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84 Cards in this Set
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Case: 52-year old man presents with vague upper abdominal discomfort, nausea, and early satiety. He is a daily NSAID user. He appears pale on exam, suggesting he may be anemic. He has mild abdominal tenderness and melanotic stool on exam.
What is the most likely diagnosis? |
Bleeding peptic ulcer |
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Case: 52-year old man presents with vague upper abdominal discomfort, nausea, and early satiety. He is a daily NSAID user. He appears pale on exam, suggesting he may be anemic. He has mild abdominal tenderness and melanotic stool on exam.
How should this patient be evaluated? |
- Stat CBC - Discontinuation of NSAID - Upper GI endoscopy - Test for H. pylori - Colonoscopy |
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Case: 52-year old man presents with vague upper abdominal discomfort, nausea, and early satiety. He is a daily NSAID user. He appears pale on exam, suggesting he may be anemic. He has mild abdominal tenderness and melanotic stool on exam.
How should this patient be treated? |
- PPI + antibiotics for H. pylori (if positive) - May need a blood transfusion (depending on CBC) - Treat results of endoscopy / colonoscopy |
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Case: 52-year old man presents with vague upper abdominal discomfort, nausea, and early satiety. He is a daily NSAID user. He appears pale on exam, suggesting he may be anemic. He has mild abdominal tenderness and melanotic stool on exam.
How should this patient reduce his risk of recurrence? |
- Discontinue and avoid NSAIDs, or if not able to completely discontinue, use of PPI or misoprostol with NSAIDs - Eradicate H. pylori if present |
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What are the Rome III criteria for dyspepsia? |
One or more of the following: - Post-prandial fullness - Early satiation - Epigastric pain or burning |
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How often is epigastric pain caused by peptic ulcer disease? |
20% |
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What are common causes of epigastric pain? |
- Peptic ulcer disease - GERD - Functional dyspepsia |
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What factors influence your choices for diagnostic workup and treatment in a patient with epigastric pain? |
- Age of patient - Presenting symptoms/signs - Response to initial management |
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What is the pathophysiology behind peptic ulcer disease? |
Problem of the GI tract --> mucosal damage secondary to pepsin and gastric acid secretion |
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Where does peptic ulcer disease occur? |
- Stomach - Proximal duodenum - Less commonly in the lower esophagus, distal duodenum, or jejunum |
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In what setting might the lower esophagus, distal duodenum, or jejunum be affected by peptic ulcer disease? |
- Zollinger-Ellison Syndrome (unopposed hyper-secretory state) - Hiatal Hernias (Cameron ulcers) - Ectopic gastric mucosa (Meckel diverticulum) |
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What is the name for unopposed hyper-secretion of acid? |
Zollinger-Ellison syndrome |
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What is the term for ulcers of the esophagus that occur with hiatal hernias? |
Cameron ulcers |
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What is the name for ectopic gastric mucosa? |
Meckel diverticulum |
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What should be done for patients with new onset dyspepsia who are >55 years or who have alarm symptoms? |
Early diagnostic endoscopy |
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What are the alarm symptoms associated with dyspepsia? |
- Unintentional weight loss - Progressive dysphagia - Recurrent / persistent vomiting - Odynophagia - Unexplained anemia - GI bleeding / hematemesis - Family history of cancer, specifically upper GI cancer - History of gastric surgery - Jaundice |
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When might you do a diagnostic endoscopy for someone <55 who doesn't have alarm symptoms associated with their dyspepsia? |
Someone at age 45-50 who is Asian, Hispanic, or Afro-Caribbean |
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What testing should be done for someone with dyspepsia who is <55 years and without alarm symptoms (or <45-50 in a person of Asian, Hispanic, or Afro-Caribbean descent)? |
- H. pylori by IgG serology (rather than 13-C urea breath test or stool antigen testing) - Confirm positive serologic result with either 13-C urea breath test or stool antigen test |
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What is the preferred method of testing for H. pylori? Why? |
IgG serology - low cost and ease of collection |
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How do you treat a patient with PUD who is positive for H. pylori? |
Treat H. pylori followed by acid-suppression therapy |
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How do you treat a patient with PUD who is negative for H. pylori? |
Empiric therapy with PPI for 4-8 weeks |
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What should be done for patients with PUD if they still have symptoms following treatment (regardless of H. pylori status)? |
Endoscopy or reconsideration of diagnosis |
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What are the classes of medications that can be used to decrease acid production? |
- H2 blockers - PPI |
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What is the mechanism of H2 blockers? |
Competitive antagonists of histamine binding to gastric parietal cell H2 receptors, preventing activation of the pathway that mediates release of acid into the gastric lumen |
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What is the mechanism of PPIs? |
Suppresses gastric acid production by irreversibly inhibiting the H+K+ ATPase proton pump in gastric parietal cells |
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Which location of ulcers from PUD is more common? |
- Duodenal ulcers (more prevalent overall) - Gastric ulcers (more common in NSAID users) |
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In someone who is using NSAIDs chronically, where are they more likely to develop an ulcer? |
Stomach |
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What are the risk factors for PUD? |
- H. pylori infection - NSAIDs - Smoking - Personal / family history of PUD - Black / Hispanic (more likely to develop PUD) |
