Stomach Disorders Flashcards

Question

peptic ulcer dx

Answer 1

-Endoscopy is procedure of choice * 5% of benign appearing GU are malignant * Must show documented healing with f/u endoscopy * Duodenal ulcers are virtually never malignant * Bx for H. pylori and cancer until healed

Answer 2

-PPI- duodenal ulcer (4 weeks) and gastric ulcer (8 weeks) -h. pylori eradication therapy 85% effective: -PPI (omeprazole) 2x day, clarithromycin 500mg bid, amoxicillin 1g BID -treat for 14 days and continue PPI x 4/8 weeks (8 weeks for gastric) -d/c aspirin, NSAIDs if possible

Answer 3

-endoscopy- procedure of choice -5% of benign appearing gastric ulcer are malignant- must show documented healing with f/u endoscopy -duodenal ulcers are virtually nerve malignant -dx for H. pylori

Answer 4

-caused by gastrin secreting gut neuroendocrine tumors (gastrinomas) -hypergastrinemia and increased acid secretion -rare <1% of PUD -primary gastrinomas arise in pancreas (25%), duodenal wall (45%) or lymph node (5-15%) other locations or unknown primary (20%) -80% arise within gastrinoma triangle: porta hepatis, neck of pancreas, and 3rd portion of duodenum -Most are solitary or multifocal nodules that are potentially resectable -2/3 are malignant -1/3 have metastasized to liver at initial presentation -25% are assoc with MEN 1 and difficult to resect

Answer 5

-90% have PUD with similar symptoms -GERD common -Diarrhea in 1/3, steatorrhea, wt loss -ulcers dont usually cause diarrhea** -Ulcers are usually solitary in duodenum, may be multiple -Isolated GU do not occur-always multiple -gastrinnnn

Answer 6

-ULCERS -Refractory ulcers, neg H pylori, or no NSAID use -Giant ulcers (>2cm) -Distal to duodenal bulb -Multiple duodenal ulcers -Freq recurrences -Assoc with diarrhea -Ulcers after ulcer surgery -Ulcer complications -Hypercalcemia, fam hx suggesting MEN1

Answer 7

-Fasting gastrin > 150 pg/ml -Median level is 500-700 pg/ml, 60%> 1000pg/ml -Gastrin>1000 and acid hypersecretion is diagnostic -> For others can do a secretin stimulation test -All patients must have PTH, prolactin, LH-FSH, GH to exclude MEN 1

Answer 8

-MUST measure gastric pH in pts with hypergastrinemia -hypochlorhydria with increased gastric pH is more common cause of hypergastrinemia than gastrinoma so must measure gastric pH in pt with hypergastrinemia -gastric pH > 3 implies hypochlorhydria

Answer 9

-ZE- high gastric and low pH- acidic -pernicious anemia- high gastric- normal pH (partital cells dont work) -pH is differential

Answer 10

-somatostatin receptor scintigraphy with SPECT scan > 80% sensitive -if neg EUS to detect small tumors -tx- -metastatic disease- control hypersecretion with PPI, resect liver metastasis, cryoblation, 30% > 10 year survival -localized disease- resect before liver metastasis, 15 year survival > 95%

Answer 11

-GI hemorrhage -ulcer perforation -ulcer penetration -gastric outlet obstruction- from inflammation

Answer 12

-50% UGI bleed from PUD -80% resolve on own -10% significant bleeding -Signs and symptoms -Melena (500cc), hematemesis (1000CC), hematochezia -Nasogastric lavage shows “coffee grounds” or red blood -> If neg doesn’t r/o duodenal ulcer -if you get bile from duodenum from NG lavage -> good sign there is no bleed (no coffee grounds or blood)

Answer 13

-decreased HCT, increased BUN -tx- -IV PPI -blood, platelets -endoscopy- dx and therapeutic procedure -> cautery, epi, endoclip -octreotide- reduces splanchnic blood flow and gastric secretions, efficiency unclear

Answer 14

-5% of ulcer patients- Anterior wall of stomach or duodenum -Consider ZE -Sudden, severe abdominal pain -Causes a chemical peritonitis- Appear ill, rigid abdomen, no bowel sounds, rebound tenderness -labs- leukocytosis -films- upright or decubitus films-free air in 75% -CT of abdomen

