Diseases of the Stomach Flashcards Preview

Gen Med: GI > Diseases of the Stomach > Flashcards

Flashcards in Diseases of the Stomach Deck (49):
1

What is Dyspepsia?

1. Impaired digestion
2. Epigastric pain or burning, early satiety or postprandial fullness
3. Dyspepsia must be distinguished from heartburn (pyrosis)

2

Causes of Dyspepsia?

Food or drug intolerance
Functional dyspepsia- no obvious organic cause
GERD
Peptic Ulcer Dz (PUD)
H. pylori infection
Biliary Tract Dz
Gastroparesis

3

What is Gastroparesis?

Delayed gastric emptying w/o evidence of mechanical obstruction

4

Signs & Symptoms of Gastroparesis?

PP fullness persisting for hours
Nausea, vomiting, early satiety, bloating

5

Causes of Gastroparesis

1. Idiopathic (50%)
2. DM
3. Postsurgical
A. Incidental injury to vagus nerve
4. Meds
A. Narcotics, CCB, dopamine agonists, clonidine, antichol.
5. Connective tissue Dz
A. Scleroderma
6. Neurologic dysfunction
A. MS
B. Parkinson’s Dz
C. Brainstem stroke/tumor

6

What is the gold standard for diagnosing gastroparesis?

Scintigraphic gastric emptying test

7

What is Scintigraphic gastric emptying test?

1. Isotope tagged meal permits pictures to be taken as the meal passes through the stomach and the GI tract
2. 4 hr test

8

Treatment for Gastroparesis

1. Freq. small meals
2. Avoid excess fat & dietary fiber
3. Prokinetic meds improve movement of food through stomach
A. metoclopramide (Reglan)
B. erythromycin
C. dicyclomine (Bentyl)
D.phenobarbitol/hyoscyamine/atropine/scopolamine (Donnatal)
E. hyoscyamine (Levsin)

9

What is gastritis?

Inflammation, irritation, or erosion of the lining of the stomach

Can occur
-Suddenly (acute)
-Gradually (chronic)

10

Causes of gastritis

Helicobacter pylori infection
NSAIDs
Severe illness/stress
ETOH
Smoking
Cocaine
Autoimmune disorders
Radiation therapy 
Crohn’s disease
CMV
Candida
Pernicious anemia

11

What is H. Pylori?

1. Bacteria infection in mucous lining of the stomach
2. W/out Tx, can lead to ulcers, & stomach cancer

12

Signs & Sx's of Erosive Gastritis

1. Epigastric pain
2. Hematemesis
A. “Coffee ground” emesis or bloody vomitus
3. Melena
4. Anorexia
5. Nausea
6. Eructations
7. Bloating
8. Early satiety

13

Diagnostic Studies for Gastritis

1. ↓ Hct
A. If significant bleeding
2. +/- Iron deficiency anemia
A. If bleeding is chronic
3. Upper endoscopy
Bx Identifies source of bleeding

14

DDx for Gastritis

Erosive gastritis
PUD
Esophageal varices
Mallory Weiss tear
Gastric AV malformations

15

Treatment for stress induced gastritis

1. Pts w/risk factors for bleeding
A. Coagulopathy
- Plt < 50,000 or INR > 1.5
2. ICU pt
3. Mechanical ventilation
4. Prophylactic Tx
A. IV H2 receptor antagonists
- cimetidine, ranitidine, famotidine, nizatidine
B. Oral sucralfate (Carafate)
C. Oral PPI + bicarbonate (Zegerid)

16

Treatment for continuous bleeding in gastritis

1. Early enteral tube feeding may ↓ risk of GI bleed in ICU pts
2. If bleeding occurs, Tx w/
A. Continuous infusions of PPI
- IV Pantoprazole (Protonix) 80 mg bolus, then 8 mg/h
B. Oral sucralfate
- 1 gm q 4-6 hrs
3. Endoscopy for clinically significant bleeding

17

Treatment for NSAID induced gastritis

1. D/C NSAID
2. Give lowest effective dose
3. Administer NSAID w/ meals
4. Oral PPI x 2-4 weeks
A. omeprazole (Prilosec)
B. lansoprazole (Prevacid)
C. pantoprazole (Protonix)
D. esomeprazole (Nexium)
E. dexlansoprazole (Dexilant/Kapidex)
F. rabeprazole (Aciphex)
G. naproxen/esomeprazole (Vimovo)

