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Disorders of the stomach - Exam 3 Flashcards

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1
Q

_____ cells secrete mucus

_____ cells secrete gastric acid

____ cells secrete pepinsogen

A

goblet secrete mucus

parietal secrete gastric acid

chief cells secrete pepsinogen

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2
Q

What are the 3 layers of the stomach mucosa?

A

epithelial layer

lamina propria

muscularis mucosa

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3
Q

What is dyspepsia? this symptom is the hallmark symptom of _______

A

Epigastric fullness or burning, early satiety, nausea, postprandial fullness; this is the hallmark of a stomach disorder

hallmark symptom of a stomach disorder

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4
Q

What is the difference between gastropathy and gastritis?

A

Gastropathy: Conditions where there is epithelial or endothelial DAMAGE

gastritis: Denote conditions in which there is histological INFLAMMATION

but practically are used interchangably

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5
Q

What are the two categories of gastritis? What are the. major differences?

A

erosive/hemorrhagic: think acute and rugae are smooth

nonerosive: think chronic and rugae are more present

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6
Q

What is the pathophys behind erosive gastritis?

A

Characterized by hemorrhagic and erosive lesions that develop shortly after exposure of the gastric mucosa to injurious substances or reduction of mucosal blood flow resulting in a damaged normal protective barrier. Now other substances can penetrate into the lamina propria

causes injury to vasculature, nerves and causes a release of histamine and other inflammatory mediators

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7
Q

What are 3 major causes of erosive gastritis?

A

medications, alcohol and stress

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8
Q

What does “stress gastritis” mean? Which medication most commonly causes erosive gastritis?

A

Stress related mucosal erosions related to clinically ill patients: d/t inadequate gastric mucosal blood flow during periods of intense physiologic stress

NSAIDs due to the decrease in prostaglandins

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9
Q

NSAIDs are a ______ medication and cause a decrease in _________

A

COX 1 inhibitors and they decrease prostaglandins which is vital as part of the stomach’s natural defenses against acid

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10
Q

Anorexia
Epigastric pain
Heartburn
Nausea
Vomiting
Dyspepsia
upper GI bleed

What am I?
**What is the MC clinical manifestation?

A

erosive gastritis

upper GI bleed

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11
Q

What does an upper GI bleed commonly present as?

A

Presents as hematemesis/“coffee ground”
Or melena

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12
Q

**What is the most sensitive method of diagnosis for erosive gastritis? When does it need to be done? What will the results show?

A

EGD

Done within 24 hours of admission

EGD: Erythema
Red or black mucosal erosions
Petechial hemorrhages
Presence of blood vessels
Absence of rugal folds

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13
Q

What is the tx for generic erosive gastritis?

A
  1. Remove any causative agent
  2. Employ limited course of acid suppression with a
    Proton Pump Inhibitor (PPI): Pantoprazole IV 80mg bolus, followed by 8mg/h continuous infusion
    Add sucralfate suspension, 1g po q4-6h
  3. Endoscopy within 24 hours
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14
Q

What is the tx of NSAID related gastritis?

A
  1. stop/reduce NSAID
  2. PPI with sucralfate: Omeprazole (Prilosec) 20 - 40mg po daily x 2-4 wks
  3. switch to COX 2 inhibitor (if possible)
    - celecoxib (celebrex)
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15
Q

What is the recommended COX -2 inhibitor as a option instead of taking NSAIDs?

A

Celecoxib (Celebrex) Cox-2 inh.

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16
Q

What is the most effective treatment in healing and preventing NSAID related gastritis/ulcers?

A

PPI!!

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17
Q

What is the tx for stress related gastritis? When does it tend to show up in critically ill pts?

A

IV PPI’s: Pantoprazole 40mg/day or IV Omeprazole 60mg to reduce risk for GI bleeding

may develop within 72 hours in critically ill patients

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18
Q

What are some common causes of nonerosive gastritis?

