tbl 2: management of dyspepsia Flashcards
Dyspepsia
- Defined as ____________ lasting at least 1 month and can be associated with any other upper GI symptom such as epigastric fullness, nausea, vomiting or heartburn
- It is a common symptom with an extensive differential diagnosis and a heterogeneous pathophysiology. It occurs in at least 20 percent of the population
- Approximately 25 percent of patients with dyspepsia have an underlying organic cause. However, up to 75 percent of patients have functional (idiopathic or _________) dyspepsia with no underlying cause on diagnostic evaluation
- Alarm symptoms include unintentional weight loss, fatigue, _____, ______, family history of GI cancers (malignancies)
epigastric pain; nonulcer;
anemia, persistent vomiting
Dyspepsia
- Defined as ____________ lasting at least 1 month and can be associated with any other upper GI symptom such as epigastric fullness, nausea, vomiting or heartburn
- It is a common symptom with an extensive differential diagnosis and a heterogeneous pathophysiology. It occurs in at least 20 percent of the population
- Approximately 25 percent of patients with dyspepsia have an underlying organic cause. However, up to 75 percent of patients have functional (idiopathic or _________) dyspepsia with no underlying cause on diagnostic evaluation
- Alarm symptoms include unintentional weight loss, fatigue, _____, ______, family history of GI cancers (malignancies)
epigastric pain; nonulcer;
anemia, persistent vomiting
Causes of dyspepsia: organic disease
Common causes
- __________
- Drug-induced
- NSAIDs (eg _______)
- Bisphosphonates (eg _______)
- Antibiotics (eg erythromycin)
- Biliary colic (gallstones/ biliary stones)
- Pancreatitis (acute/chronic)
- Gastric or pancreatic cancer
- Hepatocellular carcinoma
- Gastroparesis (eg in diabetic pts)
Less common causes
- Infiltrative diseases (eg _______, eosinophilic gastritis, Crohn’s disease)
- Metabolic disturbances (________, heavy metal toxicity)
- SMA syndrome, _____________
Peptic ulcer disease (PUD); ponstan; alendronate
gastric lymphoma; hypercalcemia; celiac artery compression syndrome
Causes of dyspepsia: functional dyspepsia
- Requires exclusion of other organic causes of dyspepsia
- Defined by the presence of 1 or more of the following
== ________
== ___________
== Epigastric pain or burning
== AND no evidence of ____________ to explain the symptoms
- Non-invasive testing for active H.pylori infection should be performed in patients with functional dyspepsia if gastric biopsies were not obtained for H.pylori on OGD
- Treatment options include PPI, _____________ or prokinetics
Postprandial fullness; Early satiation; structural disease; tricyclic antidepressants
Causes of dyspepsia: organic disease
Common causes
- __________
- Drug-induced
- NSAIDs (eg _______)
- Bisphosphonates (eg _______)
- Antibiotics (eg erythromycin)
- Biliary colic (gallstones/ biliary stones)
- Pancreatitis (acute/chronic)
- Gastric or pancreatic cancer
- Hepatocellular carcinoma
- Gastroparesis (eg in diabetic pts)
Less common causes
- Infiltrative diseases (eg _______, eosinophilic gastritis, Crohn’s disease)
- Metabolic disturbances (________, heavy metal toxicity)
- SMA syndrome, _____________
Peptic ulcer disease (PUD); ponstan; alendronate
gastric lymphoma; hypercalcemia; celiac artery compression syndrome
Causes of dyspepsia: functional dyspepsia
- Requires exclusion of other organic causes of dyspepsia
- Defined by the presence of 1 or more of the following
== ________
== ___________
== Epigastric pain or burning
== AND no evidence of ____________ to explain the symptoms
- Non-invasive testing for active H.pylori infection should be performed in patients with functional dyspepsia if gastric biopsies were not obtained for H.pylori on OGD
- Treatment options include PPI, _____________ or prokinetics
Postprandial fullness; Early satiation; structural disease; tricyclic antidepressants
Dyspepsia- History
- Look for alarm features (unintentional weight loss, progressive dysphagia, __________, unexplained iron deficiency anemia, persistent vomiting, family history of upper GI cancer) *needs early/urgent scope
- Aspirin or other NSAID use
- Any biliary colic?
