Dyspepsia, GORD, and peptic ulcer Flashcards
what is dyspesisa
= 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
How can you describe dyspepsia
- Pain or discomfort in epigastrum
may include - heartburn/regurgitation
- bloating, nausea, vomiting, excess wind
What are the red flag syndromes for dyspepsia
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
how common is dyspepsia
- 25-40% of audlts have it
- only 20-25% of these seek help
Describe the physiology of dyspepsia
Forces of Attack: acid, pepsin, H.pylori, bile salts
Forces of defence: mucin secretion, cellular mucus, bicarbonate secretion, mucosal blood flow, cell turnover
How does dyspepsia present
- Epigastric pain - related to hunger, specific food or time of the day, fullness after meals, heartburn
- Tender epigastrium
what are the causes of dyspepsia
- 50-75% - non ulcer dyspepsia
- 15-25% - peptic ulcer disease
- 5-15% oesophagitis
- less than 2% have cancer
What can cause non ulcer dyspesia
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
what does endoscopy look like for non ulcer dyspepsia
normal
How do you treat non ulcer dyspesia
- gets better with time
- symptomatic treatment with a proton pump inhibitor
What is gastro-oesophageal reflux disease (GORD)
- symptoms and/or mucosal damage resulting from reflux of gastric contents into the distal oesophagus
how severe is GORD usually
80% is mild/moderate
- few people have chronic persistent symptoms and complications
Name the causes of GORD
- 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
Describe how GORD happens
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
How do you diagnose GORD
- 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
What classification is used for GORD
Los Angeles classification of esophagitis
- classifies it from mild to severe
- at grade D there is a risk of a stricture developing
at endoscopy in GORD 50% of patients
- 50% of patients have no mucosal lesions at endoscopy
what are the complications of GORD
- oesophagitis
- ulcers
- Benign stricture
- iron deficiency
- Barrett’s oesophagus
- cancer
How can GORD lead to Barrett’s oesophagus
- 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
what are extra-oesophageal manifestations linked to
- middle ear problems
- chronic sinustitis
- dental erosions and halitosis
- sore throat/pharyngitis/laryngitis
- cough
- asthma
- aspiration pneumonia
What are the objectives of treatment for GORD
- resolution of symptoms
- healing of oesophagitis
- prevention of complications
How can you treat GORD
- Lifestyle modifications
- Drugs
- Surgery
What lifestyle modifications are for GORD
- 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
What are the two types of peptic ulcer disease
- duodenal ulcer
- gastric ulcer
what is the characterstic pain experienced with peptic ulcers
- epigastric pain - can radiate with the back and associated with either eating or not eating
Describe duodenal ulcers
- Pain after food or not
- 99% H.pylori related
- not malignant
Describe gastric ulcer
- symptoms not reliable to diagnose
- weight loss is more likley
- 60-70% H.pylori related
- NSAIDS are significant cause
- 5-10% are malignant
What are the risk factors for Gastric uulcers
- 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
What do NSAIDs cause
- dyspesia in 60%
- but 50% of NSAID ulcers are asymptomatic
What is helicobacter pylori associated with
- Duodenal ulcers
- gastric ulcers and cancer
the host response to ..
H pylori infection has a pivotal role in to what happens
Describe how H plyori can cause ulcers
- 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
describe how a duodneal ulcer forms
- antral gastritis
- increased acid secretion
- gastric metaplasia
- duodenal ulcer
describe how a gastric ulcer forms
- corpus gastirits
- decreased acid secretion
- gastric atrophy
- dysplasia and neoplasia
What is the treatment of H.Pylori
H.pylori eradication therapy
- PPI and 2 antibiotics
- eg lansoprazole 30mg/12h PO + clarithromycin 250mg/12h PO + amoxicillin 1g/12h PO
How do you confirm H pylori eradication
- urea breath test
- H.pylori faecal antigen test
what lifestyle changes should you do when you have a peptic ulcer
- stop NSAIDs
- Stop smoking
what do you need to do for all gastric ulcers
- always biospy gastric ulcers
- always re-scope after treatment to make sure that it is healed
What are the red flag symptoms for upper GI
- dysphagia
- weight loss
- persistent vomiting
- epigastric mass
- GI bleeding
- iron deficiency
- new and persistent unexplained symptoms in over 55 years old
What are the two types of hiatus hernia
- Sliding hiatus hernia (80%)
- paraoesophagheal hernia (rolling hiatus hernia; 20%)
Describe what happens in a sliding hiatus hernia
- gasto-oesophageal junction slides up into the chest
- acid reflux often happens as the LOS becomes less competent in many cases
Describe what happens in a paraoesophageal hernia (rolling hiatus hernia)
- 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
who tends to get oesophageal hernias
- common 30% of patients > 50 years, especially in obese women
