Stomach

    .

    Dyspepsia

    • General term used to describe UGI symptoms: i.e. Nausea, abdominal pain/discomfort, reduced appatite.
    • Functional Dyspepsia --> No physiologic explanation
      • Delayed gastric emptying,impairment of stretching, H.pylori/infections, visceral hypersensitivity, psychosocial.
    • Correlations:
      • Lots of crossover to IBS, headaches, fibromyalgia, depression, interstitial cystitis
    • Clinical Manifestations:
      • MOST patients have multiple sx (bloating, nausea, vomiting bleching, gas).
      • Note: if predominantly heartburn and regurgitation = label them with GERD (Not dyspepsia)
      • ROMEIII Criteria
        • ROME III Criteria - For Functional Dyspepsia

          One of the following:

          • Bothersome post-prandial fullness.
          • Early satiety
          • Epigatric burning
          • Epigastric pain with lack of structural disease seen on upper endoscopy

          Criteria should be met for 3mo AND symptom onset >6mo prior to dx.

           

    • Management
      • 50% will spontaneously resolve, rest will see physicians frequently + try many threapies.

    DyspepsiaApproach.png

    • Dyspepsia with no ALARM features:
      • If HIGH prevlance for H.pylori --> Treat for H.pylori
      • If LOW prefalence of H.pylori --> Trial of PPI

    ALARM Features

    • Include:
      • New onset dyspepsia >50yo
      • Anemia
      • Dysphagia/Odynophagia
      • Vomiting
      • Weight Loss
      • Family Hx of UGI malignancies
      • Personal history of PUD
      • Gastric Surgery, or own hx of GI malignancy
      • Physical Exam: Abdominal mass, lymphadenopathy

     

    Treatment

    • Typically trial of PPI as per above chart
    • If unresponsive, try low dose tricyclic antidepressants

    Peptic Ulcer Disease

    • Umbrella Term --> Gastic + Duodenal Ulcers
      • Ulcer --> Mucosal break >5mm that is covered in fibrin.
      • Erosion --> < 5mm
    • If biopsy --> defect in GI mucosa extending to muscularis mucosa.
    • Risk Factors:
      • Helicobacter Pylori
      • NSAIDs
        • (H.Pylori + NSAIDs = 90% of PUD)
      • Gastrinoma (Zollinger-Ellison Syndrome) - 
      • Crohn's Disease
      • Mastocytosis, G-cell hyperplasia, Viral (CMV), infiltration (Sarcoid/Amyloid), Radiation
    • Presentation:
      • Pain --> Shortly after meals, likely relieved by anti-acids.
        • 1 in 5 don't have pain (Silent Bleeding)  --> Often diagnosed with complications
        • Duodenal Ulcers --> 2-5h after meal, can awake patient from sleep (relieved by food or anti-acids)
        • (Can have weight gain = eating makes pain better)
    • Diagnosis:
      • Endoscopy *Primary Modality*
        • If see multiple ulcers +/- esophagitis/diarrhea --> concern for malignant ulcers (gastrinoma)
      • Barium Swallow (IF Cannot tolerate endoscopy)
      • Check for H. pylori infection
    • Complications
      • Risk Factors: Giant ulcers (>2cm), 2cm within the pylorus, prolonged healing.
      • Types:
        • Bleeding - Most common complication
        • Perforation
          • GI contents flow into peritoneal cavity (usually duodenal), peritonitis.
          • If perforation suspected --> DO NOT SCOPE (contraindicated)
        • Penetration
          • Penetrates into adjacent bowel/pancreas - pancreatitis).
          • Pain can feel like it's "going through the back" - Pancreatitis
        • Obstruction (Less frequent)
          • Gastric outlet obstruction
          • Early satiety, vomiting, weight loss
    • Management
      • Counseling
        • Avoid NSAIDs  (ASA may be OK if high risk CV disease, plavix makes worse)
      • Acid Suppression
        • PPI superior to H2 blockers, misoprostil, sucralfate
      • Biopsy (r/o malignancy)
          • Gastric Ulcers --> Always follow-up biopsy to r/o malignancy
                                       (If not originally obtained)
          • Duodenal Ulcers --> Don't need f/u biopsy
      • Test for H. Pylori (even if using NSAIDs)
        • Once eradicated, do not need PPI after treatment.
        • Often continue PPI 4-8w for full therapy. (gastric ulcers heal slower)
        • Prove eradication 6-8w later.
      • Gastric Outlet Obstruction
        • High dose IV PPI
        • NG tube for gastric decompression
        • Can do endoscopic dilation
        • Rarely, if severe --> Surgical vagotomy with pyloroplasty

