Stomach/Duodenum Flashcards
DIsplacement of the gastroesohageal jx above the diaphragm
Stomach remains in longitudinal alignment and fundus remains below GEJ
Hiatal hernia (type 1/sliding)
True hernia w/ a hernia sac
Fundus is upwardly dislocated
Hiatal hernia (type 2, 3, 4)
Hiatal hernia ssx?
same as GERD
heartburn and regurgitation
Diagnosis for hiatal hernia?
barium swallow
Tx for hiatal hernia?
Small hernia? GERD mgmt
Larger hernia? surgical repair
Most commonly seen in alcoholic or critically ill patients, or patients taking NSAIDs.
Often asymptomatic; may cause epigastric pain, nausea, and vomiting.
May cause hematemesis; usually insignificant
Erosive and Hemorrhagic “Gastritis” (Gastropathy)
- mucosal damage w/o inflammation?
2. mucosal damage w/ inflammation?
- gastropathy
2. gastritis
Gastritis commonly secondary to
infectious or autoimmune etiologies
Gastropathy is commonly secondary to?
Alcohol
NSAIDs
Physical stress (mech vent, prolonged surgery, trauma, burns, shock, sepsis)
Portal HTN
Pts w/ erosive/hemorraghic gastropathy can often be asymptomatic. Howevre, ssx include?
Anorexia
Epigastric pn
Clinical manifests as an upper GI bleed (hematemesis, bloody aspirate, melena…)
Stimulate epithelial cells to releasre more bicarb/mucus, thus protecting gastric epithelium (reduces permaeblity/acid back-diffusion)
prostaglandins (also act as vasodilator to increase gastric blood flow and increase resistance to injury)
Prostaglandins that cotnribute to gastroprotection are principplay derived from COX1
What is necessary for diagnosis/differentiation of gastritis/gastropathy?
Mucosal biopsy
What type of pt might NSAID gastropathy occur in/
Pt taking chronic NSAID therapy, esp. COX1 inhibtiors
Ssx and tx of NSAID gastropathy
Dyspepsia is most common (so EPIgastric, not substernal)
Tx = discontiue NSAID usage, reduce the dose, OR switch COX2
Regarding NSAID gastropathy, send for upper endoscopy if symptoms don’t imporve or alarm ssx are present. What re the alarm ssx?
Severe pn, wt loss, anemia, evidence of GI bleeding
SWAB
Two imprtoant risk factors for stress gastritis bleeding are?
An ICU patient w/ coagulopahty and respiratory failure with the need for mech vent
(Consider giving the patient prophylactic H2 blcokers/PPI)
An alcoholic w/ dyspepsia, nausea, vomiting/hematemesis… what you thinking? ANd how you treat?
Alcoholic gastropathy
Tx = discontinuation of alcohol AND PPI for 2-4 week
IN stress gastropathy, Highest risk of bleeding associated w/?
Coagulopathy
Respiratry failure (mech vent)
Tx for bedridden pts w risk of stress gastropahty?
IV PPI
Tx for portal HTN gastropahty?
beta blockade (propanol)
Neutrophilic and lymphocytic inflitration by h pylori… MAY cause a transient illness characterized by nausea and vomting. THe majority of these cases progress to chronic infection w/ mucosal inflammation…
H. pylori gastritis
PAtient presentation of h pylori infecion is related to ?
dyspepsia
However 35% of patients w/ h pylori will be asymptomatic
When is h. pylori testing indicated?
dyspeptic pts
chronic GERD
suspected/confirmed PUD pts
Tests for h pylori include? Which is preferred?
Fecal antigen test (specific and sensitive, and CHEAP)
Carbon 13 urea breath test (similar to FAT)
When getting an h pylori test, pt should stop what bfore testing?
Should discontinue anti-secretory agent TWO WEEKS before test (can replace w/ an H2 blocker)
Also, consider discontinuing any antibiotics
Standard trip therapy for H Pylori?
PPI bid
Clarithromycin 500mg BID
Amoxicilllin 1 g BID (metronidazole if PENA)
14 days
Standard quadruple therapy for H pylori?
PPI BID
Bismuth subsalicylate 2 tabs QID
tetracycline 500mg QID
Metronidzaole 500 (TID)
What are some other types of gastritis?