- patients with large hernias develop GORD whereas small hernias are asymptomatic
What imaging should you use for oesophageal hernias
- Upper GI endoscopy - this visualises the mucosa but cannot reliably exclude a hiatus hernia
what is the treatment for oesophageal hernias
- loose weight
- treat GORD
- surgery indications: intractable symptoms despite aggressive medical therapy, complications, strangulation
What are the symptoms of GORD
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
What are the differential diagnosis of GORD
- Oesophagitis from corrosives, NSAIDS, herpes or candida
- duodenal or gastric ulcers or cancers
- non-ulcer dyspepsia
- oesophageal spasm
- cardiac disease
What investigations do you use in GORD
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
What drugs do you use to treat GORD
- 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
What drugs should you avoid when you have GORD
avoid drugs affecting oesophageal motility
- nitrates
- anticholinergics
- CCBs (relax sphincter)
avoid drugs that damage the mucosa
- NSAIDs
- potassium salts
- bisphosphonates
What surgery can be used for GORD
- Nissen fundoplication
- magnet bead band
- radio frequency induced hypertrophy
When do you do surgery for GORD
- severe GORD confirmed by pH monitoring and if drugs are not working
What symptoms of GORD are less likely to improve with surgery
- atypical symptoms such as cough, laryngitis are less likely to improve withs rugger compared to patients with typical symptoms
What is the procedure of fundoplication for GORD
- 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
what is the complications that can happen for fundoplication for GORD
- dysphagia (if the wrap is too tight)
- Gas-Bloat syndrome (inability to belch/vomit)
- new onset diarrhoea
What are the differential diagnosis for dyspepsia
- Duodenal/gastric ulcer
- non-ulcer dyspepsia
- oesophagitis/GORD
- duodenitis
- gastritis
- gastric cancer
When should you test for H.Pylori
- if younger than 55 years old with GORD symptoms
if you have dysphagia at any age…
- get referred for urgent endoscopy
What are the major and minor risk factors for a duodenal ulcer
Major risk factor
- H.Pylori (90%)
- drugs (NSAIDS, steroids, SSRI)
Minor risk factors
- increase in gastric emptying (decrease duodenal pH)
- blood group O
- Smoking
What is more common gastric or duodenal ulcer
- Duodenal ulcer is 4 times more common than gastric ulcers
What are the symptoms and signs of duodenal ulcer
Symptoms
- asymptomatic or epigastric pain
- +- weight gain
Signs
- epigastric tenderness
How do you diagnose a duodenal ulcer
- 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)
What are the differential diagnosis for duodenal ulcers
- non ulcer dyspepsia
- duodenal Crohn’s disease
- TB
- lymphoma
- pancreatic cancer
What are the symptoms of a gastric ulcer
- asymptomatic or epigastric pain (relieved by antacids and worsened by eating) +- weight loss
What are the investigations used for a gastric ulcer
- upper GI endoscopy to exclude malignancy + multiple biopsies from ulcer rim and base
- repeat endoscopy after 8 weeks and exclude malignancy
What are there risk factors for gastritis
- alcohol
- NSAIDs
- H.pylori
- reflux/hiatus hernia
- atrophic gastritis
- granulomas (Crohn’s, sarcoid)
- CMV
- Zollinger-Ellison syndrome
What are the symptoms of gastritis
- epigastric pain
- vomiting
What are the investigations of gastritis
- Upper GI endoscopy only if suspicious features (alarm symptoms, dysphagia, >55 years and persistent symptoms)
What is the management of peptic ulcer disease
- 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
What is the lifestyle management of peptic ulcer disease
reduce alcohol
stop smoking
What are the complications for peptic ulcer disease
- Upper GI bleed
- perforation
- malignancy
- reduced gastric outflow
What is a peptic ulcer
- 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)
How do you manage an upper GI bleed caused by peptic ulceration
- 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
What are the signs of a perforated ulcer
- prostration
- shock
- lying still
- +ve cough test
- tenderness - +/- rebound/percussion pain
- board like abdominal rigidity
- guarding
- no bowel sounds
How do you manage a perforated ulcer
Medical management
- fluid resuscitation
- nasogastric decompression
- acid suppression
- empiric antibiotic therapy
- Surgery
What distinguishes a peptic ulcer from ulcerating carcinoma
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
What is the histology of a peptic ulcer
- 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
What do you do if a peptic ulcer recurs
- offer a PPI to be taken at the lowest dose possible to control symptoms
- surgery to remove it
Where are most perforated ulcers
- anterior surface of the duodenum
What is the operative surgical treatment of a perforated ulcer
- Laparoscopic surgery
- conservative surgery
What is globus pharynges
- 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.
What is Plummer vision syndrome
Plummer-Vinson syndrome is defined by the classic triad of dysphagia, iron-deficiency anemia and esophageal webs
