Stomach Disorders Flashcards
1
Q
What is dyspepsia?
A
Indigestion, burning sensation, epigastric/upper abdominal pain, bloating/gas, nausea, early satiety (fullness)
2
Q
What is dysphagia?
A
Difficulty swallowing
3
Q
What is odynophagia?
A
Pain with swallowing
4
Q
What is an upper endoscopy/upper GI endoscopy/EGD?
A
Procedure using a thin scope w/ a light & camera at its tip to look inside upper digestive tract
5
Q
What does EDG stand for?
A
esophagogastroduodenoscopy
6
Q
What is GERD?
A
Condition that develops when there is reflux of gastric contents into the esophagus, causing sx or complications
7
Q
GERD is most commonly caused by what?
A
A functional or mechanical problem of the LES
8
Q
What can cause functional/mechanical problems w/ the LES?
A
Transient relaxation of LES or Hypotensive LES (<10 mmHg)
9
Q
Normal pressure of the LES?
A
10-35 mmHg
10
Q
Is GERD common?
A
Very, affects 20% of adults in Western culture
11
Q
Are men or women more effected by GERD?
A
Similar prevalence
12
Q
Do men or women tend to have higher complication rates from GERD?
A
Men
13
Q
Incidence of GERD increases with what?
A
Age (after 40)
14
Q
Some degree of reflux from GERD is what?
A
physiologic
15
Q
What is pathological reflux with GERD associated with?
A
Symptoms of mucosal injury
16
Q
How is GERD classified?
A
Based on appearance of esophageal mucosa on upper endoscopy
17
Q
Presentation of erosive esophagitis?
A
Visible breaks in distal esophageal mucosa w/ or w/o troublesome symptoms
18
Q
Presentation of non-erosive reflux disease (NERD)?
A
No visible esophageal mucosal injury w/ presence of troublesome symptoms
19
Q
Most common cause of GERD?
A
Transient relaxation of the LES
20
Q
How can hiatal hernias cause GERD?
A
The LES can be displaced above the diaphragm resulting in LES dysfunction
21
Q
How can obesity cause GERD?
A
Increased intra-abdominal pressure
22
Q
How does delayed gastric emptying cause GERD?
A
Contents remain in stomach longer due to gastroparesis or partial gastric outlet obstruction
23
Q
Which meds can cause GERD?
A
Anticholinergics, nitrates, CCBs, TCAs (tricyclic antidepressants), opioids, estrogen therapy, oral radiation therapy
24
Q
Which medical conditions can cause GERD?
A
Scleroderma, Sjogren’s syndrome, pregnancy
25
Most common clinical manifestation of GERD?
Heartburn (pyrosis) - postprandial, retrosternal, worsens in supine, relieved w/ antacids
26
Other clinical manifestations of GERD?
Regurgitation w/ cough, sore throat, sour taste in mouth
Atypical sx: hoarseness, chest pain, wheezing, globus sensation, enamel erosion
27
What must be ruled out in patients with atypical symptoms before diagnosing GERD?
Other disorders
28
Alarming symptoms with GERD?
Dysphagia, odynophagia, unexplained wt. loss, evidence of GI bleed, GI cancer in 1st degree relative, persistent vomiting, anorexia, new dyspepsia in >60 y/o, IDA (iron deficiency anemia)
29
When is GERD a clinical dx?
If simple, classic sx without any alarming red flags
30
When does GERD require further workup prior to dx?
Atypical/alarming sx
31
First line diagnostic test for persistent or alarming sx or complications w/ GERD?
Upper endoscopy w/ biopsy
32
Gold standard test for confirmation of GERD w/ atypical or persistent symptoms, or to monitor adequacy of tx?
24-hr ambulatory pH monitoring
(not necessary in pts w/ typical presentation & satisfactory tx response)
33
What does 24-hr ambulatory pH monitoring measure?
Amount of esophageal acid reflux
34
What test measures the pressure generated within the esophagus with swallowing?
Esophageal manometry
35
When is esophageal manometry useful?
