Dyspepsia Flashcards
What are 3 situations when you should make an urgent referral for endoscopy someone who has dyspepsia?
- All patients with dysphagia
- All patients with upper abdominal mass consistent with stomach cancer
- Patients >55 years who have weight loss and any of the following:
- upper abodminal pain
- reflux
- dyspepsia
What are 5 situations when you should make a non-urgent referral for endoscopy?
- Patients with haematemesis
- Aged >55 and treatment-resistant dyspepsia
- Aged >55 and upper abdominal pain with low haemoglobin levels
- Aged >55 and raised platelet count with any of the following: nausea, vomiting, weight loss, reflux, dyspepsia, upper abdominal pain
- Aged >55 with nausea or vomiting with any of the following: weight loss, reflux, dyspepsia, upper abdominal pain
What are the 4 aspects of management of patients who have dyspepsia but do don’t meet referral criteria for dyspepsia?
- Review medications for possible causes of dyspepsia
- Lifestyle advice
- Trial of full-dose proton pump inhibitor for one month OR test and treat approach for H.pyloria
- If symptoms persist after either of the above approaches (PPI for month/test and treat H. Pylori), try the other one
What are 3 options for testing for H. pylori infection?
- Carbon-13 urea breath test
- Stool antigen test
- Laboratory-based serology ‘where performance has been locally validated’
What does test and treat for H. pyloria involve?
- make initial diagnosis with urea breath test/stool antigen test/ serology
- test of cure:
- don’t check for eradication if symptoms have resolves following test and treat
- if repeat testing is required then carbon-13 urea breath test should be used
If repeat testing is required for H. pyloria infection after treatment (as symptoms haven’t resolved), which test should be used?
carbon 13 urea breath test
What is the relationship between endoscopy appearance and symptoms in GORD?
poor correlation between the 2
What are 5 indications for upper GI endoscopy in the case of GORD?
- Age >55 years
- Symptoms >4 weeks or persistent symptoms despite treatment
- Dysphagia
- Relapsing symptoms
- Weight loss
What is the test that should be performed if endoscopy is negative for GORD?
consider 24-hr oesophageal pH monitoring
What is the gold standard test for diagnosis of GORD?
24hr oesophageal pH monitoring
What is the definition of GOrD?
symptoms of oesophagitis secondary to refluxed gastric contents
What do NICE recommend about the management of GORD?
treat as per the dyspepsia guidelines
What are 3 steps to treatment of endoscopically-proven oesophagitis?
- Full-dose PPI for 1-2 months
- If response, low dose treatment as required
- If no response, double-dose PPI for 1 month
What are 3 steps to the management of endoscopically negative reflux disease?
- Full dose PPI for 1 month
- If response then offer low dose treatment, possibly on an as-required basis, with a limited number of repeat prescriptions
- If no response then H2RA or prokinetic for 1 month
What are 6 complications of GORD?
- Oesophagitis
- Ulcers
- Anaemia
- Benign strictures
- Barrett’s oesophagus
- Oesophageal carcinoma
How can GOR (gastro-oesphageal reflux) present in infancy?
vomiting - GOR is commonest cause in infancy
What proportion of infants regurgitate their feeds and what can the cause be?
40% - oerlap between GOR and physiological processes
What are 2 risk factors for GOR in infants?
- Pre-term delivery
- Neurological disorders
At what age does gastro-oesophageal reflux typically develop in infancy?
before 8 weeks
How is a diagnosis of GOR usually made in infants?
clinically
What are 5 aspects of the management of reflux in infants?
- Advise regarding position during feeds - 30 degree head up
- Infants should sleep on backs
- Ensure not overfed (as per their weight), consider trial of smaller and more frequent feeds
- Trial of thickened formula (e.g. containing rice starch, cornstarch, locust bean gum, carob bean gum)
- Trial of alginate therapy e.g. Gaviscon
What is the advice regarding thickened feeds and alginate therapy when treating GOR in babies?
don’t try it at the same time
What are 4 ingredients that thickened baby formula might contain?
