Stomach & Duodenal Diseases Flashcards
Diseases of the Stomach & Duodenum
Gastritis PUD Gastric & duodenal ulcers H. pylori Zollinger-Ellison syndrome Gastroparesis
Features of Dyspepsia
Indigestion Chronic/recurrent pain in upper abdomen Upper abdominal fullness Early satiety Bloating Belching Nausea Heartburn
Types of Gastritis
Erosive & hemorrhagic gastritis
Nonerosive, nonspecific gastritis
Types of Erosive & Hemorrhagic Gastritis
Stress (medical or surgical illness)
NSAID
Alcoholic
Portal hypertension
Types of Nonerosive & Nonspecific Gastritis
H. pylori
Pernicious anemia
Eosinophilic
Asymptomatic Gastritis May Have
Anorexia Epigastric pain Nausea Vomiting Upper GI bleed
Upper GI Bleeding from Erosive Gastritis
Melena (dark, sticky feces)
Coffee ground emesis
Blood in NG tube
Work up of Erosive Gastritis
CBC
Serum iron
Upper endoscopy
Highest Risk for Bleeding in Stress Gastritis
Coagulopathy Need for mechanical ventilation Trauma, burns, shock Sepsis, liver failure, kidney disease Multi-organ failure CNS injury
Prophylaxis of Stress Gastritis
PPIs are best
H2 Blockers
Treatment for GI Bleeding due to Stress Induced Gastritis
PPI bolus followed by continuous infusion
Sucralfate suspension
Endoscopy
Red Flags for Gastritis
Severe pain Weight loss Vomiting GI bleeding Anemia Refer for Upper Endoscopy
Treatment of Gastritis
Trial of PPI for 2-4 weeks
H2 blockers
Refer for endoscopy
Pathophysiology of ETOH Gastritis
Alcohol disrupts mucosal barrier
Alcohol & aspirin increase the permeability of gastric mucosal barrier
Symptoms of Alcoholic Gastritis
Dyspepsia
Nausea
Emesis
Minor hematemesis
Treatment for Alcoholic Gastritis
H2 blockers or PPI
+ sucralfate 2-4 weeks
Decrease ETOH consumption
Portal Hypertensive Gastropathy
Congestion of gastric vessels
Chronic GI bleeding
Treatment of Portal Hypertensive Gastropathy
Porpranolol or nadolol
Nonerosive, nonspecific gastritis
H. pylori
Pernicious anemia
Eosinophilic gastritis
H. pylori
Lives beneath gastric mucous layer Secrete urease & produce ammonia Causes gastric mucosal inflammation Increases risk of gastric CA Fecal-oral spread
Risk Factors for H. Pylori
Correlates inversely with SES
Contaminated water supply
What can H. pylori lead to over time?
Cellular changes
Duodenal/gastric ulcers
Gastric CA
Low grade B cell gastric lymphoma
Testing for H. pylori
Serology
Urea breath test
Stool antigen test
Endoscopy biopsy
Treatment for H. pylori
Eradication therapy
2-3 antibiotics + PPI or bismuth
Pernicious Anemia Gastritis
Autoantibodies to gastric gland parietal cells and intrinsic factor
What causes loss of acid production in pernicious anemia gastritis?
Gastric gland atrophy
Mucosal atrophy
What can pernicious anemia gastritis be associated with?
Hashimoto thyroiditis
Addison disease
Graves disease
Define Eosinophilic Gastritis
Infiltration of eosinophils into GI tissue
Symptoms of Eosinophilic Gastritis
Abdominal pain
N/V
Early satiety
Diarrhea
Eosinophilic Gastritis is Associated with
Hx of allergies
Hx or asthma
Hx of atrophy
Diagnosis of Eosinophilic Gastritis
Biopsy
Treatment of Eosinophilic Gastritis
Elimination diet
Steroids
Define PUD
Break in gastric or duodenal mucosa which can be caused by too much acid or pepsin
>5 mm & extend through muscular mucosae
Where are gastric ulcers most common?
Antrum
Most common ages for duodenal ulcers?
30-55
Most common ages in gastric ulcers
55-70
PUD is most common in
Smokers
NSAID users
Etiology of PUD
NSAIDs
Chronic H. pylori infection
Hypersecretory states
What are the hypsecretory states that can cause PUD?
Zollinger-Ellison syndrome Systemic mastocystosis CMV Crohn's disease Lymphoma Alendronate (Fosomax) Chronic medical illness Idiopathic
Clinic Presentation of PUD
Dyspepsia Pain in epigastric area Pain may be relieved with food or antacids (return 2-4 hours alter) Nocturnal pain Periodicity Nausea & anorexia GI bleeding
Work Up of PUD
CBC FOBT/FIT Upper endoscopy Abdominal CT Biopsy
Treatment for PUD
PPIs H2 blockers Bismuth Misoprostol (Cytotec) Antacids
How do H2 blockers help with PUD
Inhibit nocturnal acid secretion
Which H2 blocker should we avoid?