-In pts with signs/sx of GERD that have normal endoscopy to rule out an esophageal motility disorder
-Prior to anti-reflux surgery to evaluate peristaltic function
-Ensuring ambulatory pH probes are placed correctly
36
Can esophageal manometry diagnose GERD?
No
37
Goal of GERD treatment?
Provide sx relief, heal esophagitis (if present), prevent complications
38
What is recommended for all patients with GERD?
Lifestyle/dietary modifications
39
How long should GERD patients keep their head elevated/avoid laying down after eating?
3 hours
40
Patients should avoid what kind of meals with GERD?
Late meals, trigger foods
41
What kind of garments should be avoided in GERD patients?
Tight fitting
42
How to promote salivation in GERD? What is the purpose of salivation?
Gum, lozenges
*helps neutralize refluxed acid/inc. rate of esophageal acid clearance
43
Which medication for mild/intermittent symptoms of GERD (<2 episodes/week), and without erosion/Barrett's?
Histamine 2 Receptor Antagonists (H2RA): Cimetidine, Famotidine, Nizatidine
44
Dosing of H2RAs for mild/intermittent GERD?
Start at low dose PRN, increase to standard BID dose if symptoms persist for minimum of 2 weeks
*concomitant antacids PRN can be used if sx occur <1x/week
45
If GERD symptoms continue even after increasing H2RA dose, discontinue and start which medication?
Once daily PPI at low-dose
If required for sx control --> inc. to standard dose
*once sx controlled, continue for at least 8 weeks
46
Which medication for moderate/severe symptoms of GERD (> or = 2 episodes/week), or if erosion/Barrett's present?
PPIs (pantoprazole, omeprazole, esomeprazole, lansoprazole, dexlansoprazole)
*standard dose once daily as initial therapy
47
Which treatment is suggested for those refractory to GERD medical therapy?
Surgical therapy w/ Nissen fundoplication (laparoscopic procedure to reinforce LES - fundus wrapped and sutured around back side of esophagus)
48
Other indications for Nissen fundoplication surgical therapy?
Hiatal hernia, GERD complications, noncompliant w/ meds, extra-esophageal symptoms
49
When should a patient with GERD be referred to a specialist?
-Typical/atypical GERD symptoms refractory to med therapy
-Alarming sx (significant dysphagia)
-Barrett's esophagus/suspicion w/ dysphagia or early muscoal cancer
-Needing upper GI endoscopy
-Considering for surgical fundoplication
50
Possible complications of GERD?
Esophagitis, strictures, Barrett's esophagus, esophageal adenocarcinoma
51
What is Barrett's esophagus?
Esophageal squamous epithelium is replaced by precancerous columnar cells from the cardia of the stomach
52
What is Barrett's esophagus a complication of?
Longstanding GERD
53
Which patients are commonly effected by Barrett's esophagus?
Middle aged white males
54
What the presentation of Barrett's esophagus similar to?
GERD
55
Diagnostic test for Barrett's esophagus?
Upper endoscopy w/ biopsy
56
Treatment for Barrett's esophagus is based on what?
Biopsy results
(often includes long-term PPI for GERD control)
57
Treatment for Barrett's esophagus with biopsy findings of metaplasia (Barrett's esophagus only)?
PPIs and surveillance (rescope w/ biopsy every 3-5 years)
58
Treatment for Barrett's esophagus with biopsy findings of low grade dysplasia?
PPIs and surveillance (rescope w/ biopsy every 6-12 months), or endoscopic ablation
59
Treatment for Barrett's esophagus with biopsy findings of high grade dysplasia?
Ablation w/ endoscopy, photodynamic therapy, endoscopic mucosal resection, radiofrequency ablation
60
How are gastritis and gastropathy differentiated?
Based on histological evidence of the presence or absence of mucosal inflammation due to gastric injury
61
What is Gastritis?
Superficial inflammation or irritation of the stomach mucosa with mucosal injury
62
What is Gastropathy?
