CBL_dyspepsia Flashcards
What is dyspepsia? (definition)
Dyspepsia = a range of upper gastrointestinal (GI) symptoms l_asting 4 weeks_ or more including heartburn (burning retrosternally), indigestion, upper abdominal pain or discomfort, gastric reflux, nausea or vomiting.
Definition of the following symptoms:
- heartburn
- gastric reflux
•Heartburn
–Typically a burning retrosternal sensation
•Gastric Reflux
–Describes the movement of stomach contents (usually acid) into the oesophagus
Definition of the following symptoms:
- indigestion
- dysphagia
- odynophagia
•Indigestion
–Pain or discomfort in the stomach associated with difficulty digesting food
•Dysphagia
–Difficulty swallowing
•Odynophagia
–Painful swallowing
What’s functional dyspepsia?
Functional dyspepsia
One or more of:
- Bothersome postprandial (after meal) fullness
- Early satiety
- Epigastric pain
- Epigastric burning
And: No evidence of structural disease (including normal OGD) that is likely to explain the diagnosis
What’s GORD?
Gastro Oesophageal**Reflux Disease (GORD)
–A condition which develops when the reflux of gastric content causes troublesome symptoms
The differential diagnosis for dyspepsia
Dyspepsia differentials
- GORD (A condition which develops when the reflux of gastric content causes troublesome symptoms)
- Peptic/duodenal ulcer disease
- Gastritis
- Duodenal obstruction (e.g. pancreatic malignancy)
- Gallbladder disease/Gallstones
- Hiatus hernia = sliding vs oesophageal
- Medication (NSAIDs, bisphosphonates, Ca2+ channel blockers, steroids)
- Functional dyspepsia
- IBS/IBD
- Eosinophilic oesophagitis = autoimmune - allergy to precipitating foods
- Cardiac causes
- Cancers (oesophageal, gastric, pancreatic)
Initial consideration in management in the patient with dyspepsia
(3 likely scenarios)
Consider if:
A. Patient needs an urgent OGD (oesophago-gastroduodenoscopy) -> if there is any GI bleed: hematemesis or malena -> refer to hospital
B. Red flag symptoms -> 2 weeks referral cancer pathway
C. If not above -> consider most likely clinical diagnosis and trial of treatment
Who to refer for direct access (2 weeks wait) upper GI endoscopy?
•With dysphagia
•Aged 55 and over with weight loss and any of the following:
–Upper abdominal pain
–Reflux
–Dyspepsia
In what group of patients (age and symptoms) we consider non-urgent direct access upper GI endoscopy?
(2 weeks oesophageal cancer referral)
Patients 55 years old or more
Symptoms:
- failed dyspepsia treatment
- upper abdo pain + anaemia
- raised platelets + nausea/vomiting/weight loss/reflux/dyspepsia/upper abdo pain
- N+V + weight loss/reflux/dyspepsia/upper abdo pain
Dyspepsia management
- lifestyle advice
Lifestyle advice:
- No spicy, citrus foods
- No smoking/alcohol
- Lose weight
- No lying down after meals
H. Pylori
- type of an organism
- transmission
H. Pylori:
- gram negative bacteria (rod shaped)
- oral-faecal or oral-oral route
-
H. Pylori
- is it usually symptomatic?
- 90% of patients do not have symptoms
What diseases does H. Pylori increase the risk of?
- gastric cancer
- doudenal ulcer
- gastric ulcer
Investigations for H. Pylori
H. pylori testing
- Breath test: looks at breakdown of urea in breath (urease activity by the bacteria) - requires 2+ weeks off PPI
- Faecal antigen test
- Biopsy on OGD (multiple biopsies)
Treatment for H. Pylori
_H. pylori treatmen_t
Triple therapy: Amoxicillin + metronidazole + PPI
for 2 weeks
Management of dyspepsia (pharmacological classes)
A. H. pylori testing -> if negative start treatment (below)
B. PPI for 4-8w
C. If symptoms reoccur - low dose PPI, H2A - PRN
D. Consider H2 receptor antagonist therapy if there is an inadequate response to PPI
*Probably should be reviewing the diagnosis and the need for endoscopy at this point
What are the components of Gaviscon?
