GERD, Dyspepsia, H pylori, Gastritis, PUD, Gastric Polyps

1
GERD, Dyspepsia, H pylori, Gastritis, PUD,
Gastric Polyps Cancer

• James W. Simmons M.D.

2
Overview

• GERD
• Definition Sxs
• Diagnosis
• Pathogenesis and Treatment
• Atypical Manifestations
• Further Testing/Complications
• Erosive Esophagitis, Barretts Esophagus

3
Overview

• Dyspepsia
• Definition
• Potential Causes
• Treatment

4
Overview

• Helicobacter pylori
• Treatment
• Association with other conditions

5
Overview

• Gastritis/Gastropathy
• Definition
• Classification
• Treatment
• Risk of Cancer

6
Overview

• Peptic Ulcer Disease
• Treatment Strategy
• H pylori testing
• Biopsy
• High risk ulcers

7
Overview

• Gastric Polyps
• Types
• Etiology
• Malignant potential
• Association with colon polyps
• Management
• Surveillance

8
Overview

• Gastric Cancer
• Statistics
• Physical signs
• Diagnosis
• Biopsy
• Staging
• Histologic types

9
Overview

• Gastric Cancer
• Less common cancers
• Risk factors
• Screening?

10
GERD Definition and Sxs

• Chronic symptoms or mucosal damage by the
  abnormal reflux of gastric contents into the
  esophagus.
• Heartburn is the most common symptom
• Dent et al. Gut. 199944(suppl 2)S1-16.

11
GERD Definition and Sxs

• The description a burning feeling rising from
  the stomach or lower chest has been found to be
  a more reliable indicator of patients symptoms
  than heartburn (40 vs. 13)
• Carlsson et al. Scand J Gastroenterol.
  1998101023-1029.

12
Symptoms of GERD

• Esophageal
• Heartburn
• Dysphagia
• Odynophagia
• Regurgitation
• Belching

• Extraesophageal
• Cough
• Wheezing
• Hoarseness
• Sore throat
• Globus sensation
• Epigastric pain
• Non-cardiac chest pain(NCCP)

13
Factors That Can Aggravate GERD

• Diet Caffeine, fatty/spicy foods, chocolate,
  coffee, peppermint, citrus, alcohol
• Position/Activity Bending, straining
• External Pressure pregnancy, tight clothing

14
GERD Prevalence

• 10 of the US population experience heartburn
  daily
• 40 experience heartburn monthly
• Prevalence increases in industrialized nations
  (Yes, USA is 1!)
• Many self-diagnose and treat
• Kahrilas et al. In Sleisenger Fordtrans
  Gastrointestinal and Liver Disease. 7th ed.
  2002599- 622.

15
GERD Prevalence

• Prevalence and severity increases with age
• Barretts esophagus and erosive esophagitis more
  common in men

16
GERD Prevalence

• Extremely common in pregnancy and increases as
  the pregnancy progresses
• Seventy-two percent of patients in their 3rd
  trimester will have GERD sxs
• Marrero et al. Br J Obstet Gynaecol.
  199299731-734

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Diagnosis of GERD

• Empiric Therapy
• Reduction in sxs suggests GERD
• pH monitoring
• Asso sxs with reflux evals tx efficacy lacks
  sensitivity
• Endoscopy
• Esophagitis and Barretts
• Barium Esophagram
• Sensitive for Dysphagia

18
Pathogenesis of GERD

• Decreased salivation
• Impaired lower esophageal sphincter pressure(Most
  patients with GERD will have normal pressure)
• Impaired tissue resistance
• Transient LES relaxation
• Impaired esophageal clearance
• Hiatal hernia
• Delayed gastric emptying
• Bile reflux

19
Agents That Lower LESP

• Hormones
• Secretin, Cholecystokinin, Glucagon,
  Somatostatin, Gastric Inhibitory Peptide, VIP,
  Progesterone
• Foods
• Fat, Chocolate, Ethanol, Peppermint
• Kahrilas et al. In Sleisenger Fordtrans
  Gastrointestinal and Liver Disease. 7th ed.
  200259-622.