= Episodic intense dull pain in RUQ or ________, constant and not ________, Lasts at least 30 minutes. Entire attack lasts less than 6 hours
- Radiation of pain to back (pancreatic)
- Any associated reflux symptoms? (________, heartburn)
odynophagia; epigastrium; colicky; sour brash
Dyspepsia: Physical Examination
Physical examination include a ______________ (eg, hepatoma) or _______________ (eg, left supraclavicular or periumbilical in gastric cancer), jaundice (eg, secondary to ____________), or pallor secondary to ______. Ascites may indicate the presence of ___________. Patients with an underlying malignancy may have evidence of muscle wasting.
palpable abdominal mass; lymphadenopathy; liver metastasis; anemia;
peritoneal carcinomatosis
Dyspepsia: Laboratory Tests
Routine blood counts and blood chemistry including ______________, serum lipase, and amylase, should be performed to identify patients with alarm features (eg, iron deficiency anemia) and underlying metabolic diseases that can cause dyspepsia (eg, diabetes, hypercalcemia)
liver function tests
Chronic H.pylori gastritis
- Associated with PUD, gastric cancer and MALT lymphoma and likely non-ulcer dyspepsia.
- Antral predominant gastritis:
== Usually at the earlier stage of infection
== decreases _______ release, increases ________ secretion, increased acid secretion
== Associated with duodenal ulcer
Corpus predominant/ extensive gastritis:
== Inflammation spreads to corpus, development of atrophy and intestinal metaplasia
== Decreased acid production
== Associated with gastric ulcer, gastric cancer
somatostatin; gastrin;
“Gastritis” often used to describe endoscopic findings of gastric mucosa inflammation/_______.
- Inflammation with associated mucosal injury
- Commonly secondary to infectious (H.pylori) or autoimmune etiologies (autoimmune gastritis)
- Mucosal biopsy required to diagnose gastritis
Gastropathy
- Epithelial cell damage and regeneration without associated inflammation
- Eg. Chemical (bile, alcohol, NSAIDs), vascular (eg, ______________)
erythema; portal hypertensive gastropathy
H.pylori
Indication for testing
Active PUD
- Hx of PUD (if not previously tested or eradication not documented)
- Early gastric cancer
- Low grade _______________
- First degree relative with stomach cancer
Other indications
- Prior to chronic treatment with NSAIDs, aspirin in those at high risk of complications (eg. Previous PUD, age>60, on concomitant aspirin/NSAIDs)
- _____________
- Unexplained iron deficiency anemia
- Immune thrombocytopenia
Testing for HP eradication
- Recommended to confirm eradication
- Especially with rising antibiotic resistance
H. pylori IgG
- Unable to differentiate between active or chronic infection
- False positive, may still remain positive after eradication
- Not recommended for diagnosing active infection or _________
mucosa-associated lymphoid tissue (MALT) lymphoma; Non-ulcer dyspepsia;
confirm eradication
- H. pylori infection is a risk factor for the development of ulcers and for ulcer bleeding in patients on ____________ treatment. H. pylori also increases the risk of NSAID-related peptic complications
- H. pylori can cause iron deficiency and iron deficiency anemia by interfering with absorption of oral iron.
