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Year 3 - Met3a > Dyspepsia, GORD, and peptic ulcer > Flashcards

Dyspepsia, GORD, and peptic ulcer Flashcards

1
Q

what is dyspesisa

A

= A group of symptoms that suggest UGI disease where the person as symptoms such as heartburn and bloating that can happen after eating
- basically means indigestion

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2
Q

How can you describe dyspepsia

A
  • Pain or discomfort in epigastrum
    may include
  • heartburn/regurgitation
  • bloating, nausea, vomiting, excess wind
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3
Q

What are the red flag syndromes for dyspepsia

A

Beware of ALARM Symptoms

  • Anaemia (iron deficiency)
  • Loss of weight
  • Anorexia
  • Recent onset/progressive symptoms
  • Melaena/haematemesis
  • Swallowing difficulty (dysphagia)

as well as

  • persistent vomiting
  • epigastric mass
  • new/persistent unexplained symptoms in those over 55 years old
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4
Q

how common is dyspepsia

A
  • 25-40% of audlts have it

- only 20-25% of these seek help

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5
Q

Describe the physiology of dyspepsia

A

Forces of Attack: acid, pepsin, H.pylori, bile salts

Forces of defence: mucin secretion, cellular mucus, bicarbonate secretion, mucosal blood flow, cell turnover

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6
Q

How does dyspepsia present

A
  • Epigastric pain - related to hunger, specific food or time of the day, fullness after meals, heartburn
  • Tender epigastrium
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7
Q

what are the causes of dyspepsia

A
  • 50-75% - non ulcer dyspepsia
  • 15-25% - peptic ulcer disease
  • 5-15% oesophagitis
  • less than 2% have cancer
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8
Q

What can cause non ulcer dyspesia

A

Disturbances in

  • GI motility
  • visceral sensation - hypersensitivity
  • gastric accomodation - stomach feels abnormally distended or quickly full
  • intestino-gastric reflexes are pronouced
  • increased senstivity to gastric acid
  • psycho-social factors
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9
Q

what does endoscopy look like for non ulcer dyspepsia

A

normal

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10
Q

How do you treat non ulcer dyspesia

A
  • gets better with time

- symptomatic treatment with a proton pump inhibitor

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11
Q

What is gastro-oesophageal reflux disease (GORD)

A
  • symptoms and/or mucosal damage resulting from reflux of gastric contents into the distal oesophagus
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12
Q

how severe is GORD usually

A

80% is mild/moderate

- few people have chronic persistent symptoms and complications

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13
Q

Name the causes of GORD

A
  • lower oesophageal sphincter (LOS) hypotension
  • hiatus hernia
  • oesophageal dysmotility (e.g. systemic sclerosis)
  • Obesity
  • gastric acid hyper secretion
  • Smoking
  • alcohol
  • pregnancy
  • drugs - TCAs, anticholinergics, nitrates
  • H.pylori
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14
Q

Describe how GORD happens

A

Dysfunction of the oesphageal gastric junction

  • causes low LOS pressure
  • high intra-abdominal pressure
  • decreased oesophageal acid clearance
  • delayed gastric emptying
  • gastric acid production is normal though
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15
Q

How do you diagnose GORD

A
  • in a young person you can have a therapeutic trial of PPI
  • others are refered to endoscopy
  • 24 pH monitoring/manometry - used in making the diagnosis and monitoring treatment
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16
Q

What classification is used for GORD

A

Los Angeles classification of esophagitis

  • classifies it from mild to severe
  • at grade D there is a risk of a stricture developing
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17
Q

at endoscopy in GORD 50% of patients

A
  • 50% of patients have no mucosal lesions at endoscopy
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18
Q

what are the complications of GORD

A
  • oesophagitis
  • ulcers
  • Benign stricture
  • iron deficiency
  • Barrett’s oesophagus
  • cancer
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19
Q

How can GORD lead to Barrett’s oesophagus

A
  • metaplasia goes to dysplasia which turns to neoplasia
  • the distal oesophageal epithelium undergoes metaplasia from squamous to columnar
  • 0.1-0.4% per year of those with Barrett’s oesophagus progress to oesophageal cancer
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20
Q

what are extra-oesophageal manifestations linked to

A
  • middle ear problems
  • chronic sinustitis
  • dental erosions and halitosis
  • sore throat/pharyngitis/laryngitis
  • cough
  • asthma
  • aspiration pneumonia
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21
Q

