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M2 GI > tbl 2: management of dyspepsia > Flashcards

tbl 2: management of dyspepsia Flashcards

1
Q

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)
A

epigastric pain; nonulcer;

anemia, persistent vomiting

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2
Q

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)
A

epigastric pain; nonulcer;

anemia, persistent vomiting

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3
Q

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, _____________
A

Peptic ulcer disease (PUD); ponstan; alendronate

gastric lymphoma; hypercalcemia; celiac artery compression syndrome

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4
Q

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
A

Postprandial fullness; Early satiation; structural disease; tricyclic antidepressants

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5
Q

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, _____________
A

Peptic ulcer disease (PUD); ponstan; alendronate

gastric lymphoma; hypercalcemia; celiac artery compression syndrome

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6
Q

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
A

Postprandial fullness; Early satiation; structural disease; tricyclic antidepressants

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7
Q

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)

A

odynophagia; epigastrium; colicky; sour brash

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8
Q

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.

A

palpable abdominal mass; lymphadenopathy; liver metastasis; anemia;
peritoneal carcinomatosis

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9
Q

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)

A

liver function tests

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10
Q

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

A

somatostatin; gastrin;

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11
Q

“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, ______________)
A

erythema; portal hypertensive gastropathy

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12
Q

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 _________
A

mucosa-associated lymphoid tissue (MALT) lymphoma; Non-ulcer dyspepsia;

confirm eradication

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13
Q
  • 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 _____________________
A

low-dose aspirin; idiopathic thrombocytopenic purpura

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14
Q

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
A

mucosa-associated lymphoid tissue (MALT) lymphoma; Non-ulcer dyspepsia

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15
Q

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
A

Stool Ag; ammonia ; Bismuth

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16
Q

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
A

amoxicillin, clarithromycin;

metronidazole; tetracycline

levofloxacin;

amoxicillin, esomeprazole

17
Q

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)

A

Cytomegalovirus; Tuberculosis

Crohn’s

mastocytosis

18
Q

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

A

food ; gastroesophageal reflux

upper endoscopy; nodular; Overhanging

19
Q

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
A

12 weeks; Zollinger-Ellison syndrome

20
Q

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)

A

1st; olling

21
Q

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.

A

dominent, parathyroid glands. anterior pituitary

hyperPTH; Prolactinoma

22
Q

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)

A

1st; enterochromaffin-like cells (ECL)

23
Q

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
&raquo_space; low pH of intestinal contents
&raquo_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
&raquo_space; secretory diarrhoea

A

peptic ulcers; pancreatic enzymes;

steatorrhea; Na and H2O

24
Q

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
A

Dyspepsia; peptic ulcer disease; gastric folds

refractory

25
Q

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)
A

low gastric pH;

increased gastric acid secretion; appropriate hypergastrinemia

dramatic rise in serum gastrin; poor response

26
Q

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 (_______)
A

Gallium-68 DOTATATE PET; prolactinoma

27
Q

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.
A

high dose PPI; resection

28
Q

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
A

7th

Atrophic gastritis; N-nitroso compounds

29
Q

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. ________, _____________/

A

pernicious anemia

Lynch syndrome; familial adenomatous polyposis

30
Q

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
A

insufficient caloric intake; proximal stomach/GEJ ; gastric outlet obstruction

Supraclavicular; Periumbilical

31
Q

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
A

linitis plastica; CT-TAP; tumor depth (T)

32
Q

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)
A

mucosa or submucosa;

Neoadjuvant chemotherapy

M2 GI (39 decks)

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