Stomach (Part 2) Flashcards
(158 cards)
1
Q
how are hiatal hernias most frequently detected?
A
on xray, CT, etc.. INCIDENTALLY
2
Q
how does the esophagus connect to the diaphragm?
A
it passes through the diaphragmatic hiatus and is anchored to the membrane there.
3
Q
why do hiatal hernias happen? what happens to the membrane?
A
it becomes worn out, thin, and ineffective
4
Q
what is the most common form of hiatal hernias?
A
type 1: sliding hernia (95%)
5
Q
why do type 1 hiatal hernias occur?
A
widening of the hiatal tunnel and circumferential laxity of the phrenoesophageal membrane
6
Q
what cavity is the hernia contained in?
A
posterior mediastinum.
7
Q
what is the test of choice for a hiatal hernia type 1?
A
barium swallow
8
Q
how big do hiatal hernias have to be in order to be seen on barium swallow or endoscopy?
A
> 2cm
9
Q
how do you detect smaller hernias?
A
manometry
10
Q
are symptoms of hiatal hernias type 1 related to the size of the hernia?
A
yes, increases with size.
11
Q
what kind of symptoms do hiatal hernias type 1 cause?
A
GERD symptoms
12
Q
what kind of treatment do you give for asymptomatic type 1 hiatal hernias?
A
none
13
Q
what kind of treatment do you give for symptomatic type 1 hiatal hernias.
A
medical or surgical control of reflux –> general surgeon.
14
Q
what types are the paraesophageal hernias?
A
type 2,3, and 4 (3 and 4 are variants of type 2)
15
Q
how common are paraesophageal hernias?
A
not very! <5%
16
Q
paraesophageal hernias can be a complication after…
A
anti-reflux procedures
partial gastrectomy
esophagomyotomy
17
Q
two ligaments that anchor the stomach in place
A
gastrosplenic ligament
gastrocolic ligament
18
Q
course of hiatal type 2’s are what?
A
progressive!
19
Q
test of choice for type 2 hiatal hernia?
A
barium swallow
20
Q
symptoms of hiatal hernia type 2?
A
many are asymptomatic or have vague intermittent symptoms
epigastric or substernal pain
postprandial fullness
substernal fullness
nausea and retching
21
Q
do type 2 hiatal hernias need intervention?
A
yes! they will not resolve on their own
22
Q
what are we preventing in treating a type 2 hiatal hernia?
A
the stomach becoming an intrathoracic organ
23
Q
5 most common causes of Upper GI Bleeding
A
H. Pylori NSAIDS Mallory Weiss Tear Stress Gastric Acid
24
Q
what do upper GI bleeds commonly present with?
A
hematemesis and/or melena
25
initial evaluation should focus on
hemodynamic instability
diagnosis studies to determine cause
treatment of the specific disorder
26
hematemesis means bleeding from where?
GI tract proximal to ligamnet of Treitz
27
frankly bloody emesis suggests
moderate to severe bleeding
28
coffee ground emesis suggests
more limited or slow bleeding (digested before vomited up)
29
majority of melena occurs from
proximal to the ligament of treitz (90%)
30
hematochezia comes from
a lower GI bleed
31
important PMH to upper GI bleeds
```
prior episodes (60%)
liver disease or alcohol abuse history
suggest esophageal varices or portal hypertension
AAA (abdominal aortic aneurysm)
aorto-enteric fistula
peptic ulcer
malignancy
```
32
important medication history for upper GI bleeds
```
asprin
NSAIDs
pill esopagitis medications (tetracycline, clindamycin, doxycycline, bisphosphonates, vitamin C, iron,...)