What are the objectives of treatment for GORD

A
  • resolution of symptoms
  • healing of oesophagitis
  • prevention of complications
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22
Q

How can you treat GORD

A
  • Lifestyle modifications
  • Drugs
  • Surgery
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23
Q

What lifestyle modifications are for GORD

A
  • eliminate triggering foods and drinks such as caffine, fatty meals
  • time meals so you eat the evening meal hours before you go to bed
  • dont wear tight things on the stomach
  • weight loss
  • stop smoking
  • prop up the end of the bed so you sleep in an inclined position
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24
Q

What are the two types of peptic ulcer disease

A
  • duodenal ulcer

- gastric ulcer

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25
Q

what is the characterstic pain experienced with peptic ulcers

A
  • epigastric pain - can radiate with the back and associated with either eating or not eating
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26
Q

Describe duodenal ulcers

A
  • Pain after food or not
  • 99% H.pylori related
  • not malignant
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27
Q

Describe gastric ulcer

A
  • symptoms not reliable to diagnose
  • weight loss is more likley
  • 60-70% H.pylori related
  • NSAIDS are significant cause
  • 5-10% are malignant
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28
Q

What are the risk factors for Gastric uulcers

A
  • H.Pylroi
  • smoking
  • NSAIDS
  • reflux of duodenal contents
  • delayed gastric emptying
  • stress
  • older patietns - greater than 70 years old
  • co-morbidity
  • other drugs such as anticoagulants
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29
Q

What do NSAIDs cause

A
  • dyspesia in 60%

- but 50% of NSAID ulcers are asymptomatic

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30
Q

What is helicobacter pylori associated with

A
  • Duodenal ulcers

- gastric ulcers and cancer

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31
Q

the host response to ..

A

H pylori infection has a pivotal role in to what happens

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32
Q

Describe how H plyori can cause ulcers

A
  • Gastric acid output decreases
  • causes increased inflammation in the stomach
  • this can cause a gastritis to develop
  • in most people gastric acid returns to normal and they never know they had a H plyori infection
  • in some people the gastric acid never returns to normal and chronic gastritis develops and cancer can be produced
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33
Q

describe how a duodneal ulcer forms

A
  • antral gastritis
  • increased acid secretion
  • gastric metaplasia
  • duodenal ulcer
34
Q

describe how a gastric ulcer forms

A
  • corpus gastirits
  • decreased acid secretion
  • gastric atrophy
  • dysplasia and neoplasia
35
Q

What is the treatment of H.Pylori

A

H.pylori eradication therapy

  • PPI and 2 antibiotics
  • eg lansoprazole 30mg/12h PO + clarithromycin 250mg/12h PO + amoxicillin 1g/12h PO
36
Q

How do you confirm H pylori eradication

A
  • urea breath test

- H.pylori faecal antigen test

37
Q

what lifestyle changes should you do when you have a peptic ulcer

A
  • stop NSAIDs

- Stop smoking

38
Q

what do you need to do for all gastric ulcers

A
  • always biospy gastric ulcers

- always re-scope after treatment to make sure that it is healed

39
Q

What are the red flag symptoms for upper GI

A
  • dysphagia
  • weight loss
  • persistent vomiting
  • epigastric mass
  • GI bleeding
  • iron deficiency
  • new and persistent unexplained symptoms in over 55 years old
40
Q

What are the two types of hiatus hernia

A
  • Sliding hiatus hernia (80%)

- paraoesophagheal hernia (rolling hiatus hernia; 20%)

41
Q

Describe what happens in a sliding hiatus hernia

A
  • gasto-oesophageal junction slides up into the chest

- acid reflux often happens as the LOS becomes less competent in many cases

42
Q

Describe what happens in a paraoesophageal hernia (rolling hiatus hernia)

A
  • gastro-oesophageal junction remains in the abdomen but a bulge of the stomach herniates up into the chest alongside the oesophagus
  • as the gastro-oesophageal junction remains in tact, GORD is less common
43
Q

who tends to get oesophageal hernias

A
  • common 30% of patients > 50 years, especially in obese women
  • patients with large hernias develop GORD whereas small hernias are asymptomatic
44
Q

What imaging should you use for oesophageal hernias

A
  • Upper GI endoscopy - this visualises the mucosa but cannot reliably exclude a hiatus hernia
45
Q

what is the treatment for oesophageal hernias

A
  • loose weight
  • treat GORD
  • surgery indications: intractable symptoms despite aggressive medical therapy, complications, strangulation
46
Q

