Stomach Disorders Flashcards by Heather McKnight

Dx of GERD

1) Heartburn: burning sensation in chest that can extend to neck, throat, and face
2) Reflux of gastric contents back into the esophagus
3) At least two heartburn episodes/week and/or complications

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GERD is the…

MOST prevalent GI disorder

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Tx of GERD

a. Lifestyle changes
b. Antacids
c. PPIs/H2RAs

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Lifestyle changes (5) of GERD Tx

1) Reduce weight
2) Avoid laying down after a meal
3) Sleep with head propped up
4) Avoid trigger foods/meds
5) Avoid caffeine/alcohol/tobacco

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Difference b/w GERD and Heartburn

GERD: Condition and disorder of the LES that either has reduced pressure or does not work as is intended (Multiple episodes of heartburn = GERD)

Heartburn: An incidence of stomach acid entering the esophagus that causes chest pain

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Medications used to treat GERD: H2RA

1) Nizatidine
2) Famotidine
3) Ranitidine
4) Cimetidine

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Medications used to treat GERD: PPI

1) Esomeprazole
2) Omeprazole
3) Lansoprazole
4) Rabeprazole

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Foods irritating to GERD

a. Tomato-based products
b. Citrus fruits/juices
c. Fatty/fried foods
d. Alcohol & caffeine
e. Chocolate
f. Peppermints
g. Yellow onions

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When do you endoscopy in GERD?

a. Refractory to PPI trial of 4-8 weeks
b. Severe erosive esophagus after a 2 month course of PPI therapy to assess healing and R/O Barrett’s esophagus
c) RED FLAGS

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RED FLAGS of GERD to endoscopy in…

dysphagia (trouble swallowing)
anemia
weight loss
recurrent vomiting
early satiety
black/bloody stools
chronic cough
hematemesis
odynophagia

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Lifestyle changes encouraged with GERD

a. Reduce/eliminate intake of alcohol, caffeine, tobacco
b. Reduce BMI <25 and avoidance of tight clothing
c. Avoidance of trigger foods (tomato products, chocolate, spicy, fatty foods) and meds (CCBs, anticholinergics, sedatives, prostaglandins, etc.)
d. Avoid laying down after a meal
e. Eat smaller more frequent meals
f. Sleep with bed elevated at 40degrees

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S/E of PPI’s that Dr. Miller wants you to recognize:

diarrhea

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A 33 year old overweight male comes into your ED with substernal chest pain which began a few hours ago. He tells you “I sure I’m having a heart attack.” His pain started after a spicy breakfast. He smokes a pack/day and his “see food” diet includes a bottle on red wine daily. His past history is unremarkable and he is on no medications. His PE shows BP-160/95, HR-105 and his EKG is normal. His CV, Respiratory, and GI exams are normal. His BP comes down with sublingual nitroglycerin. Your differential includes all of the following but which is “most likely”:

a. Esophageal spasm
b. Gastroesophageal reflux disease
c. Myocardial infarction
d. Peptic ulcer disease
e. Panic attack

b. Gastroesophageal reflux disease

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Which of the following is a true statement regarding GERD.

A. One of the more common complications is obstructive sleep apnea

B. Dietary modifications are not part of the treatment according to the current American College of Gastroenterology guidelines

C. Endoscopic surveillance for dysplasia is indicated with Barrett esophagus.

D. Corrective laparoscopic reflux surgery is not indicated when there are persistent “reflux symptoms” despite acid suppression

E. GERD does not lead to cancer unless Barrett esophagus is present

C. Endoscopic surveillance for dysplasia is indicated with Barrett esophagus.

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You have a 43 year old Hispanic female who doesn’t smoke or drink alcohol that has symptoms consistent with classic GERD. You would recommend:

A. Barium swallow study

B. Esophageal Manometry

C. Endoscopy

D. Ambulatory pH study of the esophagus

E. Trial of omeprazole and life style changes

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You see a 56 year old female who comes to your ED with a sudden episode of hematemesis. She’s had vague epigastric pain now for 4 days and dark “coffee ground” appearing stools the last two days. She woke up with nausea and started vomiting up bright red blood. Her vitals are BP 80/55, P 120, R 30 with epigastric tenderness. Which is the least helpful step to take:

A. Admission to the hospital

B. Immediate treatment with an IV H2 blocker

C. Referral for emergent endoscopy
I
D. V access and fluid resuscitation

E. Labs including CBC, coagulation studies, and blood type & cross-match

B. Immediate treatment with an IV H2 blocker

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Endoscopic definition of gastritis

Refers to a number of abnormal features such as erythema, erosions, and sub-epithelial hemorrhages

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Incidence of H. pylori and gastritis

Increases with age

<10% males <40 years
>50% pts. >50 years

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Acute Gastritis

Etiologies

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a) Alcohol, NSAID, stress (ventilators), organ failure
b) Infection (H. pylori)
c) Bile reflux, pancreatic enzyme reflux
d) Gastric mucosal atrophy: classical, autoimmune, IF/B12 deficient
e) Portal HTN gastropathy
f) Irradiation

Clinical Features of gastritis

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1) Non-specific:
a) Epigastric pain
b) Abdominal tenderness
c) Bloating
d) Anorexia
e) Nausea w/ or w/o vomiting
2) Halitosis
3) Hematemesis (coffee ground emesis)

Erosive gastropathy & ibuprofen

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a. Avoid mucosal irritants such as alcohol and NSAIDs
1) Check hematocrit if bleeding
b. Can give PPI (omeprazole) in patients receiving long-tern NSAIDs

differential diagnosis for gastritis

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a. Peptic ulcer disease
b. GERD
c. Non-ulcer dyspepsia
d. Gastric lymphoma or carcinoma
e. Pancreatitis
f. Gastroparesis

complete workup of gastritis

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a. Diagnostic workup includes comprehensive H&P with endoscopy and biopsy
1) H. pylori infection: urea breath test, stool antigen test, endoscopic biopsy, specific AB test
2) Atrophic gastritis: Vitamin B12 testing (screen for gastric cancer! At an increased risk)
3) Hematocrit if bleeding

Which of the following is a clear predisposing factor for peptic ulcer disease?

