106 - GORD/PUD Flashcards
Define GORD
Symptoms or mucosal damage produced by abnormal reflux of gastric contents into oesophagus
Key symptoms of GORD
Heartburn in retrosternal area and acid regurgitation
Physiological reflux likely if
Happens after eating
Short lived
Asymptomatic
Rarely occurs in sleep
What is dysphagia
Problems swallowing. Red flag symptom. Long term GORD - need to rule out adenocarcinoma
Differential diagnosis of GORD
Angina pectoris major differential
Stricture, ulcer, Barrett’s oesophagus, cancer. Exclude cardiorespiratory causes.
Practically - consider GORD in all cases of
Chronic heartburn
Severity and duration of GORD symptoms indicate
nothing about severity oesophagitis
Prevalence of GORD
Can be as high as 20% in US. Varies with geography and ethnicity.
Factors associated with GORD
Family history Pregnancy High BMI Lower educational level Smoking Alcohol Prescription medications
Dyspepsia is
Pain/discomfort centred in the upper abdomen
Causes of dyspepsia
25% have underlying cause
Peptic ulcer disease most common
Also biliary pain, pancreatitis, chronic abdominal wall pain, cancer, medications.
Dyspepsia Rome III definition
Postprandial fullness
Early satiation
Epigastric pain/burning
Definition of Peptic Ulcer Disease
PUD - surface breach of mucosal lining of GI tract due to acid & pepsin mediated damage
Common sites of PUD
Duodenum (80%)
Stomach (20%)
Causes of chronic gastritis
H. pylori - over 80% cases Chemical damage (bile, reflux, drugs) Autoimmune - Pernicious anaemia (Vit B12 malabsorption)
Causes of acute gastritis
Usually due to chemical injury - alcohol/drugs
What is gastritis
Inflammation of stomach lining
Peptic ulcer symptoms
Wide variety or can be asymptomatic until complications start Dyspepsia Anorexia Weight loss Fatty food intolerance Epigastric pain Pain can radiate to back
Duodenal ulcer symptoms generally occur
2-5hrs after eating on empty stomach - as acid empties into duodenum
Gastric ulcer symptoms gennerally occur
soon after meals - acid in stomach
Complications of peptic ulcer
Perforation leading to peritonitis Haemorrhage due to erosion of vessel Penetration of surrounding organ Obstruction due to scaring - pyloric stenosis Cancer - VERY RARE
PUD alarm symptoms
Weight loss Persistant vomiting Dysphagia (getting worse) Haematemesis Palpable abdominal mass Unexplained anaemia Family history of Upper GI cancer Jaundice Previous gastric surgery
Common drugs that can cause PUD
NSAIDs
What is Zollinger-Ellison syndrome
Gastrin secreting tumour in duodenum/pancreas results in increased acid production. Genetic link
PUD risk factors
Male
Smoker
Excessive alcohol intake
Common PUD presentation
Pain - relieved by food/antacid/milk Epigastric tenderness on palpation Nausea/vomiting Haemorrage Can be associated with GORD
Investigation of suspected PUD
Test and treat approach. Stop any drugs could be causing FBC - check for anaemia H Pylori testing Endoscopy if indicated
H. Pylori triple therapy
PPI - e.g. Omeprazole
2 x Abx - Amoxicillin (Metronidazole if allergic) and Clarithromycin.
H Pylori testing
Either stool antigen test or Urea breath test
How does Urea breath test work?
Urea swallowed and is broke down by H. pylori to CO2 and NH3
Red flags for PUD
Bleeding Iron deficiency anaemia Weight Loss Dysphagia Epigastric mass H Pylori & NSAID negative
Acid-reflux defences
Lower oesophageal spincter Angle of his Mucosal flap and folds Diaphragm Peristalsis - clean reflux Bicarbonate present in saliva
Pathophysiologies for GORD
Can be due to: Poor oesophageal peristalsis Incompetent lower oesophageal sphincter Hiatus hernia - stomach herniating through diaphragm and angle of his is destroyed Delayed gastric emptying
GORD investigations
FBC - exclude anaemia
Trial PPIs
Barium swallow - look predisposing factors
pH monitoring - exclude oesophageal/peristaltic dysfunction
Endoscopy - look for Barretts
Treatments for GORD
Lifestyle changes
Antacids
Acid suppressors - PPI (omeprazole) or H2 receptor antagonists (Ranitidine)
Surgery if needed
What is Oesophagitis? What causes it?
Inflammation of oesophagus due to acid and pepsins
Complications of Oesophagitis
Oesophageal stricture - dysphagia
May cause Barretts Oesophagus or chronic inflammation
Barrett’s Oesophagus - What is it?
Normal stratified squamous epithelium is replaced with columnar epithelium. Potential to transform to adenocarcinoma.
Stages of development of Barrett’s Oesophagus
Damage to epithelium
Metaplasia occurs during repair to acid damage.
Dysplasia occurs
Adenocarcinoma can occur
Barrett’s Oesophagus changes to gastric columnar epithelium - risks?
No malignant potential
Barrett’s Oesophagus changes to intestinal columnar epithelium - risks?
Malignant potential
Barrett’s Oesophagus - appearance on endoscopy
Finger like projections or sheets/patches of reddened epithelium.
Risk factors for Barrett’s Oesophagus
GORD, hiatus hernia
Male
Obesity
Smoking/Excessive alcohol
Impact of NSAIDS and H.Pylori in patient with Barrett’s Oesophagus
Protective against malignant changes
Symptoms of Barrett’s Oesophagus
Asymptomatic - found on endoscopy
Investigations for Barretts Oesophagus
Endoscopy + biopsy
Treatment for Barrett’s oesophagus
Acid suppression - slow progression.
Endoscopy to monitor.
If high grade dysplasis - ablation to burn away dysplastic epithelium or surgical resection of oesophagus.
Alternative names for urea breath test for H. Pylori
Carbon 13 test
CLO test (breath test)
Urease test
Surgical option for GORD
Nissen fundoplication
Wrap fundus of stomach around lower part of oesophagus.
