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Clin Med III > Peptic Ulcer Disease and Gastric Cancer > Flashcards

Peptic Ulcer Disease and Gastric Cancer Flashcards

1
Q

3 layer of stomach wall

A

Mucosa

Submucosa

Muscularis

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2
Q

increases stomach motility and increases acid production

what hormone

A

gastrin

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3
Q

inhibits stomach motility

decreases bile secretion

increases enzyme flow

A

secretin

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4
Q

increases bile secretion

increases enzyme flow

A

CCK release

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5
Q

CCK: stimulatory or inhibitory

A

stim

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6
Q

secretin: stimulatory or inhibitory

A

inhib

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7
Q

what causes gastrin to be released

A

food in lower stomach

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8
Q

acid and food in duodenum causes what to be released

A

secretin

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9
Q

fatty food and amino acids in duodenum causes what to be released

A

CCK

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10
Q

peptic ulcers must extend through what

A

muscularis mucosa

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11
Q

peptic ulcers can be in what two locations

A

gastric or duodenal mucosa

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12
Q

2 PUD etiology

A

H. pylori

NSAIDS

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13
Q

Can PUD be caused by stress, etoh, spicy foods, caffeine, or tobacco?

A

NO - they can make them worse and more difficult to heal, however

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14
Q

most common cause of PUD

A

H. pylori

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15
Q

describe h. pylori as an organism

A

Gram(-) rod

Motile flagella used to attach to gastric mucosa

Oral-oral or oral-fecal route

Disrupts protective properties by decreasing gastric mucus and mucosal bicarb secretion

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16
Q

what does h. pylori do to the stomavh

A

decreases gastric mucus and mucosal bicarb secretion so stomach is not as protected

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17
Q

5 factors that increase risk of PUD with use of NSAIDS

A

previous hx of PUD/ulcer complications

presence of h. pylori infection

over 75

increased dose, time, duration of use

concomitant use of steroids, NSAIDS, anticoags, low dose aspirin, SSRI, alendronate

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18
Q

most common presentation of SYMPTOMATIC pts with PUD (30% will be symptomatic and 70% will be asymptomatic)

A

abdominal pain/discomfort

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19
Q

most common clinical presentation of PUD (70%)

A

asymptomatic

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20
Q

symptoms of dyspepsia

A

belching

bloating

distention

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21
Q

symptoms of PUD complications

A

hematemesis

melena

fatigue

dyspnea

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22
Q

gastric or duodenal ulcer:

pain worse after meals

pain worse 30 min to one hour after meals

A

gastric

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23
Q

gastric or duodenal ulcer:

vomiting common

A

gastric

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24
Q

gastric or duodenal ulcer:

more likely to hemorrhage; manifests as hematemesis

A

gastric

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25
Q

gastric or duodenal ulcer

weight loss/anorexia

A

gastric

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26
Q

gastric or duodenal ulcer:

pain relieved by meals

pain occurs 2-3 hours after a meal

A

duodenal

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27
Q

gastric or duodenal ulcer

vomiting uncommon

A

duodenal

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28
Q

gastric or duodenal ulcer

less likely to hemorrhage, but if it does - melena

A

duodenal

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29
Q

gastric or duodenal ulcer

weight gain

A

duodenal

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30
Q

PUD alarm symptoms

A

bleeding

unexplained iron def anemia

early satiety

unintentional weight loss

progress dyspagia/odynophagia

acute onset of intense upper abdominal pain

persistent vomiting

family hx of upper GI cancer

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31
Q

most common complication of PUD (+ others)

A

bleeding

**others include perforation, penetation, gastric outlet obstruction (rare)

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32
Q

how can bleeding from PUD present

A

hematemesis, melena, or hematochezia

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33
Q

dx for PUD

A
  1. stabilize with IV fluids or packed red blood cells
  2. start IV PPI
  3. perform EGD - EGD is diagnostic and allows for therapeutic interventions

THESE ARE ALL PART OF DX

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34
Q

tx of PUD complication: bleeding

A

thermal coagulation, hemoclip placement, injection tx

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35
Q

if you suspect someone has PUD and a perforation (a complication of PUD), what do you NOT do

A

UGI with barium

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36
Q

someone presents with severe, diffuse, abdominal pain, tachycardia, weak pulse, N/V

these symptoms may progress to “board like abdominal rigidity”

what dx test should you NOT do?

what should you do instead

A

do not do UGI with barium

you can do upright chest and abdominal x-rays with MAYBE a CT scan to localize perforation

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37
Q

how to dx perforation complication of PUD

A

stabilize with IV fluids

NG tube

NG suction of gastric decompression

IV PPI

broad spectrum antibx

surgery

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38
Q

what will you see on chest xray to indicate perforation

A

free air under diaphragms (crescents)

