Case 8 Flashcards
How can Mr Muller’s symptoms be described?
Reflux and dyspepsia
What is dyspepsia?
Recurrent epigastric pain, heartburn or symptoms of acid regurgitation, with or without bloating, nausea or vomiting
What are underlying causes of dyspepsia?
Oesophageal reflux
Gastroenteritis
In addition to dyspepsia, what are other symptoms a patient with oesophageal reflux may experience?
Belching, excess salivation known as water brash
In addition to dyspepsia, what are other symptoms a patient with gastroenteritis may experience?
Fever, vomiting and diarrhoea
What are a list of differentials for dyspepsia?
Coeliac disease Inflammatory bowel disease GORD Gastritis Pancreatitis Medication side effects Functional dyspepsia Gallbladder disease Gastroenteritis Stress Peptic ulcer disease Coronary heart disease
What are the 5 most likely diagnosis for Mr Muller?
GORD Functional dyspepsia Gastritis Stress Peptic ulcer disease
What is functional dyspepsia?
Most common cause of dyspepsia
Its where an individual suffers symptoms of dyspepsia but routine investigations do not reveal causative abnormalities
What is gastritis?
Inflammation of the gastric mucosa
Often resolves by itself
Whats is the overlap between functional dyspepsia and gastritis?
In functional dyspepsia, endoscopy often reveals an element of gastritis
However even if gastritis is resent it doesn’t correlate with the degree of symptoms which is why its called functional dyspepsia
What can cause gastritis?
Gastritis can be symptomatic and problematic e.g. when caused by infection, medications e.g NSAIDs (effect integrity of mucous lining of stomach), or alcohol excess
What can gastritis lead to?
Stomach ulceration
What can stress be associated with?
Can be associated with functional dyspepsia, overt gastritis, peptic ulceration
What is oesophagitis?
Reflux irritates the oesophagus
What is peptic ulcer disease?
Gastric ulceration or duodenal ulceration
How would gallbladder disease present?
Dyspepsia
Pain would be more colicky in nature
What is colicky pain?
Intermittent, spasmodic pain that occurs when a hollow tube contracts to try and relieve obstruction
Eg. gallstones cause colicky pain along with renal stones and intestinal obstruction
How does pancreatitis present?
Associated with signs and symptoms of pancreatic insufficiency e.g steatorrhea or diabetes
What are risk factors Mr Muller has for coronary disease?
Stress
Smoking history
Angina pain can present as dyspepsia
What term is given to signs or symptoms with a more serious underlying pathology?
Red Flag symptoms
Why is the concept of red flags useful?
Help bus risk stratify so we can differentiate between more innocent symptoms and possible dangerous underlying pathology.
This allows those that need it to get early investigation and management
What are important red flags?
Back pain- spinal cord compression? malignancy? infection?
Red flags for back pain: previous cancer, bladder/bowel dysfunction, fever
Headaches- meningitis? intracerebral tumour? infection? acute bleed?
Red flags for headache: meningism (meninges irritated- raised inter-cranial pressure or sudden/severe headache)
What red flags make a doctor suspicious for upper GI cancer?
Mass
Dysphagia
Weight Loss
Where can you find red flag features?
Referral guidelines
E.g. NICE guidlines
What is the term given for vomiting blood?
Haematemesis
In the NICE guidelines, what are the refer outlines for suspected upper GI cancer?
Urgent referral: upper abdominal mass consistent with stomach cancer
Urgent upper GI endoscopy: dysphagia, weightloss, upper abdominal pain, reflux, dyspepsia
Non-urgent upper GI endoscopy: haematemesis
- if over 55: treatment resistant dyspepsia, abdominal pain with low Hb, low platelet count with nausea/vomiting/weight-loss/reflux/dyspepsia/abdominal pain, nausea and vomiting with weight loss/reflux/dyspepsia/upper abdominal pain
What are 7 investigations the GP should carry out for Mr Muller at initial presentation of symptoms?
Test for H. Pylori FBC LFTs Alcohol history Medication history Weight ECG
What are benefits of an ECG?
Quick and non-invasive
Ideally during pain (to see if associate with cardiac ischaemia)
Might highlight abnormalities
What are benefits of measuring weight?
Simple an free
Monitering
BMI
What is the importance of taking an alcohol history?
Above the limit? (Recommend is 14 units per week)
Clinical consequences- e.g alcoholic gastritis or liver damage
Offer support
What’s the importance of taking a medication history?
Include over the counter
Those that relax the oesophageal sphincter e.g. Ca channel blockers and nitrates
Those that affect gastric mucosa e.g. NSAIDs and aspirin
Why is it important to test for H. Pylori?
