Stomach Disorders: PUD, Gastrinoma, Gastric Carcinoma, Gastroparesis

lower, duodenum, muscularis, age, H. pylori, NSAID, ETOH

Peptic Ulcer Disease: Background

-Defects in _____ esophagus, stomach or _________, that extend through the ________ mucosa

-Epidemiology/Risk Factors

• Incidence increases with ___

• _.____ infection (MC)

• Chronic _______ use (2nd MC)

• Stress

• Hypersecretion syndromes

• ____ use

• Meds

• Radiation therapy

smoking, NSAID, age, increased, mucosal, increase, gastrin

PUD: Etiology

-H. Pylori infection (95% duodenal, 70% gastric) → _______ increases risk in H. pylori patients

-______ use → prior hx of PUD, dose/duration of therapy, ___, co-therapy with drugs that enhance toxicity

-Alcohol → leads to _________ gastric acid production and _______ injury by breaking down mucosal barrier

-Emotional stress → ________ in ulcer incidence after traumatic events

-Gastrinoma → ______ secreting neuroendocrine tumors

secretion, protection, neutralize, alkaline, inhibits, peristalsis, secretin, pancreas

PUD: Pathophysiology

-Imbalance between the rate of gastric juice ___________ and degree of __________ by the mucosal barrier

-Ability of duodenal juices to _________ gastric acid → duodenal cells secrete _______ mucus and pancreatic juices are alkaline

-Feedback Mechanisms

• Acid in duodenum → ______ gastric secretion and ___________ of stomach

• Acid in duodenum → secretion of ______ → causes _________ to secrete alkaline juices

less, epigastric, eating, nausea

PUD: Gastric Ulcer

-____ common than duodenal ulcers, seen mostly in 55-65 y/o pts

-Symptoms

• Intermittent ________ pain and dyspepsia in a “food-pain” pattern, meaning it is worse after ______

• Early satiety

• _______/vomiting

• Occasional weight loss

20, pain, relieved, nocturnal

PUD: Duodenal Ulcers

-More common, seen in ages __-50

-Symptoms

• Intermittent epigastric ____ and dyspepsia that is usually ________ by ingestion of food or antacids (“pain-food-relief” pattern)

• ________ pain, when acid secretion is maximal

perforation, hematemesis, stools, obstruction, pyloric, epigastric

PUD: Complications

-___________ → suspected if sudden development of severe, diffuse abdominal pain (peritonitis)

-Bleeding → ____________ (red blood or coffee ground emesis), melena (black, tarry ______)

-Gastric outlet __________ → typically with ulcers located in the _______ channel or duodenum. Associated with bloating, N/V, increased __________ pain

endoscopy, smooth, flat, exudate, lumen, nodular, irregular, malignancy

PUD: Diagnosis

-___________ is the gold standard

• Definitively establishes diagnosis

• Benign ulcers → ______, regular, rounded edges, with ____, smooth ulcer base filled with _______

• Malignant ulcers → ulcerated mass protruding into the _____, folds surrounding ulcer crater are ________, clubbed, fused, or stop short of the ulcer margin, or overhanging, _________ or thickened ulcer margins

-Biopsies should be done on all gastric ulcers for possible ____________

sensitive, duodenal, H. pylori, NSAID, gastrinoma

PUD: Diagnosis, pt. 2

-Barium Swallow

• Can identify PUD but less __________

• If _______ ulcer discovered and no alarm symptoms, don’t have to have endoscopy but gastric ulcers do

-Other tests

• Test for _.______

• Ask about _______ use

• If those are both negative, then consider other causes like __________

H. pylori, PPI, slower, duodenal, endoscopy

PUD: Treatment

-Lifestyle: eradication of _.______ if needed, withdrawal of offending agents

-Pharmacological: ___ drug of choice (omeprazole, pantoprazole), H2 blockers are an option but ______ to heal ulcers, and antacids/sucralfate can heal __________ ulcers but not routinely recommended

-Repeat __________ should be done on all gastric ulcers to document healing

duodenal, gastrectomy, perforated

PUD: Surgical Approaches

-_________ ulcers → vagotomy

-Gastric ulcers → partial __________, Billroth I or II reconstruction

-_________ ulcer → laparoscopy/open patching

hypersecretion, gastrinoma, duodenal, MEN-1

Zollinger Ellison Syndrome (Gastrinoma): Background

-Gastric acid _____________ from a __________ resulting in severe acid related peptic disease and diarrhea

• __________ is the most common or pancreatic neuroendocrine tumors

-Epidemiology

• 20-50 y/o

• Men > women

• 1/3 associated with ___-_

PUD, loss, bleeding, steatorrhea

Zollinger Ellison Syndrome (Gastrinoma): Symptoms

-___ with multiple refractory ulcers

-Diarrhea, heartburn, and weight ____ are other common symptoms

• The diarrhea is specifically __________, which is loose fatty stools

-Complications → ________, stricture, perforation

fasting, pH, 10, 2, secretin, persistent, US, head, duodenum

Zollinger Ellison Syndrome: Diagnosis

-Initial/Screening Tests: _________ serum gastrin concentration and gastric __ measurement

• Gastrin levels > __x normal with gastric pH <_ is diagnostic

-Confirmatory: ________ stimulation test

• If serum gastrin <10x normal and low gastric pH or differentiate gastrinoma from other processes

• __________ gastrin elevation in gastrinoma

-Imaging: somatostatin-receptor scintigraphy, __, CT, MRI, endoscopy

• Most found in ____ of pancreas or 1-2nd portion of _________

PPI, somatostatin, resection, liver, bone, chemo, MEN 1

Zollinger-Ellison Syndrome: Treatment

Local Disease

-High dose ___ is first line med

-Octreotide therapy (__________ analog)

