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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/7/31/2019 Zuhir PBL-VII (Peptic Ulcer - Gastric Cancer)
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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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Radiologic diagnosis
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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Radiologic diagnosis
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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Endoscopic mucosal resection
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Endoscopic mucosal resection
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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