anticoagulants
bismuth/iron
```
33
if an upper GI bleed presents with epigastric pain or RUQ pain
peptic ulcer
34
if an upper GI bleed presents with Odynophagia, GERD, dyspepsia
esophageal ulcer
35
if an upper GI bleed presents with emesis, cough or retching prior to episode
mallory weiss tear
36
if an upper GI bleed presents with jaundice, weakness, fatigue, abdominal distension
liver or variceal etiology
37
physical exam clues of Upper GI bleeds
hypovolemia (low BP, resting tachycardia)
abdominal pain
inflammation of peritoneal cavity
38
define orthostatic hypotension
decrease in SBP of more than 20mmHg or a rise in HR from laying to standing more than 20 bpm
blood loss of atleast 15% in upper GI bleeds
39
supine hypotension
blood loss of atleast 40% in upper GI bleeds
40
rebound tenderness
palpating the abdomen and pain starts when you remove the hand
upper GI bleeds
41
guarding
firm palpation of the abdomen because patient anticipates pain
upper GI bleed
42
Labs to order for an upper GI bleed
CBC
coagulation studies: is it caused by a low INR?
liver function
43
when should you start treatment for upper GI bleeds?
ASAP, do not wait until you figure out the cause
44
what is the initial treatment for upper GI bleeds and why?
IV PPI
reduces rate of bleeding
decreases length of stay
decreases re-bleed rate
decreases need for blood transfusions
45
which IV PPI to use with upper GI bleeds?
omeprazole or pantoprazole
46
how do we administer IV PPIs for patients with upper GI bleeds?
as a bolus then a drip
47
adjunctive therapy for GI bleeds and why?
erythromycin: promotes gastric emptying by acting as an agonist of motilin receptors therefor increasing gastric motility
48
when should we use erythromycin in upper GI bleeds?
when it's a large GI bleed and we need to do endoscopy
49
why can't we use laxatives for clearing of the stomach to improve visualization?
they don't work on the stomach, they work on the intestine and colon
50
what results from the fact that blood sitting in the GI tract?
illeus (no contractions) because it is caustic
51
what is the test of choice for upper GI bleeds?
endoscopy
52
what is contraindicated for upper GI bleeds and why?
Barium swallow because the barium will interfere with the future endoscopy, angiograms, and surgery
53
types of ulcers that classify as PUD
gastric and duodenal
54
ulcers are defined as
a break in the mucosa >5mm in size with a depth to the submucosa
55
two causes of PUD
H. Pylori
| NSAIDs
56
is H. pylori gram + or -
negative
57
where does H. pylori live?
under the mucous gel that lines the stomach
58
describe the shape of H. pylori
many flagella
| can change shape from S-shape to cocci
59
does H. pylori invade the cells?
no
60
what exposes H. pylori and causes a problem?
break to the gastric mucosa
61
transmission of H. pylori is by
fecal-oral root
62
predisposing factors of H. pylori
```
low socioeconomic status
less education
birth or residence in developing country
domestic crowding
unsanitary living condition
unclean water/ food
exposure to gastric contents of an affected individual
```
63
H. pylori is almost always associated with
chronic active gastritis
64
how often does H. pylori cause ulcerative disease
10-15%
65
what diseases can H. Pylori cause?
MALT lymphoma
| gastric cancer
66
what are the role of prostalandins in the GI tract?
to regulate release of bicarbonate and mucus
inhibit parietal cell secretion
maintain mucosal blood flow
67
role of cytooxygenase (COX)
control prostaglandin synthesis
68
what does COX-1 do?
expressed in a lot of tissues, but mostly GI and Kidney
| it's role is to maintain renal function, platelet aggregation function, and GI mucosal integrity
69
what does COX-2 do?
expressed by most cells
expressed by macrophages and leukocytes when inflammation is present
helps block anti-inflammatory
70
what is the therapy for preventing ulcers?
PPI + COX1 or COX2 inhibitors
| DO NOT DO THIS IF THEY ALREADY HAVE AN ULCER!
71
risk factors for PUD
```
prior history of ulcer disease
duration of NSAID use
over the age of 75 because of gastric atrophy and gastro-mucosal health
underlying cardiovascular disease
drugs that are bad to mix with NSAIDS
```
72
drugs that are bad to mix with NSAIDS
```
steroids
anticoagulants
SSRIs
alendronate (biphosphonates)
clopidogrel (plavix)
```
73
where do duodenal ulcers occr?
first portion of the duodenum
74
how big are duodenal ulcers?
