Dyspepsia, GU, DU, Gastritis Flashcards by Hannah Felicity Starling

What are the symptoms of dyspepsia?

Epigastric burning pain related to hunger, 
Worse after eating
Fullness after meals
Heartburn
Tender epigastrium

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What are the ALARM Symptoms?

Anaemia
Loss of weight
Anorexia
Recent onset
Melaena/haematemesis
Swallowing difficulty

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What are the differentials of dyspepsia?

Duodenal ulcer
Gastric ulcer
Duodenitis
Gastritis
Non-ulcer dyspepsia
Malignancy
GORD

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How do we manage dyspepsia?

If dysphagia or over 55 & alarm symptoms = urgent endoscopy

If not, then treat with OTC antacids, lifestyle changes and stop aggravating drugs. Review in 4 weeks and if not better then test for H Pylori.

If H Pylori neg then give omeprazole 20mg/24hrs or ranitidine 150mg/24hrs and review in 4 wks. If not better = endoscopy

If H Pylori positive give triple therapy for 1 week - lansoprazole 30mg/24hrs, amoxicillin 1g/12hrs and clarithromycin 250mg/12hrs

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What are the defence mechanisms of the stomach?

Mucins, cell turnover, cellular mucus, bicarbonate secretion, prostaglandins, mucosal blood flow.

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What are the attacking forces of the stomach?

Acid
Pepsin
H Pylori
Bile salts

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Which upper GI ulcer is the most common?

Duodenal

4x than gastric

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What are the main causes of a peptic ulcer?

H, Pylori (70% GU, 90% DU)

Drugs (NSAIDs, steroid, SSRIs)

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What else can contribute to the risk of peptic ulcers?

Alcohol
Smoking
FH
PMH
Zollinger-Ellison
Increased gastric secretion
Increased gastric emptying
Blood type O

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What are the causes of dyspepsia?

GORD
H Pylori
G/D ulcer

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What are the symptoms/signs of a duodenal ulcer?

Dyspepsia
± weight loss

Asymptomatic

Epigastric tenderness related to eating, often nocturnal and may radiate through to back

Indigestion
Loss of appetites
Nausea/V

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How do we diagnose duodenal ulcers?

Upper GI endoscopy
H.Pylori test
FBC for Hb if bleeding

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What are the differentials for peptic ulcer symptoms?

Duodenal Crohn's
Non-ulcer dyspepsia
TB
Lymphoma
Pancreatitis
Cholecystitis

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How do we treat duodenal ulcers?

Stop smoking and alcohol

Stop drug if drug causing it, or give lansoprazole/misoprostol to prevent ulcers if need NSAID.

Reduce acid by giving:
PPI (lansoprazole 30mg OD for 4 weeks)
H2A (ranitidine 300mg OD night for 8 weeks)

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What is misoprostol?

A prostaglandin E1 inhibitor that directly inhibits gastric secretion

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What are the symptoms/signs of gastric ulcer?

Dyspepsia
± weight loss

Asymptomatic

Epigastric tenderness related to eating and often nocturnal

Indigestion
Loss of appetite
Nausea/V

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How do we diagnose GU?

Endoscopy, to rule out malignancy
Biopsies for H.pylori
FBC for Hb if bleeding

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How do we follow up GU?

Endoscopy after 4-6 weeks to confirm healing and super exclude malignancy

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How do we treat GU?

Stop smoking and alcohol
Stop drugs or give lansoprazole/misoprostol if need the drug

Reduce stomach acid by:
PPI (lansoprazole 30mg OD for 8 weeks)
H2A (ranitidine 300mg OD night for 8 weeks)

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How do we get rid of H.Pylori?

Triple therapy:
Lanzoprazole 30mg OD
Amoxicillin 1g BD
Clarithromycin 250mg BD

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How do we follow up duodenal ulcers?

We don’t if there is good response to the treatment

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What are the risk factors for gastritis?

Alcohol
NSAIDS
H.pylori
Dyspepsia
Hernia

Granulomas (crohn’s/sarcoidosis)
Zollinger-Ellison syndrome
CMV
Mentriers disease

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What are the symptoms of gastritis?

Epigastric pain, vomiting

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What tests do we do for gastritis?

Upper GI endoscopy is suspicious of something else

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What is gastritis?

Inflammation of the lining of the stomach

What are the causes of gastritis?

Acute: NSAIDs, alcohol, post surgery Chronic: H.Pylori Chronic alcoholism Biliary reflux Atrophic: Stomach lining is atrophied

What is the pathophysiological cause of an ulcer?