- Limited evidence suggests that eradication of H. pylori infection improves platelet counts in some adult patients with _____________________
low-dose aspirin; idiopathic thrombocytopenic purpura
H.pylori
Indication for testing
Active PUD
- Hx of PUD (if not previously tested or eradication not documented)
- Early gastric cancer
- Low grade _______________
- First degree relative with stomach cancer
Other indications
- Prior to chronic treatment with NSAIDs, aspirin in those at high risk of complications (eg. Previous PUD, age>60, on concomitant aspirin/NSAIDs)
- _____________
- Unexplained iron deficiency anemia
- Immune thrombocytopenia
mucosa-associated lymphoid tissue (MALT) lymphoma; Non-ulcer dyspepsia
Helicobacter Pylori
Methods of Testing for HP:
If endoscopy is required:
- Gastric biopsy for rapid urease test (eg Clotest, Hpfast)
- Gastric biopsy for histology
If endoscopy not required:
- Urea breath test
- ___________- test
Urea-based test
- H.pylori produces urease: urea –> CO2 (detected in breath test), _______ (alkaline ph –> color change in Clotest/Hpfast)
Sensitivity of tests decreased if:
- ______/Antibiotics taken within 4 weeks of testing
- PPI taken within 2 weeks of testing
- Active GI bleeding
Stool Ag; ammonia ; Bismuth
H. Pylori
- Treatment regimens depend on local macrolide resistance rates
- Regimens include OAC triple therapy and bismuth based quad therapy
= OAC: omeprazole, ________, _______
= Bismuth based: omeprazole, bismuth, _________, _______ - Salvage therapies include LAO and Rifabutin based therapy
= LAO: ________, amoxicillin, omeprazole
= Rifabutin: rifabutin, _________, _______ - Duration of therapy: 14 days
- Check for eradication/clearance
amoxicillin, clarithromycin;
metronidazole; tetracycline
levofloxacin;
amoxicillin, esomeprazole
Peptic ulcer disease
- Defect in the gastric or duodenal mucosa
Causes of PUD:
- Helicobacter Pylori related
- Drugs: NSAIDs, aspirin
- Other causes:
= Malignancy: adenocarcinoma, lymphoma
= Infectious: ________, _________
= Inflammatory: _____, Eosinophilic gastroenteritis
= Hypersecretory state: Gastrinoma (Zollinger-Ellison syndrome), _________
Complications:
hemorrhage (haemetemesis or malena), gastric outlet obstruction (vomiting), and perforation (severe diffuse pain)
Cytomegalovirus; Tuberculosis
Crohn’s
mastocytosis
Peptic Ulcer Disease
Classic symptoms:
- DU: dyspepsia 1-3 hrs after meals, relieved by food, antacids.
- GU: dyspepsia exacerbated by _____
- However, up to 70% of peptic ulcers are asymptomatic;
- Frequently associated with _________
Diagnosis:
- Confirmation via _________
- Blood tests: FBC – iron deficiency anemia
- Biopsies taken at time of endoscopy for histology (GU) and H.pylori infection
- malignant endoscopic features:
= Ulcerated mass protruding into the lumen
= Folds surrounding the ulcer crater are _______, clubbed, fused, or stop short of the ulcer margin
= _________, irregular, or thickened ulcer margins
food ; gastroesophageal reflux
upper endoscopy; nodular; Overhanging
Peptic Ulcer Disease
Treatment:
- Anti-secretory agents (8-12wks):
= Histamine-2-receptor blockers (eg famotidine)
= Proton Pump inhibitors (eg omeprazole, esomeprazole, rabeprazole)
- Eradicate HP if positive
- Discontinue NSAIDs
Repeat Endoscopy
- Repeat OGD within _________ to ensure ulcer healing (if not NSAID related)
Multiple ulcers
- Especially refractory, associated with diarrhoea
- Suspect ________________ –> serum gastrin levels
12 weeks; Zollinger-Ellison syndrome
Zollinger Ellison Syndrome
Gastrinoma location:
- Only 25% pancreatic gastrinomas
- Majority have duodenal gastrinomas (predominantly ____ part of duodenum)
= Small (<1cm)
= Multiple
= Less likely to have metastasized to the liver at diagnosis (0-10% vs 22-35%)
- Rarely (5-15%), may arise from liver, bile duct, ovary, stomach, peripancreatic lymph nodes and extra-abdominal sites (heart, small cell lung cancer)
Pathophysiology (recap):
- Excessive gastrin secretion (from gastrinoma)
» trophic action on parietal cells and ______________
» high gastric acid output (4-6x)
1st; olling
MEN-1 is a rare autosomal _________ disorder classically characterized by a predisposition to tumors of the _________, ___________, and pancreatic islet cells
Multiple parathyroid tumors causing _________ is the most common manifestation of MEN1, present in 90% of cases.