A

H. pylori infection
NSAIDS
Systemic conditions: autoimmune gastritis

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19
Q

What is happening in autoimmune gastritis?

A

Immune system attacks parietal cells in stomach, causing pernicious anemia

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20
Q

**Where is H pylori commonly found? What is the MC pt type?

A

H. Pylori is a spiral gram-negative bacteria that lives in the outermost mucosal layer

**most likely to occur in children who live in crowded conditions and areas with poor sanitation.

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21
Q

What does H. pylori cause?

A

It causes an inflammatory response, triggering the release of polymorphonuclear leukocytes (PMNs) and lymphocytes, which will = gastric mucosal inflammation. Pain usually subsides over a few days and then will progress to chronic

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22
Q

Dyspepsia/Epigastric Discomfort
N/V
Anorexia
can be asymptomatic
possible epigastric pain

What am I?
How is it diagnosed? Why is this important?

A

nonerosive gastritis

EGD with bx histologically by the presence of goblet cells/Paneth cells

Gastric intestinal metaplasia is believed to be an important precursor to gastric cancer

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23
Q

What are 3 tests that be helpful when trying to determine etiology of nonerosive gastritis?

A

Urea Breath Test
Blood test
Stool test (fecal antigen test)

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24
Q

In patients younger than age 60 with uncomplicated dyspepsia, what should you order first?

A

Urea breath test, fecal antigen test to look for noninvasive H. Pylori before ordering EGD

