Stomach_Ulcer Flashcards by Nicole Gordon

Give the blood supply for the stomach

L gastric <- celiac a.

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Are benign gastric ulcers more common in older men or women?

Men

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Peak incidence of benign gastric ulcers

55-65 years of age

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Give the three main risk factors for benign gastric ulcers

NSAIDS, cigarette smoking, H. pylori infection

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What % of gastric ulcers are malignant?

10%

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What % of patients with a gastric ulcer will develop a serious complication (e.g. perforation or stricture?)

10-35%

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What is the main cause of gastric peptic ulcer in the absence of chronic NSAID use or Zollinger-Ellison syndrome?

H. pylori infection.

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What % of patients with gastric ulcers are colonized with H. pylori?

85-95%

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If the H. pylori infection is left untreated, what % of gastric ulcer will recur within 1 year of treatment?

80%

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Give three common presentations of patients with gastric ulcers

ED: Older pt. with epigastric pain and hx of arthritis. 2. Transplant or lymphoma pt. who takes steroids. 3. Critically ill post-operative patients.

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How many times does the mortality rate increase in patients with stress ulcers compared to patients who do not have a stress ulcer and bleeding?

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What are the risk factors associated with clinically significant bleeding from stress ulcers in ICU patients?

Mechanical ventilation >48 hours and coagulopathy.

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What are the prophylactic measures taken to reduce stress ulcers in ICU patients?

Antacids, H2-receptor blockers, sucralfate, PPIs, prostaglandin analogs, early nutrition.

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Clinical presentation of patients with an uncomplicated gastric ulcer

Epigastric pain following meals. Occasional referred back pain. Bloating, bealching, sx of GERD.

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Complicated gastric ulcer clinical presentation

Gastric outlet obstruction due to stricture formation from recurrent ulcers. 2. Hematemesis or melena from bleeding ulcers. 3. Acute abdomen from perforation.

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What non-invasive test may be ordered to diagnose H. pylori in pts with sx of an uncomplicated gastric ulcer?

Antibody detection by serologic or whole-blood testing.

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When should a urea-breath test be used?

For follow-up testing to verify eradication after H. pylori treatment.

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When can false-negative tests with urea breath tests occur?

For patients currently or recently taking an antisecretory drug, bismuth subsalicylate or an antimicrobial agent.

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When is endoscopy indicated to diagnose a gastric ulcer?

For inpatients with a suspected gastric ulcer without perforation.

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What tests should be used on the endoscopy bx specimen for gastric ulcers?

Urease test of the antral biopsy.

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When can a urease test not be used on an antral specimen?

If a patient has taken bismuth-containing medications, PPIs, or antimicrobials within the previous 4 weeks.

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Can blood compromise a urease test of an antral specimen?

Yes.

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How many biopsies should be taken endoscopically to evaluate a gastric ulcer?

10 - to help rule out malignancy.

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When is confirmaion of H. pylori eradication indicated?

In patients with documented peptic ulcer, or with complicated/refractory ulcers.

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How is confirmation of effective treatmen accomplished?

Either by endoscopy or by urea breath test.

What is the benefit of seroligic testing over a urea breath test when diagnosing H. pylori?

Serologic testing is less expensive.

When can eradication of H. pylori be tested?

4 weeks after the last dose of antimicrobials, and 7 days after the last dose of PPIs.

If a patient is dx with a gastric ulcer, what medications should be stopped?

Steroids, NSAIDs.

What are the aims of treatment of uncomplicated gastric ulcers?

Medication: alleviating sx, achieve ulcer healing, preventing recurrence.

What is the medical treatment for H. pylori?

PPI, clarithromycin, and (amoxicillin or flagyl). Or PPI, bismuth subsalicylates, flagyl and tetracycline.

Triple therapy with PPIs is effective in what % of cases?

90%

When should endoscopy be repeated to document healing of the ulcer?

6 weeks after treatment.

Which gastric ulcer is the most common?

Type I, 60%

Where is a type I gastric ulcer located?

Lesser curve, proximal to the incisura, at the histologic transition betweent he fundus and antrum.

What is the location of Type II gastric ulcers?