Mucosal injury without evidence of inflammation
63
What mechanism causes gastritis/gastropathy?
Imbalance between aggressive and protective mechanisms of the gastric mucosa
64
Is Gastritis erosive or non-erosive?
Non-erosive
65
Is Gastropathy erosive or non-erosive?
Erosive: superficial, deep, or hemorrhagic erosions
66
Common causes of Gastropathy?
NSAIDs, ETOH, acute medical stress, portal HTN
67
Most common cause, and second most common cause of Gastritis?
MC: H. pylori
2nd MC: NSAIDs, Aspirin
68
Other causes of Gastritis?
Heavy ETOH, med conditions (portal HTN, pernicious anemia, bile reflux, ischemia, acute stress in critically ill pts, radiation, idiopathic, corrosives
69
Are most patients with Gastritis symptomatic?
No, most commonly asymptomatic
70
If patients are symptomatic for Gastritis, how would they present?
Similar to peptic ulcer disease: dyspepsia, gnawing/burning epigastric pain, N/V, signs of upper GI bleed if erosive gastritis (hematemesis, "coffee ground" emesis, melena)
71
What should be included in the physical exam for Gastritis?
Rectal exam for hemoccult testing
72
What diagnostic test establishes the diagnosis of gastritis?
Upper endoscopy with biopsy
73
What can be seen on an upper endoscopy for gastritis?
Thick, erythematous, mucosal erosions
74
What pathogen should be tested for with gastritis?
H. pylori
75
H. pylori tests for gastritis?
Urea breath test, H. pylori stool antigen (HpSA), serologic antibodies
76
What should be held for 1-2 weeks prior to gastritis H. pylori testing?
PPIs - can decrease sensitivity of tests
77
What test assesses for anemia or if bleeding is present with gastritis?
CBC
78
What other diagnostic tests should be ordered for gastritis?
LFTs, CMP, stool for blood
79
Management of gastritis?
Tx underlying cause, D/C offender (ex. NSAIDs), eradicate H. pylori
80
Treatments for gastritis is similar to what?
Tx for peptic ulcer disease
81
Treatments for gastritis?
-Acid suppression: H2RA or PPIs
-Hydration& electrolytes if persistent vomiting/dehydration
82
Prophylaxis for patients with high risk for developing stress-related gastritis?
IV PPIs or H2 blockers (H2RA)
83
What are peptic ulcers?
Defect in the gastric or duodenal mucosa that extends through muscularis mucosa & into deeper layers of the way
84
Classification of peptic ulcer defect?
An "ulcer" or "open sore" >5mm in diameter & can be located in gastric mucosa, duodenal mucosa, or both
85
Mechanism of peptic ulcer disease (PUD)?
Imbalance between gastritis mucosal protective and destructive factors
86
Mechanism of duodenal ulcer development?
Increased aggressive factors
87
Mechanism of gastric ulcer development?
Decreased protective mechanisms
88
Which ulcers are more common: gastric or duodenal?
duodenal (4x more common than gastric)
89
Which ulcers are often benign?
duodenal
90
Which ulcers are more common in younger patients (30-55 y/o)?
duodenal
91
Which ulcers are more common in older patients (55-70 y/o)?
gastric
92
What percentage of gastric ulcers are malignant?
4%
93
What are the two major causes of peptic ulcer disease?
1. H. pylori infection (MC)
2. NSAIDs (2nd MC)
94
Which digestive disorder accounts for 1% of PUD cases?
Zollinger-Ellison syndrome
95
Which medical conditions can cause PUD?
Crohn's, CMV, lymphoma, CKD, cirrhosis, stress: burns/trauma/surgery/severe medical illness
96
Certain medications that can cause PUD?
NSAIDs, alendronate
97
Lifestyle habits that can cause PUD?
ETOH, smoking
98
Can PUD be idiopathic?
Yes
99
What % of those with peptic ulcers are asymptomatic?
70%
100
Most common symptom of both gastric & duodenal ulcers?