    H. pylori

    • Pathophysiology:
      • Flagellated organism that resists acid in the stomach through production of urease (helps diagnose H.pylori).
        • Burrows into mucosal layer of the stomach.
      • Worldwide: affects 50% of world population. (30-40% in U.S.).  
      • Infection occurs usually in childhood in low SES populations.
    • Clinical Features:
      • 3 Phenotypes:
    1. Mild pan-gastritis (88-95% of pts), most asymptomatic, no serious GI disease.
    1. Duodenal ulcers (antral-predominant gastritis).
      [H.pylori destroys antral D-cells, help produce somatostatin, which destroys natural inhibitory effect on gastric acid secretion]. 
    2. Gastric Cancer Phenotype (1% of infected individuals).  
      [Body of stomach gastritis - multifocal atrophy + descreased acid production + high gastrin level]
    3. MALT Lymphoma (Mucosa-associated Lymphoid Tissue) - treat H.pyroli alone. 
    • Diagnostic Tests:
      • Indications
        • Indications for H.pylori testing:

          • Active/prior PUD
          • MALT lymphoma
          • Dyspepsia w/o ALARM features
      • 1. Antibody Testing IgG (Sn 85%, Sp, 79%)
        • However, if previously treated: serology will be positive
      • 2. Fecal Antigen Testing (Sn, Sp ~90%), 
        • Most common (for eradication testing)
        • Interference: PPI, H2 blockers, antibiotcs, bismuth
                        (stop PPI 2w, abx/bismuth 4 weeks, H2blockers 24-48hrs before)
      • 3. Urea Breath Test  (Sn, Sp > 95%, costs more)
        • Not available at many centers.
        • Interference: PPI, H2 blockers, antibiotcs, bismuth
      • 4. Endoscopy:
        • Culture: Only if refractory persistent disease, look for resistance patterns.
        • Histology: GOLD STANDARD  (Can be false negative if recent bleeding)
        • Rapid Urease Testing of biopsy: (Not done if bismuth, PPI, H2 blocker, recent bleeding).
          • If taking those meds, histology done instead.
        • If endoscopy biopsy negative, then do serology (not affected by these things). 
        • Indication for Endoscopic Biopsy: 
          • ≥55yo
          • ALARM Symptoms (vomiting, weight loss)
          • Dyspepsia + NSAID use
          • No response to 4-8w of PPI use
    • Management:
      • H. pylori = Class 1 carcinogen
        • First Line: Triple therapy: (10-14 days)
          • Clarithromycin
          • Amoxicillin
          • BID PPI
        • If penicillin allergic: use metronidazole (instead of amoxicillin). 
        • Another way: "Sequential therapy" --> I.e. Bismuth BID x2 days, then amoxil x5 days etc..
          • Hard for patient, too complex, may be helpful in studies. 
        • 2nd Line (metronidazole and clarithromycin resistance common, avoid whichever used 1st line).
          • Quadruple Therapy (BID PPI, Amoxil, Metronidazole, Tetracycline)
        • Salvage therapy: (If 1st + 2nd line failed, involve expert, culture+ sensitivity)
          • PPI BID + Amoxicillin BID + levofloxacin/rifabutin/furazolidone daily x10 days
    • Eradication:
      • Indications: PUD, MALT Lymphoma, Gastric Ca, Dyspepsia without ALARM features.
      • Urea Breath Test OR Fecal Antigen Test
      • Test of cure ≥4 weeks after treatment.
        • Stop taking PPIs 2 weeks prior to testing and H2 blockers 24-48hrs.
        • if positive and additional symptoms, Quadruple Therapy:
          • Bismuth, metronidazole, teracycline, omeprazole

