Gastric 1+2+3 Flashcards
What is Dyspepsia?
A complex of upper GI tract symptoms which are typically present for 4 or more weeks including upper abdominal discomfort, heartburn, acid reflux, nausea and or vomiting
What is Gastro-oesophageal reflux disease?
When contents of the stomach reflux into the oesophagus through the lower oesophageal sphincter
What are the symptoms of Gastro-oesophageal reflux disease?
Heart burn
Acidic taste (potential dental erosion)
Cough
Can be asymptomatic
What are the risk factors of developing Gastro-oesophageal reflux disease?
Essentially anything that increases Intrabdominal pressure:
-obesity
-pregnancy
-delayed gastric emptying
Lower oesophageal dysfunction
Hiatus hernia
What is a Hiatus hernia?
When the Lower-oesophageal sphincter herniates through the diaphragm so it is now in the thorax rather than the abdomen
What 3 components help keep the oesophageal eal sphincter closed?
Muscular elements (intrinsic and diaphragm)
Right crus
Angle oesophagus joins stomach
What is the right crus?
Derived from intervertebral discs of L1-L3 the wrap around the lower oesopheal sphincter keeping it closed
What are some potential complications of Gastric-oesophageal reflux disease?
Oesophagitis
Ulceration
Haemorrhage
Strictures
Metaplastic changes (Barrett’s oesophagus)
What is oesophagitis?
Inflammation of epithelium of oesophagus
What layer gets damaged if ulceration?
Muscularis mucosa damaged
What complication can occur if haemorrhaging occurs?
Anaemia
What are strictures, when do they normally occur, what complications can this lead to with respect to Gastro-oesophageal reflux disease?
When continual repair leads to fibrous strictures forming
This can lead to dysphagia
What is Barretts oesophagus?
When repeat exposure of gastric contents to the oesophagus occurs leading to metaplastic changes
What cells are normally present in the lower oesophagus?
What cells do these change to in Barrett’s oesophagus?
Stratified squamous epithelia -> columnar cells
What is the risk of cells converting to columnar epithelial cells in Barrett’s oesophagus?
Columnar cells have increased risk of Dysplasia leading to Adenocariinoma development
What is adenocarcinoma?
A cancer of glandular origin
How can Gastro-oesophageal reflux disease be managed?
Lifestyle
Drugs
Surgery
What lifestyle changes can be implemented to help with gastro-oesophageal reflux disease?
Weight loss
Eat smaller meals
Don’t eat then sleep (prop up while sleeping)
Decrease alcohol and caffeine intake
What drugs can be used to manage Gastro-oesophageal reflux disease?
Proton Pump Inhibitor (omeprazole)
H2 receptor antagonists like Famotidine (decreases acid production)
What surgery is done to help treat GORD?
Fundoplication
Fundus of stomach wrapped around lower oesophagus to help with sphincter mechanism
What is Gastritis?
Inflammation of the stomach mucosa
What are some symptoms of Gastritis?
Pain
Nausea
Vomiting
Haemorrhage
What type of cells invade the lamina propria in Gastritis?
Neutrophils
What can cause Acute gastritis?
NSAIDs
Bare alcohol
Chemotherapy
Bile reflux
What can cause Chronic Gastritis?
Infection with H-pylori
Autoimmune cause
What are some pathological changes in gastritis?
Epithelial damage
Epithelial hyperplasia
Vasodilation
Neutrophil response
Lymphocyte response (lamina propria)
Glandular atrophy (lamina propria)
Fibrotic changes (lamina propria)
What is the autoimmune cause of chronic gastritis?
Autoimmune antibodies attack parietal cells
Leads to decreased acid production and decreased intrinsic factor production
Why is it important that Parietal cells produce Intrinsic factor?
Intrinsic factor needed to absorb Vitamin B12
What haematological condition can develop as a result of loss of intrinsic factor production by parietal cells?
Pernicious anaemia which is a type of Megaloblastic anaemia
What part of the body does Vitamin B12 get absorbed with the hep of intrinsic factor?
Ileum (distal part of small intestine)
In autoimmune chronic gastritis, what are some symptoms that occur as a result of atrophy of the body of stomach?
Megaloblastic anaemia (pernicious anaemia)
Neurological symptoms
Anorexia
Glossitis (symptom of pernicious anaemia)
What is Glossitis?
Inflammation of tongue
What route does H-pylori infect people?
Faecal-oral route
What type of organism is Helibacter pylori?
Gram negative helical bacteria
What are the features that help H-pylori infect?
Flagella for motility
Chemotaxis (find areas of higher acidity)
Adhesins to fix to gastric epithelia (resist peristalsis)
What enzyme is important in helping protect the H-pylori in the stomach?
Why?