Sodium alginate and sodium bicarbonate
Mechanism of action of Gaviscon and its components
- Anti-acid -> it is alkali based; neutralises the gastric acid -> symptoms relief
- Alginate -> forms a protective layer that floats on the top of gastric content
Mode of action of Histamine 2 Receptor Antagonist? (in terms of dyspepsia)
Examples of H2RA drugs
Mode of action:
- Histamine (H2) stimulates parietal cells to produce gastric acid
- H2RA competitively block this receptor -> decrease in gastric acid production
Examples: Cimetidine, Ranitidine, Famotidine
Side effects of H2 receptor antagonists
Side effects:
- Cimetidine > Ranitidine > others -> inhibit cytochrome P450 pathway
- Diarrhoea, headache, dizziness, rash
- Increased risk of pneumonia
PPI
- mode of action
- examples of drugs
Mode of action of PPI:
- Irreversibly inhibit the proton pump (H+/K+/ATPase) of the gastric parietal cells
- Stops H+ ions from being secreted into the gastric lumen
•Reduces acid production by 95-99%
Examples: Omeprazole, Lansoprazole, Pantoprazole
General side effects of PPI
General side effects PPI
•Nausea, vomiting, abdominal pain, flatulence, diarrhoea, constipation and headache
Concerns associated with PPI use
Specific PPI Concerns
- Increased risk of Clostridium difficile infection (and recurrence)
- Osteoporosis (long term use)
- Pneumonia
- Rebound acid hyper-secretion (after stopping)
- Iron deficiency anaemia
- Electrolyte disturbance (Mg/Ca/K)
- Microscopic colitis
- Drug induced Subacute Cutaneous Lupus Erythematosus (SCLE)
*generally PPI are safe to use, but try to minimase a long-term and large dose use
Risk factors and associations in gastric ulcer
Gastric ulcers
- Middle aged/older aged population
- Pain worse with food
- Gastro-toxic medications often implicated (Aspirin/NSAIDs/Steroids) & smoking
- H.Pylori implicated in >60%
- Malignancy must be considered 1-2%
Risk factors and associations with duodenal ulcers
Duodenal ulcers
- Younger and usually male
- Food relieves the pain
- Nocturnal pain more common
- H.Pylori implicated in >90%
- Malignancy is very rare
Examples of rare ulcers
- Gastrinoma/Zollinger Ellison Syndrome
- Crohn’s disease
Symptoms of Zollinger Ellison syndrome
refractory diarrhoea + persistent/multiple ulcers
What, when and why do we need to do if a gastric ulcer is identified on OGD?
Repeat OGD in 6-8 weeks
It is to asses the healing of the ulcer and for malignancy
Management of ulcers
- If Pylori positive – repeat testing after treatment should be considered to confirm eradication
- Carefully consider NSAIDs
–Can they be stopped (ideally) or if not co-prescribe PPI with NSAID or COX-2 specific NSAID
Complications of ulcers
A. Immediate
B. Long term
Immediate
Long term
- Perforation (gastric/duodenal)
- Bleeding
- Obstruction/stricture
- Fistula formation
- Malignant transformation
Management of GORD
- lifestyle
Conservative/lifestyle Measures
–Diet
–Weight loss
–Smoking cessation
–Meal times/elevating bed
Management of GORD
- medication
Medication
- Reviewing potentially exacerbating medications
Meds to relieve symptoms:
- Antacids
- PPI’s
- H2RA’s
Management of GORD
- surgery
Surgery:
Anti-reflux surgery i.e. Laparoscopic Nissen Fundoplication
*fundus of the stomach is wrapped around the oesophagus -> when stomach contracts releasing its gastric acid content -> oesophagus closes so the acid cannot irritate it
Pancreatic juice
- content
- how much is secreted each day
- where does it go?