- Rice starch
- Cornstarch
- Locust bean gum
- Carob bean gum
What is the NICE advice about use of PPI in infants? What are the 3 situations when you should consider using them?
don’t recommend its use if overt regurgitation occurs as an isolated symptom; trial if 1 or more of the following apply -
- unexplained feeding difficulties e.g. refusing feeds, gagging, choking
- distressed behaviour
- faltering growth
Why is ranitidine withdrawn from the market?
small amounts of the carcinogen N-nitrosodimethylamine (NDMA) were discovered in products from a number of manufacturers
What is a medication for GOR in infants that should only be used with specialist advice?
prokinetic agents e.g. metoclopramide
What are 5 complicatiosn of reflux in infants and children?
- distress
- failure to thrive
- aspiration
- frequent otitis media
- in older children dental erosion may occur
In infants, if there are severe complications of gastro-oesophageal reflux e.g. failure to thrive and medical treatment is ineffective, what intervention can be considered?
fundoplication - wrapping top part of stomach around lower oesophagus
What is the peak age of gastric cancer?
70-80 years
In which regions is gastric cancer more common?
Japan, China, Finland, Colombia
(more so than the West)
What is the gender ratio of gastric cancer?
male:female 2:1 - more common in males
What histology is seen in gastric cancer?
- signet ring cells
- cells contain large vacuole of mucin which displaces the nucleus to one side
How can histology predict prognosis in gastric cancer?
higher number of signet ring cells associated with a worse prognosis
What are 6 factors associated with gastric cancer?
- H. pylori infection
- blood group A: gAstric cAncer
- gastric adenomatous polyps
- pernicious anaemia
- smoking
- diet: salty, spicy, nitrates
What factor may be negatively associated with gastric cancer?
duodenal ulcer
What are 4 clinical features of gastric cancer?
- Dyspepsia
- Nausea and vomiting
- Anorexia and weight loss
- Dysphagia
What investigation is performed to diagnose gastric cancer?
Endoscopy with biopsy
What are 2 things that can be used for staging of gastric cancer? Which is superior?
- CT
- Endoscopic ultrasound: superior
What are thought to be 4 steps in the stepwise progression of gastric cancer?
- Intestinal metaplasia
- Atrophic gastritis
- Dysplasia
- Cancer
What is the favoured staging system for gastric cancer?
TNM
What are the 3 types of tumours of the gastrooesophageal junction?
- Type 1: true oesophageal cancers, may be associated with Barrett’s oesophagus
- Type 2: carcinoma of cardia, arising from cardiac type epithelium or short segments with intestinal metaplasia at oesophagogastric junction
- Type 3: sub-cardial cancers that spread acrosss the junction. Involve similar nodal stations to gastric cancer
What is the gastric cardia?
area of mucosa located distal to the anatomic gastro-oesophageal junction
What does staging of gastric cancer involve? 3 things
- CT scanning of the chest abdomen and pelvis is the routine first line staging investigation in most centres.
- Laparoscopy to identify occult peritoneal disease
- PET CT (particularly for junctional tumours)
What is the treatment for proximally sited gastric cancer greater than 5-10cm frmo the OG junction?
sub-total gastrectomy
What is the treatment for a gastric tumour <5cm from the OG junction?
total gastrectomy
What is the usual treatment of type 2 gastro-oesophageal junction cancers?
oesophagogastrectomy
What is the treatment for early gastric cancer that is confined to the mucosa (and perhaps sub-mucosa)?
endoscopic sub-mucosal resection
When treating gastric cancer, what additional surgical management should be performed?
lymphadenectomy - D2 lymphadenectomy widely advocated
In additional to surgical management of gastric cancer what else is usually performed?
most patients will receive chemotherapy pre or post-operatively
What is helicobacter pylori?
gram negative bacteria associated with variety of gastrointestinal problems, principally peptic ulcer disease
What are 4 diseases that H. pylori is associated with?
- Peptic ulcer disease (95% of duodenal, 75% of gastric)
- Gastric cancer
- B cell lymphoma of MALT tissue (eradication of H pyloria results in regression in 80% of patient)
- Atrophic gastritis
What is the current thought about the link between GORD and H. pylori?
no role for GORD for eradication of H. pylori
What are the 2 options for managemetn of H. pylori i.e. eradication?