Epigastric pain/dyspepsia
101
What % of patients with endoscopically diagnosed ulcers report epigastric pain?
80%
102
What is epigastric pain with peptic ulcers characterized by?
Gnawing or burning sensation after meals
103
Epigastric pain with PUD may have associated symptoms of what?
N/V
104
Which ulcers have dyspepsia that is relieved with food?
duodenal
105
Which ulcers have symptoms that are worse with food?
gastric
106
Which ulcers may have associated weight loss?
gastric ulcers
107
Duodenal ulcer dyspepsia can be relived with what (other than food)?
Antacids, acid suppressants
108
Are duodenal ulcer symptoms worse during the day or at night?
Night (nocturnal symptoms worse)
109
Clinical presentation of bleeding ulcers?
Hematemesis, melena (tarry stools from old blood), hematochezia (fresh blood in stool)
110
Clinical presentation of perforated ulcers?
Sudden onset, severe abdominal pain that may radiate to shoulder, signs of peritonitis: rebound tenderness/guarding/rigidity
111
Diagnostics for PUD?
CBC, upper endoscopy w/ biopsy, H. pylori testing, other labs per clinical suspicion
112
Purpose of CBC for PUD?
Check for anemia/bleeding, leukocytosis in acute GI perf
113
What is the diagnostic test of choice fort PUD?
Upper endoscopy w/ biopsy
114
All gastric ulcers require what?
Repeat upper endoscopy to document healing regardless of symptoms/if asymptomatic
115
Choice of H. pylori test for PUD depends on what?
Whether patient requires upper endoscopy for evaluation of sx or surveillance
116
Gold standard in diagnosis of H. pylori infection in PUD?
Upper endoscopy w/ biopsy
117
Non-invasive option in diagnosis of H. pylori infection in PUD?
Urea breath test
118
Which test for H. pylori infection in PUD is >90% specific, useful for dx, and confirming eradication post-therapy?
H. pylori stool antigen (HpSA)
119
Which test for H. pylori infection in PUD is useful in confirming infection but NOT eradication?
Serologic antibodies
120
Management of PUD?
Tx underlying cause, dietary/lifestyle modification (avoid ETOH, smoking)
121
All patients with PUD should be treated with what in order to facilitate ulcer healing?
PPIs
122
What do PPIs allow for people with PUD?
Quick symptom control, high ulcer healing rates, heals NSAID related ulcers rapidly and to greater extent than H2RAs
123
H. pylori + ulcer (uncomplicated) treatment?
PPI BID x 14 days + abx therapy
124
H. pylori + ulcer (uncomplicated) antibiotic choice if no abx resistance?
Triple antibiotic therapy: Clarithromycin & Amoxicillin + PPI
125
H. pylori + ulcer (uncomplicated) antibiotic choice if abx resistance?
Bismuth quadruple therapy: Bismuth, Metronidazole, Tetracycline + PPI
126
NSAID-associated ulcer treatment?
PPI for 4-8 weeks based on size of ulcer
127
Treatment for NSAID-related ulcers where patients need to remain on NSAIDs or ASA?
Maintenance PPI therapy (ex. omeprazole 20mg daily) can reduce risk of ulcer complications/recurrence
128
All patients with complicated ulcers (bleeding, perf, gastric outlet obstruction) should receive what therapy?
IV PPI until PO PPIs can be tolerated
129
Length of PPI treatment for complicated duodenal ulcers?
PPIs for 4-8 weeks
130
Length of PPI treatment for complicated gastric ulcers?
PPIs for 8-12 weeks
131
Don't d/c PPI therapy in gastric ulcers until what?
Only after ulcer healing has been confirmed by upper endoscopy
132
Treatment for Non-H. pylori & Non-NSAID induced uncomplicated duodenal ulcers?
PPI x 4 weeks
133
Treatment for Non-H. pylori & Non-NSAID induced gastric ulcers?
PPI x 8 weeks
134
What can be suggestive of a perforated duodenal ulcer on a CXR?
Air under diaphragm
135
What is Zollinger-Ellison Syndrome (ZES)?