Acid and pepsin over acting and not being countered by the bicarbonate

What is non-ulcerative, functional dyspepsia?

This is dyspepsia caused by malfunction of the upper GI tract. This could be due to the stomach not expanding properly, increased sensitivity to gastric sensation and delayed gastric emptying

What are the evidential treatment options for functional dyspepsia?

H.pylori eradication PPIs Psychotherapy Amitriptyline 10-20mg OD night

Which treatments for functional dyspepsia have less evidence?

Antacids H2As Misoprostol

What are the tests for H.Pylori?

Carbon-13 breath test | Blood test for antibodies

Why can long term omeprazole be bad?

It can mask symptoms of cancers

What is the definition of a peptic ulcer?

A break in the mucosal lining of the stomach or duodenum more than 5mm in diameter

What if there is a break in the mucosal lining <5mm?

These are called erosions

What is a peptic ulcer?

An ulcer that occurs in the stomach or the first part of the duodenum

What is H.Pylori?

It is a gram negative microaerophlic organism that can survive in acidic conditions

Which part of the stomach does the H.Pylori prefer?

Antrum

What does H.Pylori do?

Increases acid production by causing inflammation in antrum (causing G cell stimulation, D cell destruction and PNS stimulation) Disrupts mucosal defence in body of the stomach Feeds on gastric surfactant

How do you treat H.Pylori for those who are allergic to penicillin?

PPI Clarithromycin Metronidazole

How do you treat H.Pylori for those who are allergic to penicillin and have had previous exposure to clarithromycin?

PPI Bismuth Metronidazole Tetracycline

How pathophysiologically can an NSAID cause ulcers?

They inhibit COX-1 which decreases blood flow Inhibit COX-2 which causes neutrophil adherence Cause topical irritation which causes epithelial damage and mucosal injury

What are the complications of peptic ulcers?

Bleeding Perforation Gastric obstruction

What can bleeding of an ulcer cause?

Iron deficiency anaemia | Life-threatening bleed

What are the symptoms of the bleeding with which patients can present?

Anaemia - fatigue, SOB, palpitations Bleed - haematemesis and malaena, shock

What is a perforated peptic ulcer?

An ulcer that has completely eroded through the lining of the stomach or (more commonly) duodenum. Fluids and air escape into the peritoneal cavity.

What can a perforated ulcer cause?

Peritonitis | "Acute abdomen"

What can gastric obstruction lead to?

Gastric Outlet Obstruction (GOO)

What is GOO?

A clinical syndrome characterised by epigastric abdominal pain and postprandial vomiting due to obstruction

What are the most common causes of GOO?

Peptic ulcer disease | Malignancy (pancreatic)

How do NSAIDs cause ulcers?

They're directly cytotoxic to epithelial cells, (hence most have an enteric coating) causing a disruption in the barrier Inhibit COX1 causing decreased mucus secretion (which disrupts the barrier), reduces blood flow to epithelial cells (reducing the epithelial repair mechanism) and impairs platelet function. Inhibits COX2 which reduces angiogenesis, reducing blood flow to epithelial cells (reducing repair mechanism) Suppress (via COX1/2) prostaglandin production which would usually suppress acid production (so increases acid production) The barrier breakdown and repair mechanisms are the most important disruptions that causes ulcers

What is the most common oesophageal disease in the UK?

GORD

What is the commonest stomach disease in the UK?

Gastritis

What are the SCORING systems for upper GI bleed?

Glasgow-Blatchford | Rockall

What does the Glasgow-Blatchford score tell us?

Whether or not to send the patient home or admit them

What does the Rockall score tell us?

How likely a rebleed is

What are the prognostic meanings of the Rockall score?

Anything over 8 and they have a 40% chance of death Less than 3 carries a good prognosis

What do you have to have had done to be able to input the info for a Rockall score?

OGD

What Glasgow-Blatchford score means you can send them home?

What drugs are linked with formation of peptic ulcers OR GI bleeds?

``` NSAIDs SSRIs Steroids Nicorandil Antiplatelets Anticoagulants ```

What is nicorandil?

Potassium channel activator - vasodilator

What is important about ulcers caused by nicorandil?

They are refractory to treatment and only respond to the withdrawal of nicorandil

If someone is taking aspirin and clopidogrel should you give them PPIs?

Yes, if there is a high risk of ulcer development such as H Pylori or NSAID use