Answer 15

-40% seal on own with omentum or adjacent organs -surgery -H. pylori tx - fluids, IV PPI, abx

Answer 16

-Posterior wall of duodenum or stomach may penetrate into pancreas, liver or biliary tree -Change in pattern/intensity of their pain - Severe constant pain, radiates to back, unresponsive to antacids -Physical + labs nonspecific, increased amylase (if affect pancreas) -Endoscopy confirm ulcer but not diagnostic of actual penetration -IV PPI, no improvement surgical tx

Answer 17

-rare -pyloric outlet obstructed from so much inflammation -2% of ulcer pts -edema or narrowing of pylorus or duodenal bulb -Most with known history of ulcers -Symptoms- Fullness and heaviness with meals progresses to early satiety, VOMITING, wt loss -physical- succession splash may be heard in epigastrum -dx: -nasogastric aspiration > 200cc foul smelling fluid is diagnostic -more subtle obstruction is diagnosed with a saline load test or nuclear gastric emptying study

Answer 18

-correct fluid and electrolytes -IV PPI - oral after -nasogastric decompression of stomach -endoscopy in 24-72 hrs to define nature of obstruction, r/o gastric cancer, dilation of obstruction

Answer 19

-epithelial polyps -fundic gland or hyperplastic polyps (a lot of them) -> of no consequence -epithelial polys can be caused by long term PPI -adenomatous polyps 10-20%: not many -rarely ulcerate -premalignant potential -must remove

Answer 20

-adenocarcinoma -lymphoma

Answer 21

-most common gastric cancer -mean age 63 year old, uncommon <40 years -men > women -> incidence in latinos, african americans, asian americnas -antrum MC -polypoid or fungating intraluminal masses -ulcerating masses -diffusely spreading through submucosa (poor prognosis) -superficially spreading confined to mucosa or sub mucosa +/- lymph node (excellent prognosis)

Answer 22

-H. pylori, diet (nitrates) -pernicious anemia -h/o partial gastric resection > 15 yo PHYSICAL EXAM: -rarely helpful- rarely palpate gastric mass -+/- heme + stool

Answer 23

-asymptomatic till advanced and nonspecific -dyspepsia -epigastric pain -anorexia, early satiety, wt loss -GI bleed vomiting -dysphagia

Answer 24

-virchow's node- left supraclavicular node -sister mary joseph nodule- umbilical nodule -blumer's shelf- rigid rectal shelf (peritoneal cul de sac) -krukenberg tumor- ovarian metastasis

Answer 25

-lab- Fe deficiency anemia or anemia of chronic disease and increased LFTs (if spread to liver) -endoscopy: ->50% yo with new onset dyspepsia or fail short term PPI therapy -highly sensitive -no screening program in US

Answer 26

-is it cancer or an ulcer? -ulcerating gastric adenocarcinoma vs benign gastric ulcers -repeat endoscopy done for all gastric ulcers to confirm healing -staging- PET-CT- distant metastasis and invasion of adjacent structures -EUS- superior to CT in determining depth of invasion and metastasis -staging- TNM (tumor size, lymph node size, metastasis)

Answer 27

-curative surgical resection: -localized to distal 2/3 of stomach- subtotal distal gastrectomy -proximal gastric cancer or diffusely infiltration disease -> total gastrectomy is done -+/- chemo for micro metastasis

Answer 28

-palliative modalities: peritoneal, distant, metastasis, or local invasion of other organs -palliative resection for bleeding or obstruction -laser, stenting, embolization -chemo- epirubicin, oxaliplatin and capecitabine (controversial)

Answer 29

-Overall 5-year survival 35% -5-year relative survival rates for stomach cancer, according to SEER stages. -Localized: 74.7 percent -Regional: 34.6 percent -Distant: 6.6 percent

Answer 30

-2nd most common gastric malignancy** -> 95% are Non Hodgkins B cell lymphoma -primary- originating in stomach or* -nodal lymphoma- MC* -Primary or a metastasis from nodal lymphoma- Distinguish for tx and prognosis -60% of primary gastric lymphomas arise from mucosa associated lymphoid tissue (MALT) -H. pylori infection may be an important risk factor especially for MALT lymphomas

Answer 31

-Helicobacter pylori-associated chronic gastritis -Autoimmune diseases -Immunodeficiency syndromes (eg, AIDS) -Long-standing immunosuppressive therapy (ie, post-transplantation)

