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Clinical Medicine II > Stomach > Flashcards

Stomach Flashcards

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1
Q

caused by
Medications (NSAIDs)
Alcohol
Stress from severe surgical/medical illness
Portal HTN
– no inflammation (gastropathy), but damage is present

A

erosive + hemorrhagic gastritis

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2
Q

Usually asymptomatic or
Anorexia, epigastric pain, nausea, vomiting

Most common = upper GI bleeding (coffee ground emesis)

NSAID - dyspepsia

A

erosive + hemorrhagic gastritis

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3
Q

common with
Mechanical ventilation, coagulopathy, trauma, burns, shock, sepsis, CNS injury, liver failure, kidney disease, multiorgan failure, portal HTN

– alcoholics or critically ill patients

A

erosive + hemorrhagic gastritis

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4
Q

What is prophylaxis for erosive/hemorrhagic gastritis

A

(early enteral feeding), H2 receptor antagonist or PPI

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5
Q

What are alarm symptoms for erosive/hemorrhagic gastritis?

A

(severe pain, weight loss, vomiting, GI bleeding, anemia) → upper endoscopy

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6
Q

How do you treat erosive/hemorrhagic gastritis?

A

Stress → Tx: continuous PPI infusion (esomeprazole or pantoprazole) + sucralfate suspension, look for cause

NSAID → selective NSAIDs (celecoxib, etodolac, meloxicam) have less risk
Discontinue agent, reduce to lowest effective dose, take with food and
PPI
Alcoholic → H2 receptor antagonists, PPIs, sucralfate
Portal HTN → propranolol or nadolol, decompressive procedures

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7
Q

What are the different types of histologic gastritis?

A

H. pylori
- Person to person
Pernicious anemia
- Decreased B12, decreased iron
Eosinophilic
Infectious
- From acute bacterial infection, viral from CMV, fungal

inflammation present leading to destruction + cancer

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8
Q

H. pylori →
Acute = transient nausea + abdominal pain lasting for several days
Ass w/ acute histologic gastritis with PMNs
Symptoms resolve then progress to chronic
Chronic = duodenal or gastric ulcers, gastric cancer, low-grade B cell gastric lymphoma
Pernicious anemia → associated with other autoimmune disorders, B12 deficiency, psychiatric changes, glossitis, anemia
Eosinophilic → anemia, abdominal pain, early satiety, postprandial vomiting

A

histologic gastritis

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9
Q

In who is h. pylori gastritis common

A

non whites + immigrants

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10
Q

anti-intrinsic factor and anti-parietal cell antibodies w/ elevated fasting gastrin levels supports —–

A

diagnosis for histologic gastritis

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11
Q

H. pylori testing indicated w/

A

Active or past history of documented PUD
Gastric metaplasia
Gastric MALToma
Personal family history of gastric cancer

→ stool PCR (stop PPIs for 14 days and 28 days for abx)
→ endoscopy for biopsy

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12
Q

autoimmune biopsy if

A

pernicious anemia at time of diagnosis

Every 3 years with advanced atrophic gastritis

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13
Q

How do you treat histologic gastritis?

A

H. pylori – eradication w/ antibiotics
eosinophilic – steroids

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14
Q

Postprandial nausea, vomiting, belching, early satiety, bloating, discomfort, pain
Reflux symptoms common
Chronic = weight loss +/- electrolyte disturbances
Nutritional + vitamin deficiencies

A

gastroperesis

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15
Q

Delayed gastric emptying not associated w/ obstructing structural lesion

– idiopathic, diabetic, postsurgical

A

gastroperesis

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16
Q

Succussion splash when auscultating while shaking abdomen from side to side for 1+ hour after eating
→ gastroparesis cardinal symptom index for severity
Imaging, upper endoscopy: rule out causes
Scintigraphy best

A

gastroperesis

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17
Q

What’s treatment for gastroperesis

A

Correct dehydration, malnutrition, nutritional deficiencies
Dietary modification (frequent, smaller, meals)

Pharmacologic motility: prokinetics, antiemetics, pain management

Treat underlying cause

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18
Q

Epigastric pain is hallmark - relieved with food or antacids
Nocturnal pain, nausea, anorexia

Dyspepsia “hunger-like” epigastric pain
– duodenal = relieved with food, antacids, acid suppressants, and worse before meals or 2-5 hours after, worse at night, awakening from sleep
– gastric = food-provoked

Vomiting and weight loss UNUSUAL

Most common cause of upper GI bleed

A

peptic ulcer disease

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19
Q

What are RF for PUD?