20
Agents That Lower LESP

• Medications
• Nitrates, Morphine, Meperidine, Dopamine, CCBs,
  Benzos, Barbiturates, Theophylline
• Kahrilas et al. In Sleisenger Fortrans
  Gastrointestinal and Liver Disease. 7th ed.
  202599-622

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Transient LES Relaxation

• Dent et al showed that transient LES relaxation
  may be a key mechanism in the pathogenesis of
  GERD
• Occurs in the absence of a swallow
• Dent et al. GUT. 1988291020-1028.

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Hiatal Hernia

• Decreased/Displaced LESP
• Enhanced TLESRs
• Exagerates strain-induce reflux

23
Impaired Acid Clearance

• Hiatal Hernia
• Impaired Esophageal Motility
• Hyposalivation
• Underlying disorders
• Impaired Gastric Emptying increases the
  pressure gradient between the stomach and
  esophagus

24
Pathogenesis Guiding Treatment

• Problem
• TLESRs
• Impaired acid clearance
• Esophageal emptying
• Abnormal anti- reflux barrier
• Hyposalivation

• Possible Tx
• Baclofen
• (investigational)
• Lifestyle mod, H2RAs, PPIs
• Elevate head of bed
• Surgery
• Gum, stop smoking, bethanechol

25
Pathogenesis Guiding Treatment

• Problem
• Tissue Resistance
• Delayed Gastic Emptying
• Gastric Acid

• Possible Tx
• Sucralfate
• Prokinetics
• Antacids, H2RAs, PPIs

26
Acid Suppressive Agents

• H2RAs
• Only target 1 of 3 pathways that eventually act
  on the proton pump
• More effective during fasting and sleep
• Not as effective for GERD sxs, healing erosive
  esophagitis, improving QOL, or improving atypical
  sxs
• Can develop tolerance

27
Acid Suppressive Agents

• PPIs
• Targets the proton pump itself
• More effective for meal-related acid secretion
• No tolerance issues
• Efficacy enhanced at higher doses
• More effectively keeps gastric pH gt4

28
GERD Treatment

• Lifestyle modification
• Medication
• Antireflux surgery
• Endoscopic treatment

29
Empiric Therapy for GERD

• If pt has typical sxs and has no alarm
  sxs(Evidence level A)
• Consider further testing if empiric tx
  unsuccessful or pt has has long-standing
  disease(1-5 years)
• Cochrane Database System Rev 2001(4)CD002095

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Empiric Therapy for GERD

• Atypical Sxs see prior slide
• Alarm Sxs Dysphagia, Early satiety, GI
  bleeding, Fe defic anemia, Odynophagia, Vomiting,
  Weight loss
• Devault KR, Castell DO. Am J Gastroenterology.
  1999941434-1442

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Step Therapy for GERD

• Lifestyle modifications, OTC antacids/H2RAs
• Prescription dose H2RAs
• PPIs

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Step Therapy for GERD

• Step Up
• Starts with lifestyle modification
• Tend to be less effective
• Can delay diagnosis
• Favored by insurance companies

• Step Down
• Starts with PPI
• Can be more expensive
• May decrease the need for more expensive testing

33
GERD Therapy

• Goal is to maintain an intragastric pH of gt4
• Pepsin and most bile acids and pancreatic enzymes
  are inactive at a pH gt4

34
GERD Therapy Non-medical Treatment Choices

• Nissen Fundoplication
• Can cause other significant side effects
• Morbidity related to experience of surgeon
• Can effectively treat GERD sxs but a majority of
  patients may still require anti-reflux
  medications to control symptoms
• Does not work as well for atypical GERD symptoms

35
GERD Therapy Non-medical Treatment Choices

• Endoscopic Suturing(EndoCinch)
• Radiofrequency energy procedure(Stretta)
• Submucosal bulking procedure (Enteryx(recalled),
  Gatekeeper, PMMA)
• Usually only for those with milder sxs
• May not last long

36
Atypical GERD

• Atypical manifestations of GERD such as
  laryngitis, chronic cough, non-cardiac chest
  pain(NCCP) and asthma clearly benefit from acid
  suppression

37
Atypical GERD

• GERD accounts for up to 40-60 of patients with
  NCCP
• Acid suppression may help even if pH testing is
  normal
• Malagon. Curr Opin Gastroenterol.
  200117376-380.

38
Atypical GERD

• 70-80 of asthmatics also have GERD
• Clues Adult onset No family hx Reflux sxs
  precede the onset of asthma Wheezing exacerbated
  by meals exercise or supine position Asthma
  refractory to routine therapy
• Harding and Richter. Chest. 19971111389-1402.
• Richter. Cleve Clin J Med. 19976437-45.

