2)Common GI/Liver Conditions Flashcards
Pathophysiology of GORD?
LOS dysfunction leads to reflux of gastric contents -> Oesophagitis
Risk Factors for GORD?
- Hiatus Hernia
- Smoking
- Drinking
- Obesity
- Pregnancy
- Drugs (antiCh, Nitrates, CCB,TCAs)
- Iatrogenic (Hellers myotomy)
- LOS hypotension
- loss of peristaltic fx
- Gastric acide hypersectretion
Symptoms of GORD?
Oesophageal
- Heartburn related to meals, worse lying down/stooping. relieved by antacids
- Belching
- Odonophagia
- Incr salivation
Extra-oesophageal
- Nocturnal Asthma
- Laryngitis
- Chronic cough
- IDA?
Complications of GORD?
- Oesophagitis: heartburn
- Ulceration: rarely → haematemesis, melaena, ↓Fe
- Benign stricture: dysphagia
- Barrett’s oesophagus
- Intestinal metaplasia of squamous epithelium
- Metaplasia → dysplasia → adenocarcinoma
- Oesophageal adenocarcinoma
DD for GORD?
- Oesophagitis
- Infection: CMV, candida
- IBD
- Caustic substances / burns
- PUD
- Oesophageal Ca
Ix for GORD?
Isolated symptoms dont need investigating. CXR may show hiatus hernia OGD IF: ->55 -Symptoms >4wks -Dysphagia -Persistent symptoms despite Rx -Wt. loss -OGD allows grading by Los Angeles Classification Ba swallow: hiatus hernia, dysmotility -24h pH testing ± manometry -pH <4 for >4hrs
Treatment for GORD?
Conservative
- Lose wt.
- Raise head of bed
- Small regular meals ≥ 3h before bed
- stop smoking and ↓ EtOH
- Avoid hot drinks and spicy food
- Stop drugs: NSAIDs, steroids, CCBs, nitrates
Medical
- OTC antacids: Gaviscon, Mg trisilicate
- 1: Full-dose PPI for 1-2mo
- Lansoprazole 30mg OD
- 2: No response → double dose PPI BD
- 3: No response: add an H2RA
- Ranitidine 300mg nocte
- Control: low-dose acid suppression PRN
Surgical Nissen Fundoplication -Indications: all 3 of: -severe symptoms -Refractory to medical therapy -Confirmed reflux (pH monitoring)
Complications of Nissen Fundoplication?
- Gas-bloat syn.: inability to belch / vomit
- Dysphagia if wrap too tight
How is peptic ulcer disease classified?
Acute v Chronic
Acute: Usually due to drugs (NSAIDS/Steroids) or ‘Stress’
Chronic: Drugs, H.Pylori, Zollinger-Ellison
Pathology of Duodenal Ulcers?
- 4x more common than gastric ulcers
- M>F
- First part of duodenum
Risk factors for duodenal ulcers?
H. pylori (90%)
- Drugs: NSAIDs, steroids
- Smoking
- EtOH
- ↑ gastric emptying
- Blood group O
Presentation of duodenal ulcers?
Epigastric pain:
- Before meals and at night
- Relieved by eating or milk
Pathology of Gastric Ulcers?
- Lesser curve of gastric antrum
- Beware ulcers elsewhere as often malignant
Presentation of Gastric ulcers?
Epigastric pain
-Worse on eating
-Relieved by antacids
May be weight loss
Complications of PUD?
Haemorrhage -Haematemeis or melaena -Fe deficiency anaemia Perforation -Peritonitis Gastric Outflow Obstruction -Vomiting, colic, distension Malignancy - ↑ risk c¯ H. pylor
Investigations in PUD?
Bloods: FBC, urea (↑ in haemorrhage)
- C13 breath test
- OGD (stop PPIs >2wks before)
- CLO / urease test for H. pylori
- Always take biopsies of ulcers to check for Ca
- Gastrin levels if Zollinger-Ellison suspected
What are non-surgical management options for PUD?
