Peptic Ulcer and GERD Quiz

Nausea and Vomiting

• Nausea is the inclination to vomit, or a feeling in the throat or upper stomach, indicating imminent vomiting.
• Vomiting is the forceful expulsion of stomach contents through the mouth.
• Nausea and/or vomiting are part of various symptom complexes (gastrointestinal, cardiovascular, infectious, neurologic, metabolic, or psychogenic).
• Emesis includes three phases: nausea, retching, and vomiting.
• Nausea is associated with gastric stasis and can be a separate symptom.
• Retching is the labored movement of abdominal and thoracic muscles before vomiting.
• Vomiting is the forceful expulsion of gastric contents due to gastrointestinal retroperistalsis.
• Vomiting is triggered by afferent impulses to the vomiting center in the medulla.
• Sensory centers (chemoreceptor trigger zone, cerebral cortex, and visceral afferents) send impulses to the vomiting center.
• The vomiting center integrates these impulses, sending efferent impulses to centers controlling salivation, respiration, and muscles responsible for vomiting.
• Vomiting steps include: stimulus to the vomiting center, coordination by the vomiting center with cranial nerves, closing of the glottis and raising of the soft palate, deep inspiration and diaphragm-contraction, relaxation of the gastroesophageal sphincter and fundus of the stomach, forceful contraction of abdominal muscles.

Treatment of Nausea and Vomiting

• 5-Hydroxytryptamine-3 Receptor Antagonists: dolasetron, granisetron, ondansetron, palonosetron
• 5-HT-3RAs block presynaptic serotonin receptors, effectively stopping the chemotherapy-induced acute nausea and vomiting (CINV) phase.
• Metoclopramide, a procainamide, blocks the dopaminergic receptors in the CTZ.
• Metoclopramide increases lower esophageal sphincter tone, speeds up gastric emptying, and accelerates small bowel transit, possibly by releasing acetylcholine.
• Antihistamine-Anticholinergic Drugs: Cyclizine (Marezine), Dimenhydrinate (Dramamine), Diphenhydramine (Benadryl)
• These drugs block various visceral afferent pathways stimulating nausea and vomiting and may be suitable for treating simple nausea or vomiting.
• Side effects include drowsiness, confusion, blurred vision, dry mouth, and urinary retention, and tachycardia (especially in the elderly).

Diarrhea

• Diarrhea is increased fecal discharge frequency and decreased consistency compared to an individual's normal bowel pattern.
• Common causes include viral and bacterial organisms, often causing minor discomfort and self-limiting issues.
• Diarrhea may be associated with an intestinal disease or secondary to a disease outside of the intestines (e.g., bacillary dysentery affects the gut, whereas diabetes mellitus can cause neuropathic diarrheal episodes).
• Diarrhea varies by form: infectious diarrhea is generally acute; diabetic diarrhea is usually chronic.
• Four major pathophysiological mechanisms causing diarrhea: changes in active ion transport (decreased sodium absorption or increased chloride secretion), changes in intestinal motility, increases in luminal osmolarity, and increases in tissue hydrostatic pressure.
• Clinical appearance: signs and symptoms include abrupt onset of nausea, vomiting, abdominal pain, headache, fever, chills, malaise, and frequently watery bowel movements with no bleeding (that last 12-60 hrs).
• A medical history of past bouts, weight loss, anorexia, and weakness are important considerations in chronic diarrhea.
• Common lab tests for this condition include stool analysis (microorganisms, blood, mucus, fats, osmolality, pH, electrolytes, and mineral composition, cultures).
• Diagnostic tests for diarrhea can also include serological testing for gastrointestinal viruses (such as rotavirus) and total daily stool volume.

Constipation

• Doctors typically define constipation as the defecation of less than three times per week.
• Constipation is more commonly described in terms of symptoms (e.g., hard stools, increased straining, and a sense of incomplete evacuation) or a combination of quantitative (e.g., bowel movement frequency) and qualitative descriptors of bowel movements.
• Diagnostic criteria for functional constipation (fulfilled in the last 3 months, symptoms at least 6 months prior): two or more of the following: straining, lumpy or hard stools, sensation of incomplete evacuation, sensation of anorectal obstruction/blockage, manual maneuvering to evacuate, fewer than three defecations per week, and loose stools are rarely present without laxatives.
• The possible causes of constipation include: GI disorders (irritable bowel syndrome, diverticulitis, upper or lower GI tract disease, hemorrhoids, anal fissures, ulcerative proctitis, tumors, hernia, volvulus of the bowel, syphilis, tuberculosis, helminthic infections, lymphogranuloma venereum, Hirschsprung's disease, diabetes mellitus with neuropathy, hypothyroidism, panhypopituitarism, pheochromocytoma, hypercalcemia, and enteric glucagon excess); metabolic/endocrine disorders (various hormonal or metabolic disturbances); cardiac diseases (depressed gut motility, increased fluid absorption from the colon, use of iron salts, dietary changes, inadequate fluid intake, and low dietary fiber); neurogenic causes (trauma to the brain, spinal cord injury, and CNS tumors); lifestyle factors (decreased physical activity), and psychogenic causes (ignoring or postponing the urge to defecate and psychiatric diseases).
• Possible treatments and therapies include dietary modification (e.g., increasing fiber, controlling food intake), pharmacologic intervention, and antireflux surgery.

