Clinical Aspects of Stomach Diseases

Question 1

What is the general diagnostic workup employed with acute gastritis?

Answer 1

EGD - allows direct visualization of the mucosa for ulcers / erosions as well as direct biopsy

Question 2

What is type A vs type B chronic gastritis?

Answer 2

A - autoimmune gastritis, achlorhydria / anemia (pernicious), antral sparing

B = Bacterial, Helicobacter pylori

Question 3

How does the rapid urease test work?

Answer 3

Take a piece of biopsied antral material and place it on the indicator for 24 hours. If urease is present, the pH will be raised and the color indicator will change
-> very sensitize test for H. pylori

Question 4

What two tests are considered the most reliable for the diagnosis of H. pylori?

Answer 4

1. Urea breath test, with C13 or C14

2. Stool test - good sensitivity / specificity for picking up H. pylori antigen, and non-invasive

Question 5

What separates triple therapy from quad therapy? Why is it used?

Answer 5

Bismuth (pepto-bismol) - Inhibits growth of the organism and may have beneficial mucosa effects

Question 6

What two things can be detected in the serum in autoimmune chronic gastritis?

Answer 6

1. Autoantibodies - could be anti-parietal or anti-IF

2. High serum gastrin levels - loss of negative feedback due to achlorhydria

Question 7

What is the Schilling test? How will it read in autoimmune gastritis?

Answer 7

Tests for absorption of heavy B12

Abnormal part I - absorption of B12 taken orally

Normal part 2 - Will be normal excretion if you give IV

Question 8

What type of peptic ulcer disease do NSAIDs cause? Which drug generates them less?

Answer 8

Cause more gastric ulcers than duodenal

Selective COX-2 inhibitors like celecoxib are less ulcerogenic

Question 9

What is the pain pattern for gastric ulcer (GU) vs duodenal ulcer (DU) and how does this relate to presentation?

Answer 9

GU - made worse with food -> patient will have weight loss

DU - made better with food (protective secretin released with meals) -> patient will have weight gain

Both of these will be worse at night when they’re thinking about it

Question 10

What are the “alarm” signs and symptoms for peptic ulcer disease?

Answer 10

Nausea / vomiting with coffee ground emesis

Melena - upper GI bleed

Anemia

Weight loss and anorexia

Question 11

What test is done routinely in peptic ulcer disease? How do the alarm symptoms play into this?

Answer 11

EGD - need to biopsy to rule out cancer, also give urease test and histopathologic exam to show the cause.

Young patients with positive H. pylori serology and no “alarm” symptoms may be treated empirically

Older patients with “alarm” symptoms need biopsy to rule out gastric cancer

Question 12

Do we routinely biopsy duodenal ulcers?

Answer 12

Actually no - far less likely to be malignant than gastric ulcer

Question 13

What are the treatments for healing erosions / ulcers in acute gastritis / peptic ulcer disease?

Answer 13

PPI’s - mainstay of therapy, most effective

H2-receptor blockers - somewhat effective, better for maintenance therapy

Sucralfate - sticky resin that works in acidic conditions to bind the base of an ulcer, useless if conditions are not acidic

Question 14

What are the surgical options for treating PUD? When are they done?

Answer 14

Vagotomy - sometimes with antrectomy

Subtotal gastrectomy - remove acid producing organ

Usually done when complications of PUD are arising, but you should rule out gastrinoma first

Question 15

What are the complications of ulcers? How are they treated?

Answer 15

1. Hemorrhage - cautery, local vasoconstriction, or hemoclips
2. Perforation - surgical closing of hole
3. Obstruction - Balloon dilation

Question 16

Why does obstruction happen in PUD?

Answer 16

Ulcers cause so much edema and scarring that they block emptying of the stomach

Question 17

What syndrome might Zollinger-Ellison be associated with, and where is it usually found?

Answer 17

Associated with MEN1

It is found in the gastrinoma triangle: usually in duodenom or pancreas.

• > one corner of triangle made by cystic duct
• > another corner made by middle of pancreas
• > last corner made by third part of duodenum

Question 18

How does Zollinger-Ellison present?

Answer 18

Recurrent ulcers in duodenum / jejunum, with abdominal pain and diarrhea (from malabsorption because pancreatic enzymes don’t work at low pH)

Question 19

What test for ZE is diagnostic?

Answer 19

Secretin stimulation test - IV secretin normally decreases serum gastrin levels. In patients with gastrinoma, gastrin remains elevated or even increases

Serum gastrin and acid secretion will also be elevated

Question 20

What radiolabelled scan get detect ZE syndrome? What are the medical treatments of ZE syndrome then?

Answer 20

Radiolabeled octreotide scan -> these cells take up somatostatin due to many receptors

Medical treatments:
High dose PPis and Octreotide - somatostatin analog, in order to suppress tumor / acid activity

Question 21

What are the surgical options for ZE syndrome?

Answer 21

Tumor resection if localized, may need local tumor ablations if metastasized

Selective vagatomy to decrease acid

Total gastrectomy if all other acid suppression attempts fail

Question 22

What are the signs and symptoms of gastric cancer?

Answer 22

Weight loss, early satiety, pain, NVD, hematemesis, melena, edema

Palpable lymph nodes and epigastric mass may eb present

Question 23

What diagnostic workup may be required for gastric carcinoma?

Answer 23

EGD and biopsy for tissue diagnosis

Full body CT for assessing resectability and distant metastases