<1 cm in diameter
| well demarcated but can be very deep
75
do duodenal ulcers progress to cancer?
rarely
76
what relieves duodenal ulcers?
antacids
| eating
77
when does the pain from duodenal ulcers occur?
between midnight and 3am (wakes pt up)
| 90 minutes to 3 hours after a meal
78
gastric ulcers present with
pain precipitated by eating
Nausea, weight loss
older patients (60s)
79
do gastric ulcers progress to cancer?
yes, always biopsy on discovery
80
what is more common gastric or duodenal ulcers?
duodenal
81
where does the pain occur with gastric ulcers?
epigastric (burning or gnawing vague, aching, hunger pain)
constant, unrelievable dyspepsia
sudden and severe abd pain --> perforation
82
what would you check in a physical exam to look for duodenal ulcers?
epigastric tenderness
GI bleed
hemodynamically stable
83
most common complication of PUD pts
GI bleeds
84
mortality rate of GI bleeds from PUD
10%
85
how often do patients bleed without a warning or preceeding symptom with PUD?
20%
86
second most complication of PUD?
perforation
87
form of perforation where the ulcer tunnels to an adjacent organ
penetration
88
where do duodenal ulcers penetrate to?
pancreas
89
where do gastric ulcers penetrate to?
left hepatic lobe
90
least common complication of PUD
gastric outlet obstruction causing inflammation spreading to neighbor tissues
91
symptoms of gastric outlet obstruction
early satiety
N/V
increased postprandial abd pain
weight loss
92
diagnostic test of choice for PUD
endoscopy
93
what does a benign PUD endoscopy look like?
smooth, regular rounded edges, flat, filled with exudate
94
what does a malignant PUD endoscopy look like?
ulcerated mass protruding into the lumen, folds surrounding the ulcer that are nodular, fused, or thickened/ irregular
95
does the size of the ulcer affect the chance of malignancy?
yes, increases
96
what test should you do upon finding an ulcer?
urease testing for H. pylori
97
what will cause a false negative of a peptic ulcer?
```
bleeding
PPI therapy
H2 blockers
antibiotics
peptobismol
```
98
what should you do if the urease test comes back negative for H. pylori?
stool antigen test or breath test or serology
99
how does the urease test work?
```
take a biopsy from the antrum during EGD
do CLOtest (urease)
```
100
is the CLO test reliable for diagnosing PUD?
yes!
101
how does the urea breath test work?
urea + h.pylori produce CO2 and ammonia
CO2 is detected in breath samples
must take off PPIs and Abx for 2 wks before testing
102
what does serology test for?
IgG antibody for H.pylori
103
what restrictions do we have for stool antigen testing regarding PUD?
must be off PPIs and Abx for 2 wks
104
indications for noninvasive testing for PUD
test of cure (recommend urea breath test)
| repeat 4-6 weeks after completeion of treatment
105
three theories of treating H.pylori
triple therapy
quadruple therapy
sequential therapy
106
when should we use triple therapy to treat H.pylori?
when there is a low resistance to clarithromycin
107
4 meds of quadruple therapy (PUD)
PPI
bismuth
metronidazole
tetracyclin (sumisin)
108
how should the PPI be dosed for PUD
BID!
109
MOA of bismuth?
Coats ulcers and erosions
Provides a protective barrier against acid and pepsin
Has antimicrobial properties against H.pylori
110
Side effect of bismuth?
Harmless black stools
111
For what population shouldn’t you use Bismuth?
Children because there are trace amounts of asprin which cause Reye’s syndrome
112
Antiparasitic used for quad therapy for H.pylori?
Metronidazole (Flagyl)
113
Metronidazole’s MOA
Selectively absorbed by anaerobic bacteria and sensitive protozoa
After absorption it is broken down by the bacteria to release a toxin which will kill the bacteria
114
Side effects of Flagyl
Severe nausea and vomiting if taken with alcohol (antibuse effect)
Metallic taste
115
How long after flagyl therapy is completed until you can drink alcohol?
72 hours
116
Antibiotic used to treat H. Pylori
Tetracycline (sumycin)
117
MOA of tetracycline?