Pancreatic juice
Content: amylase, lipase, colipase and other proteases
- 1.5 L a day
Secreted via pancreas -> pancreatic duct -> ampulla of Vater -> sphincter of Oddi -> duodenum
What’s the role of bile acids?
How much is secreted?
Bile acids breakdown and dispose of fat and recycle products of haemolysis (e.g. bilirubin and biliverdin)
1-2 L bile secreted a day
Where parietal cells are located?
What’s their role?
Parietal cells -> located in fundus and body of the stomach
Role: secrete intrinsically factor and gastric HCl
What is the role of chief cells in the stomach?
They secrete pepsinogen, mucin and gastric lipase -> to digest food components
What’s the role of H2 receptors and Vagus nerve in the stomach?
- Histamine -> H2 receptor and vagus nerve (acetylcholine) -> stimulate acid secretion
- Vagus nerve-> stimulates the hypothalamic nuclei -> satiety feeling when stomach is distended
What do cardia and pyloric regions secrete?
- Cardia and pyloric regions secrete mucus and bicarbonate ions
What does antrum of stomach secrete?
antrum stomach -> gastrin secretion -> goes via blood stream to parietal cells to stimulate HCl secretion
Why does the patient with GORD usually wake up around 2 AM?
- no food buffering of pH (pH is not neutralised)
- lowest acidity at about 2am
- lying down position may aggravate GORD
Patient can wake up with heartburn.
What is definition of GORD?
Gastro-oesophageal reflux disease (GORD) refers to gastroscopy proven oesophagitis and gastric acid sometimes regurgitates into the mouth
Drugs that are common to cause dyspepsia
NSAID’S
Bisphosphonates
Steroids
Metformin
Calcium antagonists
Theophylline
Nitrates
Red flag symptoms for 2 weeks referral for gastroscopy
- Acute GI bleeding
- Progressive dysphagia
- unintentional weight loss
- persistent vomiting
- iron deficiency anaemia
- epigastric mass
- aged over 55 yrs with new persistent dyspepsia
Management of dyspepsia algorithms (2)
A. New onset - needing referral
B. New onset - not needing referral
What cellular changes and what type of cancer is involved in Barrett’s oesophagus?
Metaplasia: squamous epithelium into columnar epithelium
Cancer type: oesophageal adenoma
Management of Barrett’s oesophagus
- surveillance
- medication
- endoscopic intervention
‘
- endoscopic surveillance with biopsies
- high-dose proton pump inhibitor: whilst this is commonly used in patients with Barrett’s
*the evidence base that this reduces the change of progression to dysplasia or induces regression of the lesion is limited
Endoscopic surveillance
- for patients with metaplasia (but not dysplasia) endoscopy is recommended every 3-5 years
If dysplasia of any grade is identified endoscopic intervention is offered. Options include:
- endoscopic mucosal resection
- radiofrequency ablation
Side effects of H2 antagonists (Cimetidine, Ranitidine) used for dyspepsia
Can cause:
- diarrhoea
- headache
- rarely rash
- liver problems
- cimetidine -> causes gynaecomastia and erectile dysfunction (probably by blocking androgen receptors)
PPI
- examples
- side effects
- what does long term use may cause?
PPI
Examples: omeprazole, lansoprazole
Side effects: diarrhoea, nausea, vomiting, headache and abdo pain
Long term use: hyponatraemia, increased risk of C Diff contraction, reduced Mg levels, increased fracture risk
What’s CLO test?
