Disorders of the stomach

Question 1

Gastroesophageal Reflux Disease

Answer 1

Also known as GERD or Reflux Esophagitis, this is the
recurrent reflux of gastric contents into the esophagus
secondary to Gastroesophageal junction incompetence

Question 2

GERD affects about ____% of the adult
population, with over half of the population
experiencing heartburn at least once in their lives

Answer 2

10-20

Question 3

Pathophysiology of GERD

Answer 3

○ Most episodes of gastric reflux occur during transient relaxation of
the LES (TLESR), triggered by gastric distention and/or being in an
upright position. Some degree of reflux occurs in all persons
○ A smaller portion of GERD patients have an weak LES that results in gastric reflux when lying supine or with increase in abdominal pressure (lifting or bending)

Question 4

The presence of a _____ can also be a causal factor in GERD and increase the complications

Answer 4

Hiatal Hernia

Question 5

Other factors that contribute to the presence and severity of
GERD include

Answer 5

■ Increased intragastric pH
■ Impaired esophageal motility
■ Decreased salivation
■ Increased Intra-abdominal pressure

Question 6

Factors that increase intra-abdominal pressure

Answer 6

■ Obesity
■ Pregnancy
■ Smoking

Question 7

Foods or drugs can also decrease LES tone:

Answer 7

■ Chocolate, Peppermint
■ Alcohol and Smoking
■ Onions, citrus, and tomatoes
■ Caffeine
■ Certain Medications (Calcium Channel Blockers, Anticholinergics)

Question 8

Characteristic Signs and Symptoms of GERD

Answer 8

○ Heartburn (pyrosis) is the hallmark symptom
○ Regurgitation: Refluxed gastric content into mouth/throat. Sour,
acidic taste in mouth
○ “Atypical” or “Extraesophageal” symptoms of GERD may occur: Dysphagia, chronic cough, wheezing, etc.

Question 9

Diagnosis of GERD

Answer 9

○ Initial diagnostic studies are generally not required for patients with
typical GERD symptoms suggesting uncomplicated reflux
○ Upper Endoscopy (EGD) is the study to definitively diagnose GERD

Question 10

T/F Barium Swallow Esophagram is not used in the diagnosis of GERD

Answer 10

T

Question 11

Esophageal pH Monitoring

Answer 11

■ Unnecessary in most patients.
■ May be used to document significant
esophageal acid exposure in those with
atypical symptoms, or those being considered for anti-reflux surgery

Question 12

Plain radiographs help Identify hiatal hernias but can’t Dx _____

Answer 12

GERD

Question 13

Management of MILD GERD

Answer 13

○ Treatment of mild, intermittent symptoms:
■ May be treated sufficiently with a trial of antacids and lifestyle modifications (diet changes, weight loss, don’t eat 3 hours
before bed, avoid overeating and tight clothes, etc).
■ Other recommendations: Avoid caffeine, chocolate, tomatoes, carbonation, smoking, alcohol, etc, raise head of bed.

Question 14

Management of moderate to severe GERD

Answer 14

○ Pharmacologic therapies are indicated with moderate to severe
disease, or when lifestyle modification have failed.
■ Proton Pump Inhibitors, treatment of choice in severe disease

Question 15

T/F You can never discontinue a GERD treatment plan once one is started

Answer 15

F - In those who achieve good symptomatic relief with a course of PPI,
treatment may be discontinued after 4-12 weeks

Question 15

Barrett’s Esophagus

Answer 15

● The most significant complication of GERD.
● It is believed that the chronic
epithelial injury (by the gastric acid),
leads to replacement of esophageal
squamous cells with gastric columnar
cells (a process called Metaplasia).
○ These cells are considered
dysplastic and precancerous.

Question 15

The most significant complication of GERD

Answer 15

Barrett’s Esophagus

Question 16

Paradox of Barrett’s esophagus and GERD

Answer 16

The development of Barrett’s does not necessary mean the GERD
symptoms will increase.
○ Interestingly, a paradoxical effect is often seen, where Barrett’s patients often have less symptoms, suggesting decreased acid sensitivity of Barrett epithelium.

Question 17

The most common complication of Barrett’s is _____

Answer 17

Esophageal Adenocarcinoma

Question 18

Endoscopic screening with biopsy for Barrett’s esophagus is indicated in
______

Answer 18

patients with multiple risk factors for adenocarcinoma (age over 50, hiatal
hernia, male, obesity, caucasian, cigarette smoking, chronic GERD, or
family history of Barrett’s or esophageal adenocarcinoma).

Question 19

If nondysplastic Barrett’s is discovered, surveillance with _____

Answer 19

an EGD is recommended every 3-5 years

Question 20

If dysplasia is discovered with barretts:

Answer 20

○ Low grade- Endoscopic Radioablation or annual EGD surveillance.
○ Moderate to High grade- Endoscopic Radioablation

Question 21

Treatment of barretts esophagus:

Answer 21

● First line therapy: Treat the GERD! (indefinite sure of PPIs)
● If dysplasia present: Endoscopic Radiofrequency Ablation is a treatment
that ablates dysplastic cells in the epithelial lining of the esophagus.
○ Eradication of high-grade Barrett’s can be
achieved in as many as 91% of patients.

