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GI > Stomach/Duodenum > Flashcards

Stomach/Duodenum Flashcards

1
Q

DIsplacement of the gastroesohageal jx above the diaphragm

Stomach remains in longitudinal alignment and fundus remains below GEJ

A

Hiatal hernia (type 1/sliding)

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2
Q

True hernia w/ a hernia sac

Fundus is upwardly dislocated

A

Hiatal hernia (type 2, 3, 4)

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3
Q

Hiatal hernia ssx?

A

same as GERD

heartburn and regurgitation

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4
Q

Diagnosis for hiatal hernia?

A

barium swallow

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5
Q

Tx for hiatal hernia?

A

Small hernia? GERD mgmt

Larger hernia? surgical repair

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6
Q

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

A

Erosive and Hemorrhagic “Gastritis” (Gastropathy)

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7
Q
  1. mucosal damage w/o inflammation?

2. mucosal damage w/ inflammation?

A
  1. gastropathy

2. gastritis

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8
Q

Gastritis commonly secondary to

A

infectious or autoimmune etiologies

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9
Q

Gastropathy is commonly secondary to?

A

Alcohol

NSAIDs

Physical stress (mech vent, prolonged surgery, trauma, burns, shock, sepsis)

Portal HTN

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10
Q

Pts w/ erosive/hemorraghic gastropathy can often be asymptomatic. Howevre, ssx include?

A

Anorexia

Epigastric pn

Clinical manifests as an upper GI bleed (hematemesis, bloody aspirate, melena…)

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11
Q

Stimulate epithelial cells to releasre more bicarb/mucus, thus protecting gastric epithelium (reduces permaeblity/acid back-diffusion)

A

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

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12
Q

What is necessary for diagnosis/differentiation of gastritis/gastropathy?

A

Mucosal biopsy

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13
Q

What type of pt might NSAID gastropathy occur in/

A

Pt taking chronic NSAID therapy, esp. COX1 inhibtiors

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14
Q

Ssx and tx of NSAID gastropathy

A

Dyspepsia is most common (so EPIgastric, not substernal)

Tx = discontiue NSAID usage, reduce the dose, OR switch COX2

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15
Q

Regarding NSAID gastropathy, send for upper endoscopy if symptoms don’t imporve or alarm ssx are present. What re the alarm ssx?

A

Severe pn, wt loss, anemia, evidence of GI bleeding

SWAB

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16
Q

Two imprtoant risk factors for stress gastritis bleeding are?

A

An ICU patient w/ coagulopahty and respiratory failure with the need for mech vent

(Consider giving the patient prophylactic H2 blcokers/PPI)

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17
Q

An alcoholic w/ dyspepsia, nausea, vomiting/hematemesis… what you thinking? ANd how you treat?

A

Alcoholic gastropathy

Tx = discontinuation of alcohol AND PPI for 2-4 week

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18
Q

IN stress gastropathy, Highest risk of bleeding associated w/?

A

Coagulopathy

Respiratry failure (mech vent)

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19
Q

Tx for bedridden pts w risk of stress gastropahty?

A

IV PPI

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20
Q

Tx for portal HTN gastropahty?

A

beta blockade (propanol)

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21
Q

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…

A

H. pylori gastritis

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22
Q

PAtient presentation of h pylori infecion is related to ?

A

dyspepsia

However 35% of patients w/ h pylori will be asymptomatic

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23
Q

When is h. pylori testing indicated?

A

dyspeptic pts

chronic GERD

suspected/confirmed PUD pts

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24
Q

Tests for h pylori include? Which is preferred?

A

Fecal antigen test (specific and sensitive, and CHEAP)

Carbon 13 urea breath test (similar to FAT)

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25
Q

When getting an h pylori test, pt should stop what bfore testing?

A

Should discontinue anti-secretory agent TWO WEEKS before test (can replace w/ an H2 blocker)

Also, consider discontinuing any antibiotics

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26
Q

Standard trip therapy for H Pylori?

A

PPI bid

Clarithromycin 500mg BID

Amoxicilllin 1 g BID (metronidazole if PENA)

14 days

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27
Q

Standard quadruple therapy for H pylori?

A

PPI BID

Bismuth subsalicylate 2 tabs QID

tetracycline 500mg QID

Metronidzaole 500 (TID)

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28
Q

What are some other types of gastritis?

A

Pernicious anemia gastritis (Vit B12 deficiency)

Infectious gastritis (viral, bacterial, fungal)

Eosinophilic gastritis

Menetrier disease (idiopathic hypertrophic gastropathy)

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29
Q

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

A

PUD

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30
Q

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?

A

PUD

Duodenal more common in younger

Gastric ulcers more common in 55-70

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31
Q

Etiologies of PUD?

A

NSAIDS

H Pylori

(others rare: hypersecretory conditions, CMV, Crohn dz, lymphoma, chronic medical dz)

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32
Q

SSx of PUD?

