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Flashcards in Howden: PUD Deck (30):
1

53-yo WM immigrant from E. Europe. Intermittent epigastric pain for 3 years that wakes him at night. Helped by eating, taking antacids. Uses OTC Ranitidine (H2 antagonist). 1 ppd smoker. 

Differential?

- PEPTIC ULCER: 8-12 out of every 100 ppl presenting with heartburn actually have gastric/peptic ulcers

1. Need radiology/endoscopy to distinguish gastric from duodenal ulcer 

- Functional dyspepsia (FD): persistent or recurrent pain or discomfort centered in upper abdomen w/no evident cause (much more prevalent than PUD) 

- Gastric cancer

- Pancreatic disease

- Gallstones

2

What are some of the differences between PUD and FD (chart)?

- Pain; periodicity 

- Nocturnal waking with pain 

- Effect of food on pain 

- Effect of antacids/acid lowering meds 

- Other symptoms 

- NOTE: in FD, stomach looks, for all intents and purposes, normal 

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3

53-yo WM immigrant from E. Europe. Intermittent epigastric pain for 3 years that wakes him at night. Helped by eating, taking antacids. Uses OTC Ranitidine (H2 antagonist). 1 ppd smoker. 

What else do you want to know?

- No weight loss or other GI symptoms

- Family history 

- Aspirin or NSAID use

- NOTE: Eastern European ethnicity important b/c higher prevalence of H. pylori infection in people born outside US than born in US

4

53-yo WM immigrant from E. Europe. Intermittent epigastric pain for 3 years that wakes him at night. Helped by eating, taking antacids. Uses OTC Ranitidine (H2 antagonist). 1 ppd smoker.

What tests are indicated?

- Non-invasive test for H. pylori infection? Yes

- Upper endoscopy? Probably

- Barium X-ray of stomach and duodenum? Maybe

- Abdominal CT scan? Maybe

- No tests necessary. Let’s save some money and treat him for a presumed ulcer. NO

- Gall bladder ultrasound? NO

5

Upper endoscopy of your pt shows a duodenal ulcer. What MUST be done?

Test for H. pylori

6

Pt. has a (+) serological test (IgG) for H. pylori - what does this mean?

- Pt could have active infection

- Also could have been treated in the past: may remain serologically (+) for years 

- NOTE: this test does, however, have an excellent negative predictive value (NPV), i.e., if (-), probably NOT infected 

7

What do you see here?

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Duodenal ulcer: well-circumscribed lesion

- Remaining portion of the bulb is mildly edematous, but w/o any associated subepithelial haemorrhage or erosions 

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8

What is this? Arrows?

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- Chronic gastric ulcer: cellular debris + fibrinoid necrosis + granulation tissue (proliferation and fibroblasts)

- NO epithelium left b/c it all has been degraded

- Also want to look at blood vessels deep down to look for thrombi

- NOTE: duodenal ulcers are essentially never malignant (unless pt has FAP), but always something pathologists are looking for in gastric ulcers 

9

What do you see here? Arrows?

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Active gastritis: H. pylori (look like little seagulls) + neutros + plasma cells 

- Neutrophils in crypt = active gastritis 

- Lymphoplasmacytic background = chronic gastritis

1. >5-7 plasma cells in stomach, start to think this is chronic

- When inflam rare or absent = gastropathy 

10

What is going on here?

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- H. pylori infection: like the antrum (this is where you need to sample if you want to rule out H. pylori)

- Silver stain attached here: IHC stains now

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11

What is the difference b/t these 2 images?

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- LEFT: normal gastric mucosa 

- RIGHT: reactive/chemical gastropathy -> glands a little more reactive and elongated 

1. A few plasma cells, but not enough for chronic gastritis (also no neutrophils) 

12

What do you see in this gastric biopsy? Should you test this for H. pylori?

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- Intestinal metaplasia of the gastric mucosa: goblet cells

- Do NOT do H. pylori stain on this -> it does NOT like this 

13

What is going on in these images? Arrow?

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- Chronic, follicular gastritis from H. pylori: lymphoid follicles (germinal centers) are common in H. pylori gastritis 

- INC risk of cancer due to mucosa-associated lymphoid tissue, or MALT, which has the potential to transform into lymphoma  

1. Can become monoclonal 

- Bottom left image: immunostain for H. pylori 

14

What do you see in these images?

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Gastric MALT lymphoma: can often just tx these ppl for H. pylori, and they will get better (even w/mets)

- A: lymphoma replacing much of gastric epithelium; inset shows lymphoepithelial lesions with neoplastic lymphos surrounding and infiltrating gastric glands 

- B: disseminated lymphoma in small intestine with numerous small serosal nodules 

- C: large B-cell lymphoma infiltrating small intestinal wall and producing diffuse thickening (rare for it to transform into diffuse large B-cell)

- NOTE: MALT lymphoma not just possible in the stomach; can also happen in the eye, and in patients with Hashimoto’s or Sjogren’s 

15

What markers might you look for to dx MALToma? How could you test for monoclonality? Translocation?