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39
Q

what does PUD penetration complication mean

A

penetration of the ulcer through the bowel wall without free perforation and leakage of luminal contents into peritoneal cavity

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40
Q

what is the most common structure affected in penetration

A

pancreas

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41
Q

clinical presentation of penetration (PUD complication)

A

symptoms change due to what adjacent structure is involved BUT symptoms are usually pain without meal assoc, more intense pain and pain referral to back

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42
Q

gastric outlet obstruction (PUD complication) causes

A

scarring, fibrosis or inflammation/edema in pyloric channel

43
Q

gastric outlet obstruction (PUD complication) clinical presentation

A

vomiting

early satiety

bloating

epigastric pain

weight loss

anorexia

44
Q

dx and tx with gastric outlet obstruction (PUD complication)

A

imaging shows dilated stomach

stabilize with IV fluids, NG tube, gastric decompression, and IV PPIs

45
Q

what happens if gastric outlet obstruction is not treated effectively with IV fluids, NG tube, gastric decompression, and IV PPI

A

EGD with endoscopic balloon dilation

or

surgery

46
Q

PUD abdominal physical exam

A

epigastric tenderness

RUQ tenderness

peritoneal signs

succussion splash

47
Q

PUD vital signs physical exam

A

hypotension

tachycardia

48
Q

PUD rectal exam on physical exam

A

melena (in rectal vault)

hemoccult positive stool

bright red blood per rectum

49
Q

what is succussion splash

A

it is elicited by placing stethoscope over upper abdomen and rocking the pt back and forth at the hips. Retained gastric material greater than 3 hours after a meal will generate a splash sound and indicate prescence of a hollow viscus filled with both fluid and gas

50
Q

__________ is elicited by placing stethoscope over upper abdomen and rocking the pt back and forth at the hips. Retained gastric material greater than 3 hours after a meal will generate a splash sound and indicate prescence of a hollow viscus filled with both fluid and gas

A

succussion splash

51
Q

gold standard for PUD dx

A

EDG - looking for clean white base in ulcer crater with NO evidence of active bleeding

52
Q

other imaging for PUD dx

A

upper GI - small ulcer crater with smooth folds radiating into center of ulcer

53
Q

what can be done to see if PUD is caused by h. pylori

A

urea breath test

fecal antigen test

serology

biopsy during EGD

54
Q

most specific and sensitive H. pylori dx test

A

biopsy during EDG

55
Q

succision splash indicates what

A

GASTRIC OUTLET OBSTRUCTION

56
Q

h. pylori virulence factors

A

flagells

urease

adhesins

inflammation causing

57
Q

what does urease do for h. pylori

A

hydrolyzes gastric urea to form ammonia that helps neutralize gastric acid, enabling it to penetrate gastric mucus layer

58
Q

flagella does what for h. pylori

A

used to burrow into stomach mucus to reach epithelial cells where it is less acidic

59
Q

adhesins do what for h. pylori

A

adhere to epithelial cells

60
Q

why does h. pylori cause inflammation

A

inflammation causes G cells in antrum to secrete gastrin and therefore HCl increases

61
Q

what prostaglandin is assoc with stomach

A

PGE2

62
Q

how do NSAIDS lead to PUD

A

NSAIDS block COX 1 and 2 which prevents PGE2 synthesis

PGE2 stimulates mucin, inhibits gastrin, and leads to peptic ulcer formation due to change in environment

63
Q

PGE2:

increase or decreases mucin

increases or decreases gastrin

A

increases mucin

decreases gastrin (decreased acid)

SO without PGE2, there is decreased mucus (hostile environ) and increased gastrin which leads to increased acid

64
Q

3 symptoms of dyspepsia

A

belching

bloating

distention

65
Q

4 symptoms of PUD complicagtions

A

hematemesis

melena

fatigue

dyspnea

66
Q

what dx test is contraindicated if you suspect perforation (severe, diffuse abdominal pain, tachycardia, weak pulse, N/V)

what do you do instead?