Question 22

Hiatal Hernia

Answer 22

When a portion of the stomach prolapses through the Esophageal Hiatus of the diaphragm.
● These hernias are often associated
with GERD, as the LES is displaced
upward and gastric contents are more
likely to move into the esophageal
lumen. Diaphragm normally provides
strength to the LES.

Question 23

Hiatal Hernia diagnosis

Answer 23

Barium Swallow is the historical gold standard for diagnosis

Question 24

Management of hiatal hernia

Answer 24

○ Treatment is generally conservative, focusing on postural adjustments, antacids, H2 blockers, and PPIs. ○ Weight control can often times significantly improve or fix the condition ○ In severe cases (usually with large hernias or persistent symptoms), surgical intervention can be performed. ■ A Laparoscopic Fundoplication (Nissen) is the procedure of choice.

Question 25

Gastritis

Answer 25

●Gastritis is inflammation, irritation, or erosion of the stomach epithelium secondary to an irritant ●Superficial inflammation and erosion of mucosa without penetration into muscularis

Question 26

Gastritis be caused by several different factors

Answer 26

○ Infection (especially H pylori) ○ Physiologic and social stress ○ Medications (such as NSAIDs) ○ Heavy alcohol use ○ Portal hypertension

Question 27

Gastritis pathophysiology

Answer 27

○ Stress gastritis can occur in critically ill patients, which is likely histamine and inflammatory mediator-driven ○ NSAIDs diminish prostaglandin production in the stomach. Prostaglandins ↓HCL and are cytoprotective (↑mucus)

Question 28

Gastritis Signs and Symptoms

Answer 28

○ Epigastric pain ○ Abdominal tenderness ○ Bloating ○ Anorexia ○ Nausea with or without vomiting ○ May be aggravated by eating ○ Foul-smelling breath ○ Hematemesis (rare and minimal, often “coffee ground”) ○ Melena may occur

Question 29

Diagnosis of Gastritis

Answer 29

○ Upper Endoscopy (EGD) with biopsy ■ Testing is not usually needed, but if the patient presents with hematemesis, EGD is required. GI-STOM-1 ■ EGD will reveal classic mucosal erythema, possible subepithelial hemorrhages, and mucosal erosions.

Question 30

Gastritis Management

Answer 30

Proton Pump Inhibitors and H2 Blockers are important in the prevention and treatment of gastritis

Question 31

H. Pylori infection

Answer 31

●Helicobacter pylori is a Gram negative bacteria that can live comfortably in the acidic stomach ●H. pylori infection is commonly found in patients having duodenal ulcers (80-95%) gastric ulcers (65-95% percent), dyspepsia (20-60%), and gastric cancer (70-90%)

Question 32

S&S of H. Pylori infection

Answer 32

○ Most patients with H pylori infection are asymptomatic. ○ If they do develop symptoms, this may include: ■ Epigastric abdominal pain ■ Nausea with or without vomiting ■ Dyspepsia ■ Diarrhea ■ Halitosis ○ The patient may present with Chronic Gastritis, Atrophic Gastritis, Peptic Ulcer Disease, or Gastric Adenocarcinoma

Question 33

Testing for H. Pylori infection

Answer 33

○ H pylori Fecal Antigen Test- The preferred test with sensitivity of 94% and specificity of 98%. Only positive if acute, so useful to confirm eradication too. ○ Carbon-13 Urea Breath Test- Not as common. Can only be positive if H pylori is present in the stomach. ○ H pylori serum Serology Testing- High sensitivity and Specificity (>90%), but expensive and positive if history of infection. NOT useful to confirm eradication. ○ Tissue Biopsy during EGD - Commonly performed

Question 34

Management of H. Pylori infection

Answer 34

■ PBMT Quadruple Therapy (14 days): PPI (omeprazole or pantoprazole), Bismuth Subsalicylate, Metronidazole, and Tetracycline. ■ PAMC Quadruple Therapy (14 days): PPI (omeprazole or pantoprazole), Amoxicillin, Metronidazole, and Clarithromycin ○ Additionally, the FDA has approved several “Triple Therapy” regimens, although resistance is a concern now. While FDA approved, these are not 1st line

Question 35

Peptic Ulcer Disease

Answer 35

● PUD is a common disorder that includes Gastric and Duodenal ulcers. ● It is the most common cause of acute upper GI bleeding. ● Duodenal ulcers are 4-5 times more common than Gastric Ulcers

Question 36

The most common cause of acute upper GI bleeding

Answer 36

PUD

Question 37

Pathophysiology of PUD

Answer 37

○ Peptic ulcers result from disruption of gastric or duodenal mucosa secondary to an overproduction of acid or defects in the protective mucous barrier of the stomach lining. ○ Three major causes have been implicated: NSAIDs, H pylori infection, Zollinger-Ellison Syndrome

Question 38

S&S of PUD

Answer 38

○ Epigastric pain is the hallmark symptom ○ Nausea ○ Anorexia ○ Abdominal bloating ○ Hematemesis or Melena

Question 39

If the pain is relieved with eating food, suggestive of _____

Answer 39

duodenal ulcer (Gastric ulcers may be aggravated by food.)