Gastroesophageal Reflux Disease (GERD)

• GERD is the reflux of stomach material into the esophagus.
• GERD is classified as symptom-based or tissue injury-based.
• Symptom-based GERD may or may not involve esophageal injury.
• Symptom-based GERD syndromes frequently involve heartburn, regurgitation, or dysphagia. Less commonly, symptoms include painful swallowing (odynophagia) or excess saliva (hypersalivation).
• Tissue injury syndromes may or may not involve symptoms.
• Tissue injury spectrum: esophagitis (inflammation of the esophagus), Barrett's esophagus (tissue lining the esophagus replacing intestinal lining), strictures, and esophageal adenocarcinoma.
• The key factor in GERD development is the abnormal reflux of stomach contents into the esophagus.
• Factors associated with decreased lower esophageal sphincter pressure (LES) pressure or function: spontaneous transient LES relaxations, transient increases in intra-abdominal pressure, or atonic LES.
• Contributing factors: esophageal anatomy, impaired esophageal clearance of gastric fluids, reduced mucosal resistance to acid, delayed / ineffective gastric emptying, reduced salivary buffering of acid.

Gastritis

• Gastritis involves inflammatory changes in the gastric mucosa.
• Types of gastritis: erosive gastritis (caused by noxious irritants), reflux gastritis (bile and pancreatic fluid exposure), hemorrhagic gastritis, infectious gastritis, and gastric mucosal atrophy.
• Acute gastritis, frequently transient, has an acute mucosal inflammatory process; a severe erosive type is a common cause of acute gastrointestinal bleeding.
• Causes of gastritis include: H. pylori (most common cause of ulceration), NSAIDs, aspirin, gastrinoma (Zollinger-Ellison syndrome), severe stress (e.g., trauma, burns), curling ulcers, alcohol, bile reflux, pancreatic enzyme reflux, radiation, Staphylococcus aureus exotoxin, bacterial or viral infection.
• Chronic gastritis types: Type A (fundal) gastritis and type B (antral) gastritis; Type A includes circulating antibodies to parietal cells and intrinsic factor, along with low to no gastric acid secretion and hypergastrinemia, and type B is a frequently symptomatic form and/or hypersecretory with environmental gastritis that may exhibit irregularly focal involvement of the antral mucosa, and gradually extends deeper to cause mucosal atrophy.
• Hypertrophic gastritis types include Menetrier's disease, hypersecretory gastropathy, and gastric gland hyperplasia (the Zollinger-Ellison Syndrome). Menetrier's disease is characterized by a giant enlargement of gastric folds and caused by hyperplasia of epithelial cells.

Peptic Ulcers

• Peptic ulcer disease (PUD) is characterized by a disruption in the balance between aggressive factors (gastric acid and pepsin) and protective factors (mucosal defense & repair).
• Gastric acid is secreted by parietal cells, containing receptors for histamine, gastrin, and acetylcholine.
• Pepsin, a proteolytic enzyme, is secreted as pepsinogen by the chief cells in the gastric fundus. Stomach acid activates pepsin.
• Mucosal defensive mechanisms include mucus and bicarbonate secretion, intrinsic epithelial cell defense, and mucosal blood flow.
• Ulcers may be of three types: H. pylori infection-related, nonsteroidal antiinflammatory drug (NSAID)-induced, and stress ulcers.

Inflammatory Bowel Disease (IBD)

• IBD encompasses ulcerative colitis (UC) and Crohn's disease (CD).
• The exact cause of IBD is unknown, but it likely involves both infectious and immune dysregulation factors.
• UC is confined to the rectum and colon, specifically affecting the mucosa and submucosa, and characterized by crypt abscesses and necrosis of the epithelium. The presence of collar-button ulcers and pseudopolyps is common.
• CD is a transmural inflammatory process that can affect any part of the gastrointestinal tract from mouth to anus, with a frequent involvement of the terminal ileum, with extensive bowel wall injury and often narrowed intestinal lumen along with mesentery thickening.
• Typical characteristics of ulcers are deeper than normal, elongated, and extend along the bowel's longitudinal axis, penetrating the submucosa. The cobblestone appearance of the bowel wall comes from the deep ulcers and thickening of non-ulcerated submucosa.

Treatment of IBD

• First-line treatment for mild to moderate cases of UC or Crohn's colitis includes oral aminosalicylates (e.g., sulfasalazine or mesalamine), or steroid enemas or suppositories for distal areas.
• Corticosteroids are often required for acute UC or Crohn's disease.
• Infliximab is a treatment option for patients with moderate to severe active UC and for those with UC who are dependent on corticosteroids.
• Azathioprine or mercaptopurine may be used for maintenance of remission.

Other GI Disorders and Treatments

• Antacids: weak bases neutralizing stomach acid (HCl) but not suppressing acid secretion; antacids include magnesium hydroxide, magnesium trisilicate, and magnesium-aluminum mixtures; calcium carbonate, sodium bicarbonate.
• Characteristics of Antacids: varying onset and duration of action, differing effects on systemic alkalosis, and differing effects on stool (some are constipating, some are laxative).

Test your knowledge on peptic ulcer disease and GERD with this comprehensive quiz. Explore symptoms, diagnostic tests, complications, and treatment options associated with these gastrointestinal conditions. Perfect for medical students and professionals looking to refresh their understanding.