What are the symptoms of GORD

A

Oesophageal

  • heartburn (dyspepsia)
  • belching
  • acid brash = acid or bile regurgitation
  • water brash = increase in salivation
  • Odynophagia

Extra-oesophageal

  • nocturnal asthma
  • chronic cough
  • laryngitis (hoarseness, throat clearing)
  • sinusitis
47
Q

What are the differential diagnosis of GORD

A
  • Oesophagitis from corrosives, NSAIDS, herpes or candida
  • duodenal or gastric ulcers or cancers
  • non-ulcer dyspepsia
  • oesophageal spasm
  • cardiac disease
48
Q

What investigations do you use in GORD

A

Endoscopy

1) if dysphagia
2) if greater than 55 years old with alarm symptoms
3) if treatment-refractory dyspepsia

24 hour oesophageal pH monitoring and manometry to help diagnose GORD when endoscopy is normal

49
Q

What drugs do you use to treat GORD

A
  • Antacids (eg magnesium trisilicate mixture 10mL/8h) or alginates (eg Gaviscon 10-20mL/8h PO) to relieve symptoms
  • Add PPI (eg lansoprazole 30mg/24h PO)
  • For refractory symptoms, add H2 blocker and/or try twice-daily PPI
50
Q

What drugs should you avoid when you have GORD

A

avoid drugs affecting oesophageal motility

  • nitrates
  • anticholinergics
  • CCBs (relax sphincter)

avoid drugs that damage the mucosa

  • NSAIDs
  • potassium salts
  • bisphosphonates
51
Q

What surgery can be used for GORD

A
  • Nissen fundoplication
  • magnet bead band
  • radio frequency induced hypertrophy
52
Q

When do you do surgery for GORD

A
  • severe GORD confirmed by pH monitoring and if drugs are not working
53
Q

What symptoms of GORD are less likely to improve with surgery

A
  • atypical symptoms such as cough, laryngitis are less likely to improve withs rugger compared to patients with typical symptoms
54
Q

What is the procedure of fundoplication for GORD

A
  • defect in diaphragm is repaired by tightening the crura
  • reflex is prevented by wrapping the gastric fundus around the LOS
  • Nissen = 360 degree wrap
  • Toupet = 270 degree posterior wrap
  • Watson = anterior hemifundoplication
55
Q

what is the complications that can happen for fundoplication for GORD

A
  • dysphagia (if the wrap is too tight)
  • Gas-Bloat syndrome (inability to belch/vomit)
  • new onset diarrhoea
56
Q

What are the differential diagnosis for dyspepsia

A
  • Duodenal/gastric ulcer
  • non-ulcer dyspepsia
  • oesophagitis/GORD
  • duodenitis
  • gastritis
  • gastric cancer
57
Q

When should you test for H.Pylori

A
  • if younger than 55 years old with GORD symptoms
58
Q

if you have dysphagia at any age…

A
  • get referred for urgent endoscopy
59
Q

What are the major and minor risk factors for a duodenal ulcer

A

Major risk factor

  • H.Pylori (90%)
  • drugs (NSAIDS, steroids, SSRI)

Minor risk factors

  • increase in gastric emptying (decrease duodenal pH)
  • blood group O
  • Smoking
60
Q

What is more common gastric or duodenal ulcer

A
  • Duodenal ulcer is 4 times more common than gastric ulcers
61
Q

What are the symptoms and signs of duodenal ulcer

A

Symptoms

  • asymptomatic or epigastric pain
  • +- weight gain

Signs
- epigastric tenderness

62
Q

How do you diagnose a duodenal ulcer

A
  • Upper GI endoscopy
  • Test for H. pylori
  • Measure gastrin concentrations when off PPIs if Zollinger-Ellison syndrome is suspected (associated of peptic ulcers with gastrin-secreting adenoma; gastrinoma)
63
Q

What are the differential diagnosis for duodenal ulcers

A
  • non ulcer dyspepsia
  • duodenal Crohn’s disease
  • TB
  • lymphoma
  • pancreatic cancer
64
Q

What are the symptoms of a gastric ulcer

A
  • asymptomatic or epigastric pain (relieved by antacids and worsened by eating) +- weight loss
65
Q

What are the investigations used for a gastric ulcer

A
  • upper GI endoscopy to exclude malignancy + multiple biopsies from ulcer rim and base
  • repeat endoscopy after 8 weeks and exclude malignancy
66
Q