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What is the lifetime risk of developing PUD in the U.S.? |
10% |
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What are the common causes of PUD? |
- H. pylori - NSAIDs |
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What are the rare causes of PUD? |
- Other medications - Acid-hypersecretory states / gastrinomas (e.g., Zollinger-Ellison syndrome) - Malignancy - Stress |
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What are the characteristics of H. pylori? How often is it associated with PUD? |
Gram negative, motile spiral rod found in 48% of patients with PUD |
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How commonly do patients taking NSAIDs over long periods of time develop PUD? |
5-20% |
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When are NSAID-induced ulcers more common in someone's life? |
More common in elderly, those with concomitant H. pylori infection, or those on steroid or anticoagulants |
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What medications can cause PUD? |
- NSAIDs - Steroids - Bisphosphonates - Potassium chloride - Chemotherapeutic agents (e.g., IV fluorouracil) |
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What malignancies are associated with PUD? |
- Gastric cancer - Lymphoma - Lung cancer |
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What types of "stress" are associated with PUD? |
- After acute illness - Multi-organ failure - Ventilator support - Extensive burns - Head injury |
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What is the term for a peptic ulcer in the setting of extensive burns? |
Curling ulcer |
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What is the term for a peptic ulcer in the setting of a head injury? |
Cushing ulcer |
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What is the most likely cause in patients who primarily have symptoms of heartburn of acid regurgitation? |
GERD |
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What are the classic symptoms associated with PUD? |
- Epigastric abdominal pain, improved with digestion of food - Pain that develops a few hours after eating - Nocturnal symptoms (11pm-2am) - Symptoms are gradual in onset and present for weeks or months |
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At what point in the day is there maximal acid secretion? |
11pm-2am |
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How do patients often self-treat themselves with PUD? |
OTC antacids - provide some relief |
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What is typically the only exam finding associated with PUD? |
Epigastric tenderness |
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Besides epigastric tenderness, what other exam findings may you get? |
- Stool occult blood testing positive - Signs of anemia (pale conjunctiva or skin, tachycardia, hypotension, orthostasis) |
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If someone has PUD, why might the stool occult blood testing be negative? |
Bleeding from PUD may be episodic and it may be negative in the office; this does not rule out bleeding |
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If someone has RUQ pain, what diagnoses should you consider besides PUD? |
Gallbladder or biliary disease |
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If someone has RLQ pain, what diagnoses should you consider besides PUD? |
Appendicitis |
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If someone has epigastric pain radiating to the back, what diagnoses should you consider besides PUD? |
- Pancreatitis - also associated with nausea / vomiting - MI (not necessarily radiating to the back) |
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If a woman has lower quadrant pain, what diagnoses should you consider besides PUD? |
- Pelvic infections - Pelvic pathology - Ectopic pregnancy |
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What is H. pylori associated with? |
- Peptic ulcer disease (5-7% increased risk) - GAstric cancer |
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How do you get H. pylori? |
Usually maternally acquired as a child
More common in developing countries |
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What is the preferred non-invasive office test for H. pylori? |
Stool antigen testing - superior positive predictive value and ability to be used post-treatment to test for eradication |
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What may cause you to have a false negative stool antigen test for H. pylori in a patient who is in fact infected? |
Treatment with PPIs for >2 weeks prior to testing |
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What test is useful for diagnosing a history of H. pylori infection? |
Serologic testing for anti-H. pylori antibodies |
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What are the benefits / limitations of the serologic testing for H. pylori Abs? |
- Widely available - Inexpensive - Non-invasive - Very sensitive for a history of infection, but cannot distinguish between an active infection and a treated infection |
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How can you confirm an active infection of H. pylori? |
Urea breath testing - Highly sensitive and specific, but limited by availability and expense |
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What happens in the urea breath testing for H. pylori? |
- Patient ingests carbon-labeled urea compound - This compound is metabolized by urease from H. pylori organism - Labeled CO2 released is measured in the exhaled breath |
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What is the gold standard for diagnosing H. pylori? |
Endoscopy with biopsy testing - visualize bacteria microscopically using staining methods, culture, or detect by rapid testing of specimen
This is invasive and expensive |
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What is the benefit of endoscopy for diagnosing H. pylori? |
Gold standard - can also directly visualize ulcers and evaluate for presence of malignancy or other pathology in the esophagus, stomach, or duodenum |
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What are possible complications of PUD? How often? |
25% with PUD have a serious complication: - Hemorrhage - Perforation - Gastric outlet obstruction
More common in polder patients and patients taking NSAIDs |
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How common is upper GI bleeding in patients with PUD? |
15-20% |
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What is the most common cause of death from PUD? |
