stomach - GI Flashcards
GERD- Gastroesophageal Reflux Disease
-GE reflux is normal a physiologic phenomenon
-GERD occurs when excessive gastric juice that refluxes into the esophagus causing symptoms with or without associated esophageal mucosal injury (ie, esophagitis).
-25-40% of healthy adult Americans experience symptomatic GERD at least once a month
-20% weekly symptoms
-7-10% daily symptoms
-Impairment of Lower Esophageal Sphincter (LES)
-Normal tone, but excessive relaxation
-Excessive intra-abdominal pressure
-Hypotonic/incompetent sphincter
-Factors contributing: Abnormal esophageal peristalsis
(Scleroderma), Diminished saliva production (Anticholinergic meds, Sjogren’s), Delayed gastric emptying (Gastroparesis, partial outlet obstruction)
-Hiatal Hernia: Increases likelihood of GERD, but not causative
GERD - sxs, dx
Most common
-Heartburn, regurgitation, dysphagia
Also
-Bronchospasm, laryngitis, chronic cough, hoarseness, sore throat, chest pain
-Nausea, hypersalivation, globus sensation
-Clinical Diagnosis
-Symptoms often worse at night
-Sleeping upright in bed or chair to reduce symptoms
-Symptoms worse after eating big meal, particular foods
-Symptoms worse when wearing constricting clothing
-Severity is related to how often and how long esophagus is exposed to acid
-Treatment is titrated to symptom severity
-Depending on presentation, either step up from lifestyle/dietary recommendations or down from potent antisecretory agents
GERD Lifestyle Modification
- Head of bed elevation 6-8 inches with blocks or wedge - try not to increase abd pressure
- Do not lie down shortly after eating or eat just prior to bed
- Avoid tight fitting garments
- Weight loss
- Chew gum or use lozenges to promote salivation
- Quit smoking (smoking reduces salivation)
GERD Dietary Modifications
- Too stringent of recommendations insures non-compliance
- Start with eliminating core LES-reducing foods
- Fatty foods, chocolate, peppermint, alcohol
- Low pH drinks - sodas, red wine, orange juice
- Patient identified triggers (tomato sauce, garlic, onion, coffee, etc.)
- Small, frequent meals
GERD Medications
- Antacids - Gaviscon, TUMS, etc, chewable or liquid
- After each meal and at bedtime
- H2 Receptor Antagonists - ranitidine (Zantac), cimetidine (Tagamet), famotidine (Pepcid), and nizatidine (Axid)
- Effective in healing mild esophagitis only
- Good for maintenance
- Proton Pump Inhibitors - omeprazole (Prilosec), lansoprazole (Prevacid), rabeprazole (Aciphex), and esomeprazole (Nexium)
- Well tolerated long term but may interfere with calcium homeostasis and linked to hip fractures in postmenopausal women
- No real difference between the meds, but higher doses more effective
GERD Surgical Management
Indications:
- Incomplete control on PPIs
- Barrett Esophagus
- Extra-esophageal manifestations (Resp, ENT, Dental)
- Young patients, elderly women with osteoporosis, cardiac conduction defects
- Nissen fundoplication and Laparoscopic fundoplication
- Both are 360 degree
- Both as or more effective than PPIs
Gastritis
- Inflammation of the gastric mucosa
- Many causes
- Drugs; alcohol; bile; ischemia; bacterial, viral, and fungal infections; acute stress (shock); radiation; allergy and food poisoning; and direct trauma.
- Imbalance between the aggressive and the defensive factors that maintain the integrity of the gastric lining
- Most commonly seen in alcoholic, critically ill or patients taking NSAIDs
- Usually asymptomatic
- Epigastric pain, nausea, vomiting, anorexia
- Hematemesis “coffee ground” appearance, or bloody aspirate from NG tube – not hemodynamically significant
- Symptom severity does not correlate with endoscopic finding severity
- Labs not helpful, but if chronic iron deficiency anemia is possible
- Upper GI Endoscopy helps distinguish from ulcers or esophageal varices
Erosive Gastritis
Stress Gastritis
-Critical illness can precipitate gastritis within a few days
-Prophylaxis - Enteral nutrition is as good or better than pharmacologic
-H2 Blockers, PPIs, Antacids
NSAID Gastritis
-NSAID users - 25-50% have gastritis, 10-20% ulcers at endoscopy
-But only 5% develop symptoms
-COX-2 selective decrease ulcers by 75%, but increase in CV complications
-D/C or reduce dose and administer with meals
-Treat with 2-4 weeks of PPI, endoscopy if not improved
Alcoholic Gastritis
-Dyspepsia, nausea, emesis, hematemesis
-Not necessarily erosive gastritis
-Treat with H2 Blockers, PPIs, or sucralfate for 2-4 weeks
Non-Erosive Gastritis
Helicobacter pylori Gastritis
- Spiral gram neg rod between the epithelial layer and the mucous layer
- Causes mucosal inflammation
- Acute - Several days of nausea and abdominal pain
- Chronic infection with gastritis results in 30-50%, but most are asymptomatic
- 15% have inflammation in gastric antrum only … those people have
- Increased gastrin
- Increased acid production
- Increased risk of development of peptic ulcers, esp duodenal ulcers
- Few have inflammation of gastric body predominantly … and they have