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25
When would you want to order an EGD if concerned about nonerosive gastritis?
Upper endoscopy reserved for pts over 60 with new onset dyspepsia Selected younger pts with “alarm” symptoms (weight loss, rapidly progressive dysphagia, severe vomiting) When symptoms fail to respond to initial therapy Family hx of GI cancer
26
How does the urea breath test work? When do you use it?
used as to dx H. Pylori
27
**What is the urea breath test pt education before the pt has the test?
**Stop PPI’s, abx, bismuth 2 weeks prior
28
besides the urea breath test, what is an additional non-evasive test used to dx H. pylori? **What is the pt education prior to this test?
fecal antigen test **No PPI or abx 2 weeks prior to testing
29
What is the 3rd option for noninvasive testing for H. pylori? What is the pro and con?
serologic testing pro: do not have to stop abx or PPI prior to testing con: expensive!!
30
**What is first line H. pylori treatment?
31
**What is the tx for H. Pylori If allergies to amoxicillin, resistance to Clarithromycin, or triple therapy treatment failure?
32
What are the pt criteria to start quadruple therapy instead of triple therapy in H. Pylori? IN what circumstances should you treat with IV therapy?
If allergies to amoxicillin, resistance to Clarithromycin, or treatment failure patients with bleeding ulcers can be given IV treatment
33
What are 3 complications from chronic gastritis?
Ulceration GI Bleed Gastric Lymphoma (H. pylori)
34
______ is the MC cause of gastric lymphoma?
H. Pylori
35
How does the natural protection of stomach mucosa work?
mucous cells secrete a combination of mucus and bicarb to protect the mucosa from autodigestion by HCl
36
What is happening in PUD? If your patient is between 30-55, where is the most common place? If your patient is between 55-70, where is the most common place?
A break in the gastric or duodenal mucosa that extends through the muscularis mucosa into the deeper layers of the wall **30-55: duodenum **55-70: stomach
37
**In PUD, by definition ulcers extend through the _____ and are usually _____ in diameter
muscularis mucosa over 5mm
38
What are the 3 common causes of PUD? Which one is MC in the duodenum? MC in the stomach?
H. pylori infection: M/C in duodenum NSAIDS: M/C in stomach Zollinger-Ellison
39
______ block prostaglandin synthesis that helps protect mucosal layer of stomach lining. What does it lead to?
NSAIDS peptic ulcer disease
40
What are the 4 risk factors for PUD?
NSAIDs older than 60 Prior h/o PUD or H. Pylori infection smoking
41
** What is the hallmark presentation for PUD? Describe the pattern. When does it occur?
Dull, gnawing, aching, “hunger-like” that starts approx 1.5-3 hours after eating cyclical presentation: Symptoms for weeks, then weeks pain free nocturnal pain waking the pt
42
What is the diagnostic of choice for PUD? What may also be done?
EGD with bx establishes dx Noninvasive assessment for H. pylori with fecal antigen assay or urea breath testing may be done in patients
43
What is the tx for PUD? What is PUD is H.pylori?
Different Treatments Depending on Cause of PUD triple therapy: omeprazole, amoxicillin and clarithromycin for 10-14 days
44
When do you need to avoid giving Clarithromycin as part of triple therapy for H. Pylori?
***avoid in settings where h.pylori resistance to Clarithromycin is > 15%
45
What do you need to do once the pt has completed H. pylori therapy for PUD?
Confirm eradication with urea breath test or EGD 4 weeks after therapy
46
Under what circumstances does the pt need to continue therapy for PUD? How long do pts need to continue _____?
Pt was diagnosed with large (>2cm) ulcer Failure to eradicate H. Pylori: Even after “salvage therapy” Recurrent ulcers Continued NSAID use Should continue PPI for 4-6 weeks after antibiotic course
47
What is the MC cause of H. Pylori PUD recurrence?
The most common cause of recurrence is unsuccessful eradication
48
What is the tx for NSAID induced PUD?
4-8 week course PPI Remove offending agent if possible if the pt cannot stop NSAID: PPI is recommended for as long as the NSAID is being used
49
up to 50% of GI bleeds are due to ______. What is the clinical presentation? What lab study do you need to order?
Up to 50% of all UGI bleeds d/t PUD **melena and hematemsis hemoglobin and HCT to check RBC
50
** What is the tx for a GI bleed?
51
What is a VERY severe complication of PUD? How do they present? What will you expect to find on PE?
perforation sudden and severe abdominal pain!!! Rigid, Guarding & Rebound Tenderness on PE
52
What need to be part of your work up for a pt with stomach perforation? ____ establishes diagnosis. What is the management?
CBC Abdominal CT establishes diagnosis Surgery-laparoscopic perforation closure
53
What will the diagnostic tool of choice show for a pt with stomach perforation?