What are there risk factors for gastritis

A
  • alcohol
  • NSAIDs
  • H.pylori
  • reflux/hiatus hernia
  • atrophic gastritis
  • granulomas (Crohn’s, sarcoid)
  • CMV
  • Zollinger-Ellison syndrome
67
Q

What are the symptoms of gastritis

A
  • epigastric pain

- vomiting

68
Q

What are the investigations of gastritis

A
  • Upper GI endoscopy only if suspicious features (alarm symptoms, dysphagia, >55 years and persistent symptoms)
69
Q

What is the management of peptic ulcer disease

A
  • Lifestyle
  • H.Pylori eradication - triple therapy is 80-85% effective at eradication

Drugs to reduce acid

  • PPI - e.g. lansoprazole 30mg/24h PO (for 4 weeks for DU or 8 weeks for GU)
  • H2 blockers - e.g. ranitidine 300mg each nigh PO for 8 weeks

Surgery

  • indicated for perforated/haemorrhaging peptic ulcers
  • rare as elective surgery for peptic ulcers
70
Q

What is the lifestyle management of peptic ulcer disease

A

reduce alcohol

stop smoking

71
Q

What are the complications for peptic ulcer disease

A
  • Upper GI bleed
  • perforation
  • malignancy
  • reduced gastric outflow
72
Q

What is a peptic ulcer

A
  • this is a break in the lining of the stomach (gastric ulcer) or first part of the small intestine (duodenal ulcer) or the oesophagus (oesophageal ulcer)
73
Q

How do you manage an upper GI bleed caused by peptic ulceration

A
  • insert 2 large bore (14-16G) IV cannulae and take blood for FBC
  • U&Es - increase in urea out of proportion to creatine which is indicative of a massive blood meal
  • LFTs, clotting and cross match
  • give IV fluids to restore intravascular volume wile waiting for crossmatched blood, if haemodynamically deteriorating despite fluid resuscitation give blood group O
  • insert a urinary catheter and monitor hourly urine
  • organise CXR, ECG and check ABG
  • consider CVP line to monitor and guide fluid replacement
  • transfuse if significant haemoglobin drop (<70g/L)
  • correct clotting abnormalities
  • if varices then give terlipressin IV e.g. 1-2mg/6hour for <3 days which reduces the risk of death by 34%
  • initiate broad spectrum IV antibiotic cover
  • monitor pulse, BP, and CVP at least hourly
  • arrange an urgent endoscopy
74
Q

What are the signs of a perforated ulcer

A
  • prostration
  • shock
  • lying still
  • +ve cough test
  • tenderness - +/- rebound/percussion pain
  • board like abdominal rigidity
  • guarding
  • no bowel sounds
75
Q

How do you manage a perforated ulcer

A

Medical management

  • fluid resuscitation
  • nasogastric decompression
  • acid suppression
  • empiric antibiotic therapy
  • Surgery
76
Q

What distinguishes a peptic ulcer from ulcerating carcinoma

A

Symptoms of carcinoma that are different from a peptic ulcer

  • mild upper abdominal discomfort
  • difficulty swallowing due to a tumour
  • feeling of fullness after eating a small amount of for
  • weight loss
  • vomiting blood or dark material that looks like coffee ground for passing black stools caused by bleeding
77
Q

What is the histology of a peptic ulcer

A
  • muscle replaced by fibrous tissue
  • serosal fibrosis
  • hyperplasia of adjacent lymph nodes
  • proximal mucosa may be overhanging
  • surface neutrophils, bacteria, necrotic debris and possible Candida
  • fibrinoid necrosis at base and margins
  • granulation tissue with chronic inflammatory cells
  • fibrous or collagenous scars in muscular proprietary with sickened blood vessels
78
Q

What do you do if a peptic ulcer recurs

A
  • offer a PPI to be taken at the lowest dose possible to control symptoms
  • surgery to remove it
79
Q

Where are most perforated ulcers

A
  • anterior surface of the duodenum
80
Q

What is the operative surgical treatment of a perforated ulcer

A
  • Laparoscopic surgery

- conservative surgery

81
Q

What is globus pharynges

A
  • Globus pharyngis (also known as globus hystericus) is the persistent sensation of having a ‘lump in the throat’, when there is none.
  • Symptoms are often intermittent and relieved by swallowing food or drink. Swallowing of saliva is often more difficult.
82
Q

What is Plummer vision syndrome

A

Plummer-Vinson syndrome is defined by the classic triad of dysphagia, iron-deficiency anemia and esophageal webs

Year 3 - Met3a (43 decks)

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