Zuhir PBL-VII (Peptic Ulcer - Gastric Cancer)

7/31/2019 Zuhir PBL-VII (Peptic Ulcer - Gastric Cancer)

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PBL-VIIZuhir Bodalal

Libyan International Medical University

www.limu.edu.ly
http://www.limu.edu.ly/http://www.limu.edu.ly/


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Disclaimer

The following is a collection of medical

information from multiple sources, both

online and offline. It is to be used for educational purposesonly.

All materials belong to their respective owners

and the authors claims no rights over them.


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Peptic Ulcer Disease


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PUD: definition

Break in the gastrointestinal mucosa exposed togastric acid and pepsin more than 5 mm indiameter.

Erosions (superficial to the muscularismucosa, thusno scarring) or ulcer (penetrates the muscularismucosa and can result in scarring)


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Etiology of Erosions/Ulcer


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PUD: Clinical Features

dyspepsia is the most common presentingsymptom; however, only 20% of patients withdyspepsia have ulcers

may present with complications

bleeding 10% (severe if from gastroduodenal artery);

perforation 2% (usually anterior ulcers)

gastric outlet obstruction 2%

penetration (posterior) 2%; may also causepancreatitis


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PUD: Clinical Features

duodenal ulcers present with 6 classical features: epigastric pain; but may localize to tip of xyphoid burning

develops 1-3 hours after meals relieved by eating and antacids interrupts sleep periodicity (tends to occur in clusters over weeks with

subsequent periods of remission)

Gastric ulcer edges must always be biopsied,duodenal ulcers are rarely malignant.


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Investigations

Endoscopy (most accurate)

Radiology (no longer used)

Upper GI series H. pyloritests

Fasting serum gastrin measurement if

Zollinger-Ellison (ZE) syndrome suspected


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Endoscopy in PUD: GU


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Radiology in PUD


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Diagnosis of H. pylori


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Management

Specific management depends on etiology; (i.e. H.pylori, Stress-Induced, NSAID induced)

eradicate H. pyloriif present, chief advantage is tolower ulcer recurrence rate

stop NSAIDs if possible PPI inhibits parietal cell H+ /K+-ATPasepump which

secretes acid heals most ulcers, even if NSAIDs arecontinued

discontinue tobacco no diet modifications required but some people have

fewer symptoms if they avoid caffeine, alcohol, andspices


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H. pylori Eradication


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Role of H.pylori in GI diseases

Healthy subjects 20-50%

Chronic active gastritis 100%

Duodenal ulcer >90%

Gastric ulcer 50 - 80%

Gastric adenocarcinoma 90% Gastric lymphoma 85%


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Helicobacter pylori


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Research Corner


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Research Corner


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Research Corner


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Research Corner


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Surgical Management

Increasingly rare due to improved medical

treatment.

Distal gastrectomy Vagotomy and pyloroplasty in hyper-secretion

only.


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Gastric Carcinoma


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Gastric

Cancer

Environmental factors

H. pylori Genetic factors

Etiological Factors of Gastric Cancer

Precancerous changes


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Environmental factors

Environmental factors are involved

Japanese immigrants in US: 25%

Second generation: >50%

Subsequent generations: comparable to General USpopulation


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Postulated sequence of histologic events in the progressionto gastric adenocarcinoma and potential contributory factors

H. Pylori Other factors

ChronicSuperficialGastritis

IntestinalMetaplasia

AtrophicGastritis

Dysplasia

FAP orAdenomas

GastricAdenocarcinoma

Other factors

Association StrongAssociation

Correa hypothesis


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Epidemiology


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Research Corner


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Morphology


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Morphology---early stage


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Morphology---early stage


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Morphology ---advanced stage


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Investigations and Dx


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Laboratory tests

Iron deficiency anemia

Fecal occult blood test (FOBT)

Tumor markers (CEA, Ca19-9)


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Diagnosis

Endoscopic diagnosis

--- biopsy needed for definitive diagnosis

Radiologic diagnosis

Detection of early gastric cancer


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Endoscopic diagnosis

In patients with signs and symptoms suggestive of

GC, and/or with compatible risk factors or paraneoplastic

conditions, the diagnostic procedure of choice could bean endoscopic examination

The diagnostic criteria for early or advanced gastric

cancer under endoscopy are based on the JRSGC and

Bormanns classification


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Endoscopic features of gastric cancer


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For reasons of cost and availability, radiography maysometimes be the first diagnostic procedure performed

Classic radiography signs of malignant gastric ulcer

asymmetric/distorted ulcer crater

ulcer on the irregular mass

irregular/distorted mucosal foldsadjacent mucosa with obliterated /distorted area gastricae

nodularity, mass effect, or loss of distensibility


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Distal GC Proximal GC Linitis plastica


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Detection of early gastric cancer

Endoscopic screening

general population or high risk persons

Careful observation

Japan is the only country that had conducted large

nationwide mass population screening of asymptomatic

individuals for gastric malignancy


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Differential diagnosis

Gastric Cancer

Gastric Ulcer


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Treatment


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Treatment

Surgical resection

EMR

Adjuvant therapy

Palliative therapy


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Endoscopic mucosal resection

Gastric cancerlesion confined

to mucosa layer

Endoscopic ultrasound(EUS) is helpful instageing GC


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Chemotherapy

Adjuvant chemotherapy may increase 5 years survivalrates and decrease the relapse rates

Combination chemotherapy are recommended


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Complications

GI bleeding 5%

Pylorus/cardiaobstruction

Perforation ulcer type


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Prognosis

The TNM classification/staging of gastric cancer is thebest prognostic indicator

The 5 years survival rate depends on the depth ofgastric cancer invasion

Patients in whom tumors are resectable for cure alsohave good prognosis


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GASTRIC BEZOAR

Concretions in the stomach

Tricho-bezoar (hair)

Young girls who pick and swallow their hair

Phyto-bezoar (vegetable fibre)

Can cause erosions and bleeding

Seldom perforate but if mortality 20%

Endoscopic breakage


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Thank You

Zuhir PBL-VII (Peptic Ulcer - Gastric Cancer)

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