Common is dyspepsia
Gastric, peptic ulcer diseases and gastric malignancies (inc. adenocarcinoma, MALT lymphoma)
Highly prevalent (~50% of population have it living in their stomachs))
Why is it important to take a FBC?
Anaemia- due to occult blood loss and cancer can impact RBC production through interference with erythropoietin production High platelets (thrombocytosis)- no of cancer can cause this due to release of cytokines which promote platelet production
What is the significance of taking liver function tests (LFTs)?
Biliary disease?
Alcohol-induced changes?
Opportunistic
When would we use stool tests?
Diarrhoea
Recent travel
Suspected gastroenteritis
When is an abdominal radiograph used?
In an acute setting when looking for intestinal obstruction or perforation
Don’t show subtle findings
When would you do a rectal examination?
To look for upper GI bleeding- can identify presence of malaena
What is malaena?
Dark and offensive smelling faeces containing digested blood from upper GI tract
What is the site of infection of H. Pylori?
The stomach- has HCl which H. Pylori can survive in
How is H. Pylori infect the stomach?
H. Pylori s ingested
H. Pylori synthesises urease which catalyses a reaction to neutralise the acid surrounding it
Uses flagella to propel itself and is guided by chemotactic gradient towards the stomach lining
What is the role if urease?
Converts urea into ammonia and CO2
What is the role of urease?
Converts urea into ammonia and CO2
Ammonia is basic and neutralises HCl
What happens when H. Pylori reaches the mucous layer?
pH is very neutral close to surface of epithelial cells- this is where it needs to get
It has special molecules e.g. LPS/BabA which help it to adhere to cells on the stomach lining once its reached here
This process is not harmful to the human host
What toxins does H. Pylori release once its adhered?
cagA- Disrupts the tight junctions between cells in the stomach lining leading to inflammation- gastritis
vacA- Causes cells in stomach lining to undergo apoptosis and die
What is the effect of the toxins H. Pylori releases?
Toxins disrupt the continuity of the stomach lining and cause underlying cells to now be exposed to corrosive effects of HCl which can lead to ulcers
How do different strains of H. Pylori differ?
Not all strains cause gastritis or ulcers
More than 50% of the world population have H.Pylori in their stomachs- not all these people suffer from upper GI problems
What tests can be carried out to test for H. Pylori?
Carbon 13 urea breath test- probes for H. Pylori protein
Stool antigen test- Probes for H.Pylori protein
Serum serology test- Probes for human protein
CLO test- probes for H. Pylori protein
What are advantage and disadvantages of carbon-13 urea breath test?
A:
- non invasive, simple and safe
- high sensitivity and specificity
- can be used for diagnosis and as a test of cure
D:
- Requires specialist analysing equipment, samples may need sending away
- If patient is on ABs or PPIs results may be falsely negative
- Requires fasting conditions
What are advantage and disadvantages of stool antigen test?
A:
- non-invasive, simple, safe
- highly sensitive and specific
- can be used for diagnosis ad theoretically as a test of cure
D:
- pateints might prefer other tests
- samples need refrigeration
- If patient is on ABs or PPIs results may be falsely negative
- Sufficient evidence lacking for use of test of cure
What are advantage and disadvantages of serum serology test?
A:
- Cheap and widely available
- Maybe useful for diagnosing patient the is newly infected
D:
- IgM poorly sensitive for new infection
- IgG does not tell you if infection is current (as will remain positive after infection cleared)
- Cannot test for cure
What are advantage and disadvantages of CLO test?
A:
High sensitivity and specificity
- Instantaneous results
D:
- If patient is on ABs or PPIs results may be falsely negative
- Invasive
Why do NICE guidelines recommend a carbon-13 urea test or stool antigen test be used initially to test for H. Pylori?
They highly specific and sensitive
They’re non-invasive, simple and safe
Stool antigen test was chosen fr Mr Muller as c13 urea breath test requires specialist equipment
What cells secrete HCl
Parietal cell lines gastric gland- it secretes HCl
How is HCl produced?
CO2 from capillaries/ interstitial fluid moves into parietal cell
CO2 combines with water to form H+ and HCO3- via carbonic anhydrase
K+ moves in from lumen and H+ moves out into lumen via gastric H+/K+ ATPase
K+ moves in from capillaries/ interstitial fluid into parietal cell
Cl- moves into cell as HCO3- moves out of cell
Cl- moves into lumen via chloride channel
What receptors are found on the parietal cell and what is their role?
ACh receptor
H2 receptor (histamine receptor)- initiate signalling cascade that result in getting proton pump from cytoplasm to the apical cell membrane
Gastrin receptor
Where to drugs which reduce HCl production act?
Act on the proton pump- proton pump inhibitors
Act of H2 receptor- H2 antagonists
Act on HCl- acid-base neutralisation
These drugs are known as antacids
What is the effect of PPIs?