abdominal CT will show free air in the anterior peritoneal space indicating some sort of perforation
54
What are 3 complications of PUD?
perforation penetration to other organs gastric outlet obstruction
55
What will penetration due to PUD present like? How do you dx? What is the management?
Gradual increasing pain (radiates to back) Becomes severe and constant Unresponsive to antacids/food EGD to reveal ulceration and CT will CONFIRM penetration management: IV PPIs Surgery for those who do not improve
56
Early satiety, vomiting, weight loss, epigastric fullness May develop dehydration What am I? What is the underlying cause? What is the tx?
gastric outlet obstruction Due to edema or cicatricial (scarring) narrowing of the pylorus or duodenal bulb tx: IV PPI, upper endoscopy, dilation of obstruction by hydrostatic balloons- depends on how sick the pt presents
57
______ MOA replaces protective prostaglandins that are consumed by NSAIDS. Also inhibits gastric acid secretion and protects gastric mucosa. What are the indications?
Misoprostol (Cytotec) NSAID gastritis/ulcer prevention
58
** What is the BBW for Misoprostol (Cytotec)?
Pregnancy!! Women Desiring to Become Pregnant because it is used in pregnancy termination and used in labor induction
59
What are the SE of Misoprostol (Cytotec)? What test do you need to order 2 weeks before?
diarrhea and abdominal pain/cramping need to order pregnancy test 2 weeks before
60
_______ stimulates prostaglandin synthesis of mucous AND directly adheres to lining of stomach - forms mucoprotective barrier Adheres to ulcers, allowing them to heal
Sucralfate (Carafate)
61
What is the MC SE of sucralfate? What is the pt education point?
Constipation Can alter the absorption of other drugs - **do not take within 2 hours of other medications**
62
What is the MC malignanct cause of gastric outlet obstruction? What is it called in babies?
distal gastric adenocarcinoma pyloric stenosis due to hypertrophy muscle
63
Postprandial N/V Epigastric Pain Early Satiety Abdominal Distention Weight loss What am I? **What is the highlighted s/s?
Gastric Outlet Obstruction in adults **Postprandial N/V
64
Postprandial vomiting between ages 2 and 4 weeks; can be as late as 12 weeks Infants hungry, fussy, nurse/feed avidly Often “projectile vomiting” Weight loss What am I? **What is the highlighted s/s?
pyloric stenosis in children **Often “projectile vomiting”
65
What are both children and adults at high risk for if they have a gastric outlet obstruction?
Both children and adults may show electrolyte abnormalities d/t persistent vomiting
66
What will the PE of adults with gastric outlet obstruction present like? **What is a common PE finding in children with pyloric stenosis?
Abdominal Distention Epigastric Tenderness Succussion Splash **Palpable 5-15mm “olive shaped mass” present in RIGHT upper abdomen, especially after vomiting
67
adults with gastric outlet obstruction what need to be part of their diagnostic work-up? **What confirms dx? What will each show?
Plain films: enlarged gastric bubble and a dilated proximal duodenum CT will confirm obstruction: gastric distention, along with retained material within the gastric lumen and an associated air-fluid level **EGD to CONFIRM diagnosis and establish etiology luminal narrowing of the stomach or duodenum
68
** What is the imaging of choice for a child with pyloric stenosis? What will it show?
Abdominal ultrasound imaging of choice Show hypoechoic muscle ring greater than 4mm thickness with hyperdense center and pyloric channel length greater than 15mm
69
What is the management for a gastric outlet obstruction in an adult?
70
What is the tx for a child with pyloric stenosis?
71
What is gastroparesis? What is the MC pt?
Delayed gastric emptying Food emptying from the stomach to small intestines M/C in women & DM
72
Nausea Vomiting (1-3 hours after meals) Abdominal (Epigastric) Pain Early Satiety Bloating GERD/Regurgitation What am I? What will the PE show?
gastroparesis May reveal epigastric distention or tenderness but NO GUARDING or rigidity, may have succussion splash
73
What needs to be including as part of the pt w/o for gastroparesis? What confirms the diagnosis?
EGD to r/o mechanical obstruction Gastric emptying test - confirms the diagnosis blood tests to look for the cause!
74
What does the gastric emptying test NOT tell you in a pt with gastroparesis? What else do you need to order?
Does not uncover CAUSE of gastroparesis Blood tests as needed to look for CAUSE
75
Describe the gastric emptying test. ** What confirms the dx of gastroparesis?
** Gastric retention >than 10% at 4 hours is diagnosed delayed gastric emptying
76
What is the management for gastroparesis? What is the tx for severe refractory gastroparesis? What can be used as a short term tx?
Severe Refractory cases - may require PEG or jejunostomy tube for enteral feedings Erythromycin for a short term tx