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Atypical GERD

• Asthma/Cough symptoms may be triggered by
  aspiration of gastric refluxate or by stimulation
  of the Esophageal-Bronchial Reflex via the Vagus
  nerve
• Irwin and Richter. Am J Gastroenterol.
  200095(suppl 8)S9-S14.

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Atypical GERD

• Empiric treatment with a PPI for atypical GERD is
  a good option since the sensitivity of pH testing
  is lower
• Treatment often requires BID dosing and at least
  2-3 months to obtain a good response

41
When to do Further Testing

• 24-hr pH Monitoring
• PPI failures, pre-antireflux surgery
• Endoscopy
• Alarm symptoms, exclude Barretts
• Barium Esophagram
• Dysphagia
• Esophageal Manometry
• Suspected dysmotility

42
24-Hour pH Monitoring

• Measures pattern, frequency and duration of
  reflux episodes
• Can correlate symptoms with reflux episodes
• Most useful when empiric therapy has failed and
  endoscopy normal

43
Endoscopy

• Alarm symptoms
• Pre-antireflux surgery
• Long-standing, frequent, or severe symptoms
• To detect and manage EE and Barretts
• Patient reassurance

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Barium Esophagram

• Most sensitive tool for evaluation of dysphagia
• Can identify a subtle stricture not easily
  noticed on endoscopy
• May identify impaired motility and hiatal hernia

45
Esophageal Manometry

• Can identify esophageal dysmotility
• Measures LES pressure
• Cannot evaluate/diagnose GERD

46
GERD Complications

• There is an association between alarm symptoms
  and complications of erosive esophagitis(EE) and
  peptic stricture
• Wo et al. Am J Gastroenterol. 1999942603.
  Abstract 104.

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GERD Complications

• However, typical GERD symptom frequency and
  severity do NOT predict the presence of EE
• Chronic acid exposure/ esophagitis can lead to
  esophageal stricture and/or Barretts esophagus
• Venables et al. Scand J Gastroenerol.
  199732965-973.

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Risk Factors for Erosive Esophagitis and
Barretts Esophagus

• Erosive Esophagitis
• GERD gt1year
• Male gender
• Regular ETOH
• Smoking(current or previous)

• Barretts
• Age gt50 years
• White race
• 41 MenWomen
• Early age at onset of sxs longer duration

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Erosive Esophagitis

• LA Classification
• Grade A - gt1 isolated mucosal breaks lt5mm long
• Grade B - gt1 isolated mucosal breaks gt5mm long
• Grade C - gt1 mucosal breaks bridging the tops of
  folds lt75 of circumference
• Grade D same as Grade C but involves gt75 of
  circumference

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Erosive Esophagitis

• Treatment
• PPIs have been shown to be more effective in
  healing EE and in maintaining remission

51
Erosive Esophagitis

• Peptic Stricture
• Occurs in 7-23 of patients with untreated
  esophagitis
• Dysphagia is usually the most common symptom
• May require dilation
• Chronic PPI therapy required to decrease the risk
  of stricture reformation
• Murphy et al. Endoscopy. 199830367-370.

52
Barretts Esophagus

• Definition
• A change in the esophageal epithelium of any
  length that
• -Can be recognized at endoscopy
• -Is confirmed by biopsy to have intestinal
  metaplasia
• -Excludes intestinal metaplasia of the cardia
• Sampliner. Am J Gastroenterol. 2002971888-1895.

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Barretts Esophagus

• Columnar-lined mucosa
• -Gastric fundic type(stomach)
• -Junctional type(between esophagus and stomach)
• -Intestinal metaplasia(Goblet and mucous
  secreting cells)
• Dysplasia and cancer are almost invariably asso
  with intestinal metaplasia

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Barretts Esophagus

• Spechler. NEJM. 2002346836-842.

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Barretts Esophagus

• Premalignant Condition
• Prevalence of Barretts increases as symptom
  duration increases
• Prolonged acid and bile exposure compared to pts
  with GERD
• Higher prevalence of Hiatal Hernia

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Barretts Esophagus

• Aggressive acid suppression can decrease both
  acid and bile reflux
• Patients with chronic GERD sxs are those most
  likely to benefit from endoscopy to rule out
  Barretts
• Once-in-a-lifetime endoscopy to exclude Barretts?