- Destruction of acid-secreting glands, mucosal atrophy
- Decreased acid secretion, intestinal metaplasia
- Increased risk of gastric ulcers and cancer
- Best diagnosed with biopsy on UGI endoscopy
- Treatment is with multiple antibiotics and PPI
- Results in resolution of gastritis, peptic ulcer disease and reduces gastric cancer risk
- Routine screening recommended in areas of high prevalence (Japan, Korea, China)
Peptic Ulcer Disease
-Defects in the gastrointestinal mucosa that extend through the muscularis mucosae
-Protective mechanisms - secretory, defense, and repair - make this uncommon
-H pylori and NSAIDs are biggest offenders
-BUT still, incidence is only 1% yearly in these patients
Risk Factors:
-Acid Hypersecretion - H pylori related or not
-Bicarb undersecretion in the duodenum
-Familial - some genetic predisposition
-Smoking + H pylori
Peptic Ulcer Disease - Clinical Presentation
-Epigastric pain, indigestion, or asymptomatic
-Classic epigastric pain when acid secreted in absence of food buffer
-Burning, gnawing, hunger-like, vague, or crampy
-May have radiation to back, RUQ, or LUQ
-2-5 hrs after meal or empty stomach;11 pm - 2am
-Food-provoked indigestion - epigastric discomfort and fullness, nausea, early satiety
-Other symptoms
-High incidence of GERD with PUD
-Constipation, Irritable bowel like symptoms
-Asymptomatic in 43-87% of bleeding duodenal ulcers
Complications
-Most often in chronic peptic ulcers with fibrosis, present for months
-Penetration - more intense pain, radiating to back
-Perforation - sudden, severe,diffuse abd pain
-Pyloric Outlet Obstruction - vomiting
-Hemorrhage - nausea, hematemesis, melena, dizziness
Peptic Ulcer Disease - dx, tx
Dx: Upper GI endoscopy with biopsies
tx:
- Antisecretory therapy - PPIs or H2 blockers
- PPIs are faster (2-4 weeks vs 4-8 weeks)
- Treat H pylori if present
- Withdraw offending or potentiating agents: NSAIDs, smoking, alcohol
- In non-H pylori, non-NSAID users, explore other causes
- Maintenance therapy (H2 blockers or PPIs) decreases recurrence - use in complicated or higher risk groups
- Withdraw from PPIs gradually to prevent rebound
- Controversial as to which need follow up UGI endoscopy
- Uncomplicated duodenal ulcers do not
- High risk for cancer do
Pyloric Stenosis
- Post-natal hypertrophy of the pylorus
- Progressive gastric outlet obstruction in children under 12 weeks (mean age 43 days)
- Cause unknown
- 1-8 per 1000 births; 4:1 male predmoninance
- Family history in 13%
- Projectile post-prandial vomiting, beginning at 2-4 weeks or as late as 12 weeks
- Non-bilious, may be blood-streaked
- Hungry, avid nursers
- Constipation, weight loss
- Dehydration
- Gastric peristaltic waves L to R can be seen
- Oval mass 5-15 mm on deep palpation in RUQ, especially after vomiting in 14%
- Electrolytes/BMP: Hypochloremic alkalosis (14%) with potassium depletion (23%)
- CBC - Dehydration may cause elevated hemoglobin and hematocrit
- Barium Upper GI Series: Retention of contrast in stomach and long, thin pyloric canal
- Ultrasound: Hypoechoic muscle ring
Pyloric Stenosis - Tx
-Admit to hospital for IV rehydration, IV cimetidine
-Consult Pediatric Surgeon
-Pyloromyotomy
-Post Op barium xray stays abnormal for months despite symptom relief
Children more likely to have chronic abdominal pain
- will see on X-ray string sign
Gastric Adenocarcinoma
Gastric Adenocarcinoma
- Second most common cause of cancer death worldwide - Still high incidence in Japan and many developing regions
- US - 21,500 new dx/yr; higher incidence in Latinos, African and Asian Americans
- Asymptomatic until advanced
- Vague epigastric pain, dyspepsia, anorexia, early satiety, weight loss
- Ulcerating lesions lead to hematemesis or melena
- Pyloric obstruction - postprandial vomiting
- PE - gastric mass in 20%
- Anemia - iron deficiency or anemia of chronic disease
- LFTs (Alk Phos) may be elevated if liver mets
- UGI Endoscopy essential
- Obtain in ALL pts over 55 with new onset dyspepsia or anyone who fails antisecretory therapy
- Curative Surgical Resection
- Palliative Therapies
- Long-term survival: <15%
- 45% for patients who have successful curative resection
Gastric Lymphoma
- May be primary (arising from gastric mucosa) or secondary (patients with nodal lymphomas)
- Presentation similar to adenocarcinoma
Gastric Carcinoid
- Rare neuroendocrine tumors, < 1% of gastric neoplasms
- Sporadic (20%); or
- Secondary to hypergastrinemia -> hyperplasia -> transformation of enterochromograffin cells in fundus
- Most solitary, over 2 cm
- Strong propensity for metastatic spread
- Tumors release hormone products, which cause symptoms
- Profuse diarrhea
- Flushing - hot, red face
- Telangiectasias on cheeks
- Wheezing, SOB, Cardiac arrhythmias
- R-sided valvular disease, heart failure
- Above make up carcinoid syndrome
tx: - Usual cancer treatments ineffective due to slow growth
- Presentation usually quite late
- Mainstay is Octreotide, which mimics somatostatin, to control symptoms