A gastrin-secreting tumor resulting in hypersecretion of gastric acid,
"gastrinoma"
136
ZES can occur sporadically, or as a manifestation of what?
MEN1
137
What % of ZES cases are a manifestation of MEN1?
20-30%
138
45% of ZES is most commonly seen where?
Duodenal wall
139
25% of ZES is seen where?
Pancreas
140
5-15% of ZES is seen where?
Lymph nodes & other sites
141
Most patients with ZES are how old?
20-50 y/o
142
Is ZES more common in men or women?
Men
143
Patients with ZES may present with what?
Severe peptic ulcer disease: multiple peptic ulcers, refractory ulcers, abdominal pain
144
Other common symptoms of ZES?
Diarrhea, heartburn, weight loss, other complications of acid hypersecretion (bleeding, stricture, perforation)
145
Patients with which symptoms should have a high suspicion of gastrinoma?
Severe, recurrent, multiple, or refractory ulcers & diarrhea
146
>90% of patients with ZES also develop what?
Peptic ulcers (presence confirmed by upper endoscopy)
147
Best initial test for ZES?
Fasting serum gastrin levels & gastrin pH
148
Results of Fasting serum gastrin levels & gastrin pH with ZES?
Elevated fasting gastrin levels: >1000 pg/mL + gastrin pH <2
149
Results of a secretin stimulation test with ZES/gastrinomas?
Persistent gastrin elevations in gastrinomas
150
Why is are gastrin levels elevated by gastrinomas?
Usually gastrin release is inhibited by secretin, w/ gastrinomas it is persistently elevated
151
What can a secretin stimulation test help differentiate?
Gastrinomas vs. other causes of hypergastrinemia
152
When should a secretin stimulation test for ZES/gastrinomas not be performed?
While on PPI - false negative results
*RISKY TO D/C--> consult GI specialist
153
All patients with ZES should have which tests at the time of diagnosis and periodically thereafter?
Serum PTH, Ionized calcium levels, Prolactin levels
154
Goal of medical therapy with ZES?
Limit clinical manifestations/complications of PUD
155
Medical therapy for ZES?
High dose PPI (ex. omeprazole 40mg BID)
156
Medical therapy for ZES if PPI is unsuccessful?
Octreotide
157
Surgical therapy for ZES (local disease)?
Tumor resection
158
Surgical therapy for ZES (if liver involvement)?
Surgical resection
159
Therapy for ZES if metastatic?
Chemotherapy (? efficacy)
160
Therapy for metastatic & non-resectable disease w/ ZES?
Lifelong high dose PPIs
161
What is gastroparesis?
Syndrome characterized by delayed gastric emptying in the absence of mechanical obstruction
162
What is gastroparesis defined by?
Objective data
163
Epidemiology of gastroparesis?
Limited (lack of studies)
164
Is gastroparesis more common in men or women?
4-fold higher in women compared to men
165
A majority of gastroparesis cases are what?
Idiopathic
166
What is the most frequently recognized condition associated with gastroparesis?
Diabetes Mellitus (DM)
167
Which medications can induce gastroparesis?
Narcotics, CCBs, TCAs (tricyclic antidepressants)
168
What is one of the most common post-surgical causes of gastroparesis?
Fundoplication
169
What thyroid condition can cause gastroparesis?
Hypothyroidism
170
Which neurological conditions can cause gastroparesis?
MS, Parkinson's
171
Classic symptoms of gastroparesis?
N/V, early satiety/postprandial fullness, belching, bloating, and/or upper abdominal pain
172
Abdominal exam for gastroparesis may reveal what?
Epigastric distention or tenderness, but WITHOUT guarding or rigidity
173
Patients may have signs and symptoms of what that results in gastroparesis?
Underlying disorders
174
What labs should be drawn to rule in/out underlying diseases that cause gastroparesis?
TSH, A1C, LFTs, etc.
175
Imaging for gastroparesis is done to rule out what? What imaging modalities are used?
