Dyspepsia

Question 1

What is dyspepsia

Answer 1

Dyspepsia - complex of upper GI tract symptoms which are typically present for 4 weeks or more. Includes upper abdominal pain or discomfort, heartburn, acid reflux, vomiting, nausea

Question 2

Name some common gastric disorders

Answer 2

GORD

Acute and chronic gastritis

Peptic ulcer disease

Zollinger-Ellison disease

Stomach cancer

Question 3

What are the symptoms of GORD

Answer 3

Chest pain

Acid taste in mouth

Cough

Burning, retrosternal pain

Question 4

What are the consequences of GORD

Answer 4

Nothing

Oesophagitis

Strictures

Barrett’s oesophagus

Question 5

What physiological structures are there at the lower oesophageal sphincter that help prevent reflux

Answer 5

Muscular element - resting tone keeps oesophagus closed

Right crus of diaphragm - keeps oesophagus closed when coughing

Angle of entry of oesophagus into stomach

Intra-abdominal pressure helps oesophagus to collapse to keep it closed

Question 6

What is the treatment for GORD

Answer 6

Lifestyle modifications - decrease intra-abdominal pressure, stay away from certain foods, eating ealier before bed

Pharmacological - antacids, PPIs, H₂ antagonists

Question 7

What is gastritis

Answer 7

Gastritis is inflammation of the mucosa of the stomach lining

It is a symptom complex of pain, nausea, vomiting and bleeding

It is an endoscopic appearance

Question 8

What causes acute gastritis

Answer 8

Heavy use of NSAIDS - decreases prostaglandins which decreases blood flow to cells so there is decreased repair of damaged cells

Heavy alcohol consumption - alcohol destroys mucus layer so epithelium beneath can be damaged

Chemotherapy - affects rapidly dividing cells, i.e. cells in stomach

Bile reflux - bile reacts with stomach lining causing inflammation

Question 9

What are the symptoms of acute gastritis

Answer 9

Asymptomatic or they have:

Abdominal pain

Nausea

Vomiting

Bleeding

Question 10

What are the causes of chronic gastritis

Answer 10

Bacteria - H. pylori

Autoimmune chronic gastritis - antibodies attack gastric parietal cells. Can lead to pernicious anaemia

Prolonged acute gastritis

Question 11

What are the symptoms of autoimmune chronic gastritis

Answer 11

Symptoms of anaemia

Glossitis

Anorexia

Neurological symptoms

Question 12

What are peptic ulcers

Answer 12

Peptic ulcers are defects in the gastric/duodenal mucosa that extend through the muscularis mucosa

They are most common in the first part of the duodenum

If they occur in the stomach, most commonly affects lesser curve/antrum

Question 13

What are the causes of peptic ulcers

Answer 13

Stomach acid

H. pylori

NSAIDS

Smoking

Stress

Burns

Question 14

Describe the morphology of peptic ulcers

Answer 14

Generally <2cm in diameter

Base of ucler is necrotic tissue/granulation tissue

Muscularis propria can be replaced by scar tissue -> contracts stomach down -> decreased ability of stomach to distend

Question 15

What are the consequences of peptic ulcers

Answer 15

Scar tissue shrinks, narrowing the stomach lumen or causing a pyloric stenosis

Perforation causes peritonitis

Erosion into adjacent structures

Haemorrhage from vessel at base of ulcer - causes haematemesis

Malignancy

Question 16

Name some symptoms of peptic ulcer disease

Answer 16

Epigastric pain

Burning/gnawing pain

Follows meal times - gastric ulcer pain is closer to meal time than duodenal ulcer pain

Often have symptoms at night - especially DU

Bleeding/anaemia - haematemesis, melaena, haematochezia

Satiety

Weight loss

Question 17

What is functional dyspepsia

Answer 17

Where there is no physical/organic evidence of disease processs

Diagnosis of exclusion

Question 18

What pharmacological interventions can be used in dyspepsia

Answer 18

H2 blocker - histamine blocker. E.g. cimetidine and ranitidine

PPI - blocks proton pumps -> decreases acid secretion. E.g. omeprazole

Question 19

What is Zollinger-Ellison syndrome

Answer 19

Zollinger-Ellison syndrome is a non-beta islet cell, gastrin producing tumour of the pancreas

Causes proliferation of parietal cells resulting in increased acid production causing severe ulceration of stomach and small bowel

Symptoms - abdominal pain, diarrhoea

Question 20

Describe H. pylori - type of bacteria, where it is found and how it is spread

Answer 20

H. pylori is a helix shaped, gram -ve microaerophilic bacteria.

Lives in the stomach where it lives in the mucus layer and adheres to the gastric epithelia

Spread by oral to oral or faecal oral route

Question 21

How does H. pylori cause disease

Answer 21

Releases cytotoxins causing direct epithelial injury

Expresses enzymes

Possibly degrades mucus layer

Promotes inflammatory response

Question 22

What are the symptoms of chronic gastritis caused by H. pylori

Answer 22

Asymptomatic or similar to acute gastritis

Symptoms may develop due to complications: peptic ulcers, adenocarcinoma, MALT lymphoma

Question 23

How does the location of H. pylori colonisation affect disease progression

Answer 23

If mainly in antrum, H. pylori causes increased gastrin secretion resulting in increased acid secretion which causing duodenal epithelia metaplasia to gastric epithelium. This results in colonisation of the duodenum by H. pylori

If in antrum and body, patient is asymptomatic

If mainly in body, H. pylori causes an atrophic effect resulting in gastric ulcers

Question 24

How is H. pylori diagnosed

Answer 24

Urea breath test - H. pylori releases urease which breaks urea down into ammonia and CO2. If given urea containing C¹³, urease will break down the urea and release the C¹³ as CO2 -> can detect if C¹³ is present in CO2 breathed out

Stool antigen test

Blood test