57
Barretts Esophagus

• Classification
• Short segment - lt3cm above GE jxn(more prevalent)
• Long segment - gt3cm above GE jxn(more likely to
  have intestinal metaplasia)

58
Barretts Esophagus

• Esophageal adenocarcinoma develops in
  approximately 0.5 of patients with Barretts
  esophagus each year
• Up to 40 of patients with esophageal
  adenocarcinoma have no history of GERD
• Approx 30-fold increase risk of cancer over the
  general population
• Spechler. NEJM. 2002 346836-842.

59
Barretts Esophagus

• Treatment options
• Medical therapy
• Antireflux surgery
• Should you treat an asymptomatic patient with
  Barretts?

60
Barretts Esophagus

• Barretts epithelium is less sensitive to acid,
  so patients who report a decrease in sxs after
  long-standing GERD may be developing Barretts
• NO ANTIREFLUX THERAPY HAS BEEN SHOWN TO REDUCE
  THE RISK OF ADENOCARCINOMA OR THE EXTENT OF
  BARRETTS

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Barretts Esophagus

• So why treat?
• Prolonged acid exposure has been associated with
  cell proliferation in Barretts esophagus
• How aggressively do you treat?
• Controversial

62
Barretts Esophagus

• ASA/NSAIDs multiple studies have shown a
  protective association between ASA/NSAIDs and
  esophageal cancer
• Epithelial expression of COX-2 has been detected
  in 100 of high-grade dysplasia or
  adenocarcinoma
• Morris et al. Am J Gastroenterol.
  200196990-996.

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Barretts Esophagus

• Surveillance
• Spechler. NEJM. 2002346836-842

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Barretts Esophagus

• Management options for high-grade dysplasia
• Esophagectomy
• Endoscopic ablative therapies
• Endoscopic mucosal resection
• Intensive surveillance until actual cancer is
  found

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Barretts Esophagus

• Endoscopic ablative therapies
• Photodynamic Therapy(PDT)
• Inject photosensitizing drug
• Deliver red laser light to targeted cells
• Cells containing the drug are destroyed
• Used in past for esophageal cancer patients with
  difficulty swallowing

66
Barretts Esophagus

• Cryotherapy
• Electrocautery
• Laser (Argon, Yag)
• Argon plasma coagulation high frequency current
  delivered by ionized argon gas

67
Barretts Esophagus

• Radiofrequency ablation
• Sizing balloons determine diameter of lumen to be
  ablated
• A 3cm balloon-based electrode delivers a lt1sec
  burst of energy which should control depth of
  injury
• Video http//www.barrx.com/procedure.html

68
Barretts Esophagus

• Danger of ablative therapies
• All but PDT are investigational
• No documentation of improved outcomes yet
• Possibility of leaving some dysplastic tissue
  under new squamous mucosa that would not be
  detected

69
Barretts Esophagus
70
Barretts Esophagus

• Endoscopic Mucosal Resection
• Video demonstration
• http//mayoresearch.mayo.edu/mayo/research/wang_la
  b/endoscopic.cfm
• Safer resection of dysplastic tissue or hard to
  resect lestions
• Provides a tissue for diagnosis and depth of
  invasion

71
Barretts Esophagus
72
Barretts Esophagus

• No direct evidence that surveillance changes
  outcomes

73
Dyspepsia

• Pain or discomfort in the upper abdomen without
  heartburn or regurgitation
• Bloating, indigestion, fullness, nausea, early
  satiety
• Approx 40 will have an organic cause 60 will
  be functional

74
Dyspepsia

• Potential causes
• PUD
• GERD
• Gastric Cancer
• Motility disorder
• Malabsorption
• H pylori?