C ampylobacter like organism test
- Rapid diagnostic test
- Ability of H pylori to secrete the urease enzyme, which catalyse the conversion of urea to ammonia and carbon dioxide
*it is done during gastroscopy -> gastric mucose is placed onto medium containing urea
1st and 2nd line treatment to eradicate H Pylori
First line
◦7 days, twice daily course of PPI, Amoxicillin & either clarithromycin or metronidazole
*Allergic to Penicillin – PPI, clarithromycin or metronidazole
Second line
◦7-days twice day course of PPI, Amoxicillin & clarithromycin or metronidazole (whihever was not used before)
◦ could use tetracycline or Quinolone
◦Levofloxacin, PPI & metronidazole – Penicillin allergy
Gastric vs duodenal ulcer
Classical signs of pancreatitis
- Classically epigastric pain radiating to the back
- Grey-Turner’s sign (flank ecchymoses)
- Cullen’s sign (peri-umbilical ecchymoses)
Two most common causes of pancreatitis
80% of causes:
- alcohol
- gallstones
What is used to predict the outcomes of pancreatitis?
- Marker for prognostic severity = CRP (high at 48h –> bad prognosis)
- Modified Glasgow score = pancreatitis severity scoring system
Markers (2) for pancreatitis
- how long are they raised for?
- Amylase = can rise rapidly within 3–6 hours of the onset of symptoms, and may remain elevated for up to five days (normally 3-4 days)
- Lipase = elevated for longer and more sensitive marker
Initial imaging in suspected acute pancreatitis
- Initial investigation in acute pancreatitis = USS -> identification of gallstones
- If diagnostic uncertainty = CT
Hypocalcaemia and pancreatitis - what does it tell us?
poor prognostic sign in pancreatitis –> extensive retroperitoneal necrosis
Complications of pancreatitis
A. before 4 weeks
B. after 4 weeks
Before 4w
After 4w
- Peripancreatic fluid collections
- Necrosis
- Pseudocyst
- Abscess
What’s Courvoisier’s sign?
Courvoisier’s sign:
palpably enlarged gallbladder + nontender + painless jaundice -> the cause is unlikely to be gallstones
*possible malignancy of the gallbladder or the pancreas
Interpretation of AST:ALT
- AST:ALT = 1
- AST:ALT >2.5
- AST:ALT <1
Aminotransferases (AST, ALT) - generally associated with hepatocellular damage
-
AST: ALT =1
- Associated with ischaemia (CCF and ischaemic necrosis and hepatitis)
-
AST: ALT >2.5
- Associated with Alcoholic hepatitis
- Alcohol induced deficiency of pyridoxal phosphate
-
AST: ALT <1
- High rise in ALT specific for Hepatocellular damage
- Paracetamol OD with hepatocellular necrosis
- Viral hepatitis, ischaemic necrosis, toxic hepatitis
What’s the role of ALP and GGT?
ALP, γ**GT - generally associated with cholestasis
-
ALP primarily associated with cholestasis and malignant hepatic infiltration
- Marker of rapid bone turnover and extensive bony metastasis
-
GGT sensitive to alcohol ingestion
- Marker of Hepatocellular damage but non-specific
- Sharpest rise associated with biliary and hepatic obstruction
What is Whipple’s procedure?
Whipple’s procedure = pancreaticoduodenectomy - removal of the head of the pancreas, the first part of the small intestine (duodenum), the gallbladder and the bile duct.
The most common pancreatic cancer
A. adults
B. children
95% of pancreatic cancers are exocrine tumours
A. adults: ductal adenocarcinoma
B. children: pancreatoblastoma
What set of symptoms does need an urgent referral for endoscopy?
Urgent (2ww endoscopy)
- dysphagia
- an upper abdominal mass consistent with stomach cancer
- Patients aged >= 55 years who’ve got weight loss, AND any of the following:
- upper abdominal pain
- reflux
- dyspepsia
Set of symptoms for non-urgent referral for endoscopy
- all age patient + what symptoms
- if a patient is >=55 + what symptoms
Non-urgent
Patients with haematemesis
Patients aged >= 55 years who’ve got:
- treatment-resistant dyspepsia or
- upper abdominal pain with low haemoglobin levels or
- raised platelet count with any of the following: nausea, vomiting, weight loss, reflux, dyspepsia, upper abdominal pain
- nausea or vomiting with any of the following: weight loss, reflux, dyspepsia, upper abdominal pain