Conservative
- Lose wt.
- Stop smoking and ↓ EtOH
- Avoid hot drinks and spicy food
- Stop drugs: NSAIDs, steroids
- OTC antacids
Medical
- OTC antacids: Gaviscon, Mg trisilicate
- H. pylori eradication: PAC500 or PMC250
- Full-dose acid suppression for 1-2mo
- PPIs: lansoprazole 30mg OD
- H2RAs: ranitidine 300mg nocte
- Low-dose acid suppression PRN
What are the surgical options for PUD?
Vagotomy (truncal or selective) Antrectomy +/- vagotomy Subtotal gastrctomy (for zollinger ellison)
What are the physical complications of PUD surgery?
Stump leakage
- Abdominal fullness
- Reflux or bilious vomiting (improves c¯ time)
- Stricture
What are the metabolic complications of PUD surgery?
Dumping syndrome
- Abdo distension, flushing, n/v
- Early: osmotic hypovolaemia
- Late: reactive hypoglycaemia
Blind loop syndrome → malabsorption, diarrhoea
- Overgrowth of bacteria in duodenal stump
- Anaemia: Fe + B12
- Osteoporosis
-Wt. loss: malabsorption of ↓ calories intake
What is dyspepsia?
Non specific group of symptoms:
- Epigastric pain
- Bloating
- Heartburn
What are alarm symptoms in dyspepsia?
Anaemia Loss of wt. Anorexia Recent onset progressive symptoms Melaena or haematemesis Swallowing difficulty
What are the causes of dyspepsia?
- Inflammation: GORD, gastritis, PUD
- Ca: oesophageal, gastric
- Functional: non-ulcer dyspepsia
What is the management of new onset dyspepsia?
OGD if >55 or ALARMS Try conservative measures for 4 wks Stop drugs: NSAIDs, CCBs (relax LOS) Lose wt., stop smoking, ↓ EtOH Avoid hot drinks and spicy food OTC Antacids: magnesium trisilicate Alginates: gaviscon advance Test for H. pylori if no improvement: breath or serology +ve → eradication therapy Consider OGD if no improvement -ve → PPI trial for 4wks Consider OGD if no improvement PPIs can be used intermittently to control symptoms.
Management of proven GORD?
Full dose PPI for 1-2mo
Then, low-dose PPI PRN
Management of proven PUD?
Full dose PPI for 1-2mo
H. pylori eradication if positive
Endoscopy to check for resolution if GU
Then, low-dose PPI PRN
What is H Pylori eradication therapy?
7 day course NB PPIs and cimetidine → false –ve C13 breath tests and antigen tests t/f stop >2wks before. PAC 500 PPI: lansoprazole 30mg BD Amoxicillin 1g BD Clarithromycin 500mg BD PMC 250 PPI: lansoprazole 30mg BD Metronidazole 400mg BD Clarithromycin 250mg BD
What is the failure rate of eradication therapy?
95% success rate, failure mainly due to poor compliance. Can add bismuth (make stool black)
What is barretts and how is it graded?
Distal oesophageal epithelium undergoes metaplasia from squamous to columnar.
- Gastric metaplasia is low risk
- Intestinal metaplasia is 2 yrly surveillance
- Low grade dysplasia= 90% chance of Ca at 6yr
- High Grade dysplasia+ half will already have adenocarcinoma
What is the classification system in GORD?
LA classification 1- mucosal break <5mm 2- mucosal break >5 mm 3- large mucosal break but <75% of circumference 4- mucosal break > 75% of circumference
What are the two types of hiatus hernia? which gives yu reflux?
Sliding and rolling
Sliding gives you reflux as sphincter is in chest and becomes less competent
Rolling rarely gives reflux as sphincter is in abdomen, needs repair though as more likely to strangulate= bad