    Gastroparesis

    • Symptomatic delayed gastric emptying without mechanical obstruction.
    • Causes:
      • Diabetes, Gastric surgery, idiopathic
      • Prescription drugs, parkinson's, connective tissue disease, amyoid, autonomic failure syndromes.
    • Symptoms:
      • Nausea, vomiting, early satiety
      • Ensure patient vomiting (not "ruminating" - effortless regurgitation of undigested food, rechew, reswallow).
    • Diagnosis:
      • Upper endoscopy --> retained food in stomach (not diagnostic).
      • R/O mechanical obstruction.
      • **Gastric emptying study** --> following low-fat technetium egg-white meal (Images @ 0, 1, 2, 4 hours).
        • Opioids, anticholinergic cause false positives.
        • 1/3 of pts with functional dyspepsia will have positive.
    • Treatment:
      • Small, frequent meals.
        • Calorically dense liquids, (less solids)
        • Avoid high-fat foods (also avoid carbonated beverages, indigestible fiber - big bezoar)
      • ***Prokinetic agents***  (cornerstone)
        • Erythromycin - tachyphylaxis (can give IV acutely)
        • Metoclopramide (10% risk of irreversible tardive dyskinesia if taking >3mo)
        • Domperidone (Canada/Mexico only) - less extrapyramidal
        • Others (taken off market)
      • Anti-emetics
      • Improve diabetes control (fluctuations of sugar = worse hypomotility)
        • Some hypoglycemic drugs (i.e. GLP-like, etc..) can decrease gastric emptying.
      • Worst Case:
        • Feed J-Junostomy tube (bypass stomach)
        • Ventin gastrostomy tube (open tube to release pressure)
        • TPN (last line)

    Vomiting Differential

    Differential Diagnosis of Vomiting/Gastroparesis

     

    DDx

    Evaluation

    Rumination syndrome

    History of passive regurgitation of pleasant-tasting gastric contents, w/o nausea

    Cyclic vomiting syndrome

    History of stereotypical bouts of vomiting with intervening periods without symptoms

    Medication effect

    opioids, calcium channel blockers, clonidine, tricyclic antidepressants, dopamine agonists, lithium, nicotine, marijuana, progesterone

    Pregnancy

    Pregnancy test

    Gastric outlet obstruction

    Upper endoscopy or upper GI barium series

    Complete small-bowel obstruction

    Abdominal radiograph

    Partial small-bowel obstruction

    Small-bowel follow-through or CT enterography versus enteroclysis

    Crohn disease with small-bowel stricture

    Small-bowel follow-through

    Intestinal pseudo-obstruction

    Abdominal radiograph or CT with dilated small bowel in the absence of obstruction; ANA, anti-Scl 70, lactate, CPK, fat pad biopsy, ANNA-1

    Cannabinoid hyperemesis syndrome

    History of marijuana use.  Compulstive hot baths/showers (relieves symptoms)

