Disorders of the Stomach and Duodenum Flashcards by Katie Keller

Inflammation of the lining of the stomach

Seen with endoscopic or radiologic evaluation

Multiple variety of causes

Gastritis

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Why can gastritis be worrisome?

erosions can progress to ulcers

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What are some signs/symptoms of gastritis?

Epigastric abdominal pain – gnawing or aching
Nausea
Indigestion
Loss of appetite
Vomiting (+/- hematemesis)

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How is gastritis diagnosed?

History and PE

endoscopy

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What are some treatment options for gastritis?

Treat the underlying cause

Mostly symptomatic:
H2 blockers
PPIs
carafate

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List some causes of gastritis

H. pylori
NSAIDs/ASA
Alcohol
Caffeinated beverages
Medical or surgical stress
Autoimmune gastritis (Pernicious anemia)
Viral
Duodenogastric reflux
Fungal
Granulomatous (Crohns disease, Tuberculosis, Syphilis, sarcoid)
Hypersensitivity reactions
Eosinophilic Lymphocytic
Infection
Hyperplastic (Zollinger-Ellison syndrome, Menetrier’s disease)

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Caused due to the inhibition of prostaglandin synthesis (Prostaglandins are needed for mucosal protection and healing)

Stomach lining constantly being turned over- prostaglandins are vital

Affects approximately 2/3 of patients on this medication chronically

NSAID Gastritis

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Important to eradicate

Associated with chronic gastritis, PUD, gastric carcinoma

Transmission uncertain

Creates persistent inflammation

H. Pylori Infection

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spiral, gram negative urease producing bacterium

H. pylori

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Recurrence rate of ulcer is what percentage if patient is infected with H. pylori and not treated?

85%

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If patient has PUD and not on NSAID/ASA, assume or test for what?

H. pylori

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What are some non-invasive methods used to diagnose H. pylori infections?

Non-invasive:

Urea breath test - Must be off PPI, bismuth, antibiotics; Detects active infection – 90% PPV (Only for 18+ year olds)

Serology IgG antibody - Not useful for confirming eradication

Stool testing – H. pylori antigen; Useful for confirmation eradication

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What are some invasive methods used to diagnose H. pylori infections?

Invasive:

Endoscopy with biopsy

Rapid urease test (Biopsies added to urea solution containing phenol red)

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What is the treatment and follow up for H. pylori infections?

Treatment: triple therapy (abx and anti-ulcer)

Follow up with urea breath test or stool 1-3 months after completion (still need to be off PPI for accurate test)

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Confined to the rugae in the gastric body and fundus

Associated with an excessive number of mucosal epithelial cells

Two major types

Hyperplastic Gastritis

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What are the two major types of hyperplastic gastritis?

Menetrier’s disease

Zollinger-Ellison syndrome

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Which type of hyperplastic gastritis is described below?

Large gastric folds

Decreased gastric acid secretion

Enhanced protein loss into the stomach

Menetrier’s disease

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Which type of hyperplastic gastritis is described below?

Increased number of parietal cells with no change in surface and mucous cells

Caused by a gastrin-secreting neuroendocrine tumors (gastrinomas)

<1% of PUD

Zollinger-Ellison Syndrome

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What amount of gastrinomas are malignant?

2/3 of gastrinomas are malignant

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When a gastrinoma is diagnosed, what amount of cases have already metastasized to liver?

1/3 have already metastasized to liver at time of diagnosis

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In patients with Zollinger-Ellison Syndrome, what percentage of patients will develop PUD?

90% of patients will develop PUD

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How is Zollinger-Ellison Syndrome diagnosed?

Fasting serum gastrin

In the presence of gastric pH <4.0, a serum gastrin value >1000 pg/mL is virtually diagnostic of ZES

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What is a test you can use to differentiate gastrinomas from other causes of hypergastrinemia?

Secretin stimulation test

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What is the treatment for Zollinger-Ellison Syndrome?

PPIs (90-100% ulcer healing within 4 weeks)
Surgery
chemotherapy

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Consider this gastritis if you have a younger person who comes in with asthma and trouble eating

Eosinophilic Gastritis

What are the most common causes of gastric ulcers?

NSAIDs and H. pylori are the most common causes of ulcers

Loss of surface epithelium that extends to penetrate muscularis mucosae

Ulcer: >5mm in diameter Erosions: <5mm in diameter

Which type of ulcer is described below? Pain worse at night or in a fasting state Occurs 2-3 hours after eating Relieved by food ingestion Have to rule out ZE with duodenal ulcers Majority secondary to H. pylori

Duodenal ulcer

Which type of ulcer is described below? Worsened with food

Gastric Ulcer

Which type of ulcer is the most common?

Duodenal ulcers are 5x more common than gastric ulcers

Stress- related mucosal erosions that lead to upper GI hemorrhage Develop within 72 hours in critically ill patients Pathogenesis poorly understood Bleeding is associated with a HIGH mortality

Stress Ulcers

Stress ulcers are associated with what conditions?