75
Dyspepsia

• Some believe that with the high rate of organic
  dyspepsia endoscopy should be performed before
  any treatment is started
• No likely advantage to early endoscopy in the
  absence of alarm sxs

76
Dyspepsia Treatment

• If age lt45 years and no alarm symptoms may do
  non-invasive testing for H pylori and if
  proceed to directly to eradication treatment
• If H pylori may try lifestyle changes or
  PPI/Prokinetic
• If unsuccessful proceed to endoscopy
• (Patients with co-existing psychiatric symptoms
  may benefit from psychiatric evaluation and
  treatment)

77
Noninvasive H pylori Testing

• Serum IgG antibody high false rate
• Urea Breath Test can use to monitor response to
  treatment
• Stool Antigen Test useful for initial diagnosis
• Positive identification of active H pylori
  infection can significantly decrease
  inappropriate antibiotic usage

78
Dyspepsia

• Although role of H pylori in dyspepsia is
  unclear, many prefer to treat
• Prevent progression of gastritis to ulcer disease
• Link to gastric adenocarcinoma

79
H pylori Treatment

• Triple Therapy
• PPI
• Amoxicillin 1000mg bid
• Clarithromycin 500mg bid
• Metronidazole 500mg bid
• Treat for 7 10 days

80
H pylori Treatment

• Quadruple Therapy
• PPI bid
• Bismuth 525mg qid
• Metronidazole 250mg qid
• Tetracycline 250mg qid
• Treat for 14 days
• Used in areas of high resistance to
  Clarithromycin
• Go to TID dosing if compliance is an issue

81
Helicobacter pylori Induced Gastritis

• Prevalence in US is increasing
• Strong link to gastric cancer and MALT lymphoma
• Controversial role in NSAID-induced ulcers
• Controversial role in functional dyspepsia
  Cochrane review suggests only 9 improvement with
  eradication
• Unclear relationship with GERD

82
Helicobacter pylori

• Responsible for the majority of duodenal and
  gastric ulcers
• Labeled as a Type I(definite) carcinogen in 1994

83
Helicobacter pylori

• Japanese study with 1526 subjects showed
• 2.9 of H pylori subjects developed gastric
  cancer
• 0 of H pylori patients developed gastric
  cancer
• 0 of H pylori subjects who were treated to
  eradicate H pylori developed gastric cancer
• Uemura, Okamoto, Yamamoto. NEJM. 2001345784-789.

84
Helicobacter pylori

• Increased risk of MALT lymphoma
• 72-98 of patients with MALT lymphoma have H
  pylori
• Eradication induces regression of lymphoma in
  70-80 of cases
• Suerbaum. NEJM. 20023471175-1186.

85
Helicobacter pylori Induced Gastritis

• Pathogenesis
• Causes continuous gastric inflammation
• Antral predominant gastritis-most common
  duodenal ulcers
• Corpus predominant gastritis-gastric atrophy
  gastric ulcers intestinal metaplasia gastric
  cancer
• Suerbaum. NEJM. 20023471175-1186.

86
Helicobacter pylori

• Suerbaum. NEJM. 20023471175-1186.

87
H pylori GERD

• Multiple studies show no effect of H pylori
  eradication on GERD sxs and multiple studies
  show a worsening of GERD sxs after H pylori
  eradication
• Patients who are H pylori may have a better
  response to PPI therapy for GERD
• Vakil et al. Am J Gastroenterol. 2000952438.
  Abstract 96.

88
Gastritis/Gastropathy

• Gastritis Epithelial damage and regeneration
  with associated inflammation
• Gastropathy Epithelial damage and regeneration
  without associated inflammation

89
Causes

• Gastritis
• Infectious
• Autoimmune
• Hypersensitivity

• Gastropathy
• Irritants(NSAIDS, ETOH)
• Bile reflux
• Hypovolemia

90
Gastritis/Gastropathy
91
Gastritis/Gastropathy
92
Gastritis/Gastropathy

• Diagnosis
• Biopsy

93
Gastritis/Gastropathy
94
Gastritis/Gastropathy

• Treatment
• Remove offending agent
• Prevent further damage with antisecretory therapy
• Prevent stress irritation in those at risk

95
Gastritis/Gastropathy

• Atrophic gastritis/intestinal metaplasia
• Increased risk for cancer
• No agreed upon surveillance strategy if any
• Consider surveillance if any Fam Hx or dysplasia

96
Peptic Ulcer Disease

• Peptic ulcers have variable behavior
• Prior ulcer history tends to predict future
  behavior
• Usually continue to recur until offending agent
  is removed(H pylori, NSAIDS)

97
Peptic Ulcer Disease

• Treatment strategy
• Treat H pylori if present
• Antisecretory therapy
• Remove offenders Etoh, smoking, NSAIDS
• No evidence that stress or certain dietary
  changes influence treatment or course