    Hypothyroidism

    TSH

    Diabetes mellitus

    Hemoglobin A1c, plasma glucose

    CNS disorders

    Examination: cranial nerve palsies, cerebellar signs, CNS imaging

    Functional dyspepsia

    Mild symptoms of vomiting

    Gastric Malignancies

    Gastric Pollyps

    • Common, asymptomatic (usually).
      • Bleeding/obstruction can occur.
    • "Fundic glad polyps" are common --> numerous small <1cm lesions in fundus or body.
      • Benign, no malignant potential. 
      • Numerous Gastric Fundic Gland Polyps who are <40yo should undergo colorectal eval for FAP.
      • If FAP (Familial Adenomatous Polyposis) - must biopsy.
    • Hyperplastic Polyps:
      • Usually single (rarely multiple).
      • Range <1cm to 10cm in size, <3% have dysplasia (low malignant potential)
    • Adenomatous Polyps
      • Single, can be large, usually in antrum.
      • Chronic atrophic gastritis in surrounding mucosa.
      • Malignant potential, must remove.
      • Repeat endoscopy 1 year post-resection, and 3-5y.

     

    Subepithelial Masses

    • Usually seen incidentally on upper endoscopy.
    • Diagnosis:  Endoscopic Ultrasound to see size, layer, intramural lesions. + take tissue samples.
      • CT/MRI can be useful.
    • DDx:
      • Intramural (benign)
        • Lipoma, leiomyoma, gastric varices, ectopic pancreatic tissue, duplication cyst.
      • Intramural (malignant)
        • GI Stromal Tumor (GIST), Carconoid, Lymphoma, Glomus Tumor, Metastatic Disease
      • Extramural:
        • normal abdominal structures (left hepatic lobe or gallbladder), Intra-abdominal tumor, abscess, pancreatic pseudocyst, etc... 

      GIST

    • Gastrointestinal Stromal Tumors
    • Most common mesenchymal tumors in stomach. 
    • Symptoms:
      • Anemia, early satiety, abdominal discomfort.
      • (Can be single/multiple)
    • Diagnosis:
      • Pathology + Immunohistochemical test CD117 (C-kit protein) and CD34 confirms dx.
    • Treatment:
      • Surgical resection +/- imatinib mesylate (pre or post-op) [Greevec, Tyrosine Kinase Inhibitor]

     

      Gastric Carcinoid Tumors

    • Symptoms:
      • Non-specific GI symptoms (Abdo pain, dyspepsia, bleeding)
    • Types:
      • Type I - Gastrin Producing (from chronic atrophic gastritis)
      • Type II - Gastrin Producing (from Gastrinoma)
      • Type III - Sporatic (more aggressive, need radical gastrectomy + lymph node removal)
    • Management:
      • If ≤ 2cm --> endoscopic resection. (5y survival 95%)
        • Endoscopic surveillance (q6-12mo, x3years)
      • >2cm --> surgery
      • Type III --> radical gastrectomy, LN removal (if no metastasis)
        • Octreotide if unresectable disease. 

     

    Zollinger-Ellison Syndrome

    • Symptoms:
      • Diarrhea (acid hypersecretion + inactivation of gastric enzymes & bicarb)
    • Diagnose with: 
      • Serum Gastric Level
      • Secretin Stimulation Test
        • Secretin releases gastrin from gastrinomas, but inhibits gastrin release from normal stomach. 
        • Secretin can determine if gastrin elevation is secondary to autonomous release of gastrin from a gastrinoma.
        • False Positive: PPIs, Gastric Outlet Obstruction, Gastroparesis (all raise gastrin level)
      • Octreotide Scan
      • Endoscopic Ultrasound
        • Helpful before surgical excision (focal vs. multifocal)
      • NOTE: MRI has very poor detection rate (10-40%) - not recommended. 