Enteropancreatic tumors affects 30-70% of pts with MEN1. Can be functioning or non functioning. Gastrinoma most common of the functioning pancreatic tumors.
Pituitary adenomas – 30-40% of MEN1. _________most common.
dominent, parathyroid glands. anterior pituitary
hyperPTH; Prolactinoma
Zollinger Ellison Syndrome
Gastrinoma location:
- Only 25% pancreatic gastrinomas
- Majority have duodenal gastrinomas (predominantly ____ part of duodenum)
= Small (<1cm)
= Multiple
= Less likely to have metastasized to the liver at diagnosis (0-10% vs 22-35%)
- Rarely (5-15%), may arise from liver, bile duct, ovary, stomach, peripancreatic lymph nodes and extra-abdominal sites (heart, small cell lung cancer)
Pathophysiology (recap):
- Excessive gastrin secretion (from gastrinoma)
» trophic action on parietal cells and ______________
» high gastric acid output (4-6x)
1st; enterochromaffin-like cells (ECL)
Zollinger Ellison Syndrome Pathophysiology
High gastric output results in:
- Acid-related diseases: ________, gastro-oesophageal reflux
- Diarrhoea:
= High volume of gastric acid secretion, cannot be fully reabsorbed by small intestine/colon
= Rate of gastric acid secretion exceeds neutralizing capacity of pancreatic HCO3 secretion
»_space; low pH of intestinal contents
»_space; inactivates ___________, interferes with fat digestion, damages epithelial cells/villi
» fat malabsorption/maldigestion
» _________
Extremely high serum gastrin concentrations inhibit absorption of __________ by the small intestine
»_space; secretory diarrhoea
peptic ulcers; pancreatic enzymes;
steatorrhea; Na and H2O
Zollinger Ellision Syndrome
Clinical manifestations:
- ________ (epigastric pain, discomfort, burning, bloating)
- Heartburn, acid brash
- Diarrhoea
- Complications of _________ (eg bleeding, stricture, perforation)
- Endoscopic features:
Duodenal ulcers, jejunal ulcers, reflux oesophagitis, prominent _________
Suspect ZES when:
- Multiple, ________ peptic ulcers
- Ulcers distal to duodenum
- Peptic ulcers with diarrhoea
- Diarrhoea responsive to acid suppressive therapy (eg with Proton pump inhibitors)
- Family hx of PUD, MEN1
Dyspepsia; peptic ulcer disease; gastric folds
refractory
Diagnosis for Zollinger Ellison Syndrome
- demonstrate elevated basal or stimulated gastrin levels (in the setting of __________)
- two-thirds of patients with ZES have serum gastrin concentrations less than 10 times the upper limit of normal (between 110 and 1000 pg/mL).
- This degree of hypergastrinemia is nonspecific and can also be present in patients with ______________ (eg, antral G-cell hyperplasia, gastric outlet obstruction, and retained gastric antrum) or _________________ (atrophic gastritis, PPI)
In pts with appropriate hypergastrinemia, with increased acid production but borderline elevation of gastrin, The secretin test can be performed.
- Can differentiate from antral G-cell hyperplasia
- IV secretin (over 1 min), measure serum gastrin
- ZES: ________________
- Antral G cell hyperplasia: _________ (antral G-cells inhibited by secretin)
low gastric pH;
increased gastric acid secretion; appropriate hypergastrinemia
dramatic rise in serum gastrin; poor response
After ZES diagnosed:
- gastrinoma must be located and staged
= Upper endoscopy
= Computed tomography (CT)/ Magnetic resonance imaging (MRI) scans
= Somatostatin receptor scintigraphy/____________/CT
= Endoscopic ultrasound
- Screen for MEN-1
= Parathyroid hormone levels, = Ca2+ (hyperparathyroidism)
= Prolactin levels (_______)
Gallium-68 DOTATATE PET; prolactinoma
ZES Management
MEN-1 related gastrinoma –> Medical therapy (_______; ie omeprazole 60mg OD)
Sporadic gastrinoma (without metastases) –> Medical + Surgical ________ with curative intent
Hepatic-predominant metastatic disease
- Resectable => Surgical resection of hepatic metastases along with the primary tumor
- Unresectable => Bland embolization, chemoembolization, selective internal radiation therapy, radiofrequency ablation, cryoablation AND Systemic therapy: chemotherapy, molecularly targeted agents etc.