A

Dyspepsia (epigastric pain) most common

Described as gnawing, aching, or hunger pangs

Some report relief w/ eating (esp. those w/ duodenal ulcer)

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33
Q

Increase/decrease in pn for gastric/duodenal ulcer?

A

Gastric ulcer pts have increae in pn w/ eating

Duodenal ucler pts have decrease in pn w/ eating

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34
Q

What hsoudl a histroy and PE look like for h pylori?

A

IN the histroy, inquire about NSAIDs/prior h pylori infection

PE is often unremarkable (w/w/o epigastric pn)

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35
Q

Procedure of choice for h pylori?

A

upper endoscopy to establish diangosis (biopsy taken to r/o malignancy if gastric [duodenal biopsy not warranted])

Perofrm CBC (for anemia), FOBT

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36
Q

Tx for PUD?

A

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

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37
Q

Goals of tx for h pylori assocaited ulcer?

A

1 - relieve dyspeptic symptoms

2 - promote ulcer healing

3 - eradicate h pylori

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38
Q

Most common cause of recurrence of h pylori-associated ulcers after abx therapy?

A

failture to acheive succesful eradication

39
Q

All patients w known hx of PUD who are treated w/ NSAIDs/antiplatelet agents should receive testing for?

A

H pylori

40
Q

Ssx of acute upper GI bleed from PUD?

note that this may be the presenting symptom for some pts w/ PUD

A

hematemesis (coffee grounds emesis)

Melena

(high incidence of bleeding, but low mortality)

41
Q

Tx for acute upper GI bleed?

A

hemostasis

endoscopy

42
Q

“Coffee grounds” emesis, hematemesis, melena, or hematochezia.

Emergent upper endoscopy is diagnostic and therapeutic.

A

Upper GI bleed from PUD

43
Q

Just because you have a NG lavafe that is negative for blood.. don’t r/o active bleeding…

A

Especially consider an active bleed from a duodenal ulcer

44
Q

Pts w/ ulcers whose endoscopyu exams suggests high risk of bleeding should receive what?

A

3 days of PPI to reduce rebleed risk

45
Q

Peptic ulcer perforation results in?

What are the ssx of a pt w/ ulcer perforation?

A

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.

46
Q

Up to 40% heal spontaneously (adhered omentum)

Tx = admission for fluids/NG suction/IV PPI/Abx

A

Peptic ulcer perf

consider surger if evidence of free air or pt deteriorates

47
Q
  • 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…?

A

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

48
Q

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?

A

ulcer PENETRATION

… MAY have elevation of serum amylase levels. ABDOMINAL CT established the dx w/o need for further studies

49
Q

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?

A

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)

50
Q

Tx for gastric outlet obstruction

A

High dose PPI (IV, then liquid, then pill)

Endoscopic dilation

(r/o gastric neolplam on endoscopy)

51
Q

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).

A

Zollinger Ellison Syndrome

Diarrhea relieved by nasogastric suction.

If N/V were relieved by NG suction we would think Gastroparesis!

52
Q

Gastrin secreting neuroendocrine tumor

results in hypergastrinemia and gastric acid hypersecretion

A

Gastinoma (zollinger ellison suydrome)

53
Q

Porta hepatitis, pancreatic neck, 3rd portion of duodenum.. significance?

A

gastrinoma triangle (zollinger ellison syndrome)

80%of gastrinomas within this triangle!!

54
Q

Pancreas

Duodenal wall

lymph nodes

(common in patients w/ MEN1) 25%

A

gastrinoma locations (zollinger ellison syndrome) - for thsi diagnosis think SEVERE and ATYPICAL

55
Q

Most patietns w/ ZES develop PUD indistinguidhable from other forms of PUD… so how do we discern ZES from other PUD’s?

A

screen w/ fasting gastrin levels… if fasting gastrin is elevated it’s a neurosecretory tumor of gastrin and ZES is confirmed

56
Q

What pts should be screened for ZES?

A

pts w/ refratory ulcers or pts w/ PUD/fam hx of MEN1

Pts w/ PUD who are h pylori neg and not taking NSAIDS

57
Q

Most sensitive/specifc test for ZES is fasting gastrin levels…tx for confirmed ZES?

A

referral to GI

58
Q

delayed gastric empytimg in the absence of mechnical obstruction

usually idiopathic but strongly linked to DM

A

gastroparesis

other causes include surgery/.inury to vagus nerve

59
Q

nausea

vomiting

early satiety

bloating/upper abd pn

wt loss in severe cases

A

gastroparesis

60
Q

How would a PE look for a pt w/ gastroparesis?

What must be ruled out?

A

PE is typically unremarkable

Clinician should suspect gastroparesis based on hx and ssx BUT MUST R/O mechanical obstruction

Referral for EGD and GI

61
Q

How wold you treat acute gastroparesis?

