avoidance of NSAIDs where possible
- PPI after initial conservative management for 8 weeks to reduce acid production if negative for H. Pylori.
- If positive for H.Pylori, Triple Therapy started
- Lansoprazole
- Clarithromycin
- Amoxicillin
7
Q
What is the the surgical management of Peptic Ulcer disease? Classifical findings of Zollinger-Ellison syndrome?
A
- Surgical Management is rare except in emergencies or management of Zollinger-Ellison Syndrome.
- Zollinger-Ellison syndrome refers to triad of
- Severe peptic ulcer disease
- Gastric acid hypersecretion
- Gastrinoma.
- Characteristic finding is fasting gastrin level of >1000 pg/ml
- 1/3 are part of Multiple Endocrine Neoplasia type 1 syndrome.
- Zollinger-Ellison syndrome refers to triad of
- In severe or relapsing disease, either partial gastrectomy or selective vagotomy may be considered
8
Q
What are complications of Peptic Ulcer Disease?
A
- Perforation
- Haemorrhage
- Pyloric Stenosis
Requires injections of adrenaline and cauterization of bleeding.
9
Q
What are types of gastric cancers?
A
- Majority arises from the gastric mucosa as Adenocarcinomas.
- Remainder are mixture of connective tissue, lymphoid or neuroendocrine malignancies.
10
Q
What are risk factors for Gastric Cancers?
A
Risk factors are:
- Male
- H.Pylori infection
- Increasing age
- Smoking
- Salt in diet
- Heavy alcohol consumption
- Positive family history
- Pernicious anaemia
- Chronic gastritis
- Low fibre diet
11
Q
What are clinical features of Gastric Cancers?
A
Vague and non-specific symptoms with patient presenting at an advanced stage:
- Dyspepsia
- Dysphagia
- Nausea
- Vomiting
- Melaena
- Haematemesis.
12
Q
What are examination findings seen for Gastric Cancers?
A
- Evidence of anaemia
- Jaundice
- Hepatomegaly
- Acanthosis nigricans,
- Trosier’s sign (enlarged Virchow’s node)
- Palpable epigastric mass.
Diagnosed via urgent pathway in 40% of patients
13
Q
What are investigatory tests undertaken for Gastric Cancers?
A
- Urgent routine bloods
- Full blood count
- Liver function tests.
- CEA is a marker of gastric malignancy
- Imaging
- Urgent GI endoscopy for direct visualisation of any malignancy present and subsequent biopsies taken. Biopsies sent for:
- Histology for classification and grading of neoplasia
- CT scan may show thickening of gastric wall but does not allow direct visualisation or biopsy hence OGD only definite means.
- For staging CT Chest-Abdomen-Pelvis and a staging laparoscopy. TNM staging used most commonly
- Urgent GI endoscopy for direct visualisation of any malignancy present and subsequent biopsies taken. Biopsies sent for:
- CLO test for presence of H.Pylori
- HER2/Neu protein expression allows for targeted monoclonal therapies
14
Q
How are Gastric Cancers managed?
A
- Discussed at a specialist upper GI cancer multi-disciplinary team meeting.
- Ensuring adequate nutrition is essential and challenging in patients. Each patient should undergo nutritional assessment and seen by dietician if necessary. Many patients need formal nutritional support via NG or RIG tube pre or post treatment
- Curative treatment is Surgery.
- Patient fit enough offered peri-operative chemotherapy. Aim is to achieve loco-regional control by removing the tumour and its local lymph nodes.
- Types of operations are Total gastrectomy for proximal gastric cancer and subtotal gastrectomy for distal gastric cancers
- Patient with T1a tumours offered an endoscopic mucosal resection. Can only be sued in early tumours due to risk of local lymph node invasions in tumours that have invaded beyond the muscularis mucosae. Rarely used.
15
Q
How are Gastric Cancer palliatively managed?
A
- Most patient offered due to extent of disease at presentation.
- May include chemotherapy, best supportive care, stenting for obstruction or palliative surgery
- Surgical palliative care is best used when stenting fails or is not available yet can also be used cautiously in palliation of bleeding gastric tumours
