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H.Pylori, Peptic Ulcer, Gastric Cancer - Coggle Diagram
H.Pylori, Peptic Ulcer, Gastric Cancer
H. Pylori
Characteristics
Gram -ve, helical bacteria, virulence factors (flagella - motility in mucus, adhesins - adherence to surface foverolar cells, urease - make ammonia, increases local pH, toxins - cytotoxin-associated gene A
Diagnosis
Serology: Good first test, Urea Breath test for eradication
Peptic Ulcer Disease
Clinical Manifestations
Dyspepsia, Nausea, Sometimes asymptomatic
Complicated ulcer: Perforation (severe pain), Obstruction (pain and vomiting), Bleeding (coffee groundemesis), Black stool (melena), Rarer (fistula)
Causes: Acid Pepsin, Smoking, Alcohol, Bile, Stress ulcers, Chemotherapy/Radiation, Acid hypersecretion, Crack Ccaine, Idiopathic
Gastric Acid: Necessary to ulcer development, but does not cause ulcers
Healing occurs when acid is suppressed
Complications:
Bleeding
Most common complicated due to erosion of ulcer into an artery
Treatment: Supportive care, IV PPI, benefit is additive over endoscopic therapy
Perforation and Penetration
NSAIDS
Topical Action (superficial Erosions)
Decreased Mucosal Integrity via COX-1 pathway
Risk factors: Age >60, comorbidity, prior history of PUD, concomitant use of corticosteroids, type of NSAID, Dose of NSAID
Treatment
Quadruple Therapy: PPI bid, Metronidazole 500 mg TID, (Tetracycline 500 mg qid, bismuth qid) or (Amxoil 1g BID, Clarythromycin 500 mg BID)
Surgery: Removal of acid secreting part of stomach, or vagotomy of nerve to stomach
Issues: Decreased gastric motility, dumping
If unable to remove NSAID, give PPI
Benign vs Malignant
Benign: Extends outside expected lumen, normal mucosa surrounding ulcer, mucosal folds may radiate from ulcer
Typically in lesser curvature of the stomach
Appears as smooth collection of barium
Malignant: Located inside the expected lumen, abnormal mucosa surrounding ulcer, mucosal folds may radiate from ulcer
Appears as smooth surfaced mass outlined, with central triangular shaped ulcer
Pathology
Gastric adenocarcinoma
Risk factors
Decreased incidence with : Less food presevatives, higher intake of fresh fruits and vegetables, less food contaminents, cigarette smoke is also a factor
Presentation
Wight loss, Abdominal pain, anorexia, early satiety, melena, dysphagia, gastric outlet obstruction, paraneoplastic symptoms
Physical Exam
Usually normal, Cachexia, pallow, epigastric mass, hepatomegaly, edema
Left supraclavicular node (virchow's), periumbilical node (Sister Mary Joseph's node), Ovarian mets (krukenberg tumor), Mass in pouch of dougas (rectal shelf of Blummer)
Natural Couse
Metastasis
Liver, Lung, Peritoneum, Bone Marrow, Kidney, bladder, skin, adrenals, thyroid, brain, bone
Investigations
MRI
Able to local and regional stage of cancer, and assess extragastric findings
PET
Uses radionuclide to assess metabolic activity
CT
Modality of choice for staging and follow up
Fluoroscopy
Filling defects in barium pool with separate portion of lesion outlined in white
Infitrating Gastric Cnacer
Thickened wall, enlarged nodes, small volume of ascites
Pathology
Signet Rings
Gastritis
Lymphocytic: Association with celiac
Eosinophilic - Association with food allergies
Granulomatous - Chron's Sarcoid, Infections
Acute: Damaging factors overwhelm protective factors (Drugs: NSAIDs, iron etc., Alcohol, Bile
UGI (Fluoroscopy)
Thickened folds, erosions, enlarged areae gastricae
Enlarged Areae gastricae (white vs black)
Punctate (white, linear (white top right) collections of barium surrounded by edema (black arrows)
Dyspepsia
Definition: Pain or discomfort centered in upper abdomen (midline) that is not obviously due to GERD, IBS, pancreatic, cardiac pathology
Functional Dyspepsia: Gastric dysmotility, visceral hypersensitivity, psychosocial factors
Treatment: Possible TCA benefit
Approach
<60 and no Alarm Features
Test HP
+ve Treat HP
-ve Empiric PPi
Endoscopy/GI Consult
60 with alarm features
+ve -> Treat -> Follow up
-Ve -> PPI, prokinetic, Tricyclic, Evaluate at 6 weeks and change drugs