77
**What is Zollinger-Ellison Syndrome? ** What are the 3 underlying pathologies?
rare endocrine disorder 1. gastrinoma: gastrin secreting tumor large amounts of gastrin lead to excess HCL acid and ulcer formation 2. increased gastric acid secretion by the parietal cells 3. peptic ulcer all leads to excessive amounts of HCL and can perforate stomach, invade tissues and spread through lymph
78
Where do the gastrinomas present as part of Zollinger-Ellison Syndrome? What are the components of the triangle?
Arise in pancreas, duodenum, lymph nodes confluence of cystic and common bile ducts, neck of pancreas, and junction of 2nd and 3rd portion of duodenum
79
the majority of gastrinomas present in Zollinger-Ellison Syndrome are ____ and _______. 25% are associated with ______
2/3 are malignant and SLOW growing MEN1
80
How does Zollinger-Ellison Syndrome present?
**refractory PUD: that often goes undetected for years hearburn weight loss diarrhea
81
** How do you dx Zollinger-Ellison Syndrome? What is the pt education point? What test results are considered diagnostic?
**Dx with fasting serum gastrin level Stop PPI’s 6 days prior to obtaining gastrin levels A serum gastric value greater than 10 times the upper limit of normal in the presence of a gastric pH below 2 is diagnostic
82
What characteristics would make you think to look for Zollinger-Ellison Syndrome and order serum gastrin levels?
Ulcers refractory to standard therapy Large, atypical appearing ulcers (>2cm) Multiple ulcers/frequent recurrences Ulcers associated with diarrhea Ulcers in patients who are H. pylori negative and who are not taking NSAIDS
83
If your pt's fasting serum gastrin is positive, what do you do next? Describe it. What would you expect the result to be if the pt has ZES?
Secretin stimulation test Secretin (digestive hormone) is administered IV. Secretin produces a marked increase in gastrin in most patients with a gastrinoma. Samples of gastrin collected at -10, -1, 2, 5, 10, 15,20, and 30 minutes The administration of secretin produces a marked increase in gastrin in most pts with a gastrinoma
84
Both the fasting serum gastrin and secretin stimulation test are positive, what do you do next? What is the Somatostatin Receptor Scintigraphy?
imaging!! CT or MRI to location other sites/mets Gastrinomas express somatostatin receptors that bind radiolabeled octreotide, which helps detects primary gastrinomas
85
What is the management for ZES? The ____ is the major metastatic site, ____ is second MC metastatic site
PPI and surgical resection liver bone
86
What are the 2 kinds of benign gastric tumors? Which one has premalignant potential?
Inflammatory epithelial polyps Adenomatous polyps - premalignant potential
87
What are the 3 kinds of malignant gastric tumors? Which one is MC with H. Pylori?
Gastric Adenocarcinoma Gastric Lymphoma- MC with H. Pylori Gastric Carcinoid Tumors (from Zollinger-Ellison)
88
**_____ are most common cancers of the stomach. What do they develop from?
Adenocarcinomas Develop from the gland cells in the lining of the stomach
89
What are the 2 difference "types" of gastric adenocarcinoma? Which one is MC? What are features of each?
“Intestinal-type”: MC Chronic H. pylori infection Smoking, high nitrate/salt diet More common in advanced age “Diffuse-type”: Genetic mutations/Hereditary Spreads faster, difficult to treat
90
What are the different stages of stomach cancer? What layers are involved in each?
Stage 0: mucosa layer only Stage 1: mucosa and submucosa only Stage 2: mucosa, submucosa and muscle layer Stage 3: mucosa, submucosa, muscle layer and serosa Stage 4: mucosa, submucosa, muscle layer, serosa that has spread outside of the stomach
91
Asymptomatic until advanced Dyspepsia, vague epigastric pain Anorexia, weight loss, early satiety Hematemesis Masses causing obstruction = postprandial vomiting What am I? **What are 3 signs of metastasis? Which one is MC?
Gastric Adenocarcinoma Left supraclavicular lymph node (virchow’s node) -MC Umbilical nodule (Sister Mary Joseph nodule) Rigid rectal shelf (Blumer shelf)
92
Left supraclavicular lymph node is known as ______ Umbilical nodule is known as ______ Rigid rectal shelf is known as ______ Which one is MC presented in gastric adenocarcinoma?
(virchow’s node)** MC (Sister Mary Joseph nodule) (Blumer shelf)
93
What is part of the diagnostic work up for gastric adenocarciomas? What is the tx?
EGD is procedure of choice CT of chest, abdomen, pelvis to delineate primary tumor/distal metastases Surgical Resection, Chemotherapy and or Radiation, Palliative Measures
94
How common is gastric lymphoma? **What is the MC risk factor? How do you make dx? What is the tx?
Primary accounts for 3% of gastric cancer M/C Risk Factor - Chronic H. pylori infection Dx - made by EGD with bx Treatment - radiation and/or chemotherapy
95

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