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Cameron Stomach > Stomach_Ulcer > Flashcards

Stomach_Ulcer Flashcards

1
Q

Give the blood supply for the stomach

A

L gastric <- celiac a.

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2
Q

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

A

Men

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3
Q

Peak incidence of benign gastric ulcers

A

55-65 years of age

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4
Q

Give the three main risk factors for benign gastric ulcers

A

NSAIDS, cigarette smoking, H. pylori infection

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5
Q

What % of gastric ulcers are malignant?

A

10%

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6
Q

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

A

10-35%

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7
Q

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

A

H. pylori infection.

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8
Q

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

A

85-95%

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9
Q

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

A

80%

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10
Q

Give three common presentations of patients with gastric ulcers

A
  1. 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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11
Q

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?

A

4X

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12
Q

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

A

Mechanical ventilation >48 hours and coagulopathy.

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13
Q

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

A

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

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14
Q

Clinical presentation of patients with an uncomplicated gastric ulcer

A

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

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15
Q

Complicated gastric ulcer clinical presentation

A
  1. 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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16
Q

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

A

Antibody detection by serologic or whole-blood testing.

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17
Q

When should a urea-breath test be used?

A

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

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18
Q

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

A

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

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19
Q

When is endoscopy indicated to diagnose a gastric ulcer?

A

For inpatients with a suspected gastric ulcer without perforation.

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20
Q

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

A

Urease test of the antral biopsy.

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21
Q

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

A

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

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22
Q

Can blood compromise a urease test of an antral specimen?

A

Yes.

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23
Q

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

A

10 - to help rule out malignancy.

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24
Q

When is confirmaion of H. pylori eradication indicated?

A

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

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25
Q

How is confirmation of effective treatmen accomplished?

A

Either by endoscopy or by urea breath test.

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26
Q

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

A

Serologic testing is less expensive.

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27
Q

When can eradication of H. pylori be tested?

A

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

28
Q

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

A

Steroids, NSAIDs.

29
Q

What are the aims of treatment of uncomplicated gastric ulcers?

A

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

30
Q

What is the medical treatment for H. pylori?

A

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

31
Q

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

A

90%

32
Q

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

A

6 weeks after treatment.

33
Q

Which gastric ulcer is the most common?

A

Type I, 60%

34
Q

Where is a type I gastric ulcer located?

A

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

35
Q

What is the location of Type II gastric ulcers?

A

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

36
Q

What is the location of a Type III gastric ulcer?

A

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

37
Q

Where do type IV gastric ulcers occur?

A

Near the gastroesophageal junction on the lesser curve.

38
Q

What is a type V gastric ulcer?

A

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

39
Q

What types of ulcers are acid secreting?

A

Type II and III.

40
Q

Describe the Pauchet’s procedure

A

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.

41
Q

Describe the Kelling-Madlener procedure

A

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

42
Q

Describe the Csendes procedure

A

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.

43
Q

Can an ulcer be exised?

A

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

44
Q

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

A

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

45
Q

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

A

Short gastrics

46
Q

Define a giant gastric ulcer

A

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

47
Q

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

A

30%

48
Q

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

A

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

49
Q

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

A

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

50
Q

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

A

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

51
Q

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

A

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

52
Q

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

A

Distal gastrectomy with ulcer, with a Billroth 1 anastomosis.

53
Q

When is a vagotomy indicated for gastric ulcer surgery?

A

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

54
Q

What has caused a decrease in performance of vagotomies?

A

PPIs and recognized morbidity of vagotomies

55
Q

Can one perform an omental patch for gastric ulcer surgery?

A

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

56
Q

What % of gastric ulcer bleeding is self-limited?

A

85%.

57
Q

What are the benefits of endoscopy during gastric ulcer bleeding?

A

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

58
Q

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

A

Active pulsatile bleeding or a visible vessel

59
Q

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

A

Nonpulsatile bleeding or an adherent clot.

60
Q

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

A

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

61
Q

What is the surgery for gastric outlet obstruction?

A

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

62
Q

Define a marginal ulcer

A

An ulcer that occurs following gastrojejunostomy in the perianastomotic region

63
Q

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

A

Distal to the anastomosis

64
Q

What is the treatment of marginal ulcer disease?

A

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

65
Q

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

A

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

Cameron Stomach (8 decks)

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