A

Acutely w/ NG decompression and IV fluid/electrolytes

62
Q

Aside from acute mgmt, what are some tx measures for gastroparesis? What meds?

A

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)

63
Q

Special pt concern for gastroparesis?

A

Diabetics… ensure you optimize glycemic control (hyperglycemia may slow gastric emptying)

64
Q

One of the most common cancers worldwide… affects men more than women…

A

Gastric adenocarcinoma

65
Q

Asymptmatic until advanced… so, Late presentation = increased mortality

A

Gastric adenocarcinoma

66
Q

SSx = late

Dyspepsia
Epigastric pn
Anorexia
Early satiety
Wt loss
Dysphagia
A

Gastric adenocarcinoma

67
Q

Gastric adenocarcinoma PE is typically unremarkable… BUT

WHat are the classic signs of metastatic dz?

A

Sister Mary Joseph Nodule

VIRCHOW NODE

68
Q

Gastric adenocarcinoma…

  1. Labs show?
  2. What confirms diagnosis?
  3. What are some other radiographs we can use?
A
  1. CBC shows anemia… (LFTs may be elevated)
  2. Endoscopy confirms diagnosis
  3. Once cancer has been confirmed by endoscopy… use CT/PEt to find other mets
69
Q

What is this the tx for gastric adenocarcinoma? Prognosis?

A

Surgery/chem/rad

Prognosis = 28% at 5 years

70
Q

what might be a secondary spread from non-hodgkin lymphoma? Where might it arise?

A

Gastric lymphoma… that arises from MALT

Associated w/ chronic h pylori infection

71
Q

Associated with chronic H pylori infection

A

Gastric lymphoma

72
Q

Gastric lymphoma presents And is diagnosed and treated like adenocarcinoma

A
  1. CBC shows anemia… (LFTs may be elevated)
  2. Endoscopy confirms diagnosis
  3. Once cancer has been confirmed by endoscopy… use CT/PEt to find other mets
73
Q

Neuroendocrine tumor originating in the digestive tract or lungs

A

Carcinoid tumor

74
Q

constellation of
symptoms mediated by various humoral
factors that are elaborated by some
carcinoid tumors

A

Carcinoid syndrome

75
Q

What are the features of carcinoid syndrome?

A

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)

76
Q

What are the 3 features of carcinoid syndrome?

A

Cutaneous flushing

Venous telangiacetasis

Diarrhea

77
Q

3-6 week old child

Immediate postprandial projecting vomiting

Hungry immediately afterwards

A

Pyloric stenosis (infantile hypertrophic pyloric stenosis)

78
Q

PE exam reveals undernourished, dehydrated child

Palpation of olive in RUQ?

A

Infantile hypertrophic pyloric

79
Q

Imaging is necessary for suspected pyloric stenosis (w/ or w/o palpitation of olive)… What type of imaging?

Tx for pyloric stenosis?

A

Abd US

Tx = surgical pyloromyotomy

80
Q

NG tube relieves your N/V think?

How about relieves your chronic diarrhea?

A

N/V relieved think gastroparesis

Chronic diarrhea think Zollinger Ellison

81
Q

what are some alternatives to COX-1?

A

Just remember Celecoxib, etodolac, and meloxicam as options for COX 2

82
Q

LIST ALL THE “BAD” COX1’s from his slide:

A

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

83
Q

What are some issues caused by COX-1 inhibitors?

A

decrease in mucosal blood flow

decrease in mucus and bicarb secretion

84
Q

Can any NSAID cause epithelial damage?

A

YES… he said any can, but also referenced cause acid back diffusion and platelet aggregation. Just remember that COX-1 NSAIDs do it worse

85
Q

ethanol has a direct toxic effect on the gastric mucosa… how?

A

slows gastroparesis… prolongs contact with gastric mucosa or more time with acid stuck and no movement —> injury

86
Q

what is one thing we worry about with trauma and ICU patients in regards to their tummy and what should we do for them?

A

stress gastropathy - prophylactic IV PPI to supress gastric acid

87
Q

What do we do before we H pylori test as well as afterwards?

A

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

88
Q

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?

A

gastric adenocarcinoma

endoscopy with biopsy

89
Q

if you hear Achlorhydria think…

A

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.

90
Q

how doe we treat portal hypertensive gastropathy?

Ex drug given in lecture?

A

beta blockade to lower portal pressure

metopranol

91
Q

how do we treat portal hypertensive emergency AKA esophageal varices?

A

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

92
Q

when we treat portal hypertensive emergency what is our Pharmacologic Therapy (maybe during stabilization or procedure to stop bleed)

A
  1. Abx prophylaxis (3rd gen cephalosporin)
  2. Vasoactive drugs (octreotide and somatostatin)
  3. Vitamin K (for abnormal PTT time)
  4. Lactulose (encephalopathy pts)
93
Q

how do we prevent rebleeding in esophageal varices?

A

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)

94
Q

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

A

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)

GI (9 decks)

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