Diseases of the Stomach and Duodenum

Question 1

Describe the two types of hiatal hernias 1 and 2-4

Answer 1

1: Displacement of the gastroesophageal junction above the diaphragm. Fundus below

2-4: True hernia with a hernia sac. *Fundus through defect in the phrenoesophageal membrane

Question 2

How does a Hiatal hernia present? How do we diagnose? What is the treatment?

Answer 2

Present: GERD symptoms

Diagnosis: Barium Swallow

Tx: Small –> Gerd mgmt
Large –> Surgical repair

Question 3

Muscosal biopsy is necessary to differentiate what?

Answer 3

Gastritis and gastropathy

Question 4

What are the most common etiologies of Erosive and hemorrhagic gastropathy?

Answer 4

*NSAID
*Alcohol
Physical stress
Portal hypertension

Question 5

What are the general symptoms and signs of erosive and hemorrhagic gastropathy?

Answer 5

Anorexia, Epigastric pain, *could be asymptomatic

Can have Upper GI bleed.

Question 6

Gastroprotective prostaglandings are derived from what? What are the functions of Gastric prostaglandins?

Answer 6

COX-1

1. Release more bicarb and mucus ( dec perm and dec acid back-diffusion)
2. Vasodilators (increase res to injury)

Question 7

Describe S/Sx of NSAID gastropathy, Tx, and further evaluation

Answer 7

S/Sx - mainly Dyspepsia

Tx - discontinue NSAID or reduce to lowest dose. Switch to COX 2.

• If NSAID must be continued, take with milk of food and **Add daily PPI

If stuff doesnt resolve or + alarm signs, Upper endoscopy

Question 8

Ethanol has direct toxic effect on gastric mucosa. Also, it impairs ______ leading to ______ gastric emptying.

Answer 8

Gastric motility

delayed

**Leads to prolonged contact w/ gastric mucosa –> injury

Question 9

How does Alcoholic Gastropathy present? How do we treat?

Answer 9

S/Sx: Dyspepsia, nausea, vomit, minor hematemesis

Tx= no alcohol. H2 or PPI for 2-4 weeks.

Question 10

Stress gastropathy is often seen in ________ patients. Highest risk of signifigant bleeding is associated with what 2 conditions?

Answer 10

Critically ill

Coagulopathy, Resp failure w/ mech vent

Question 11

Critically ill patients should prophylactically recieve what medication for stress gastropathy? How do you treat an active bleed?

Answer 11

IV PPI

IV PPI

Question 12

Portal hypertensive gastropathy leads to congestion which increases gastric blood flow pathalogically. How do we tx this?

Answer 12

Beta blocker for portal hyper

Question 13

H. Pylori is the most common cause of what?

Answer 13

Peptic ulcer disease

Question 14

Who gets tested for H Pylori (generally)

Answer 14

Dyspeptic pts
Chronic GERD patients
PUD patients

Question 15

Pts should discontinue what for how long prior to H pylori testing?

Answer 15

Anti-secretory therapy x 2 weeks

Question 16

Look at “Other types of gastritis”

Pernicious, infectious, eosinophil, menetrier

Answer 16

Pernicious - b12
Infectious - infectious usually immunocomp
Eosinophil - rare, post eat vomit
Menetrier - ideopathic hypertrophic

Question 17

Define peptic ulcer disease. Where is it most common? What age groups alter this?

Answer 17

A break in the gastric or duodenal mucosa due to impaired mucosal defense mechanisms.

5x more common in the **Duodenum

Young = duodenum
55+ = gastric

Question 18

What are the 2 main etiologies of peptic ulcers? List the “others”

Answer 18

**NSAID and H pylori (#1)

Hypersecretion
CMV
Chronic diseases
Crohns
Lymphoma

Question 19

Up to ______% of peptic ulcers are asymptomatic. This means patients usually present with what complications/S/Sx?

Answer 19

70%

Bleeding or perforation

Question 20

What are the S/Sx of PUD?

Answer 20

Dyspepsia (#1) *gnawing, aching, hunger. Cyclic (immed after eating w/ gastric. 2-4 hours w/ duodenal)

May complain of nocturnal pain (mainly duodenal)

Often report relief w/ food or antacids*

Question 21

Gastric ulcer =_______ pain with eating

Duodenal ulcer = ______ pain with eating

Answer 21

Increase

Decrease

Question 22

Any Alarm signs with PUD warrant what?

Answer 22

Immediate endoscopy and referral

Question 23

How do we work up a PUD patient?