18

Treatment for alcohol induced gastritis

1. Tx empirically for 2-4 weeks (choice)
A. H2 receptor antagonist
B. PPI
C. Oral sucralfate

19

H. Pylori Gastritis increases risk for what kinds of cancer?

↑ risk of gastric adenocarcinoma & primary B cell gastric lymphoma

20

H Pylori Gastritis Signs & Sx's

Epigastric pain

21

H. Pylori Gastritis Diagnostic Testing

1. Serologic ELISA test for H pylori
A. 80% specificity
2. Urea breath test
3. Fecal antigen immunoassay
A. Above 2 tests excellent specificity & sensitivity (>95%)
B. More expensive when compared to ELISA
C. Must be off of PPI’s, abx wks prior to testing

22

Treatment for H. Pylori gastritis

1. Standard Triple Therapy x 10-14 days
A. Oral PPI bid
B. Clarithromycin (Biaxin) 500 mg po bid
C. Amoxicillin 1 gm po bid or metronidazole (Flagyl) 500 mg po bid (if PCN allergic)
OR
D. Prevpac (lansoprazole/amoxicillin/clarithromycin) x 10-14 d

2. Standard Quadruple Therapy x 10-14 days
A. Used if pt tests (+) after standard triple therapy or previously on macrolide
- Oral PPI bid
- Bismuth subsalicylate (Pepto-Bismol) 500 mg po qid
- Tetracycline 500 mg po qid
- Metronidazole (Flagyl) 500 mg po tid

23

What is PUD?

1. Circumscribed lesions in mucosal membrane extending below epithelium
2. Ulcers extend thru muscularis mucosae
3. > 5mm in diameter
4. PUD - any ulcer of upper digestive system
A. Gastric ulcer
B. Duodenal ulcer (5x’s more common)
5. Assoc. w/ gastric malignancy
6. M = F

24

Duodenal ulcers are more common in what age group?

30 & 55 yrs

25

Gastric ulcers are more common in what age group?

55 & 70 yrs

26

Signs & Sx’s of PUD?

1. Dyspepsia
A. Acid-provoked:
- Burning pain; epigastric hunger-like pain; relief w/food, antacids
B. Food-provoked:
- PP epigastric discomfort & fullness, belching, early satiety, nausea, & occasional vomiting

2. Quality of pain:
A. Burning, gnawing, or “hunger-like”
B. Can be vague, dull, crampy

27

Sxs of gastric ulcers?

Pain worsens w/food
Assoc w/nausea, anorexia

28

Sxs of duodenal ulcers?

Sx’s occur 2-5 hrs PP, occur during night
Pain improves w/food

29

Silent ulcers

NSAIDs
Elderly

30

2 major causes of PUD

1. NSAIDs
A. COX-2 inhibitors safer

2. Chronic H pylori infection
A. Most important risk factor for duodenal ulcer
B. Most common chronic bacterial infection in humans

31

Pathophysiology of PUD

1. Ulceration stems from
A. Inhibition of prostaglandin synthesis
B. ↑ gastric acid & pepsin secretion
C. ↓ gastric mucosal blood flow
D. ↓ cytoprotective mucus production

32

Risk of NSAID complications are greater with?

1. W/in 3 months of starting therapy
2. > 60 yr
3. Hx of PUD
4. NSAIDs in combination w/
5. ASA, steroids or anticoagulants
6. Alcohol

33

Pathophysiology of H. Pylori ulcers?

1. H pylori release toxin that destroys gastric & duodenal mucosa
A. Reduces epithelium’s resistance to acid digestion
B. Causes gastritis & ulcer disease

34

Diagnostic Studies for PUD?

1. Upper Endoscopy
A. Most sensitive (90-95%) & most specific (95-100%)
B. Bx to R/O cancer & H pylori

2. Rapid Urease Test via endoscope on antral biopsy
A. If H pylori suspected, RUT kit gives results w/in one hr
B. MUST stop PPI/H2 antagonist 4 weeks prior to test

3. Noninvasive testing
A. Urea breath test
B. Fecal antigen testing
C. Serology- H pylori Ab

35

What is a rapid urease test (RUT)?

Mucosal Bx from the antrum of the stomach, & placed into a medium containing urea & an indicator (phenol red).

The urease produced by H. pylori hydrolyzes urea to ammonia, raises the pH of the medium, and changes the color of the specimen from yellow (-) to red (+)

36

What is a urea breath test?