Pernicious anemia gastritis (Vit B12 deficiency)
Infectious gastritis (viral, bacterial, fungal)
Eosinophilic gastritis
Menetrier disease (idiopathic hypertrophic gastropathy)
Hx of dyspepsia in 80-90% in pts
Ulcer symptoms characterized by rhythmicity and periodocity
ulcer complications present w/ out antecedent ssx in 10-20% of patients
Most NSAID induced ulcers are asymptomatic
Upper endoscopy w/ gastric biopsy for H pylori is the diagnostic procedure of choice in most patients
Gastric ulcer bipsy/documentation of complete healing necessary to exclude malignancy
PUD
A break in the duodenal (5x more common) or gastric mucosa due to impaired mucosal defense mechanisms
Highly prevalent
Duodenal more common in olds or younger?
PUD
Duodenal more common in younger
Gastric ulcers more common in 55-70
Etiologies of PUD?
NSAIDS
H Pylori
(others rare: hypersecretory conditions, CMV, Crohn dz, lymphoma, chronic medical dz)
SSx of PUD?
Dyspepsia (epigastric pain) most common
Described as gnawing, aching, or hunger pangs
Some report relief w/ eating (esp. those w/ duodenal ulcer)
Increase/decrease in pn for gastric/duodenal ulcer?
Gastric ulcer pts have increae in pn w/ eating
Duodenal ucler pts have decrease in pn w/ eating
What hsoudl a histroy and PE look like for h pylori?
IN the histroy, inquire about NSAIDs/prior h pylori infection
PE is often unremarkable (w/w/o epigastric pn)
Procedure of choice for h pylori?
upper endoscopy to establish diangosis (biopsy taken to r/o malignancy if gastric [duodenal biopsy not warranted])
Perofrm CBC (for anemia), FOBT
Tx for PUD?
PPI
(2nd line = mucosal defense; sucralafate, misoprostol)
NSAID-induced = discontinue or lower dose
H pylori = quadruple therapy
FOR THE MUCOSAL DEFENSE DRUGS ABOVE:
Which is PROphylaxis for NSAID pt’s = misoPROstol
Sucralfate = Site covering of ulcer
Goals of tx for h pylori assocaited ulcer?
1 - relieve dyspeptic symptoms
2 - promote ulcer healing
3 - eradicate h pylori
Most common cause of recurrence of h pylori-associated ulcers after abx therapy?
failture to acheive succesful eradication
All patients w known hx of PUD who are treated w/ NSAIDs/antiplatelet agents should receive testing for?
H pylori
Ssx of acute upper GI bleed from PUD?
note that this may be the presenting symptom for some pts w/ PUD
hematemesis (coffee grounds emesis)
Melena
(high incidence of bleeding, but low mortality)
Tx for acute upper GI bleed?
hemostasis
endoscopy
“Coffee grounds” emesis, hematemesis, melena, or hematochezia.
Emergent upper endoscopy is diagnostic and therapeutic.
Upper GI bleed from PUD
Just because you have a NG lavafe that is negative for blood.. don’t r/o active bleeding…
Especially consider an active bleed from a duodenal ulcer
Pts w/ ulcers whose endoscopyu exams suggests high risk of bleeding should receive what?
3 days of PPI to reduce rebleed risk
Peptic ulcer perforation results in?
What are the ssx of a pt w/ ulcer perforation?
Ulcer perf resutls in chemical peritonitis (spilling of gatric contents)
Ssx = sudden/sever abd pain. Pts presetn w/ rigid abdomen and reduced bowel sounds. Pneumoperitoneum may also be present. Leukocytosis is almost always presnet.
Up to 40% heal spontaneously (adhered omentum)
Tx = admission for fluids/NG suction/IV PPI/Abx
Peptic ulcer perf
consider surger if evidence of free air or pt deteriorates
- Penetration of the ulcer through the bowel wall WITHOUT FREE PERFORATION OR LEAKAGE OF LUMINAL content into the peritoneal cavity
- penetration into pancreas, liver, biliary tree
For ulcer penetration, what do patients often report…?
ulcer PENETRATION
….change in typical PUD symptoms i.e. frequency of dyspepsia, more frequent, more intense, radiation to back - LACK OF RELIEF WITH FOOD OR ANTACID
Patients often report a change in their typical PUD ssz
Change in frequency of dyspepsia (more frequent/intesne, radiaates to back)
Lack of relief from food/anatacid
HOWEVER…what is one serum finding associated with ulcer penetration and what established the diagnosis?
ulcer PENETRATION
… MAY have elevation of serum amylase levels. ABDOMINAL CT established the dx w/o need for further studies
Chronic edema of the pylorus/duodenal bulb…
Early satiety, postprandial vomitng (esp undigested food contents), wt loss
When does the vomiting normally occur? What can we look for on physical exam?