- PPI + amoxicillin + clarithromycin or
- PPI + metronidazole + clarithromycin
What is dyspepsia?
also known as indigestion; discomfort or pain in the upper abdomen, often after eating or drinking
What is Barrett’s oesophagus?
metaplasia of lower oesophageal mucosa, with usual squamous epithelium beign replaced by columnar epithelium
By how much does the risk of oesophageal adenocarcinoma increase with Barrett’s?
50-100x
How is Barrett’s oesophagus usually identified?
patients having endoscopy for evaluation of upper GI symptoms such as dyspepsia
What 2 types can Barrett’s oesophagus be divided into?
short (<3cm) and long (>3cm)
What proportion of those who undergo endoscopy for reflux is Barrett’s oesophagus identified in?
12%
What are the histological features of Barrett’s oesophagus?
- squamous to columnar
- columnar epithelium may resemble that of either cardiac region of stomach or that of the small intestine e.g. with goblet cells, brush border
What are 4 risk factors for Barrett’s oesophagus?
- GORD
- Male (7:1)
- Smoking
- Central obesity
note not alcohol
What are 2 aspects of the management of Barrett’s oesophagus?
- Endoscopic surveillance with biopsies
- if metaplasia - every 3-5 years
- if dysplasia - endoscopic mucosal resection or radiofrequency ablation offered
- High-dose protein pump inhibitor: commonly used but evidence base limited
What 2 treatment options are offered if dysplasia is found during endoscopic surveillance and biopsy of Barrett’s metaplasia?
- Endoscopic mucosal resection
- Radiofrequency ablation
What is the most common type of oesophageal cancer?
until recently, most commonly squamous cell carcinoma
incidence of adenocarcinoma is now most common - more likely to develop in patient with GORD or Barrett’s
What type of oesophageal cancer does Barrett’s metaplasia predispose to?
Adenocarcinoma
Where are most adenocarcinomas of the oesophagus located?
near gastro-oesophageal junction
Where are most squamous cell carcinomas of the oesophagus located?
upper two thirds of the oesophagus
What are 5 risk factors for oesophageal adenocarcinoma?
- GORD
- Barrett’s oesophagus
- Smoking
- Achalasia
- Obesity
What are 5 risk factors for oesophageal squamous cell carcinoma?
- Smoking
- Alcohol
- Achalsia
- Plummer-Vinson syndrome
- Diets rich in nitrosamines
What are 7 symptoms of oesophageal cancer?
- Dysphagia - most common
- Anorexia and weight loss
- Vomiting
- Odynophagia
- Hoardseness
- Melaena
- Cough
What is the first line test for diagnosing oesophageal cancer?
Upper GI endoscopy
How is staging usually undertaken for oesophageal cancer? 4 aspects
- CT of chest, abdomen and pelvis
- if CT doesn’t show metastatic disease, local stage may be ore accurately asssessed using endoscopic ultrasound
- staging laparoscopy for occult peritoneal disease
- PET CT if negative laparoscopy
What is the commonest surgical procedure for operable oesophageal cancer?
Ivor-Lewis type oesophagectomy
- mobilisation of stomach and division of oesophageal hiatus
- abdomen closed and right-sided thoracotomy performed
- stomach brought into chest and oesophagus mobilised further
- intrathoracic oesophagogastric anastomosis constructed
What are 3 alternative surgeries that can be performed for operable oesophageal cancer, in addition to the Ivor Lewis type oesophagectomy?
- Trans-hiatal resection (if distal)
- Left thoracoabdominal resection (thoracic aorta makes it difficult)
- Total oesophagectomy (McKeown) with cervical oesophagogastric anastomosis
In addition to oesophagectomy for operable oesophageal cancer, what else does the managemen tof many patients involve?
adjuvant chemotherapy
What is the biggest surgical challenge of operating on oesophageal cancer?
anastomotic leak, with intrathoracic anastomosis this will result in mediastinitis - high mortality
Which type of oesophageal cancer has an intrinsically lower systemic insult in the event of anastoomtic leakage?
McKeown technique