Urea breath testing — UBT is based upon the hydrolysis of urea by H pylori to produce CO2 & ammonia

Labeled carbon isotope is given by mouth; H pylori liberate tagged CO2 that can be detected in breath samples

False (-) results in pts taking antisecretory therapy, bismuth, or abx
-Off PPI’s for 1-2 wks
-Off abx for 4 wks

37

Ddx of PUD

1. GERD
A. Epigastric pain
2. Biliary tract disease
A. Intermittent abd pain, colicky
3. Perforated peptic/gastric ulcer
A. Severe epigastric pain
4. Acute pancreatitis
A. Epigastric pain, LUQ pain/tenderness, radiates to back
5. Acute cholecystitis
A. RUQ pain/tenderness, + Murphy’s

38

Treatment for PUD

1. PPI's
A. 1st line therapy
2. H2 receptor antagonists
3. Mucosal Defense Agents
A. Bismuth (Pepto Bismol)
- Antibacterial action against H pylori
B. Misoprostol (Cytotec)
- Prostaglandin analog that stimulates mucus and bicarbonate secretion (↓ proton pump)
- Used for ulcer prevention w NSAID
C. Antacids
A. Commonly supplement anti-secretory agents during the first few days of treatment

39

H. Pylori Tx

1. Standard Triple Therapy x 14 days – 1st line
PPI po bid
Clarithromycin 500 mg po bid
Amoxicillin 1 g po bid
(PCN allergy, Metronidazole 500 mg po bid)
2. Standard Quadruple Therapy x 14 days – 2nd line
PPI po bid
Bismuth 2 tabs po bid
Tetracycline 500 mg po qid
Metronidazole 500 mg po tid

40

For patients with large ulcers (H. Pylori treatment continued)

1. For pts with large ulcers
A. Cont. PPI additional 2-4 weeks for duodenal ulcer
B. Cont. PPI additional 4-6 weeks for gastric ulcer
2. Confirmation of H pylori eradication approx 4-6 weeks after therapy completion
A. Urea breath test
B. Fecal Ag test- more widely available
C. Endoscopy
- If Abx resistance is suspected, endo w/Bx & culture

3. Hold Abx & bismuth 4 wks prior to testing(retesting) & PPIs at least 2 wks

41

Treatment NSAID-Induced Ulcers

1. Stop NSAID
2. PPI once daily → healing rates 80% at 8 weeks
3. All pts with NSAID associated ulcers should undergo testing for concomitant H pylori infection
- If (+) , standard triple therapy

42

Prevention NSAID Induced Ulcers

1. Weigh benefits NSAID therapy w/ risks GI & CV complications
2. For all pts, NSAIDs should be prescribed w/ lowest effective dose possible for shortest period of time
3. Misoprostol (Cytotec) 100-200 mcg po qid
A. Reduces incidence of NSAID induced gastric & duodenal ulcers by 50-75%
- Inhibits gastric acid secretion
- Increases mucus and bicarb secretion

43

Complications of PUD

GI Hemorrhage

~50% of all UGI bleeds are due to PUD
Clinically significant bleeding occurs in ~ 10% of pts
~ 80% stop bleeding spontaneously
~ 20% have more severe bleeding

44

Most Common Causes of UGI Bleed

Gastric and/or duodenal ulcers
Esophagogastric varices
Esophagitis
Severe or erosive gastritis/duodenitis
MWS
Polyps/cancers

45

Risk Factors for bleeding PUD

H pylori
NSAIDs
Physiologic stress
Excess gastric acid

46

Signs & Sx’s of a GI Hemorrhage

1. Melena
2. Hematemesis
3. “Coffee ground” emesis or bright red blood w/ NG lavage indicates UGI bleed
4. Assess for signs of hypovolemia
A. Tachycardia, orthostatic hypotension

47

Diagnostic Studies for GI Hemorrhage

1. Hct may ↓
2. ↑ BUN
- Absorption of blood nitrogen from small intestine

48

Diagnostic Testing for GI Hemorrhage

1. Upper EGD
A. Identify cause & location to stop bleeding, Bx for H pylori
- Epi injection, heat coagulation or hemoclip application
2. IV PPI’s
3. If suspect perforated ulcer, stat CT abdomen/pelvis emergently
4. Surgery if endoscopic measures fail

49

Complications PUD

1. Ulcer Perforation
A. Usually on anterior wall of stomach or duodenum
B. Results in chemical peritonitis
- Sudden severe abd pain
- Sick appearing
- Rigid & quiet abdomen
- Rebound tenderness
- Hypotension w/ bacterial peritonitis
C. Abd CT establishes Dx
D. CXR can help. How?
E. Laparoscopic perforation closure treatment of choice