Broad spectrum bacteriostatic antibiotic that inhibits protein synthesis
Covers +,-,anaerobes
118
When should you take tetracycline
On an empty stomach to improve absorption
| No food, dairy, or antiacids
119
Side effects of H.pylori
Photosensitivity
120
Severe peptic ulcer disease secondary to a gastrin secreting tumor (gastrinoma)
Zollinger-Ellison Syndrome (ZES)
121
where do most gastrinomas originate from?
pancreas
122
ZES tumors can be grouped as
multiple endocrine neoplams (type 1)
123
ZES gender predominence
men
124
age group for ZES
30-50
125
blood abmormality in ZES
hypergastrinemia
126
80% of ZES ulcers are where?
gastrinoma triangle
common bile duct
2-3 portion of the duodenum
neck and body of pancreas
127
are many of the ZES tumors considered malignant
yes, 1/2 will have mets upon presentation
128
% patients with a presentation of PUD with ZES
90%
129
suspect ZES if
```
second part of duodenum and behind
refractory to medical therapy
recurrence after fundiplication
complications like bleeding or perforation
diarrhea
```
130
why do patients get diarrhea in ZES
malapsorption and digestion
131
two tests needed to diagnose ZES
fastin grastrin level (serum)
| secretin stimulation test
132
what will throw off ZES creating a false positive?
H. pylori pts will have increased serum but not nearly as high as ZES
133
test which helps differentiate gastrinomas from other causes of hypergastrinemia?
secretin stimulation test
134
MOA of secretin stimulation test
secretin when given, prompts the release of gastrin from the tumor cells, but not in normal uneffected people
135
options for ZES to locate the location of the tumor
```
esophageal ultrasound (pancreatic tumors)
somatostatin uptake testing (radioactive tag)
abdominal CT vs MRI
```
136
treatment goals for ZES
address the overproduction of gastrin
| resect neoplasm and control metastatic disease
137
treatment of choice for ZES
PPIs (dosing higher than GERD or PUD)
138
treatment inhibiting gastrin secretion is
somatostatin analouge , octrotide (Sandostatin)
139
serious reactions to octrotide, sandostatin
pancreatitits
cholecystitis
cholestatic hepatitis
140
how is the prognosis of gastric cancer>
deadly
141
why have rates of gastric cancer gone down?
refridgeration
less salting of foods
h. pylori decrease
142
ethnicities most prone to gastric cancer?
world:asian and south americanus: asian and pactific islanders
143
gender and age predominance in gastric cancer
male
| male: 70, women 74
144
symptoms
early: none
late: n/v, dsyspagia, postprandial fullness, melena, anorexia
145
hallmarks sign of gastric cancer
meriumbilical met, sister mary joseph nodule
virchows nodes: left supraclavicular
blumers shelf: peritoneal cul de sac palpable
leser-trelat: senporheic keratosis
146
risk factors for gastric cancer
```
chronic h.pylori infection (strongest)
pickled veggies
salted fish
smoked meats
smoking
previous gastric cancer
genetics
pernicious anemia
```
147
diagnostic method for gastric cancer
EGD
| staging done with CT and esophageal ultrasound
148
two main types of gastric cancer
adenocarcinoma (95%)
| MALT
149
two types of adenocarcinoma gastric cancer
diffuse and intestinal
150
no cell adhesion, thickening of the stomach wall, occus in younger patients,leather bottle appearance, poorer prognosis
diffuse type of ZES
151
forms cohesive group of cancer cells from little tube like masdes
intestinal type adenocarcinoma
152
treatment for adenocarcinoma
total gastrectomy
153
what does a total gastrectomy use
tumor removal in no populariopn
154
most frequent extra nodal site of lymphoma
gastric cancer (stomach)
155
how does lymphoma present
same as adenocarcinoma
156
is lymphoma treatmble
much more so
157
are MALT lymphoma patients chronic?
no, resolves itself with h.pylori
158
maintenence of lymphoma
surveillance EGD done periodically
questions
we might have to retreat pylori