A

Duodenum in bulb or pyloric channel in 30-55 years

Stomach in antrum or junction in 55-70 years

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20
Q

Break in gastric or duodenal mucosa
NSAIDs = gastric
Generally w/n first 3 months of therapy, >60, prior hx (lowering PROTECTION) worse with meals, 1-2 hrs
MC in old
Chronic H. pylori infection = duodenal (increasing DAMAGE)
Better with meals, worse 2-5 hours after
MC in young
Or CMV, acid hypersecretory, crohn’s, lymphoma, meds

A

peptic ulcer disease

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21
Q

a break in the gastric mucosa can be caused by –

A

NSAIDs
lowering PROTECTION

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22
Q

gastric ulcers are worse with –

A

meals, 1-2 hours after eating

more common in older patients

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23
Q

a break in the duodenum can be caused by –

A

h. pylori infection
increasing DAMAGE

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24
Q

Duodenal ulcers are better with –

A

meals, worse 2-5 hours after eating
more common in young

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25
gold standard diagnosis for PUD is
upper endoscopy
26
duodenal ulcers are not ---, while gastric ulcers need a biopsy
malignant
27
Other tests for h. pylori
fecal antigen or PCR w/ Hx of PUD (hold PPIs)
28
What does sudden onset diffuse abdominal pain, tachycardia, and abdominal rigidity in PUD indicate?
perforation
29
PE: normal or mild, localized epigastric tenderness to deep palpation FOBT or FIT + in ⅓ Labs: ordered to exclude other causes
PUD
30
How do you treat gastric ulcers (NSAID made)
NSAID acid-antisecretory agents – PPIs (-prazole) or H2 receptor antagonists (-tidine) Mucosal enhancers PRN to supplement antisecretory agents during first few days
31
How do you treat an active gastric ulcer?
Active ulcer = discontinue offending agent + start PPI therapy, test for h. Pylori Consider risks and prevent! Oral PPI once daily when taking NSAIDs, lowest dose/time
32
How do you treat a duodenal ulcer?
**Bismuth, tetracycline, PPI, metronidazole** need 2-3 antibiotics w/ PPI or bismuth w/ antibiotic susceptibility testing
33
How do you treat a duodenal PUD with an active ulcer?
Active ulcer = 14 days w/ eradication regimen followed by antisecretory agent (PPI or H2RA) for 2-4 weeks (d) or 4-6 weeks (g) confirm eradication >4 weeks after completion w/ non invasive tests Prevent recurrence w/ PPI
34
Projectile postprandial vomiting (2-4 weeks of age), blood streaked Infants are hungry Abdominal distention after feeding
pyloric stenosis
35
What predisposes someone to pyloric stenosis?
Babies – males Erythromycin (macrolides) First 3-12 weeks of life
36
Thickening of pyloric sphincter, hypertrophy and hyperplasia of pyloric muscles
pyloric stenosis
37
Oval mass in RUQ “olive sign” Lab: hypochloremic alkalosis w/ potassium depletion Dehydration = Hgb and Hct US = hypoechoic muscle ring >4mm thickness w/ hyperdense center Barium upper GI = retention of contrast; “string sign”
pyloric stenosis
38
How do you treat pyloric stenosis?
Pyloromyotomy Treat dehydration + electrolyte imbalance Post-op vomiting is common because of gastritis, esophagitis, reflux
39
90% will develop PUD - solitary and located in duodenal bulb GERD symptoms Diarrhea, steatorrhea, weight loss (nasogastric aspiration of stomach acid stops diarrhea), abdominal pain, heartburn
Zollinger-Ellison syndrome
40
fasting gastrin levels should be obtained in zollinger-ellison syndrome if