98
Peptic Ulcer Disease

• May not need to continue antisecretory tx after
  treating H pylori
• If complicated, continue antisecretory tx until
  documented healing

99
Peptic Ulcer Disease

• H pylori testing
• Can be falsely negative in the presence of PPI,
  antibiotics or bismuth
• Can confirm with histology of antrum biopsy

100
Peptic Ulcer Disease

• Gastric ulcers need to be biopsied at the margin
  to eval for cancer
• PPIs slightly better at healing compared to
  H2RAs
• Can discontinue therapy in 4-6 weeks in an
  uncomplicated, asymptomatic patient(if H pylori
  -)
• If H pylori can stop therapy after treating if
  small(lt1cm) uncomplicated, and asymptomatic

101
Peptic Ulcer Disease

• If complicated, continue antisecretory tx until
  documentation of H pylori eradication
• If ulcers are recurrent, may need to continue
  antisecretory tx
• May need to do work up for recurrent ulcers,
  including eval for gastrinoma

102
Peptic Ulcer Disease

• High risk ulcers
• Patient from endemic area
• Absence of duodenal ulcer
• Ulcer gt2-3 cm
• No NSAID use
• No protracted ulcer history

103
Gastric Polyps

• Usually found incidentally
• Rarely cause symptoms
• Can have malignant potential

104
Gastric polyps

• Study of 13,000 patients over 4 years who
  underwent EGD
• 157 had gastric polyps(1.2)
• Hyperplastic(75.6), adenomatous(6.6),
  inflammatory(17.8)
• None were malignant
• Archimandritis, A, Spiliadis, C, Tzivras, M, et
  al. Ital J Gastroenterol 1996 28387.

105
Gastric Polyps

• Study over 20 years of 4,852 patients who had
  polyps removed
• Hyperplastic(75.3), adenomatous(10), other
  mixed
• 7.2 were malignant
• Stolte, M, Sticht, T, Eidt, S, et al. Endoscopy
  1994 26659.

106
Gastric Polyps

• Etiology
• Irritation
• H pylori
• PPIs
• ?
• Familial syndromes

107
Gastric Polyps

• Malignant potential
• Up to 10 in adenomatous polyps
• Small risk in hyperplastic polyps(up to 2 in
  some studies) invasive cancer rare
• Potential increases as size increases

108
Gastric Polyps

• Familial adenomatous polyposis
• No definite risk of gastric cancer
• Definite risk of duodenal and periampullary
  adenocarcinomas
• Offerhaus, GJ, Giardiello, FM, Krush, AJ, et
  al. Gastroenterology 1992 1021980.

109
Gastric Polyps

• Peutz Jeghers
• Hamartomatous polyps
• Tendency to progress to adenocarcinoma

110
Gastric Polyps

• Questionable association between gastric polyps
  and colon polyps
• Some recommend colonoscopy at least once when
  gastric polyps are found

111
Gastric Polyps

• Management
• Eradicate H pylori if present
• Removal for pathology
• Biopsy prior to polypectomy

112
Gastric Polyps

• Surveillance
• ?All polyps or just adenomatous
• ?Appropriate interval
• ?Every 3-5 years?
• Sooner if any Fam Hx or adenomatous polyps

113
Gastric Polyps
114
Gastric Cancer

• Estimated 21,860 Americans dx with gastric cancer
  in 2005
• 13,510 men 8,350 women
• Estimated 11,560 deaths in 2005
• 2/3 dx at age gt65
• 1/100 lifetime chance of developing gastric
  cancer
• 2005 Cancer Statistics American Cancer Society

115
Gastric Cancer

• More common in under-developed countries
• Second leading cause of cancer death worldwide
• 700,000 deaths in 2002
• Gastric cancer in America is 25 of what it was
  in 1930
• Less salted/smoked foods?
• More antibiotic usage?
• 2005 Cancer Statistics American Cancer Society

116
Gastric Cancer
117
Gastric Cancer

• Usually diagnosed at an advanced stage
• 23 5 year survival rate
• African-Americans have higher death rates from
  gastric cancer
• 2.4 times more likely to die than white Americans
• 2005 Cancer Statistics American Cancer Society

118
Gastric Cancer
119
Gastric Cancer

• Palpable mass usually first physical sign
  usually indicates advanced disease
• Sister Mary Josephs node peri-umbilical
• Virchows node left supraclavicular
• If ascites present perform paracentesis