Upper GI bleeding |
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What ist he most common indication for surgery with PUD? |
Upper GI bleeding |
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What impacts the risk of rebelling and death in patients with PUD? |
- Age - Comorbidities - Hemodynamic status |
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What studies should be done in a patient you suspect of having PUD? |
- Stool occult blood test - CBC (for anemia) - Basic chemistry (in patient who has not been eating or has been vomiting) - Liver enzymes (to rule out biliary disease if suspected) - Amylase / lipase (to rule out pancreatic disease if suspected) - ECG (to rule out cardiac disease if suspected) - CXR (if considering abdominal visceral perforation) - Abdominal U/S (if considering gallstones) - Pregnancy test (reproductive-age woman) - Cervical cultures (if suspect pelvic infection) |
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What test can help you determine if your patient has an abdominal visceral perforation? |
CXR |
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What factors would make you hospitalize a patient with PUD? |
- Significant anemia - Hemodynamic instability (hypotension, tachycardia, orthostasis) - Suspected acute abdomen |
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What steps should be taken to treat hospitalized patients with PUD? |
IV rehydration and/or blood transfusion as necessary |
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What tests can determine an active H. pylori infection? |
- Stool antigen - Serum IgA ELISA |
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What are the treatment regimens for an active H. pylori infection? |
Triple therapy for 7-14 days - Bismuth subsalicylate + Metronidazole + Tetracycline OR - Ranitidine bismuth citrate + Tetracycline + Clarithromycin or Metronidazole OR - Omeprazole + Clarithromycin + Amoxicillin or Metronidazole |
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What is the preferred therapy for patients with active H. pylori? |
7-14 days: - Omeprazole (20 mg BID) - Clarithromycin (250 or 500 mg BID) - Amoxicillin (1 g BID) OR Metronidazole (500 mg BID) if allergic to PCN |
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What are the components of quadruple therapy for H. pylori? |
- Omeprazole (20 mg daily) - Bismuth subsalicylate (525 mg QID) - Metronidazole (250 mg QID) - Tetracycline (500 mg QID) |
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Are PPIs or H2 blockers better for suppressing acid production and hastening ulcer healing? |
PPIs |
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How do you treat a patient with PUD and no H. pylori? |
4-8 weeks of acid suppression |
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What offending agents should be stopped in patients with PUD? |
- NSAIDs - Tobacco |
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What testing should be done for patients suspected of having PUD with alarm symptoms? |
Endoscopy |
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What testing should a patient >50 years who has blood in the stool get? |
- Endoscopy - Colonoscopy (regardless of endoscopic findings) |
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A 30-year old woman with no known medical problems comes to you for advice. She attended a health fair where she tested positive for H. pylori on a blood test. She has no abdominal discomfort, nausea, vomiting, or diarrhea. Her stool has been negative for blood. She occasionally has to use OTC antacids after eating spicy foods.
What can you tell her about the results of her test? |
She may or may not have an H. pylori infection
Blood tests are testing for antibodies. They cannot distinguish between active and past infections, nor can they diagnose the presence of ulcers. Treating a positive serum test in an asymptomatic patient is not indicated. |
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A 62 year old man presents to clinic with increasing SOB and fatigue. Cardiac exam is negative and lungs are clear. No jaundice, JVD, or peripheral edema. Mucus membranes are pink with no evidence of cyanosis; capillary refill is good. CBC reveals a microcytic anemia and a gastric ulcer is diagnosed on upper GI endoscopy. A biopsy and testing confirm an H. pylori infection. His last colonoscopy was 2 years ago and was normal.
What further testing is indicated at this time? |
Colonoscopy
The presence of blood in the stool or anemia in a patient >50 years even when an ulcer is found, is an indication for colonoscopy, as this may also represent a prevention of a concomitant colon cancer. A urea breath test may be beneficial after completion of treatment to confirm eradication of the infection. |
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A 41-year old man presents for evaluation of upper GI discomfort that he has had for about 2 months. He says that he has a "full" sensation in the epigastric region. He recently began smoking after increased stress at work. He has had no blood in his stool, no vomiting, and no dysphagia. He has lost about 10 lbs, but does not exercise. His mother has hemorrhoids, but no family member has ever had colon cancer. He has never had a colonoscopy.
What is the most appropriate test? |
Endoscopy
The patient presents with the alarm symptom of weight loss. |
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A 19-year old woman arrives to the ER with a 15-hour history of abdominal pain, n/v. She was awoken early in the morning by severe abdominal pain. She does admit to drinking heavily the prior evening that is not unusual during the weekends. She does not use NSAIDs regularly. Her BP is 100/60, pulse 130 bp, RR 14, and temp is 39C. Acute abdominal series upon admission displayed substantial amount of free air under the right hemidiaphragm.
What is the most likely diagnosis? |
Perforated peptic ulcer
Acute abdomen and free air under diaphragm indicates a perforated viscus. Patient has perforated ulcer with hemodynamic instability. Additional workup includes a chemistry panel, CBC, and urgent laparotomy. |
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What testing might a patient who requires long-term NSAID therapy benefit from? |
Testing for active H. pylori infection, followed by eradication, if positive, as this may lower their risk for developing an ulcer.
PPI therapy along with the NSAID can also lower their risk. |
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Are peptic ulcers caused by stress or spicy foods? |
No, they are primarily caused by H. pylori and NSAIDs |