Question 40

Peptic Ulcer Disease diagnosis

Answer 40

○ Upper Endoscopy (EGD) provides great visualization of the pathology and is the diagnostic test of choice ○ H pylori testing should be strongly considered. ○ Ordering lab tests to rule out Zollinger-Ellison Syndrome (ZES) should also be considered (more to come). ○ Anemia may be present if slowly bleeding peptic ulcer. ○ Also order an X-ray or CT scan if concern for perforation

Question 41

Medical Management of PUD

Answer 41

■ PPIs are the treatment of choice ■ H2 blockers also help and can be added to PPI if needed ■ Sucralfate, Antacids, and Bismuth enhance mucosal barrier defense and promote ulcer healing

Question 42

Perforation of Peptic Ulcer - presentation

Answer 42

Patient will present with acute increase in abdominal pain, board-like abdomen, rebound tenderness, and possibly hypotension and pallor. X-ray or CT may reveal pneumoperitoneum (surgical emergency!)

Question 43

Zollinger-Ellison Syndrome

Answer 43

A hypergastrinemic state caused by a Gastrin-secreting tumor

Question 44

About 1/3 of all Gastrinomas are part of ____

Answer 44

the autosomal dominant Multiple Endocrine Neoplasia

Question 45

S&S of Zollinger-Ellison Syndrome

Answer 45

○ Most patients present with symptoms indistinguishable from regular PUD ○ Anemia may be present secondary to bleeding of peptic ulcers. ○ Abdominal pain with accompanying secretory diarrhea is common, often improved with PPI treatment.

Question 46

Diagnosis of Zollinger-Ellison Syndrome

Answer 46

○ Fasting serum Gastrin level greater than 150 pg/mL indicates hypergastrinemia (normal is 0-100 pg/mL) ○ A secretin stimulation test confirms the presence of a gastrin secreting mass

Question 47

Management of Zollinger-Ellison Syndrome

Answer 47

○ Use of PPIs are the mainstay of controlling gastric acid secretion. ○ If the tumor is found, surgical resection of the gastrinoma should be attempted if possible

Question 48

Gastric Neoplasm

Answer 48

● Adenocarcinoma is the most common stomach cancer (>90%) and arises from the glandular cells of the stomach (goblet and Paneth cells). ● Gastric adenocarcinoma is among the most common cancers worldwide (4th most common), but is less common in the US ● Because early gastric cancer is usually asymptomatic, this cancer is difficult to cure because it is most often in advanced stages by the time the diagnosis is made

Question 49

Pathophysiology of a Gastric Neoplasm

Answer 49

○ Chronic H pylori Gastritis has been strongly associated with the development of Gastric cancer ○ Other risk factors include: ■ Tobacco and/or alcohol consumption ■ Possibly food additives and carcinogens ■ Possibly occupational exposures to heavy metals ■ Genetic mutations may play a role

Question 50

S&S Gastric Neoplasm

Answer 50

○ Dyspepsia and weight loss associated with anemia and fecal occult GI bleeding in a patient over 40 is gastric cancer until proven otherwise. ○ Progressive dysphagia may develop ○ Classic signs of metastatic spread: ■ Virchow’s Node- An enlarged, firm node in the left supraclavicular region is strongly associated with Gastric cancer. ■ Sister Mary Joseph Node- Palpable node bulging into the umbilicus is often seen with metastatic gastrointestinal cancers.

Question 51

Classic signs of metastatic spread for gastric neoplasm

Answer 51

■ Virchow’s Node- An enlarged, firm node in the left supraclavicular region is strongly associated with Gastric cancer. ■ Sister Mary Joseph Node- Palpable node bulging into the umbilicus is often seen with metastatic gastrointestinal cancers

Question 52

Gastric Neoplasm Diagnosis

Answer 52

○ EGD is the diagnostic study of choice, as biopsy is possible. ○ Biopsy ○ CT and Endoscopic Ultrasound are used to determine the depth of spread and likelihood of metastatic disease. (chest X-ray also 4 mets) ○ CBC and CMP are important lab studies as well.

Question 53

Management of a Gastric Neoplasm

Answer 53

○ Treatment generally involves palliative or curative resection of the tumor, depending on size, depth, and location. ○ Chemotherapy is often utilized after surgery. ○ Radiation plays more of a palliative role.

Question 54

Prognosis of Gastric neoplasm

Answer 54

■ Only a small percentage of people who undergo surgery will be cured and most experience a recurrence. ■ The overall 5-year survival rate is 29.3% in the US. ● Much more grim if widespread metastatic disease