Gastric outlet obstruction
vomiting occurs typically one to several hours after eating
PE: succussion splash may be heard in epigastrum (sloshing sound when pt moves from undigested material in stomach)
Tx for gastric outlet obstruction
High dose PPI (IV, then liquid, then pill)
Endoscopic dilation
(r/o gastric neolplam on endoscopy)
Peptic ulcer disease; may be severe and atypical.
Gastric acid hypersecretion.
Diarrhea common, relieved by?
Most cases are sporadic; 25% with multiple endocrine neoplasia type 1 (MEN 1).
Zollinger Ellison Syndrome
Diarrhea relieved by nasogastric suction.
If N/V were relieved by NG suction we would think Gastroparesis!
Gastrin secreting neuroendocrine tumor
results in hypergastrinemia and gastric acid hypersecretion
Gastinoma (zollinger ellison suydrome)
Porta hepatitis, pancreatic neck, 3rd portion of duodenum.. significance?
gastrinoma triangle (zollinger ellison syndrome)
80%of gastrinomas within this triangle!!
Pancreas
Duodenal wall
lymph nodes
(common in patients w/ MEN1) 25%
gastrinoma locations (zollinger ellison syndrome) - for thsi diagnosis think SEVERE and ATYPICAL
Most patietns w/ ZES develop PUD indistinguidhable from other forms of PUD… so how do we discern ZES from other PUD’s?
screen w/ fasting gastrin levels… if fasting gastrin is elevated it’s a neurosecretory tumor of gastrin and ZES is confirmed
What pts should be screened for ZES?
pts w/ refratory ulcers or pts w/ PUD/fam hx of MEN1
Pts w/ PUD who are h pylori neg and not taking NSAIDS
Most sensitive/specifc test for ZES is fasting gastrin levels…tx for confirmed ZES?
referral to GI
delayed gastric empytimg in the absence of mechnical obstruction
usually idiopathic but strongly linked to DM
gastroparesis
other causes include surgery/.inury to vagus nerve
nausea
vomiting
early satiety
bloating/upper abd pn
wt loss in severe cases
gastroparesis
How would a PE look for a pt w/ gastroparesis?
What must be ruled out?
PE is typically unremarkable
Clinician should suspect gastroparesis based on hx and ssx BUT MUST R/O mechanical obstruction
Referral for EGD and GI
How wold you treat acute gastroparesis?
Acutely w/ NG decompression and IV fluid/electrolytes
Aside from acute mgmt, what are some tx measures for gastroparesis? What meds?
Dietary mods (smaller, frequent meals, avoid high fat/carbonation/alcohol)
Meds include prokinetics (metoclopramide, domperidone, erythromycin)
(acute mgmt = NG decompression and IV fluid/electrolyte replacement)
Special pt concern for gastroparesis?
Diabetics… ensure you optimize glycemic control (hyperglycemia may slow gastric emptying)
One of the most common cancers worldwide… affects men more than women…
Gastric adenocarcinoma
Asymptmatic until advanced… so, Late presentation = increased mortality
Gastric adenocarcinoma
SSx = late
Dyspepsia Epigastric pn Anorexia Early satiety Wt loss Dysphagia
Gastric adenocarcinoma
Gastric adenocarcinoma PE is typically unremarkable… BUT
WHat are the classic signs of metastatic dz?
Sister Mary Joseph Nodule
VIRCHOW NODE
Gastric adenocarcinoma…
- Labs show?
- What confirms diagnosis?
- What are some other radiographs we can use?
- CBC shows anemia… (LFTs may be elevated)
- Endoscopy confirms diagnosis
- Once cancer has been confirmed by endoscopy… use CT/PEt to find other mets
What is this the tx for gastric adenocarcinoma? Prognosis?
Surgery/chem/rad
Prognosis = 28% at 5 years
what might be a secondary spread from non-hodgkin lymphoma? Where might it arise?
Gastric lymphoma… that arises from MALT
Associated w/ chronic h pylori infection
Associated with chronic H pylori infection
Gastric lymphoma
Gastric lymphoma presents And is diagnosed and treated like adenocarcinoma
- CBC shows anemia… (LFTs may be elevated)
- Endoscopy confirms diagnosis
- Once cancer has been confirmed by endoscopy… use CT/PEt to find other mets
Neuroendocrine tumor originating in the digestive tract or lungs
Carcinoid tumor
constellation of
symptoms mediated by various humoral
factors that are elaborated by some
carcinoid tumors
Carcinoid syndrome
What are the features of carcinoid syndrome?