Ulcers refractory to standard therapy Giant ulcers >2cm Ulcers located distal to duodenal bulb Multiple duodenal ulcers Frequent recurrence Associated w/ diarrhea After surgery Complications H.pylori neg and not taking NSAIDs
41
Gastrin-secreting gut neuroendocrine tumors → hypergastrinemia + acid hypersecretion In pancreas, duodenal wall (MC), lymph nodes, elsewhere 80% within “gastrinoma triangle” MEN
zollinger-ellison syndrome
42
Elevated fasting serum gastrin (>150) Discontinue meds before hand (H2 receptor antag for 24 hours, and PPI for 6 days) Only if patient is stable + free from disease IF elevated – measure gastric pH **FSG > 10x normal AND gastric pH<2 = confirm** → secretion stimulation test can distinguish from other causes
zollinger-ellison syndrome
43
FSH >-- normal and gastric pH <--- confirms diagnosis of zollinger-ellison syndrome
>10x and pH<2
44
FSG <--- rules out zollinger-ellison diagnosis
<100
45
When you confirm zollinger-ellison syndrome, what's next?
Imaging to localize tumor – CT and MRI scans, full body gallium 68 PET/CT to find small ones If negative → US
46
How do you treat metastatic zollinger-ellison syndrome?
If multiple metastases → initial therapy to control hypersecretion → oral PPI Isolated hepatic metastases → surgical resection or cryoablation Systemic therapy = octreotide, tyrosine kinase inhibitors, peptide receptor radionuclide therapy
47
How do you treat localized zollinger-ellison syndrome?
Resect prior to hepatic spread! Laparotomy to verify no metastasis Surgery not recommended with MEN 1
48
Asymptomatic until advanced – dyspepsia, vague epigastric pain, anorexia, early satiety, weight loss Ulcerating lesions = acute GI bleeding Pyloric obstruction = postprandial vomiting Lower esophageal obstruction = progressive dysphagia
gastric adenocarcinoma
49
What are RFs for gastric adenocarcinoma
Increasing age Male sex Non-white race Smoking H. pylori infection
50
intestinal gastric adenocarcinoma is more/less common
more -- forms glandular structures and common in men, older people, from H. pylori infections
51
diffuse type gastric adenocarcinoma is common in
men and women and younger, worser prognosis and not as associated w/ h. Pylori, may be due to genetics
52
Lab: Iron deficiency anemia + occult blood Elevated AST if in liver Circulating tumor markers (monitor treatment) After diagnosis - preop eval with contrast CT of chest, abdomen, pelvis and EUS to delineate extent of tumor → PET or PET-CT for distant mets
gastric adenocarcinoma
53
Get an endoscopy --
Obtain in >60 years w/ new onset epigastric symptoms Young patients with “alarm” symptoms Biopsy needed - vertical
54
What are signs of metastatic spread
Left supraclavicular lymph node (Virchow) Umbilical nodule (Sister Mary Joseph) Rigid rectal shelf (Blumer) Ovarian metastasis (Krukenberg)
55
How do you treat gastric adenocarcinoma
Surgical resection Systemic chemo Radiotherapy Immunotherapy Targeted therapy
56
Abdominal pain, weight loss, bleeding Systemic symptoms
gastric lymphoma
57
Primary (gastric mucosa) - 95% being non-Hodgkin B cell lymphoma - or secondary (advanced nodal lymphomas
gastric lymphoma
58
Endoscopy → horizontal infiltration Diagnosis established with biopsy Test for h.pylori and EUS for depth All need staging with CT of chest, abdomen and pelvis
gastric lymphoma
59
how do you treat gastric lymphoma
MALT-Type lymphoma H. pylori eradication, radiation Diffuse large b-cell lymphoma Chemo, radiation (CHOP or r-CHOP)
60
What is gold standard for pyloric stenosis?
US

Clinical Medicine II (50 decks)

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