Peptic Disease/Gastritis

Question 1

Ranitidine= H2 antagonist

Answer 1

Note that there is much more H. pylori in eastern europe

Question 2

What is the Ddx?

Answer 2

Question 3

What is a peptic ulcer?

Answer 3

A discontinuity that occurs in the Gi epithelium that is exposed to acid and pepsin, most commonly in the stomach or duodenum

Question 4

T or F. You cannot distinguish a gastric from duodenal peptic ulcer based on the pts. symptoms

Answer 4

T.

Question 5

What parts of this mans Hx favor peptic ulcer over functional dyspepsia?

Answer 5

• localized pain to the epigastrium
• waking the pt. at night
• helps by eating (pain with functional dyspepsia usually get worse with eating)
• helps with acid suppressing meds. (also true of functional dyspepsia)
• the intermittent nature of the pain (chronic, every-day pain would be highly uncharacteristic of peptic ulcer)

Question 6

T or F. The pain of peptic ulcer typically waxes and wanes

Answer 6

T. Not constant like in functional dyspepsia

Question 7

Question 8

Functional dyspepsia is much more common today!

Question 9

What is ‘dyspepsia’?

Answer 9

really more of a symptom than a diagnosis- can be interchanged with indigestion, but it is a localized pain/burning in the upper abdomen

Question 10

T or F. With a diagnosis of functional dyspepsia, the normal anatomy of the GI will be normal and functioning properly

Answer 10

T. It is more idiopathic

Question 11

Want to know about OTC pain meds

Being from eastern europe (and east asia, south america)= H. pylori risk

Answer 11

Question 12

Answer 12

Endoscopy too expensive

Barium X-ray pretty hardcore- endoscopy better

Gall bladder might be bad

H. pylori can be checked at the time of endoscopy or via blood draw

Question 13

Youre not expecting to feel a peptic ulcer on abdominal exam

Pointing sign= can the pt. point to the source of pain with 1 finger. If they can, increased likelihood of peptic ulcer

Answer 13

Note that a positive test for H. pylori means hes been infected at some pt. and he may/may not still have it.

Most H. pylori infections are acquired pediatrically (first 6-7 yrs of life) and highly unlikely to be acquired after. These infections manifest during adulthood, however.

Children can clear the infection on their own and get re-infected but adults cannot clear the infection alone despite the presence of an immune response

Question 14

How does H. pylori spread?

Answer 14

• fecal-oral spread
• gastric-oral spread
• mother-child via close contact

Question 15

Note that for Americans, the incidence of H. pylori infection has continually dropped so that most positive pts. will be older

Question 16

Endoscopy of pt. 1

Question 17

the tx of an ulcer depends on whethers its H. pylori + or -

Answer 17

Note that H. pylori is the cause of roughly 60-70% of duodenal ulcers and

you cant tell whether its H. pylori positive or negative just by looking a the ulcer via endocopy OR by biopsy

Question 18

Need an ANTRAL biopsy. The neutrophils have to be in the glands!!!

If you have either active (neutrophils) or chronic (lymphocytic) inflammation, look for H. pylori!

Answer 18

Must get a biopsy of the antrum and like to live in the crypts- described as seagulls. Can also do silver stains or IHC (right- black things)

Question 19

there there is no inflammation but the crypts become very squiggly and elongated in reactive/chemical gastropathy

Question 20

H. pylori will not be found in intestinal metaplasia (notice the goblet cells).. it needs normal gastric epithelium

Question 21

These pts. have an icnreased risk of LYMPHOMA due to the presence of MALT tissue (note that this is kind of a fake lymphoma in that it is a monoclonal proliferation of cells but if you treat the H. pylori a lot of pts, will get better)

Notice that HP is brown on IHC

Question 22

Question 23

Note that if a population of B cells in the GI express BOTH CD20 and CD43, it is a lymphoma

Question 24

Note that pts. should never be given the diagnosis of gastritis.. that is a histological finding and doesnt describe any clinical or endoscopic abnormality

Question 25

Note that duodenal ulcers are almost (99+%) NEVER malignant (so dont biopsy typically), while gstric ulcers are more likely and warrant a biopsy. You are NOT going to find H. pylori anywhere but the stomach

Answer 25

Definitely treat the infection

Question 26

T or F. ALL peptic ulcer pts. MUST be tested for H. pylori and all who have it MUST be treated for it

Answer 26

T.

Question 27

Despite feeling better, you MUST complete the full 14 days

Question 29

Only need to recheck endoscopy to make sure if it healed if it was a gastric ulcer, but not a duodenal ulcer (duodenal malignancies very rare) You do want to confirm eradication of H. pylori infection (only about 70% will clear with ABX)

Answer 29

NEVER do serology in a pt. after tx for H. pylori- pts. may remain positive for yrs. even after clearing

Question 30

The negative breath test **does** mean he's cured chances of re-infection are **less than 1%/yr** in adults (more likely in children)

Question 31

Note that H. pylori clarithromycin resistance is a big problem

Question 32

H. pylori has urease activity! It will split the urea to ammonia and Co2 to be breathed out Notice the causes of false-negatives

Answer 32

Question 33

Question 34

Answer 34

Question 35

Probably has an upper GI bleed the black, tarry stool comes from melana (means 'black')

Answer 35

Question 36

Answer 36

Question 37

Dont want to biopsy the ulcer for risk of further bleed (might be okay if she hadnt bled before)

Answer 37

H. pylori serology has a very good NEGATIVE predictive value (but not good positive predictiveness)

Question 38

The process of NSAID induced damage is typically painless.. especially in older pts.

Question 39

Answer 39

Yes it is right to restart aspirin therapy dont restart diclofenac, switch to the safer celecoxib She definitiely needs to be on a PPI for the rest of her life if shes gonna stay on aspirin She does need another EGD

Question 40

Answer 40

Remember that peptic uclers can have no Hx of pain especially in older pts and those taking NSAIDs!!