high dose PPI; resection
Gastric cancer
- One of the most common cancers worldwide
- In Spore, it’s the ___ most common cancer in males and 9th in females
Epidemiology
- Highest in Eastern Asia, Eastern Europe and South America
Men > women
- Age of onset in Chinese younger than West
Histology:
- Intestinal type: >males, older age grp, worldwide decline in recent decades
- Diffuse/infiltrative type: men=women, younger, worse prognosis.
Risk factors:
- ______, intestinal metaplasia, adenomatous gastric polyps
- Gastric ulcer, h. pylori infection
- Smoking, alcohol, diet (salt-preserved food, ___________)
- Obese, high socioeconomic status (for proximal gastric cancers)
- Family history
7th
Atrophic gastritis; N-nitroso compounds
Gastric cancer
At diagnosis: approximately 50% have unresectable disease , only 1/2 of those who appear to have locoregional tumor involvement can undergo a potentially curative resection
Screening:
- Value controversial
- Population-based screening: some countries with high incidence of gastric cancer
- Korea: OGD every 2yrs (Age 40-75yrs old)
- Japan: Barium meal every yr, OGD every 2-3yrs (age >50yrs)
- Selective screening in high risk groups : Intestinal metaplasia , atrophic gastritis, after resection gastric adenomatous polyp , _________
Hereditary syndromes eg. ________, _____________/
pernicious anemia
Lynch syndrome; familial adenomatous polyposis
Gastric cancer (clinical features)
- Dyspepsia, epigastric pain
- Unintentional weight loss (from ___________)
- Dysphagia (if ____________affected)
- Nausea/early satiety
- Vomiting (if ______________ from advanced distal tumor)
- Iron deficiency anemia
Signs of metastases/spread:
- Ascites: peritoneal carcinomatosis
- Palpable liver mass
- ________ lymph node (Virchow’s node)
- ________ nodule (Sister Mary Joseph’s node)
- Paraneoplastic manifestations: diffuse seborrheic keratosis (sign of Leser-Trelat) acanthosis nigricans
insufficient caloric intake; proximal stomach/GEJ ; gastric outlet obstruction
Supraclavicular; Periumbilical
Gastric Cancer
Diagnosis
- Upper endoscopy (OGD)
= Direct visualisation, anatomic localisation, obtain tissue for diagnosis
= Look for ________ (if stomach fails to distend with air insufflation)
- Barium meal
= False negative rate up to 50% especially in early stages
Staging
- TNM staging (T: tumor / N: node / M: metastasis)
- _______ (computed tomography of the thorax, abdomen and pelvis) for metastases (M), nodal spread (N)
- Endoscopic ultrasound for assessment of ___________ and nodal spread (N)
- Staging laparoscopy:
20-30% patients with a negative CT, intraperitoneal disease found at staging laparoscopy or at open exploration
linitis plastica; CT-TAP; tumor depth (T)
Gastric Cancer- Management
Early gastric cancer
- Adenocarcinoma limited to gastric ____________
- Endoscopic resection can be performed:
= Without ulceration
<20mm in size
= Intestinal histology
= No lympho-vascular invasion
= Without suspected lymph node involvement
Stage 1-3 (locoregional disease)
- Potentially curable with surgery
- ________ or chemoradiotherapy considered in T2 or higher disease
- However, invasion of a major vascular structure ie aorta > unresectable
Stage 4 (advanced systemic disease) Palliative chemo/radio-therapy (depends on symptoms and functional status)
mucosa or submucosa;
Neoadjuvant chemotherapy