    Gastric Adenocarcinoma

    • 2nd in terms of cancer mortality (poor pronosis)
    • >70% are from Eastern Asia (China), M>F (2:1)
    • Types:
      • Intestinal
      • Diffuse - More infiltrative (younger, worse prognosis)
    • Risk Factors:
      • #1 H. pyroli
      • heavily salted foods
      • Ionizing Radiation
      • High Carb Diet
      • Gastric Adenoma
      • **Fresh fruit/vegetables reduce risk**
    • Screening:
      • NO SCREENING in US/Canada b/c incidence is LOW!
      • Only screen if hereditary cancer syndrome hx.
    • Presentation:
      • Nausea, dyspepsia, vague abdominal pain
      • Early satiety, unintentional weight loss
      • Usually asymptomatic, present advanced.
      • On Exam:
        • Abdo mass, obstruction, malignant ascites, lower edema
    • Diagnosis:
      • Upper Endoscopy + Biopsy
      • Staging: CT chest/abdo/pelvis.  (or endoscopic US for local staging).
      • PET for indeterminate lesions. 
    • Prognosis:
      • Often discovered advanced, 80-90% have mets at diagnosis.
      • 5y survival is 26%.

     

    Bariatric Surgery

    • Types:
      •  

         

        Type of Procedure

        Various Surgeries

        Restrictive procedures

        Laparoscopic adjustable gastric banding

        Vertical banded gastroplasty

        Sleeve gastrectomy

        Combined restrictive-malabsorptive procedures

        Roux-en-Y gastric bypass

        Biliopancreatic diversion with duodenal switch

    • Complications:
      • Post-operative mortality
        • VTE, anastomotic leaks, pre-existing conditions
        • Anastomotic Leak:
          • Extravasated contrast (oral contrast on stomach CR or AXR) diagnostic
          • Heart Rate > 120 is the best indicator of a leak.
      • Band Procedures:
        • Early: Band infection, stomal obstruction, gastric perforation
        • Late: Erosion into gastric wall (bleeding), Slipping of the band (obstruction)
        • 1/3 will require band removal
      • Malabsorptive Procedures:
        • Internal hearnias (less adhesions, can herniate through mesentary) --> ischemia, pain, vomiting.
          • CT scan or surgical exploration
        • GI bleeding
        • Dehiscense of staple line of stomach (AXR)
        • Biliary Stones *** (1/3 of pts)
          • Often cholecystectomy also performed if pt has symptomatic stones.
          • choledocholithiasis is difficult b/c limited by length of scopes.
      • Nutritional Complications:
        • Anemia (Decreased iron, B12, folate)
          • Bypasses duodenum where iron absorption occurs.
          • Vitamin B12 deficiency --> intrinsic factor from stomach not present.
          • Small intestinal bacterial overgrowth
        • Need Ca, VitD, thiamine supplementation (risk of Wernike-Korsokoff)
      • Dumping Syndrome
        • Occurs 25% post-gastric resection, and 85% after RYGB.
        • Rapid emptying of sugars from small stomach --> high osmotic load in small bowel --> water into lumen
        • 30-60min postprandial (early) --> gaseous distention, nausea, diarrhea.
        • 1-3h (late) --> sweating, tremulousness, confusion.  (insulin surge)
          • Due to glycemic rollercoaster (first high then low post-insulin).
        • Counsel patients to eat small, frequent meals; avoid rich-carbohydrate foods

    Notes

    • Heyde's syndrome
      • Bleeding and angioectasias in pts with aortic stenosis.
      • Mechanical distruption of von Willebran's multimers during turbulent flow through AS
    • Prophylaxis of NSAID induced injury:
      • Look at risk of bleeding + CV risk.
        • If low bleeding and low CV risks --> No prophylactic PPI.
        • If high risk for both --> NO NSAID
        • Otherwise, prophylax with PPI or misoprostol.
      • Misoprostil --> synthetic prostaglandin E1,
        • More effective than H2 blockers and PPI use
        • High side effect profile (20% diarrhea, cramping, abortive if late term). 
        • Low dose: = as effective as PPI.
      • High-dose H2 blockers --> worse S/E, less effective,.
      • COX-2 inhibitor -->
        • Many taken off market (CV death risk), celecoxib only one, and has black death warning. (200mg OD)
      • Naproxen --. less worrisome (vs. ibuprophen).
      • Enteric coating --> no help, systemic threapy causes dauses penetration.
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