Case 8: Dyspepsia Flashcards
What is dyspepsia?
Recurrent epigastric pain or symptoms of acid regurgitation leading to bloating.
What are some other terms for dyspepsia?
- Heart burn
- Acid reflux
What are some of the causes of dyspepsia?
- Oesophageal reflux
- GORD
- Gastroenteritis
- Gastritis
- Functional dyspepsia
- Peptic Ulcer disease
- Stress
- Coeliac disease
- Inflammatory bowel disease
- Gallbladder disease
- Coronary heart disease
- Upper GI malignancies
What are the symptoms of Oesophageal reflux?
- Burping
- Excess saliva production (water brash)
What does GORD stand for?
Gastro-Oesophageal Reflux Disease
What is gastroenteritis and what are its symptoms?
Inflammation of stomach and bowels caused by infection (e.g. rotavirus or salmonella)
- Fever
- Vomiting
- Watery, loose Diarrhoea
What is gastritis?
Inflammation of stomach lining which can be caused by infection, excess alcohol etc.
What is the difference between gastritis and gastroenteritis?
Gastritis is inflammation of solely the stomach lining and symptoms include vomiting and pain. It does NOT include diarrhoea, unlike Gastroenteritis.
What type of pain is common in gallbladder disease?
Colicky pain
What is colicky pain?
Pain that comes in spasms due to gallstones/wind/intestinal obstruction.
What are the symptoms of upper GI malignancies? FLAWS
- Weight loss
- Bleeding (anaemia)
- Palpable mass
- Haematemesis (blood in vomit)
- Dysphagia (inability to swallow)
- Upper abdominal pain
- Odynophagia (pain upon swallowing)
F
Lethargy
Anaemia
Weight loss
Sweat at night
What are indicators of serious underlying conditions/pathology called?
Red flag symptoms
When is an urgent (2-week-wait) referral considered for a person with suspected upper GI cancer?
If they have an upper abdominal mass consistent with stomach cancer
When is an urgent upper GI endoscopy offered?
For people
- with dysphagia
or
- aged 55 with weight loss and either upper abdominal pain, reflux or dyspepsia.
When is non-urgent upper GI endoscopy offered?
- For people with haematemesis
- For people >55 with treatment resistant dyspepsia/ low Hb levels with abdominal pain/ raised platelet count with dyspepsia or pain/ nausea with other cancer symptoms
What basic investigations are carried out for a patient reporting heartburn?
- Stool antigen test
- FBC
- ECG
- Weight check
- Thorough alcohol history
- Liver function test (opportunistic test for those with high alcohol intake)
- Medication history
What is the stool antigen test for?
Testing for H. pylori
What is the purpose of conducting a full blood count?
To check for HB levels and platelets.
If anaemia is discovered, it could be a sign of GI bleeding or reduced erythropoiesis.
What is the recommended alcohol intake for both men and women?
14 units per week, evenly distributed
Why is medication history important?
Over the counter drugs, beta blockers and calcium channel inhibitors can all loosen the lower oesophageal sphincter, increasing likelihood of acid reflux.
When would a digital rectal examination be done?
If malaena (blood in stool) is found
What can H-pylori cause?
- Gastritis
- Peptic Ulcer disease
- Gastric malignancies (e.g. adenocarcinoma, MALT lymphoma)
How can it cause inflammation?
- Acid neutralisation
- Locomotion
- Adherence to host cell
- Release of toxins
What viral enzyme is responsible for acid neutralisation (1st step)?
UREASE.
Urea + H20 -> Ammonia + CO2
Why is acid neutralisation important?
Although H. pylori can survive in acid, it is not an acidophile so needs to enter the mucosa swiftly.
How does H. pylori move into the mucosa (2nd step)?
Via its flagella
How does it adhere to host cells (3rd step)?
Via
- BabA
- Lipopolysaccharides (LPS)
What toxins can H. pylori release?
- cagA
2. vacA
How does cagA cause inflammation?
It disrupts tight junctions b/w cells -> inflammation
How does vacA cause inflammation?
It induces apoptosis.
What cells in the stomach produce HCl?
Parietal cells
What pump is responsible for pumping H+ into the stomach lumen?
Gastric hydrogen/potassium ATPase pump
What are the receptors found on the basolateral side of the parietal cells, which when bound, can stimulate HCl production?
- Histamine receptor (H2)
- ACh receptor
- Gastrin receptor
What can be targeted by acid reflux treatments?
- H2 antagonists
- Proton pump inhibitors
- Antacids
Name some H2 antagonists
- Cimetidine
- Ranitidine
Name some proton pump inhibitors
- Omeprazole
- Lansoprazole
How can proton pump inhibitors help with H. pylori infections?
Its main action is to irreversibly bind to the K+/H+ ATPase pump. HOWEVER, it also has…
- Weak anti-microbial action
- Anti-urease activity
Name some antacids
- Aluminium hydroxide
- Magnesium carbonate
What are the different tests for H. pylori?