- Express the B-cell markers, CD19 and CD20 (do NOT express CD5 or CD10, T-cell markers)

1. CD20 + CD43: can feel pretty confident this is a MALToma (25% of cases CD43+)

- MONOCLONALITY may be demonstrated by restricted expression of either κ or λ immunoglobulin light chains or by molecular detection of clonal immuno-globulin heavy chain rearrangements

- Translocation t(11;18)

- NOTE: H. pylori eradication results in remissions with low recurrence in most MALToma patients

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16

Should duodenal ulcers be biopsied?

- Nope, but should biopsy gastric ones (unless the pt. has FAP)

- Also, do NOT need to perform endoscopy to check for healing after treatment 

17

What are 2 things that can diminish the effectiveness of H. pylori tx regimen?

- SMOKING: weak evidence that smokers respond less effectively to H. pylori tx

- ADHERENCE: if you don’t take all of your meds, you lower your chance of getting better, and INC your chances of drug-resistant bug 

18

Do you need to verify elimination of H. pylori infection post-tx? What are the pt's chances of re-infection?

- Yes, you need to verify elim of the bug 

1. Do NOT use serology b/c pt will still test (+) 

2. Urea breath test is a viable option: looking for (-) urease activity (can also do fecal Ag test; endoscopy NOT needed to dx H. pylori)

- No more than 1%/yr chance of re-infection

19

How does the urea breath test (UBT) work?

- 14C- and 13C-labelled urea given orally, and when degraded by bac urease, labeled CO2 will equilibrate w/body fluids and be expired from the lungs into the breath (can be detected by mass spectrometry)

1. Should not be urease activity (cleaves urea into ammonia and CO2) in stomach unless there is H. pylori infection

- Qualitative test: + or –

- Can be used to diagnose pre-tx, or monitor tx to see if eliminated

1. Pre- and post-test accuracy similar 

- False (-)'s may occur w/recent acid suppression, bismuth, or AB's 

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20

What is the most common cause of PUD?

- H. pylori infection: responsible for 60-70% of ulcers 

1. Does not explain all ulcers: most others are due to NSAID (or Aspirin) use 

- H. pylori can be associated with both duodenal and gastric ulcers 

21

What types of pts may not know they have a peptic ulcer?

- Older pts on NSAIDs for chronic pain or inflam -> can be totally asymptomatic, then present suddenly with melena and orthostatic hypotension (systolic change >20 or diastolic change >10) 

- Give fluids, keep NPO, and admit to hospital 

22

Should you do a hemoccult on a pt that presents with melena?

- NO! It's not going to tell you anything you don't already know

23

What do you see here? What features might you see on radiography?

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- Benign-appearing gastric ulcer: doesn't necessarily mean it is not a cancer (although it is not in this case)

- Large and well-circumscribed, with a symmetrical appearance 

- Radiographic features suggestive of a benign ulcer include: projection of the ulcer away from the lumen, absence of mass effect or mucosal nodularity, and rugal folds of normal appearance, which extend to the ulcer crater

24

What do you see here? Significance?

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- Stigmata of recent hemorrhage: much higher risk of further bleeding from this ulcer

- Close-up of lesion demonstrates a visible vessel: 50% chance of rebleeding

- Certain colors of the visible vessel may increase the chance of rebleeding to 90%

25

Why should biopsies for H. pylori be taken away from the ulcer?

- Don't want the patient to bleed (again)

 

26

Should elderly pt. on low-dose ASA continue to take this after tx for a peptic ulcer?

- YES: early re-introduction of aspirin reduces all-cause mortality, even though it also slightly INC risk of ulcer recurrence 

27

How do NSAID's damage the gastric mucosa (image)?

- More likely to happen in pts with H. pylori 

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28

What is a safer alternative to NSAID tx for pts with osteoarthritis who have had a peptic ulcer? What else should they be taking? Dietary advice?

- A COX-2 selective NSAID, like Celecoxib 

1. CV risk with non-selective and COX-2 selective NSAIDs -> still best thing for pt to go with COX-2  (and also take Aspirin), but this is a highly contentious/controversial area 

- Pt should also stay on oral PPI indefinitely, or at least as long as they are taking their anti-inflammatory

No specific dietary advice, but they must stop smoking 

29

Does pt. presenting with bleeding, gastric, NSAID-induced ulcer need another EGD after tx?

- YES 

- To check for healing 

- To exclude gastric cancer 

30

In what patients can peptic ulcers be asymptomatic? How might these patients present?

- Elderly patients 

- Patients on aspirin/NSAID's

- May present with a life-threatening complication (e.g. bleeding) without antecedent symptoms 

1. May have no hx of abdominal pain or bleeding

2. Mortality from peptic ulcer bleeding 7-10% b/c often elderly people, and ulcer may be the straw that breaks the camel’s back; die of decompensation of other medical illnesses