-Exploratory laparotomy and _________ (ideal for local disease) → sporadic gastrinoma without metastatic spread

Metastatic Disease

-______ most common, next is ____

-Limited efficacy of treatment options → ____ or surgery

-Screen all pts with ZES for ___ _

adenocarcinoma, antrum, intestinal, differentiated, Asia, >

Gastric Carcinoma: Background

-_____________ most common

-Location

• ______

• Body and fundus

• Cardia

• Entire organ

-Types

• ________-type (resembles intestinal cancers in forming glandular structures)

• Diffuse-type (poorly ___________ and lacks glandular structures)

-Epidemiology

• Highest incidence in East _____, East Europe, and South America

• Men _ women

• > 40yo

gastritis, salt, smoking

Gastric Carcinoma: Risk Factors

-Chronic _________ (H.pylori infection most common)

-Atrophic gastritis (autoimmune disorder)

-High ____ diet (leads to chronic gastritis)

-Nitrous compounds (preserved foods, tobacco smoke)

-Obesity

-__________, ETOH

-Gastric surgery

loss, anemia, supraclavicular, palpable

Gastric Carcinoma: Symptoms

-Weight ____ (anorexia, nausea, early satiety)

-Abdominal pain (epigastric, vague)

-GI bleed (iron deficiency ______)

Signs of Metastatic Dz

-Left _____________ adenopathy

-Periumbilical nodule

-__________ liver or abdominal mass

endoscopy, biopsy, metastatic, LAD

Gastric Carcinoma: Diagnosis

-___________ → most sensitive and specific for diagnosis

• ______ needed for confirmation

• EUS to determine the local extent of primary tumor

-Chest/Abdominopelvic CT

• Performed early after dx is made

• Evaluate for _________ disease

-PET Scan → can confirm malignant involvement if CT detected ___

-Laparoscopy → advantage of directly visualizing abdomen

resection, I-III, mucosal, total, chemotherapy, palliative

Gastric Carcinoma: Treatment

-Curative Surgical _________ (mainstay)

• Stage _-___

• Endoscopic _______ resection for small, early gastric cancer

• Radical surgical resection → _____ or subtotal gastrectomy

-Perioperative ___________ or adjuvant chemoradiation

• Associated with improved survival in pts with localized or locoregional cancer who undergo surgical resection

-________ Modalities

• Metastases or local invasion of other organs

• Surgery and chemo considered not curative

Dumping, immediate, diarrhea, hyperglycemic, surgical, B12

Gastric Carcinoma: Postgastrectomy Considerations

-________ Syndrome → symptoms after a meal due to rapid gastric emptying

• Early → _________ symptoms after meal; tachycardia, diaphoresis, abdominal cramping, and __________

• Late → symptoms hours after a meal; can become very ____________ → need insulin bolus → hypoglycemia

-Bile reflux → often needs ________ correction

-Vitamin ___ Deficiency → any pt with total gastrectomy or gastric bypass needs supplementation

emptying, absence, autonomic, enteric

Gastroparesis: Background

-Delayed gastric ___________ in the ________ of mechanical gastric outlet obstruction

-Pathophysiology → abnormalities of the _________ nervous system, smooth muscle cells, _______ neurons and GI hormones

Diabetes, >, autonomic, vagus, narcotics, vagus

Gastroparesis: Etiology

-Idiopathic

-_________ mellitus

• Type 1 _ Type 2

• Due to __________ dysfunction and/or abdominal intrinsic nervous system, leading to neuropathy involving the _____ nerve and loss of interstitial cells of Cajal

-Iatrogenic → induced by several meds, like _________

-Postsurgical → d/t injury of ____ nerve, fundoplication one of most common

nausea, pain, satiety

Gastroparesis: Symptoms

-___________

-Vomiting

-Abdominal ____

-Early ______

-Postprandial fullness/bloating/weight loss

obstruction, endoscopy, motility, imaging, retention, 10, 60

Gastroparesis: Diagnosis

-Exclude mechanical obstruction

• Upper __________

• CT or MRI enterography → if unavailable, then barium follow through

-Assess gastric ________

• Gastric scintigraphy → ingestion of meal followed by ________ immediately after then at 1, 2, and 4 hours

• Delayed emptying defined as gastric _________ > __% at 4 hours and/or __% at 2 hours

glucose, myopathic, neuropathy

Gastroparesis: Establish Etiology

-Known underlying disease → no further investigation

-No known underlying disease → consider labs, manometry, and/or autonomic testing

-Laboratory studies → Hgb, fasting ______, total serum protein, TSH, ANA

-Gastroduodenal manometry → __________ vs neuropathic process

-Autonomic testing → preganglionic or central lesion vs peripheral ___________

dietary, fiber, dehydration, Metoclopramide

Gastroparesis: Management

-First Line (Mild) → ________ Modification

• Small, frequent meals

• Low fat; contain only soluble _____

• No carbonated or ETOH beverages

-Hydration and Nutrition

• Vomiting and decreased intake can cause hypokalemia, metabolic alkalosis, and __________

• Vitamin deficiencies

-Glycemic control

-Pharmacologic therapy

• DOC is _____________

• Can consider erythromycin IV or antiemetics

venting, decompress, enteral

Gastroparesis: Refractory Symptom Treatment

-Percutaneous endoscopic gastrostomy ______ tube → _________ upper GI tract

-Percutaneous endoscopic jejunostomy tube → ______ nutrition, pts with unintentional weight loss of > 10% of normal body weight

-Surgery → rarely indicated