120
Gastric Cancer

• Diagnosis
• Upper endoscopy ability to biopsy
• Barium meal can have high false negative rate,
  especially early in disease

121
Gastric Cancer

• Biopsies
• Graham, et al showed that 1 biopsy yielded a
  correct diagnosis in 70 of patients while 3 and
  7 biopsies increased the yield to 95 and 98
  respectively
• Question of whether or not to repeat endoscopy to
  document healing in non-malignant ulcers
• Graham, DY, Schwarz, JT, Cain, GD, Gyorky, F.
  Gastroenterology 1982 82228.

122
Gastric Cancer

• Question of whether or not to repeat endoscopy to
  document healing in non-malignant ulcers
• May be prudent to do repeat endoscopy 8-12 weeks
  later with repeat biopsies taken of any remaining
  ulcers(ASGE recommendation)

123
Gastric Cancer

• Staging
• CT use to look for metastases (liver)
• Endoscopic ultrasound better for depth of
  invasion and nodal involvement
• Laparoscopy -

124
Gastric Cancer

• Two main histological types of gastric
  adenocarcinoma
• Intestinal type more common in men and older
  ages
• Diffuse type equal distribution between sexes
  more common in younger population worse prognosis

125
Gastric Cancer

• Distribution is reversing
• Moving from more distal to more proximal,
  especially at gastric cardia

126
Gastric Cancer

• Other less common gastric cancers
• MALT lymphomas, carcinoids, sarcomas
• Rare
• Scirrhous carcinoma linitus plastica

127
Gastric Cancer

• Linitus plastica
• Poorly differentiated mixture of mucin-producing
  cells that invade into the gastric musculature
  and makes the stomach more rigid and
  leather-like impairs distention and digestion
• Can be difficult to detect endoscopically

128
Gastric Cancer
129
Gastric Cancer

• Risk factors
• Diet Nitrites, nitrates, salt increase risk
  fresh vegetables protective
• Sex/Ethnicity Males, especially
  African-American
• H pylori antrum
• Autoimmune gastritis achlorhydria and
  pernicious anemia
• Gastric polyps
• Chronic GERD?
• Familial syndromes

130
Gastric Cancer

• Screening
• Not in America incidence too low
• It is unclear if screening programs in Japan have
  been successful in decreasing gastric cancer
  incidence
• H pylori eradication programs?
• Only where cancer incidence is high unsure if
  effective

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GERD Summary

• Pathogenesis is multifactorial
• Treat empirically if no alarm sxs
• Tailor treatment based on symptoms, pathology,
  and patient preference
• Recognize atypical presentation
• Increased risk of stricture and Barretts with
  prolonged acid exposure

133
GERD Summary

• Barretts is a pre-malignant condition
• No evidence treatment reduces incidence of cancer
• ASA/NSAIDS may be protective against esophageal
  cancer

134
Dyspepsia Summary

• Acceptable to treat prior to endoscopy if no
  alarm sxs
• H pylori has controversial role
• Positive identification of active H pylori
  infection can decrease inappropriate antibiotic
  usage

135
H pylori Summary

• Major contributor to Gastritis and PUD
• Believed to be a carcinogen
• Eradicate when it is discovered
• May lessen symptoms of GERD

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Gastritis Summary

• H pylori gastritis is linked to duodenal
  gastric ulcers, gastric cancer and MALT lymphoma
• Corpus gastritis is less common but more likely
  to lead to cancer
• Unclear relationship to GERD

137
PUD Summary

• Ulcers can have a variable history
• H pylori and NSAID use are the most common
  culprits
• Uncomplicated ulcers do not necessarily need
  documentation of healing

138
PUD Summary

• Complicated ulcers may need more surveillance and
  documentation of healing and documentation of
  eradication of H pylori if

139
Gastric polyps Summary

• They do have malignant potential
• Remove for pathology
• Surveillance depends on histology and risk
  factors

140
Gastric Cancer Summary

• Low incidence in the US
• Second-leading cause of cancer death world-wide
• Usually diagnosed at an advanced stage
• Take at least 7 biopsies of any suspicious lesion
  and consider f/u endoscopy to document healing

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Gastric Cancer Summary

• Screening programs only done in areas of higher
  incidence still no proven benefit