Sepsis Multiorgan failure Hypotension Trauma Major surgery Severe burns Prolonged mechanical ventilation

Caused when normal mucosal defenses are impaired or overwhelmed by acid or pepsin Loss of surface epithelium that extends to penetrate muscularis mucosae (Ulcer >5mm in diameter; Erosions <5mm in diameter) Many upper GI bleeds are due to this Lifetime prevalence 10% Slight male propensity (1.3:1)

Peptic Ulcer Disease

delay healing of ulcer

EtOH, smoking

Which ulcers have a higher incidence of recurrence throughout life?

Duodenal ulcers

Describe the clinical presentation of peptic ulcer disease?

May be asymptomatic Dyspepsia - 80-90% of patients (But <25% of patients with dyspepsia will have PUD) Frequently relieved by food – duodenal Worse after eating - gastric Mild epigastric pain - Gnawing, aching feeling Anemia Occult blood in stool Hematemesis Melena Coffee-ground emesis

What is the procedure of choice to diagnose PUD?

Endoscopy

What are some red flags with peptic ulcer disease?

Anemia Weight loss Positive hemoccult Hematemesis/melena Persistent vomiting Hepatomegaly/abdominal mass Dysphagia Progressive symptoms

What are some complications with peptic ulcer disease?

GI hemorrhage Ulcer perforation/penetration Gastric outlet obstruction

Abdominal xray: free air under the diaphragm suggests what?

Ulcer perforation/penetration

In an otherwise healthy infant aged 2-3 months; seems to be in pain and cries for >3 hours a day, >3 days a week, for more than 3 weeks (rule of threes) Most common cause is GERD

Colic

What is the clinical presentation of infants with colic?

Severe and paroxysmal crying that occurs mainly in the late afternoon Knees drawn up into chest Fists are clenched Flatus is expelled Faces are pained in appearance Minimal response to soothing techniques

Olive shaped mass right of midline Projectile vomiting – sometimes can see visible peristalsis after feeding Post-prandial, projectile, non-bilious vomiting Begins between the ages of 2-4 weeks (Rare at birth or over 6 months of age) More prevalent in males

Pyloric Stenosis

What is the pathophysiology of pyloric stenosis?

Caused by hypertrophy of muscles of the pylorus with elongation and thickening leading to obstruction

Avoid giving Zithromax in kids under 3 because it can cause what?

pyloric stenosis

How is pyloric stenosis diagnosed?

Ultrasound – highly sensitive and specific; Can see hypertrophied pyloric valve (stenosis) Barium swallow - will see tapering

What is the treatment for pyloric stenosis?

Surgical repair

The congenital absence or complete closure of a portion of the lumen of the duodenum (during gestation)

Duodenal Atresia

Duodenal atresia is also associated with what other conditions/disorders?

Can be associated with Down Syndrome Associated with cardiac anomalies and GI defects: Malrotation of intestines, Imperforate anus, Annular pancreas

How does duodenal atresia typically present?

Bilious emesis (vomiting bile) and epigastric distension within the first few hours of birth

What Xray finding would you see in duodenal atresia?

“double bubble” sign

What is the treatment for duodenal atresia?

Surgical repair

2nd most common cancer worldwide Uncommon in US

Gastric Adenocarcinoma

What is the strongest risk factor for gastric adenocarcinoma?

Chronic H. pylori infection – stronger risk factor

What are some risk factors for gastric adenocarcinoma?

H. pylori High salt diets Dietary nitrates Smoking First-degree relatives of patients with gastric cancer have a 2-3 fold chance of developing the disease

In gastric adenocarcinoma, what are two signs of metastatic spread?

Virchow’s node - Left supraclavicular node/area Sister Mary Joseph node - umbilical

In gastric adenocarcinoma, what percentage will survive 5 years after “curative” resection?

25-35%

2nd most common gastric tumor >95% are B cell non-Hodgkins lymphoma

Gastric Lymphoma

Rare (<1% of gastric tumors) More common in the bowel - 95% present in rectum, small intestine, appendix Sporadic or secondary to chronic gastrinemia

Carcinoid Tumors

Symptomatic delay in gastric emptying of solid or liquid meals in absence of obstruction

Gastroparesis

What are the most common causes of gastroparesis?

Diabetic autonomic neuropathy (poorly controlled diabetes) Post-vagotomy

What is the treatment for gastroparesis?

Prevention/Maintenance: Small frequent meals, Avoid agents that slow down gastric motility, Maintain good control of DM Acute exacerbations: NG tube, IV fluids Chronic or Subacute exacerbations: Metoclopramide (reglan), Domperidone, Erythromycin, Gastric pacemaker?

Disorders of the Stomach and Duodenum Flashcards

(62 cards)