Answer 32

-Abdominal pain, wt loss, early satiety -Bleeding (occult) -Night sweats ABSENT in primary gastric lymphoma*

Answer 33

-PE- Often normal, +/- Palpable mass, Peripheral lymphadenopathy (advanced disease) -labs- tend to be normal at presentation -> anemia, high ESR -endoscopy: -ulcer, mass, or difficulty infiltration lesion -bx to confirm dx -PET-CT (abdomen and chest) for staging -EUS most sensitive for perigastric lymphadenopathy

Answer 34

-not staged with TNM* -use diaphragm as landmark* -IE: limited to the stomach -IIE1: stomach and contiguous lymph nodes -IIE2: stomach and noncontiguous subdiaphragmatic lymph nodes -III: stomach and lymph nodes on both sides of diaphragm -IV : Hematogenous spread (stomach and one or more extra lymphatic organs or tissues) -Prognosis of Primary Gastric Lymphoma -> Long-term survival -> Stage I >85%, and Stage II 35-65%

Answer 35

-Secondary nodal lymphomas-advanced and seldom curable -Primary low grade gastric lymphomas are usually localized to stomach wall (stage IE) or adjacent ln (stage IIE) -> Excellent prognosis -Test for H pylori in those with MALT-lymphoma and tx if + -> Complete regression in 75% of stage IE low grade lymphoma after tx H. pylori -> Neg for H pylori or fail tx : radiation -Failures, recurrence, advanced stage disease (ie, stage III or IV disease), and those with diffuse large B-cell lymphoma -> Multiagent chemotherapy

Answer 36

-250,000 hospitalization/year -above ligament of trietz -mortality rate 7-10% -> 50% over 60 year old -> ulcers caused by NSAIDs -die from complications of underlying disease not exsanguination -self limited in 80% -presentation: -hematemesis -melena - dark stool -hematochezia (10% cases) - rushing through

Answer 37

-in order of frequency- many can cause acute or chronic bleed -PUD- 50% of bleeds, incidence declining -portal HTN- 10-20%, bleeding varices (esophageal most common), hypertensive gastropathy, if untreated -> 50% varices rebleed -mallory-weiss tear- 5-10%, associated with alcohol and retching (less than 10% have continued or recurrent bleeding)- self limiting -vascular anomalies (vascular ectasias, angiodysplasias)- 7%; throughout GI tract -gastric neoplasms- 1% -erosive gastritis- typically superficial, more commonly associated with chronic bleed -erosive esophagitis- rare

Answer 38

-Stabilization: Assess hemodymamics = severity of blood loss -IV- Two 18 gauge IVs in patients with significant bleed -collect labs- CBC, INR (bleeding/clotting time), creatinine, LFTs, cross-matching -NG Tube placement: confirmation of bleed with coffee grounds or bright red blood -> neg in 10% especially if duodenal source -cant rule out duodenal source with NG tube

Answer 39

-Amount is based on vitals, labs, aspirate -Maintain HCT 25-30% -Transfuse if actively bleeding -May give platelets -<50,000 or if on aspirin or clopidogrel regardless of count -May give FFP (fresh frozen plasma) if coagulopathy

Answer 40

-> 60yo -Comorbid illness -Systolic BP <100mm Hg -Pulse >100 beats/min -Bright red blood on aspiration or rectal exam- huge sign

Answer 41

-Reliable patients without comorbidities -Normal hemodynamics -No hematemesis or melena within 48hrs -Negative NG lavage -Normal labs -Do not admit and evaluate as outpatient -Low to Moderate Risk: those that arnt high risk, Admitted to medical floor, Endoscopy in 12-24 hrs

Answer 42

-Active bleeders -Hematemesis or bright red blood on NG aspirate -Shock -Poor response to fluids -Serious comorbidities -Advanced liver disease -Admit to ICU -Endoscopy within 12 hours

Answer 43

-Subsequent Evaluation and Treatment: -Upper Endoscopy: -All patients have endoscopy within 24 hrs -Identifies source -Risk of rebleeding -Therapy-if needed- Cautery, injection, endoclips, Meds -pharm therapy- -IV PPI -octreotide- decrease splanchnic blood flow and portal pressures -> given until liver disease and increased portal pressure ruled out -other tx- intra arterial embolization (rare) and/or TIPS - hepatic vein portal vein shunt