Two simultaneous ulcers: body of stomach near the incisura, and duodenum (active or healed).

What is the location of a Type III gastric ulcer?

Prepyloric: within 2-3 cm of the pylorus and can be multiple.

Where do type IV gastric ulcers occur?

Near the gastroesophageal junction on the lesser curve.

What is a type V gastric ulcer?

Can occur anywhere in the stomach and is caused by medications.

What types of ulcers are acid secreting?

Type II and III.

Describe the Pauchet's procedure

Antrectomy w/ extension proximally to include the lesser curve of the stomach in order to include an ulcer near the GE jxn. A Billroth II gastrojejunostomy is commonly performed.

Describe the Kelling-Madlener procedure

An antrectomy, truncal vagotomy, and ulcer biopsies, while leaving a large GE junction/Type IV ulcer in place

Describe the Csendes procedure

Option for uclers 2 cm or less from GEJ: Most of stomach is resected up to the GEJ, inlcluding the ulcer, followed by a Roux-en-Y gastrojejunostomy.

Can an ulcer be exised?

Yes, and anatomosed with a jejunal Roux limb if the defect cannot be closed primarily due to narrowing.

What is the emergency procedure in an unstable patient with a bleeding gastric ulcer w/o pre-op localization?

Perform an anterior gastrotomy, examine for bleeding source. If patient is too unstable ligation of gastric vessels or a near-total gastrectomy are indicated.

During gastric devascularization for emergent bleeding gastric ulcer surgery, what vessel(s) is/are spared?

Short gastrics

Define a giant gastric ulcer

An ulcer with a diameter of > or equal to 3 cm.

Wha tis the incidence of underlying malignancy in giant gastric ulcers?

30%

When is non-operative management indicated for a perforated gastric ulcer?

Nonseptic, stable patients with benign gastric ulcers. H2O-soluble contrast upper GI series shows a sealed perforation.

What steps are taken for non-operative managemet of gastric ulcer perforations?

NPO, abx, NGT, gastric acid secretion suppression and serial abdominal exams

When is non-operative management of a perforated gastric ulcer no longer indicated?

If the patient does not demonstrate improvement in 12 hours or they become unstable.

What is required after the patient is discharged after non-op management of a perforated gastric ulcer?

FU endoscopy in 6 weeks to confirm healing of ulcer and obtain a tissue biopsy.

What is the preferred procedure in a stable pt with a perforeated gastric ulcer?

Distal gastrectomy with ulcer, with a Billroth 1 anastomosis.

When is a vagotomy indicated for gastric ulcer surgery?

For noncompliant patients with recurrent type II and type III ulcers with no other reason in their history to have an ulcer

What has caused a decrease in performance of vagotomies?

PPIs and recognized morbidity of vagotomies

Can one perform an omental patch for gastric ulcer surgery?

Yes, in an unstable patient. However, a FU endoscopy to rule out malignancy is warranted

What % of gastric ulcer bleeding is self-limited?

85%.

What are the benefits of endoscopy during gastric ulcer bleeding?

Can bx for malignancy and H. pylori. Can also asess the likelihood of recurrent bleeding.

What are the 2 characteristics at endoscopy that predict a high bleeding risk?

Active pulsatile bleeding or a visible vessel

For a bleeding gastric ulcer, what characteristics are associated with a low risk of rebleeding on endoscopy?

Nonpulsatile bleeding or an adherent clot.

What is the usual cause of gastric outlet obstruction in the setting of ulcer disease?

Usually a complication of a scarred duodenal ulcer rather than a gastric ulcer. But gastric stricutures could occur.

What is the surgery for gastric outlet obstruction?

Antrectomy. If there is concern for a duodenal stump leak with antrectomy, can do a diverting gastrojejunostomy as an alternative.

Define a marginal ulcer

An ulcer that occurs following gastrojejunostomy in the perianastomotic region

In relation to the anastomosis where do the marginal ulcers usually occur?

Distal to the anastomosis

What is the treatment of marginal ulcer disease?

Medical therapy: H. pylori treatment, stop ASA/NSAIDs, smoking cessation, etc.

T/F: Most benign gastric ulcers never present to a medical professional

T. If they do, they see a PCP first and rarely a surgeon