Urease
Urea converted to ammonia using water
Ammonia is basic and it coats the outer membrane helping protect the bacteria from the acidic conditions
How does H-Pylori cause gastritis?
Produces digestive enzymes like Mucinase, Protease, and lipases
Ammonia they produce damages the stomach epithelium
Produces Cytotoxin associated Gene A (CAG.A)
Produces Vacuolting Toxin A (VacA)
How does CAG.A made by H-pylori cause Gastritis?
Stimulates interleukin 8 production leading to inflammation of stomach epithelia
How does Vacuolating Toxin A (VacA) produced by H-pylori cause Gastritis?
Directly toxic to the stomach epithelia
What affect do h-pylori have on G cells in the antrum?
Leads to increased activity increasing amount of Gastrin
Leading to the chyme become very acidic
What affect does increased acidity if chyme have on h-pylori movements?
Can colonise duodenum
What happens if h-pylori infects stomach body?
Atrophy of parietal cells
Leads to increased cancer risks
How do you diagnose infection with H-pylori?
Urea breath test
How does the urea breath test work?
Gastric urea contains C12
Give patients C13, urea gets injected and if H pylori present the urea gets broken down to ammonia
You can then detect a high level of C13 in the CO2 exhaled
How do we treat H-pylori infection?
Proton Pump Inhibitor (PPI) Omeprazole
2 x antibiotics (clarithromycin + metronidazole)
What is peptic ulcer disease?
Defect in the gastric or duodenal mucosa that extends through the muscularis mucosa
Where is peptic ulcer disease most common?
Duodenum
If a peptic ulcer disease occurs in the stomach, where s the most common location?
Lesser curve/antrum
Go to last slide of gastric disease 3 and label the image of the peptic ulcer disease:
1 = epithelium
2 = lamina propria
3 = muscularis mucosa
4 = sub mucosa
5 = muscularis externa
What is the ratio of gastric ulcer to duodenal ulcer incidence?
Gastric 1: 3 duodenal
What is the most common blood group for gastric ulcers?
What is the most common blood group for duodenal ulcers?
Gastric = A
Duodenal = O
What are the levels of acid like for gastric ulcers?
What are the levels of acid like for duodenal ulcers?
Gastric = Normal/low
Duodenal =Normal/high
Why do duodenal ulcers lead to high levels of acid?
Chyme is more acidic which overwhelms the intestines ability to neutralise it
Which type of ucler normally always is associated with H-pylori infection?
Duodenal (95-100%) (the H-pylori increase G cell activity meaning more Gastrin made so more parietal cells stimulated to make stomach acid)
Gastric = 70%
What is the alkaline layer of the stomach defences?
Mucus layer + HCO3- secretion
What medication inhibits production of prostaglandins which then leads to reduced support to the protective mucus layer?
NSAIDs
What are the risk factors for peptic ulcer disease?
H-pylori
NSAIDs (inhibits prostaglandins)
Smoking (leads to ulcer relapse)
Massive physiological stress (burns)
How do Acute ulcers develop?
They develop as part of acute gastritis (transient with healing)
Where do chronic ulcers occur?
Mucosal junctions like where the antrum meets the curve
How can peptic ulcer diseases lead to Pyloric stenosis?
Ulceration thought the Muscularis mucosa that extends to the muscularis externa leads to the muscularis externa being replaced by fibrous scar tissue
This scar tissue can build up leading to narrowing of the pyloric sphincter
How can peptic ulcer disease lead to peritonitis?
The peptic ulcer can go all the way through the Musculariating the stomach wall leading to leakage of contents into peritoneum
What is malaena?
Relatively slow upper GI bleed
What artery can be ruptured if a peptic ulcer perforates posteriorly in the stomach?
Splenic artery
What happens as result of a peptic ulcer perforating into the gastroduodenal artery?
Duodenum or stomach can fill with blood
What often happens pyloric stenosis?
Vomiting
What is haematemesis?
When someone bleeds internally leading to them vomiting
What region is pain experienced in Peptic Ulcer Disease?
Epigastric pain (burning or gnawing pain)
What are symptoms of Peptic Ulcer Disease?
Epigastric pain
Haematemesis from bleeding
Anaemia due to Malaena
Early satiety
Weight loss
How does the onset of pain differ between Duodenal ulcers and gastric ulcers?
Duodenal ulcers = food stops pain since pyloric sphincter contracts preventing chyme getting into duodenum
Gastric ulcer = pain made worse straight away with food
How do you manage a peptic ulcer disease that isn’t actively bleeding with H-pylori present?
PPI + x2 Antibiotics
How do you manage a peptic ulcer disease that isn’t actively bleeding without H-pylori present?
Stop the meds worsening it like NSAIDs
How do you manage a peptic ulcer disease that is actively bleeding?
Endoscopic injection
Injecting adrenaline and cauterising