Answer 23

EGD
Labs - CBC (anemia) FOBT
H pylori biopsy if PUD found on endoscopy

Question 24

How do we treat peptic ulcers?

Answer 24

NSAID related - stop, titrate or swtich to COX2

H Pylori - Triple or quad x 14 days

General - PPI (antisecretory), Mucosal defense w/ Sucralfate (protective coating) or Misoprostol (NSAID prophylaxis)

Question 25

Peptic ulcers have a high incidence of _______. But this carries a low mortality

Answer 25

Bleeding.

Question 26

PUD can cause ulcer perforation. What can this result in, what are the S/Sx?

Answer 26

Chemical peritonits due to spilling of gastric contents. Sudden, severe ABD pain Rigid abd, reduced bowel sounds Pneumoperitoneum (air under diaphragm)

Question 27

Up to 40% of _______ seal spontaneously. How do we treat the other ones?

Answer 27

Ulcer perforations (adhered omentum) Tx Admit for fluid, ng suction, IV PPI, ABX Surgical repair if --> free air or peritonitis Pt deterioration Look @ CT

Question 28

How is an Ulcer Penetration different from a perforation?

Answer 28

Penetration goes through bowel wall but has **no leakage into peritoneal cavity. Pens to pancreas, liver and biliary tree

Question 29

What will a patient tell you they feel like with a ulcer penetration?

Answer 29

Change in typical PUD symptoms. Change in frequency of dyspepsia (more... rad to the back**) No relief w/ food or antacid** Look @ CT

Question 30

Gastric Outlet Obstruction is a complication of _________. Describe it including s/sx and Tx

Answer 30

PUD Chronic edema of pylorus of duodenal bulb S/Sx Early satiety, Postprandial vom(undigested), weight loss Tx IV -> liquid -> PO PPI** Endoscopic dilation of gastric outlet

Question 31

What Zollinger-Ellison Syndrome

Answer 31

Gastrin secreting neuroendocrine tumor

Question 32

Where is the gastrinoma triangle?

Answer 32

Porta hepatis, Pancreatic neck, 3rd portion dudenum

Question 33

What are common gastrinoma locations? what patients are they common in?

Answer 33

Pancreas Duodenal Wall Lymph nodes MEN-1

Question 34

90% of ZES patients develop what? | How do we screen patients for ZES?

Answer 34

PUD Fasting Gastrin levels 1. Ulcers/PUD w/ fam Hx MEN1 2. PUD w/ no NSAID or H Pylori

Question 35

If we find gastrinoma/ZES what do we do?

Answer 35

Refer to GI

Question 36

What is Gastroparesis? What two things is it generally linked with?

Answer 36

Delayed gastric emptying w/ no Mech obstruction ** Most common = Idiopathic Linked w/ DM 15%** Otherwise could be injury to vagus

Question 37

What are cardinal symptoms of Gastroparesis? How do we actually detect this? What do we do?

Answer 37

NV, Early satiety, bloating, weight loss Pt hx. Rule out mechanical obstruction via CT or EGD. ** Refer for GI/EGD**

Question 38

How is gastroparesis managed?

Answer 38

Acute bad = NG decompress and IV fluid/electro General = small meals, low fat food, no soda/alcohol. Optimize glycemic control in diabetics** Prokinetic meds - Metoclopramide ** Domperidone Erythromycin

Question 39

Gastric Adenocarcinoma is one of the most _______ cancers worldwide. Its highest rates are in _______, ________, and __________

Answer 39

common Eastern asia, europe, S. America ** Men >> women

Question 40

Symptoms of Gastric Adenocarcinoma include:

Answer 40

``` Dyspepsia Epigastric pain Anorexia Early Satiety Weight loss Dysphagia ``` **General, vague symptoms = increased mortality due to late presentation.

Question 41

What are the typical physical exam signs of Gastric adenocarcinoma

Answer 41

Usually nothing Sometimes Virchow node or Sister Mary Joseph Nodule ****

Question 42

What would diagnostic studies show in gastric adenocarcinoma?

Answer 42

CBC = Anemia LFT = elevated Endoscopy confirms CT PET can find mets once cancer is found.

Question 43

What is Gastric lymphoma? Where do primary tumors arise from? What is this associated with?

Answer 43

Secondary tumors from spread of non-hodgkin lymphoma. MALT Chronic H Pylori infection Tx/workup same way as Gastric Adenocarcinoma*****

Question 44

What is carcinoid syndrome?

Answer 44

Carcinoid tumor (digestive tract/lungs) causing myriad symptoms. Super flushed for 30 mins.... Might burn ** Venous telaniectasias Diarrhea (non bloody)