Gastroesophageal Reflux, Gastritis and Gastropathy, and Gastric Cancer

Question 1

GERD path

Answer 1

Mostly due to LES relaxation…vagally mediated events triggered by gastric distension

More freuqnelty if supine or intra-ab pressure inc

HIatal hernies in 25%

Mucosal damage depending on acidity and amount of times

Question 2

CM of GERD

Answer 2

Retrosternal burning sensation

Regurgitation

1/3 may get dysphagia which suggests complication

Infantlile GERD - back arching and lifting the chin during episdoes of reflux

Question 3

Comps of GERD

Answer 3

Erosive esophagitis from ulcerationf of distal esohageal mucosa is most common comp

May get pelvic stricture

Barrett esophagus is another long term comp related to adenocarcinoma

Question 4

Dx of GERD and

Answer 4

If sx persist despite PPI therapy…then consider

Erosive esophagitis - dysphagia with GI bleeding or anemia

Peptic strictture - dysphagia with recurrent vomiting

Esoph adenocarcinoma - weight loss

Question 5

Path of GERD

Answer 5

Simple hypererema on gross inspection

More severe - will see eosinos followed by neutrophils…hyperplasia of basal zone exceeding 20% of total thickness with elongation of lamina propria may also be found

Question 6

Mg of GERD

Answer 6

Weight loss and elevation of head

Mild and IM - antacids or H2 receptor antagonists

If failed above - PPIs…irreversibly inhibit and hsould be taken prior to meal

If failed PPI - then antireflux surgery

Question 7

Prognosis of ERD

Answer 7

Screening endoscopy in pts over 50, mnale, and GERD sx

Question 8

Gastriris/opathy patho

Answer 8

Any imblanace of acid secretion

Acute - H pylori
Chornic - autoimmune or H pulori

Gastropathy - Aspirin, NSAIDs, alcohol, bile refluex

Type B - predominats in antrum but spreads

Acute - neutrophils above basment membrane

Chroonic - subepithali llyhmph oinfiltration

H pylori also associated with MALT and gastric cancer

Type A hronic from CD4 T cells directed aginat parietal cell components…lose vit B

Progressive dec in acid stimulates gastrin release and induces hyperplasia of antral gastrin producing G cells and can form carcinoid tumors

Question 9

Dx of gastritis

Answer 9

Endoscopy with biopsy is produce of choice

Chronic - patchy atrophic antral mucosa is more of type B…type A is more diffuse atrophic mucosa of body and fundus

Autoimmune - look for vit B12 def, anemia

Also inc serum gstrin and ABs to IF and parietal cells

Question 10

Pathology of types

Answer 10

Gastropathy - intact surface epithelium with edema of lamina propria…few scattered neutro and lymphos in epithelium

Acute - intact to erosive surface peithelium with edema of propria…dense neutrophil infil

Type A chronic - diffuse mucosal atrophy in body and fundus with loss of P and C cells..muscoal inflam composed of lymphos and macros

B - pathces of mucosal atrophy…mostly in antrum with intraepithelial neurtops ad subepi lymphocytes

Question 11

Mg of gastritis and gastropathy

Answer 11

Remove the offending agent

Acute and B tx with H pyolri eradictaion

Type A chronic with B 12 supp to prevent sequele of pareital cell loss

Question 12

Gastric cancer types

Answer 12

Intestinal - cellular adhesion present
INtestinal metaplasia with tubular/glandular formmation
From chronic inflamm or deit/enriovnement
Older pts

DIffuse - defective due to loss of E-cadherin
Infiltrating with signet ring cell
Genetic mutations

Question 13

Intestinal type path

Answer 13

Non-atrophic gastritis - initially after H pylori…inflmation in the antrum with lymphocytic inflammation with a superimpoased PMN infiltrate

Atrophic gastritis - a subset of pts with H pylori develop loss of gastric glands

INtestinal metaplasia - appearance of glands resembling intestinal glands at jxn of antrum and gastric body…hypochlorhydria

Dysplasia - dysplastic cells appear but ndo NOT penetratr basemebt membrane

Invasive adenocarcinoma - ulcerated mass at jcxn between antrum and body

Question 14

Diffuse type path

Answer 14

Rapid progression and early metastasis…invade the gastric wall and may get a rigidi and thickened stomach

Most due to CDH1 - E cadherin gene inactivvation

Question 15

Progression and epi of gastric cancers

Answer 15

Direct exten through gastric wall and may spread to pancreas colon and liver

Peritoneal seeding may lead to ascites or metastasis to the overy or periumbilical region

Question 16

CM of gastric cancer

Answer 16

GE jxn - dysphagia
Stomach and pylorus - N/V

Hx of gastric ulcer

Most PE findings with later dz

Colonic obstruction - direct spread
Virchows node - supraclavicular LN
Sister mary janes node - periumbilical metast from peritoneal spread
Enlarged ovary - ovarian metastasis from peritoneal space
Blumers shelf - peritoneal metastasis in cul de sac on rectal
Malignant ascities - peritoneal carcinomatosis

Question 17

Dx of gastric cancers and biopsy findings

Answer 17

Upper endoscopy with exophytic mass (intestinal) or loss of rugal folds (diffuse)

Intestinal - bulky glandular structures with broad cohesive cells…may contain vacuoles with abundant mucin

Diffuse - thickened gastric wall containing signet ring cells

Question 18

Mg of gastric cancers

Answer 18

Cure - surgical resection

Intestinal more suysceptible t 5-FU and oxaliplatin

Diffuse - more cisplatin

Question 19

Primary gastric lymphoma

Answer 19

Most common extranodal site for lymphoma

H pylori associated

Almost identical to gastric adenocarcinoma…endoscopic same as intestinla

Biopsy - B cell infiltrated of gastric wall ranging from well-diff (MALT) to poorly diff high grade lymphoma (large cell)

Far more responsive to tx

MALT - AB tx

Question 20

Gastric Sarcoma

Answer 20

Leiomyosarcoma and GISTs are minority

Rarely metastasive but may spread hematogenously to liver or lung