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Disorders of the Stomach

Peptic Ulcer Disease

• Defined as a break in the mucosal lining of the stomach or the duodenum.
• An ulcer is four to five times more likely to be found in the duodenum than in the stomach.
• PUD is the most common cause of a GI bleed

Risk factors

• Helicobacter pylori is associated with up to 90% of peptic ulcers
• NSAIDS
• Smoking

Clinical Presentation

• Dyspepsia (epigastric pain) – Pain may be described as dull, aching or gnawing
• Food
  • Duodanel ulcers – pain improves with food
  • Gastric ulcers – pain is exacerbated by food
• Anorexia – with gastric ulcers
• Nausea
• Bloating
• Belching

Labs and Studies

• CBC
• Fecal occult blood test
• Fasting serum gastrin level
• H. Pylori
  • Urea breath
  • Stool antigen test
• Endoscopy with biopsy is the gold standard

Treatment

• Triple therapy for two weeks with a PPI and two antibiotics
  • omeprazole + clarithromycin + amoxicillin
• Quadruple therapy PPI and 3 antibiotics for 2 weeks
  • omeprazole + bismuth subsalicylate + tetracycline + metronidazole
• PPIs long term
• Surgical repair of ulcer if necessary

Pyloric Stenosis

A narrowing of the opening from the stomach to the duodenum. The average age of occurrence is 6 weeks.

Clinical Presentation

• Projectile vomiting
• Distended abdomen after feeding

Labs, Studies and Physical Exam Findings

• Epigastric olive like mass
• BMP
• Barium swallow
  • String sign
  • Railroad track sign
• Ultrasound shows the thickened pylorus

Treatment

• Fluids for dehydration
• Pyloromyotomy

Gastric Adenocarcinoma

Risk factors

• Smoking can increase the risk of gastric cancer between 40% and 80%
• H. Pylori is found in up to 80% of cancer patients
• Males 3:1

Clinical Presentation

• Unexplained weight loss
• Abdominal discomfort
• Dysphagia
• Anorexia
• An enlarged left supraclavicular lymph node – Virchow’s node
• An enlarged umbilical node – Sister Mary Joseph nodule

Labs and Studies

• CBC
• Iron panel
• Endoscopy
• CT
• PET

Treatment

• Surgical resection is the only curative treatment
• Chemotherapy and radiation

Zollinger Ellison Syndrome

• A gastrin secreting tumor resulting in excessive acid production
• Causes PUD and therefore symptoms are similar

Clinical Presentation

• GERD symptoms
• Diarrhea
• Unexplained weight loss

Labs and Studies

• CT/MRI
• Somatostatin receptor scintigraphy
• Endoscopy with U/S
• Fasting serum gastrin
• Secretin stimulation test which under normal conditions would cause serum gastrin levels to decrease, will cause serum gastrin to rise.

Treatment

• PPIs omeprazole, pantoprazole
• Surgical resection of the tumor if possible

Diseases of the Pancreas

Acute Pancreatitis

• Acute pancreatitis is inflammation of the pancreas days
• Gallstones and excessive alcohol intake are the most common causes of acute pancreatitis
• Patients may be severely hypovolemic
• Ranson Criteria on admission is an indicator of disease severity
  • Age > 55 years old
  • WBC > 16,000
  • Glucose > 200
  • Lactate dehydrogenase (LDH) > 350
  • Aspartate aminotransferase (AST) > 250

Risk Factors and Causes

• Gallstones
• Alcohol abuse
• Smoking
• Autoimmune disease
• Abdominal trauma

Clinical Presentation

• Acute epigastric pain radiating to the back
• Nausea and vomiting
• Sweats

Physical Exam Findings

• Epigastric pain is somewhat alleviated by sitting and leaning forward, worse in the supine position
• Fever
• Tachycardia
• Hypotension
• Diminished bowel sounds secondary to possible ileus
• Abdominal tenderness and guarding
• Cullen sign – ecchymosis in the periumbilical region
• Turner sign – ecchymosis in the flanks

Labs and Studies

• Serum amylase and lipase at 3x higher than high
• CBC with elevated WBCs
• Liver pane
• Abdominal x-ray
• U/S – Looking for gallstones
• CT with IV contrast is the test of choice for diagnosis

Treatment

• NPO
• IV fluids
• Monitoring of vitals
• Pain medication
• Antibiotics may play a role in preventing infection secondary to pancreatic necrosis but is not currently indicated
• ERCP with sphincterotomy if gallstones are the cause
• Stop drinking alcohol

Chronic Pancreatitis

• Chronic pancreatitis is characterized by ongoing inflammation of the pancreas and structural changes within the organ.

Risk Factors

• Excessive alcohol consumption is the #1 risk factor
• Smoking
• Autoimmune disease
• Gallstones
• Cancer

Clinical Presentation

• Epigastric pain radiating to the back
• Nausea and vomiting
• Sweats
• Steatorrhea

Physical Exam Findings

• Fever
• Tachycardia
• Hypotension
• Diminished bowel sounds secondary to possible ileus
• Cachexia (weight loss)

Labs and Studies

• Serum amylase and lipase elevated
• CBC with elevated WBCs
• Abdominal x-ray – may see calcifications in the pancreas
• U/S – Looking for gallstones
• CT with IV contrast is the test of choice for diagnosis

Treatment

• IV fluids
• Monitoring of vitals
• Pain medication
• NPO

• Antibiotics may play a role in preventing infection secondary to pancreatic necrosis but is not currently indicated
• ERCP with sphincterotomy if gallstones are the cause
• Enzyme replacement
• Management of diabetes
• Stop drinking alcohol

Pancreatic Cancer

Things to know

• 95% are adenocarcinoma
• Fourth most common cause of cancer deaths in the U.S.
• The median survival for most cases is less than 1 year

Risk Factors

• Age > 55
• Family history
• History of chronic pancreatitis
• Male > Female
• Smoking
• Diet
  • Low in fruits and vegetables
  • High in red meats
  • High in sugar
• Obesity
• Alcohol abuse does not come up as a risk factor

Clinical Presentation

• Typically there are no symptoms in the early stages
• Advanced disease has very vague symptoms
  • Jaundice (secondary to obstruction)
  • Epigastric pain which radiates to the back
  • Heartburn
  • Anorexia
  • Nausea and vomiting
  • Diarrhea particularly steatorrhea
  • Cachexia (weight loss)

Labs, Studies and Physical Exam Findings

• Trousseau sign – Tender nodules within veins which are small venous thrombi. These are hallmarks of a hypercoagulable state associated with some cancers.

• Liver function tests
• CT
• Endoscopic ultrasound

Treatment

• About 20% of patients with pancreatic cancer are surgical candidates
  • Whipple procedure – major surgery involving a pancreaticoduodenectomy, a gastro-jejunostomy and a cholecystojejunostomy. A successful procedure results in a five year survival rate of about 20%
  • A distal pancreatectomy may be performed alone depending on the location of the tumor
• Radiation
• Chemotherapy
• Palliative care and pain control