Mechanical obstruction (by upper endoscopy or CT)
176
What test is definitive for gastroparesis?
Gastric emptying study (nuclear)
177
Gastric emptying studies for gastroparesis show what?
Gastric retention of:
>10% @4hrs
and/or
>60% @2hrs with low fat diet
178
Delayed gastric emptying is classified by what?
Extent of gastric retention at 4 hours
179
Values for mild delayed gastric emptying?
10-15%
180
Values for moderate delayed gastric emptying?
15-35%
181
Values for severe delayed gastric emptying?
>35%
182
Initial management for gastroparesis consists of what?
Dietary modification, optimizing glycemic control & hydration, pharmacologic therapy in patients w continued symptoms
183
First-line treatment for mild gastroparesis (10-15%)?
Dietary modification
-Smaller meals, avoid fatty/spicy/rough foods
-Avoid carbonation (aggravates distention), avoid ETOH/smoking
-Hydration & vitamin supplements if N/V, dehydration, vit. deficiency
184
What to optimize in gastroparesis patients with DM?
Glycemic control
185
When is pharmacologic therapy indicated for gastroparesis patients?
Pts w/ continued symptoms despite dietary modification
186
Pharmacologic for gastroparesis?
Prokinetics to inc. rate of gastric emptying: Metoclopramide (Reglan) first line
187
Adverse drug reactions of Metoclopramide for gastroparesis?
Anxiety/depression, restlessness, QT prolongation, hyperprolactinemia
188
Alternative pharmacologic therapy for gastroparesis if Metoclopramide is not tolerated (HINT: this med is not available in US but available in Canada & other countries)?
Domperidone
189
Which medication is recommended for gastroparesis if 1st line therapy fails?
Macrolide abx:
-Erythromycin (inc. gastric emptying by stimulating gastric contractions)
190
Adverse drug reactions of Erythromycin?
Tachyphylaxis, GI toxicity, Ototoxicity, QT prolongation, and sudden death with CYP3A4 inhibitors
191
Limited use of erythromycin in gastroparesis treatment due to what?
side effects, tachyphylaxis
192
Alternative to erythromycin for gastroparesis?
Azithromycin
193
Surgery may be recommended for which gastroparesis patients?
Those refractory to medications
194
Surgery for gastroparesis?
Includes: jejunostomy or gastrostomy that cannot be placed endoscopically
*Gastric electrical stimulation (GES) may be an option
195
Surgical therapy to relieve refractory N/V in gastroparesis patients with partial gastrectomy?
Complete/subtotal gastrectomy
196
What is a gastrectomy?
Removal of all or part of the stomach
197
Types of gastrectomy?
Partial, complete, or sleeve
198
Indications for gastrectomy?
Gastric carcinoma, Severe/recurrent PUD, Large duodenal perfs, Morbid Obesity (sleeve), Bleeding gastric ulcers, Corrosive stomach injury, Benign stomach tumors, Gastroparesis, GI stromal tumors
199
What is a sleeve gastrectomy?
Portion of stomach is removed, with the gastric sleeve as the "new stomach"
200
Complications of gastrectomy?
Infections (wound, chest), Anastomotic leak, Stricture, Bleeding, Acid reflux, Dumping syndrome, Diarrhea, Vit. deficiencies
*not an all inclusive list
201
What is a gastrojejunostomy?
Procedure creating anastomosis between stomach and proximal loop of jejunum
*open or laparoscopic
202
Indications for gastrojejunostomy?
Gastric outlet obstruction**MC, morbid obesity (gastric bypass), Corrosive stomach injury (from acid), To maintain continuation of GI tract post radical subtotal gastrectomy, Palliative tx in non-resectable malignancy, gastroparesis
203
What does a gastrojejunostomy consist of?
Gastric pouch is connected to jejunum and bypasses portion of the stomach
204
Complications of gatrojejunostomy?
Secondary hemorrhage, Anastomosis leakage, Duodenal leak, Infection, Anastomotic stricture, Intra-abdominal abscess
