Dyspepsia, GORD and Peptic Ulcer Flashcards
Define dyspepsia
Group of symptoms suggesting upper GI disease
Describe dyspepsia
Pain or discomfort in epigastrium (ulcer like)
Heart burn/regurgitation (GORD like)
Bloating, nausea, vomiting, excess wind (dysmotility like)
Red flag symptoms
Dysphagia Weight loss unintentional Persistent vomiting Epigastric mass GI bleeding Iron deficiency New unexplained symptoms in >55
What happens if there are red flag symptoms?
Cancer Patient Pathway
2ww
Uncertainty with dyspepsia
Clinical diagnosis often
Non specific symptoms
Often no cause found but doesn’t mean nothing is wrong
50-75% non ulcer dyspepsia
Types of dyspepsia
Non ulcer dyspepsia (50-75%)
Peptic ulcer disease (15-25%)
Oesophagitis (5-15%)
Cancer (<2%)
Non ulcer dyspepsia Causes
NUD Disturbances in - GI motility - visceral sensation - gastric accommodation - intestine-gastric reflexes - gastric acid sensitivity - psycho-social factors - H pylori relationship
GORD define
Symptoms and/or mucosal damage resulting from reflux of gastric contents into distal oesophagus
Pathophysiology of GORD
- Dysfunction of OG junction = low LOS pressure and high intra-abdominal pressure so increased risk in obese and pregancy
- decreased oesophageal acid clearance
- delayed gastric emptying
- gastric acid production is normal
- H pylori role?
- Hiatus hernia may contribute
Diagnosis of GORD
PPI therapeutic trial in young person Endoscopy 50% have no mucosal lesion at endoscopy Los Angeles scoring for oesophagitis 24h pH monitoring/manometry
Los Angeles scoring for oesopahgitis
A to D D = stricture formation risk A = normal B = mild ulceration C = severe ulceration
GORD Endoscopy result
Macroscopic oesophagitis in minority of patients
Complications of GORD
Stricture
Barrett’s oesophagus
Cancer
Extra-oesophageal manifestations
Extra-oesophageal manifestations in GORD
Middle ear problems Asthma Aspiration pneumonia Cough Chronic sinusitis Dental erosions and halitosis Sore throat/pharyngitis/laryngitis
What is gold standard for extra-oesophageal manifestations in GORD
24 hour ph monitoring/manometry
Treatment for GORD
Education and explanation Lifestyle Modifications Antacids and alginates Acid suppression = PPI/H2RA Endoscopic/surgical last resort
Lifestyle Modifications for GORD
Eliminate triggering foods and drink Rigorously timed meals Weight loss Eliminate smoking No pressure on stomach tight clothing Sleeping at higher up position inclined
GORD lifestyle effects
Unable to enjoy meals Sleep disturbances Fatigue Reduced overall productivity Altered social well being Altered emotional well being
Peptic ulcers 2 types
Duodenal ulcer
Gastric ulcer
Classic symptoms of peptic ulcer
epigastric pain
can or cannot be associated with eating
Duodenal ulcer features
Pain after food or not
99% H pylori related!!!
Not malignant!
gastric ulcer features
Symptoms not reliable to diagnose Weight loss more likely as pain while eating more than after 2/3 associated H pylori NSAIDs significant cause!!! 5-10% malignant!
NSAID related gastric ulcer RF
- older patients >70
- first 3m of treatment
- smokers
- co-morbidity
- other drugs (anticoagulants)
NSAIDs features for gastric ulcer
60% cause dyspepsia
50% NSAID ulcers are asymptomatic
Therefore tricky to spot
H. pylori
Duodenal and gastric ulcer and cancer associated
2 phenotypes of mutually exclusive so will not get both at same time
Response to H. pylori infection
Gastric acid secretion decreases
May develop chronic gastritis
Most people acid output returns to normal and have asymptomatic infection
Some people never pick up acid secretion so develop atrophic gastritis, gastric ulcer, cancer, lymphomas
Others have rebound of acid production so develop duodenal ulcer
Duodenal ulcer pathway of H pylori
Antral gastritis
Increased acid secretion
Gastric metaplasia
Duodenal ulcer
gastric ulcer pathway of H pylori
Corpus gastritis
Decreased acid secretion
gastric atrophy
Dysplasia and neoplasia
Treatment of peptic ulcer
PPI = to heal and prevent recurrence sometimes
H pylori eradication = PPI and 2 ABs
Always confirm H pylori eradication = urea breath test and faecal antigen test
Stop NSAIDs
Stop smoking
What to be careful with gastric ulcers?
Always biopsy
Always re-scope for healing
As can be malignant!