Cimetidine
Medical Treatment of PUD
Smoking decreases ulcer healing & increases recurrence rates
Moderate ETOH is okay
Balanced Diet
Goals of Therapy for H. pylori Associated Ulcers
Relieve symptoms
Promote ulcer healing
Eradicate infection
Treatment after Triple or Quadruple Therapy for PUD
Small ulcer: no further treatment
Large/complicated ulcer: PPI fo 6 weeks
When should we retest for H. pylori?
> 4 weeks post antibiotics
>2 weeks post PPI
Medical Treatment of NSAID Induced Ulcers
Stop offending agent
H2 blockers or PPIs
Prevention after NSAID Ulcer Healing
Long term PPI
Prescribe NSAID at lowest dose
Cox-2 inhibitors if no CV risks
Risk Factors for NSAID Uler Related Complications
>60 years Hx of PUD or complications ASA or other anti-platelet therapy Oral steroids Serious underlying medical illness
Zollinger-Ellison Syndrome
Gastrin secreting gut neuroendocrine tumor
Sites of Primary Gastrin Tumors
Pancreas 25%
Duodenal wall 45%
Lymph nodes 5-15%
Unknown
Clinical Presentation of Gastrin Tumors
Dyspepsia Peptic ulcers in duodenum usually No isolated gastric ulcers Diarrhea Steatorrhea Weight loss
When should you check fasting gastrin levels?
Large ulcers > 2 cm Ulcers distal to duodenal bulb Multiple duodenal ulcers Frequently recurrent ulcers Ulcers with diarrhea Ulcers + hypercalcemia Ulcers + negative NSAID use + negate H. pylori
Imaging for Gastrin Tumors
CT/MRI to evaluate for hepatic mets & primary lesions
SPECT SRS
Endoscopic ultrasound
Treatment of Metastatic Disease in Gastrin Tumors
PPIs
Check for hepatic mets
Treatment for Localized Disease in Gastrin Tumors
Resection before hepatic mets occur
Define Gastroparesis
Delayed gastric emptying in the absence of a mechanical obstruction
Gastroparesis Usually Secondary to
DM
Post surgical
Idiopathic
Etiologies of Gastroparesis
Viral
Medications
Neurologic disease
Autoimmune
Diabetic Gastroparesis
Chronic hyperglycemia can lead to neuropathy
Autonomic dysfunction
Abnormal intrinsic nervous system
Viral Gastroparesis
Norwalk Rotavirus Sudden onset Symptoms improve in a year CMV, EBV & VZV may lead to severe long term symptoms
Medications that can Delay Gastric Emptying
Oxycodone Clonidine TCAs CCB Dopamine agonists Muscarinic cholinergic receptor antagonists Ocreotide Phenothiazines Cyclosporine GLP-1 agonists & Amylin analongues
Examples of Muscarinic Cholinergic Receptor Antagonists that can Cause Gastroparesis
Scopolamine
Atropine
Ocreotide
Treat acromegaly
Diarrhea associated with certain tumors
Examples of Phenothiazines that can Cause Gastroparesis
Antipsychotics
Antiemetics
Reasons for Postsurgical Gastroparesis
Injury to vagus nerve Gastrectomy Fundoplication Lung/heart transplant Vatical sclerotherapy Botox injections
Neurologic Disease Causes for Gastroparesis
MS Brainstem stroke or tumor DM neuropathy Amyloid neuropathy AIDS DM Parkinson's
Autoimmune Gastroparesis
Idiopathic or part of a paraneoplastic syndrome
Other Types of Gastroparesis
Mesenteric ischemia
Scleroderma
Gastroparesis Symptoms
N/V
Early satiety
Bloating
Upper abdominal pain
PE for Gastroparesis
Epigastric tenderness
Abdominal distension
Signs of underlying disorder
Workup of Gastroparesis
Upper endoscopy
CT eneterography
MRI
Assessment of gastric motility
Scintigraphic Gastric Emptying
Nuclear med study
Overnight fast
Breakfast of eggs & toast with dash of isotope
Imaging at interval up to 4 hours to determine degree of gastric emptying
Further Workup to Determine Etiology of Gastroparesis
Hemoglobin Fasting glucose Serum total protein Albumin TSH ANA HbA1C
Treatment of Gastroparesis
Dietary modifications Hydration Vitamin supplementation Optimize glycemic control Prokinetics
Dietary Modifications in Gastroparesis
Small/frequent meals
Low Fat
Avoid insoluble fiber, ETOH, carbonated drinks, tobacco
Examples of Prokinetics
Metaclopramide (Reglan)
Macrolide antibiotics
Metoclopramide (Reglan)
Use prior to eating
12 week prescriptions with 2 week holiday
SE & Drug Interactions of Metoclopramide (Reglan) can lead to
Irreversible tardive dyskinesia
Erythromycin
Induces gastric contraction
Stimulates fundic contractility
No longer than 4 weeks at a time
Antiemetics
Use for persistent N/V
Refractory Cases of Gastroparesis
Surgical treatment
G-tube
J-tube