- Carbon-13 urea breath test
- Stool antigen test
- Serum serology test
- CLO test
Which tests are recommended for diagnosing H.pylori infections?
- Stool antigen test
2. Carbon-13 urea breath test
How does Carbon-13 urea breath test diagnose H.pylori?
It checks for H. pylori antigens.
IT CAN BE USED FOR DIAGNOSIS + AS A TEST FOR CURE.
What is the main disadvantage of using a Carbon-13 urea breath test?
It requires fasting conditions.
How does the stool antigen test diagnose H.pylori?
It checks for catalase.
CAN BE USED FOR DIAGNOSIS.
What is the main disadvantage of using a stool antigen test?
It cannot be used to test for cure after treatment.
How does the serum serology test work?
It checks for human proteins (IgM and IgG antibodies) made against H. pylori.
What is the main disadvantage of using a CLO test?
It is an invasive test.
What is the treatment offered for someone with a suspected H. pylori infection?
- PPIs + antibiotics are prescribed.
- Carbon-13 urea breath test used to test for cure, 4 weeks after antibiotics are stopped.
- If symptoms persist, try alternative drugs like ranitidine.
Why do you wait for 4 weeks after treatment before conducting the curative test?
H. pylori activity may be affected by medication.
If symptoms persist even after alternative medical treatment, what is the condition known as?
Treatment resistant dyspepsia
How is treatment resistant dyspepsia investigated further?
OGD (Oesophago-gastro-duodenoscopy)
Why might symptoms persist despite PPIs?
If the symptoms are caused by non-acid reflux. This can be confirmed through Gastro-oesophageal pH monitoring.
What is treatment for non-acid reflux?
Alginate medication like Gaviscon
How does Gaviscon work?
It precipitates into a gel which can react with stomach contents to form a foamy raft.
This raft floats on top of the stomach contents and acts as a barrier, preventing acid from entering the oesophagus.
What is a hiatus hernia?
When part of the abdominal viscera herniates (pushes) through the oesophageal opening in the diaphragm.
What can cause a hiatus hernia?
- widening of diaphragmatic hiatus
- pulling of stomach due to oesophageal shortening
- pushing up of stomach due to increased abdominal pressure
All of these can cause the lower oesophageal sphincter to loose its function-> GORD
What are the risk factors for a hiatus hernia?
- Male gender
- Obesity
- Pregnancy
- Age
- Genes
What are the 2 types of hiatus hernia?
- Sliding hiatus hernia -> GOJunction moves upwards
2. Rolling hiatus hernia -> portion of abdominal organ herniates into chest next to GOJ
Which type is the most common cause of GORD?
Sliding hiatus hernia
What are the constituents of ‘refluxed’ material?
- Ingested food
- Acid
(Bile- rare)
What type of cells are found lining the oesophagus?
Non-keratinizing squamous stratified epithelial cells
What is metaplasia in the oesophagus called?
Barrett’s oesophagus
1. Cardiac mucosa 2. Intestinal mucosa
What is the next stage in oesophageal cancer progression?
Dysplasia/ Carcinoma in situ/ intra-epithelial neoplasia/ Stage 0 cancer
A group of abnormal cells that remain in the place where they’re found
If high grade dysplasia is found in the biopsy, what treatments are available?
- mucosal resection
- radiofrequency ablation (scarring the mutated oesophageal tissue)
- oesophagectomy
Who is monitored for Barrett’s oesophagus?
People with…
- family history of BO
- a long history of GORD
- other factors of GORD
What are some lifestyle changes that can reduce acid reflux?
- smaller, frequent meals
- raise end of bed so head higher than abdomen
- loss of weight
- find ways to relax (reduce stress)
- don’t eat 3/4 hours before bed
- stop smoking and lower alcohol intake
- don’t eat reflux- triggering foods or drinks
How does eating smaller but more frequent meals help with reflux?
- Less acid secretion
- Less of an increase in intra-abdominal pressure
How does losing weight help?
It decreases abdominal pressure (less fat pushing the abdominal organs)
How does stress cause acid reflux?
Stress can…
- slow gastric emptying (more acidic chyme remains in stomach)
- relax lower oesophageal sphincter
- increase oesophagus’ susceptibility to damage from inflammation and refluxed material
How does nicotine in cigarettes cause acid reflux?
It relaxes the lower oesophageal sphincter
How does alcohol cause acid reflux?
It causes
- damage to gastric mucosa
- inhibition of gastric emptying
- loss of control of sphincter
What is Coeliac disease?
It is an autoimmune condition where your immune system attacks your own tissues when you eat gluten.
Other than PPIs and medication, how can GORD be treated?
Laproscopic fundoplication
What conditions are associated with prolonged PPI use?
- hypergastrinaemia (rebound acid production after finishing long course of PPIs)
- Pneumonia (low acidity allows for bacteria from microaspiration to escape death from acid)
- C. diff diarrhoea
- Fractures (reduced calcium absorption due to acid suppression)
- Hypomagnesemia
- Vitamin B12 deficiency
- Acute interstitial nephritis
- Lupus