A

UGI - barium swallow

upright chest and abdominal x-rays looking for free air under diaphragm

67
Q

why can’t you use serology to detest h. pylori

A

because it looks for IgG antibodies (so could indicate past or present infection)

68
Q

what two tests can you do for h. pylori eradication testing

A

urea breath testing

fecal antigen test

69
Q

what are instructions for urea breath and fecal antigen testing

A

stop PPI use 2 weeks prior and bismuth/antibx 4 weeks prior

70
Q

PUD tx (5 steps if symptoms persist)

A
  1. eradicate H. pylori and confirm eradication 4 weeks post-tx
  2. if no H. pylori and symptoms persist, tx with 4-8 weeks of PPI
  3. if symptoms persist, tx with 8-12 weeks of TCA
  4. if symptoms persist, treat with 5 weeks of prokinetic
  5. if symptoms persist, perform EGD
71
Q

How to eradicate H. Pylori

A

bismuth quadruple therapy for fourteen days

PPI (BID)

Bismuth 524 mg (QID)

Tetracycline 500 mg (QID)

Metronidazole 250 mg (QID)

72
Q

syndrome with gastrinomas

A

ZES

73
Q

where do ZES gastrinomas arise from

A

duodenum or pancreas

74
Q

pathophys of ZES

A

gastrin stimulates the secretion of gastric acid by the parietal cells of the stomach and aids in gastric motility

75
Q

ZES more common in whom?

A

men

MEN1-assoc in 20% of cases

76
Q

clinical presentation of ZES

A

recurrent PUD (often distal to duodenal bulb) OR multiple ulcers at once

abdominal pain

diarrhea (steatorrhea)

77
Q

gold standard dx test of ZES

A

fasting serum gastrin over 1000 pg/mL

78
Q

tx of ZES

A

PPIs or H2 blockers (usually PPIs)

79
Q

risk factors for gastric cancer

A

gastric ulcers

ETOH/tobacco use

chronic H. pylori infection

diet high in salt/smoked meats

80
Q

early gastric cancer signs

A

none - asymptomatic

81
Q

gastric cancer signs not assoc with early or late gastric cancer

A

weight loss

persistent abdominal pain

early satiety

nausea

anorexia

dysphagia

gastric ulcer hx

occult GI bleeding

82
Q

late gastric cancer clinical presentation

A

palpable stomach mass, succussion splash, paraneoplastic syndromes

83
Q

dx test for gastric cancer

A

EGD - use for grading too

84
Q

90-95% of gastric cancers are ____

A

adenocarcinomas

85
Q

on EGD, how might gastric cancer appear

A

subtle polypod protrusion, superficial plaque, mucosal discoloration, depression, ulcer

86
Q

stage 0 of stomach cancer

A

in mucosa

87
Q

stage 1 of stomach cancer

A

to submucosa

88
Q

stage 2 of stomach cancer

A

to muscle (considered a tumor)

89
Q

stage 3 of stomach cancer

A

touches outer layer but not through

90
Q

stage 4 of stomach cancer

A

goes through outer layer (serosa) and metastasizes

91
Q

most common sign of metastatic disease with gastric cancer

A

Virchow’s node (left supraclavicular lymph node)

92
Q

other signs of metastatic disease of gastric cancer

A

sister mary joseph’s node/nodeule - periumbilical nodule

left axillary node (irish node)

93
Q

tx of early gastric cancer

A

endoscopic mucosal resection (very rare - doesn’t usually get caught early)

94
Q

tx of advanced gastric cancer

A

total or partial gastrectomy if resection possible

95
Q

tx of unresectable cancers

A

chemo or chemoradiation but poor prognosis

96
Q

55 y/o presents with abdominal discomfort, bloating, belching, and distention for 4 weeks.

NO: early satiety, weight loss, dysphagia, odynophagia, recurrent vomiting, hematemesis, melena, hematochezia, shortness of breath, palpations, fatigue

LABS ARE NORMAL

what are you thinking?

A

dyspepsia

97
Q

abdominal discomfort sometimes accompanies by bloating, belching, or abdominal distention

defines what disorder

A

dyspepsia

98
Q

1st thing to look at with dyspepsi

A

AGE

99
Q

if 60+ y/p with dyspepsia, what do you do

A

EDG and biopsy

PUD present - tx accordingly

if no evidence of organic disease, test for H. pylori and tx as necessary

100
Q

how do you proceed with a pt less than 60 with symptoms of dyspepsi

A

ONLY perform EDG IF:

    • sig weight loss
    • overt GI bleeding
    • 2+ alarm features
    • rapidly progressive alarm features (progressive dysphagia in 2 weeks)
101
Q

Dyspepsia alarm features

A

unintentional weight loss

progressive dysphagia

odynophagia

unexplained iron def anemia

persistent vomiting

palpable mass or lymphadenopathy

family hx of upper GI cancer

(if pt less than 60, has 2+ of these symptoms OR rapidly progressing symptom, do EGD)

102
Q

if pt is less than 60, no alarm features, how do you proceed

A

H. pylori testing as indicated

103
Q

pt is less than 60, no alarm features, so you do H. pylori test and it is positive, what do you do?

A

you tx H. pylori with quadruple tx

then you do urea breath test to confirm eradication

if neg - then you tx with trial of PPI

if PPIs do not work and symptoms persist, consider EGD

Clin Med III (6 decks)

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