A. Caffeine
B. Stress
C. Tobacco
D. Chili peppers
E. Mother-in-laws

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C. Tobacco

In considering NSAID-induced ulcers, which of the following is not a risk factor? ``` A. Advanced age (>60) B. No history of ulcer C. Concomitant corticosteroid therapy D. Concomitant anticoagulation therapy E. Serious systemic disorders ```

B. No history of ulcer

You see a 32 year old female with a three year history of intermittent GI complaints after eating. She describes epigastric pressure and bloating after eating. Her weight is stable. She denies heartburn, vomiting, diarrhea, constipation or blood in his stools. Her exam is normal. You diagnose non-ulcerative dyspepsia and place her on a PPI with dietary changes. One week later she calls your office with a complaint of left lower abdominal pain and diarrhea. She denies blood in her stool. Your next step is to: A. Assume she is having fructose withdrawal from her dietary changes and have restart sodas. B. Check a fasting gastrin level C. Start an antibiotic for bacterial overgrowth D. Discontinue the PPI E. Start an antidiarrheal for the next week

D. Discontinue the PPI

When treating H. pylori, which of the following statements is true? A. Most therapies approach 100% effectiveness B. Use of antisecretory agents with antimicrobials increase eradication rate C. PPIs have no intrinsic in vivo activity against H. pylori D. An increased gastric pH decreases the efficacy of some antibiotics E. Antisecretory therapy is optional for non-smokers

B. Use of antisecretory agents with antimicrobials increase eradication rate

Peptic ulcers - definition

- Ulceration in the stomach or the duodenum resulting from an imbalance between mucosal protective factors and various mucosal damaging mechanisms - Occurs due to high acid production

Predisposing factors of PUD

1) H. pylori infection 2) Environmental factors 3) Host factors 1) Gene polymorphisms 2) Immune Response 3) Zollinger-Ellison syndrome = hypersecretion

Environmental factors of PUD

1) Smoking a) MUCH higher PUD rate and slower healing 2) Alcohol a) Worse than NSAIDs 3) NSAID (double risk) 4) Food a) Milk may slow healing of PUD b) Caffeine shows no clear evidence of worsening c) Peppers show no slowing of PUD healing 5) Stress is controversial

Hematemesis & PUD

50% of patients presenting with hematemesis is from PUD

Definite risk factors for NSAID related ulcers

1) Advanced age (>60) 2) History of ulcer 3) Concomitant corticosteroid therapy 4) Concomitant anticoagulation therapy 5) High doses of NSAIDs 6) Serious systemic disorders

Possible risk factors for NSAID related ulcers

1) Concomitant infection with H. pylori 2) Cigarette smoking 3) Consumption of alcohol

Chronic treatment of PUD and NSAID use

Treated with misoprostol or PPI as most effective - Can also use an H2RA

Requirements for Dx of non-ulcerative dyspepsia

1) Must have at least one of the following criteria for the past three months and first noticed within six months of dx: a) Postprandial fullness b) Early satiety c) Epigastric pain d) Epigastric burning e) AND no evidence of structural disease to explain symptoms

What is non-ulcerative dyspepsia?

Non-ulcerative dyspepsia describes signs and symptoms of persistent or recurrent dyspepsia centered in the upper abdomen that have no identifiable organic cause

Endoscopy use in non-ulcerative dyspepsia

- Endoscope pts that are > 55 years ONLY (or if RED FLAGS are present) - Patients < 55 years and w/p alarming symptoms can be treated without endoscopy

What is a gastrinoma

pancreatic or extrapancreatic non-beta islet cell tumor that secretes gastrin

Gastrinoma and Zollinger-Ellison syndrome link

Hypergastrinemia from the gastrinoma stimulates the production of more hydrochloric acid. This results in a peptic ulcer disease known as Zollinger-Ellison syndrome.

Approx. ___ % of gastrinomas are malignant

60%

Most common sites of metastasis for gastrinoma

liver | regional lymph nodes

Causes of false-positive gastric acid secretion results are...

``` pernicious anemia renal failure retained gastric antrum syndrome diabetes mellitus rheumatoid arthritis ```

When to genetically test a family with gastric cancer

patients with familial diffuse cancer because gastric cancer develops in three of every four carriers of a mutant CDH1 gene

Epidemiology of gastric carcinoma

Male : Female is 3:2

Pathogenesis of of gastric carcinoma

- Familiar diffuse gastric cancer is autosomal dominant inheritance - Gastric cancer develops at a young age

Which of the following statement regarding gastric tumors is true? A. 95% of the cancers are squamous cell carcinomas adenocarcinomas B. Adenocarcinoma is the most common histologic type C. They are more common in women men D. The five year survival rate is 35% 12% E. The overall occurrence decreases with age increases

B. Adenocarcinoma is the most common histologic type

Consider H. pylori in these unique situations

idiopathic thrombocytopenic purpura | Iron Deficiency Anemia

Stomach Disorders Flashcards

(47 cards)