Reduce production of HCl- 80% of acid is blocked by PPIs
Have weak antibacterial effects against H. Pylori
Have anti-urease activity and anti- ATPase activity
Whats the most effective way to treat H Pylori infection?
Couple PPIs with antibiotics
By suppressing acid secretion, PPIs cause ABs to concentrate enhancing their effect
What are examples of antacid drugs?
PPIs: omeprazole, Lansoprazole
H2 antagonists: Cimetidine, Ranitidine
HCl neutralisers: Magnesium carbonate, aluminium hydroxide
What was Mr Muller treated with?
Omeprazole, Amoxicillin, clarithromycin
Re-tested with carbon-13 breath test
How are carbon-13 breath test false negatives avoided?
Nice recommends the test is proceeded by at least 2 weeks of no PPIs and four weeks of no ABs
Wta is a hiatus hernia?
It’s where part of the abdominal viscera herniates through the oesophageal opening in the diaphragm.
What are risk factors for a hiatus hernia?
Male gender, obesity, age, pregnancy, genetic predisposition
What causes a hiatus hernia?
Widening of the diaphragmatic hiatus
Pulling up of the stomach (eg due to oesophageal shortening)
Pushing up of the stomach (eg due to increased intra-abdominal pressure)
What does a hiatus hernia lead to?
Leads to the function og the lower oesophageal sphincter to be compromised and anti-reflux barrier to be lost allowing stomach contents to be refluxed into the oesophagus
What are the 2 variants of a hiatus hernia?
Sliding and rolling
Whats the difference between a sliding and rolling hiatus hernia?
Sliding: 85-95% of causes, GOJ moves upwards, predominantly causes GORD
Rolling: 5-15% of causes, GOJ remains in place, a portion of the stomach, bowel, pancreas or spleen herniates into chest next to the GOJ
What is ideal treatment for non-acidic reflux?
Alginate medication e.g. gaviscon
Alginates precipitate into a gel which reacts with stomach contents to form a foamy raft that floats onto of stomach contents
This can act as a physical barrier to reflux or will preferentially reflux into into the oesophagus into the irritating stomach contents
What is important about identifying Barrett’s oesophagus?
A small proportion of those with Barrett’s oesophagus will go on to develop oesophageal cancer (~1-5%)
What are the different tissues along the GI tract?
Oesophagus- stratified squamous epithelium
Stomach- columnar tissue with gastric pits and glands (foveolar cels, parietal cells, g cells and chief cells)
Small intestine- Columnar tissue (enterocytes, goblet cells)
Large - columnar epithelium
What happens in barrettes oesophagus?
Squamous epithelium undergoes metaplasia to columnar epithelium
Intestinal metaplasia is characterised by columnar epithelium and distinct intestinal- type goblet cells
How does the Barretts mucosa differs in appearance to the normal oesophageal mucosa?
Barretts mucosa is more red and velvety
What is cardiac metaplasia?
Cardiac refers to the cardia part of the stomach
Cardiac metaplasia is sometimes considered as a precursor of intestinal metaplasia
Why is Barrett oesophagus a problem?
Metaplasia leads to the excessive production of growth signals in a non-native location.
These metaplastic cells are vulnerable to developing architectural and cytological abnormalities- leads to dysplasia
What do we call a group of high grade dysplasia cells that hasn’t extended beyond their original location?
Carcinoma in situ
Intra-epithelial neoplasia
Stage 0 cancer
What happens if dysplasia cells extend beyond their original location?
Become an invasive carcinoma
In a patient who has Barretts oesophagus this leads to oesophageal cancer
What are 6 suggestion that should be given to Mr Muller?
- Raise 1 end of bed by 10-20cm (gravity limits reflux)
- Try to lose weight (excess weight on abdomen can increase abdominal pressure and reflux)
- Try to find ways to relax (stress affects brain-gut axis, stress my lower o- sphincter, slow gastric emptying, affect inflammatory pathways)
- Do not eat 3-4 hours before bed (gives stomach time to digest)
- Do not smoke (nicotine relaxes lower o-sphincter)
- Do not drink too much alcohol (chronic alcohol may damage gastric mucosa and increase acid production, inhibit gastric emptying, effect function of los)
What are common food triggers for acid reflux?
Spicy food
Acidic fruits
Coffee
Whats the difference between squamous cell carcinoma and adenocarcinoma?
Squamous cell carcinoma: a subtype of oesophageal cancer, occurs at any level
Adenocarcinoma: occurs in inferior 1/3 of oesophagus, related to Barretts oesophagus
What is oesophageal varicose?
Abnormally dilated sub-mucosal veins in the anastomosis between the systemic and portal circulation
This can cause portal hypertension