SUDDEN cutaneous flushing of the face/neck/upper chest that lasts up to 30 mins
Can be associated w/ a mild burning snesation
(also the presence of venous teleangiectasias and watery diarrhea)
What are the 3 features of carcinoid syndrome?
Cutaneous flushing
Venous telangiacetasis
Diarrhea
3-6 week old child
Immediate postprandial projecting vomiting
Hungry immediately afterwards
Pyloric stenosis (infantile hypertrophic pyloric stenosis)
PE exam reveals undernourished, dehydrated child
Palpation of olive in RUQ?
Infantile hypertrophic pyloric
Imaging is necessary for suspected pyloric stenosis (w/ or w/o palpitation of olive)… What type of imaging?
Tx for pyloric stenosis?
Abd US
Tx = surgical pyloromyotomy
NG tube relieves your N/V think?
How about relieves your chronic diarrhea?
N/V relieved think gastroparesis
Chronic diarrhea think Zollinger Ellison
what are some alternatives to COX-1?
Just remember Celecoxib, etodolac, and meloxicam as options for COX 2
LIST ALL THE “BAD” COX1’s from his slide:
D- PIANO Man had NSAID gastropathy from COX1’s
D - Diclofenac (Relafen)
P - Proxicam (Feldene) I - Indomethacin (Indocin) A - Aspirin N - Naproxen (Aleve) O - Oxaprozin (Daypro)
MOTRIN - Ibuprofen
What are some issues caused by COX-1 inhibitors?
decrease in mucosal blood flow
decrease in mucus and bicarb secretion
Can any NSAID cause epithelial damage?
YES… he said any can, but also referenced cause acid back diffusion and platelet aggregation. Just remember that COX-1 NSAIDs do it worse
ethanol has a direct toxic effect on the gastric mucosa… how?
slows gastroparesis… prolongs contact with gastric mucosa or more time with acid stuck and no movement —> injury
what is one thing we worry about with trauma and ICU patients in regards to their tummy and what should we do for them?
stress gastropathy - prophylactic IV PPI to supress gastric acid
What do we do before we H pylori test as well as afterwards?
BEFORE: stop antisecretory therapy 2 weeks out (PPI, but can do an H2 blocker because it doesn’t effect test results!)
AFTER: confirmation of eradication 4 weeks after
What is a high risk factor (3 times increase of risk) for patients with pernicious anemia?
Therefore, what should we do AT TIME of Dx?
gastric adenocarcinoma
endoscopy with biopsy
if you hear Achlorhydria think…
Pernicious anemia gastritis or malapsorption of B12 that may lead to low HCl in stomach… (also seen in bacterial overgrowth malabsorption of the small intestines but caused by B1 thiamine)
ACHLORHYDRIA - also known as hypochlorhydria, refers to states where the production of hydrochloric acid in gastric secretions of the stomach and other digestive organs is absent or low, respectively.
how doe we treat portal hypertensive gastropathy?
Ex drug given in lecture?
beta blockade to lower portal pressure
metopranol
how do we treat portal hypertensive emergency AKA esophageal varices?
STABILIZE pt first (blood etc)
Pharmacologic Therapy (maybe during stabilization or next procedure)
AFTER STABILIZATION
Emergent endoscopy (banding etc)
Balloon Tube Tamponade (adjunct until Portal Decompressive procedures can be done after endoscopy fails)
***TIPS or emergent portosystemic shunt surgery (after emergent endoscopy fails
when we treat portal hypertensive emergency what is our Pharmacologic Therapy (maybe during stabilization or procedure to stop bleed)
- Abx prophylaxis (3rd gen cephalosporin)
- Vasoactive drugs (octreotide and somatostatin)
- Vitamin K (for abnormal PTT time)
- Lactulose (encephalopathy pts)
how do we prevent rebleeding in esophageal varices?
if we use TIPS (transvenous INtrahepatic Portosystemic SHunt there is lower risk first of all)
treating though…combination beta blockers adn variceal band ligation (propanolol, nadolol)
You have a pt who you are suspect an ulcer… what are the first two things you are worried about? THey are negative for both…. what test should you do next?
READ MY MIND
Rule out NSAIDS and make sure they are H. pylori negative
If the two above are confirmed… do a FASTING GASTRIN LEVEL TEST and look for ZES!!!!
(also do fasting gastrin for: pts w/ refratory ulcers or pts w/ PUD/fam hx of MEN1)
