Gastric conditions Flashcards
What is dyspepsia (7)
AKA INDIGESTION Is a collective name for a group of symptoms: Upper abdo pain/retrosternal pain Anorexia - appetite loss Nausea Vomiting Bloating Fullness/early satiety Heartburn
When is an UGIE indicated (6)
If they have ALARM features: Anorexia Loss of weight Anaemia - iron deficiency anaemia Recent onset - >55yrs age Melaena/haematamesis & Masses
What drugs can cause dyspepsia (7)
NSAIDs Steroids Bisphosphonates CCBs Nitrates Theophyllines OTC
Peptic ulcer MOST COMMON cause
H. pylori infection
Duodenal ulcers are more likely caused by H. pylori infection but what are gastric ulcers more commonly caused by
NSAIDs
Peptic ulcer pathophysiology (2)
+ 2 types of peptic ulcers
+ is acid secretion high or normal or low in the respective types
Imbalance between acid secretion and level of mucous protection –> epithelial damage and subsequent mucosal/submucosal damage
DU - acid hyper secretion
GU - normal/low acid secretion
Peptic ulcer risk factors
H pylori infection
NSAIDs
Smoking
Peptic ulcer symptoms (5) + signs (1)
-location of pain + 3 characteristics of the pain
Symptoms:
Dyspepsia - epigastric pain
-pain worsen after eating in GU/better after eating in DU
-pain often worsens at night
-pain can radiate to back in DU perforated
Nausea + vomiting
Signs:
Epigastric tenderness
Peptic ulcer investigations (3)
Urea breath test/H.pylori faecal antigen test
UGIE
FBC (ordered if anaemic or evidence of GI bleed)
Peptic ulcer treatment (4)
- if due to H. pylori (3)
- medical measures (2)
- triggers to avoid
- when is surgery indicated
If caused by H. pylori then eradication therapy - amoxycillin (or metronidazole if penicillin allergic) + clarithromycin + omeprazole
PPI - omeprazole
OR Hydrogen receptor blocker - ranitidine
Stop NSAIDs if being used
Surgery if ulcer –> complicated peptic ulcer disease
Initial treatment for acute bleeding ulcer (2)
Blood transfusion
Endoscopic ligation
Complications of peptic ulcer (4)
Acute bleed (haemorrhage) - haematemesis (coffee ground vomit) or melaena
Chronic bleed - iron deficiency anaemia
Perforation - ulcer can erode through stomach wall into peritoneum –> peritonitis
Stricture –> gastric outlet obstruction
Where can you get peptic ulcers (3)
Lower oesophagus
Stomach (body and antrum)
Duodenum (1st/2nd part)
3 types of gastritis
Type A - autoimmune
Type B - bacterial
Type C - chemical
What is gastritis
Gastric mucosal lining inflammation
Type A (autoimmune) gastritis pathophysiology (4)
Autoantibodies attack parietal cells + intrinsic factor –> atrophy of parietal cells –> decreased acid secretion + loss of intrinsic factor –> vit B12 deficiency
Type A gastritis risk factors (2)
Existing autoimmune diseases
Critically ill
Gastritis symptoms (4)
Dyspepsia - epigastric pain
Nausea
Vomiting
Loss of appetite
Type A gastritis investigations (6)
- 2 investigations to rule out H. pylori
- imaging
- bloods (for a certain vitamin and 2 autoantibodies)
Urea breath test - to exclude H. pylori
H pylori faecal antigen test - to exclude H. pylori
Endoscopy + biopsy
Serum vitamin B12
Parietal cell autoantibodies
Intrinsic factor autoantibodies
Type A gastritis treatment (3)
CORRECT VITAMIN DEFICIENCY
-Vit B12 injection
Hydrogen receptor blocker - ranitidine
PPI - omeprazole
Type B gastritis cause
H pylori infection
Type B (bacterial) gastritis pathophysiology
H pylori causes inflammation of gastric mucosa –> increased mucosal permeability
Difference between H. pylori infection in upper stomach and lower stomach
(describe if the acid secretion is increased or decreased and what disease it is more likely to progress on to)
If H. pylori infects upper stomach –> gastritis of body –> DECREASED ACID PRODUCTION –> gastric cancer
If H. pylori infects lower stomach –> antral gastritis –> INCREASED ACID PRODUCTION –> duodenal disease
Type B gastritis/H. pylori investigations (4)
- tests to confirm H. pylori
- imaging + histological diagnosis
Urea breath test - to confirm H. pylori
H. pylori faecal antigen test - to confirm H. pylori
Endoscopy + biopsy
Serology - IgG against H. pylori
Type B gastritis treatment (H.pylori eradication therapy)
Eradication therapy for 14 days (2 antibiotics + 1 PPI):
- Clarithromycin
- Amoxycillin (or metronidazole if penicillin allergic)
- Omeprazole
Type C gastritis risk factors (3)
Long term use of
- NSAIDs
- alcohol
Chronic bile reflux
Type C (chemical) gastritis pathophysiology
Caused by Drugs (NSAIDs), alcohol, bile reflux
NSAIDs reduce prostaglandin production (which protects stomach) –> inflammation
Type C gastritis investigations (4)
- 2 investigations to rule out H. pylori
- imaging
- bloods
Urea breath test - to rule out H .pylori
H pylori faecal antigen test - to rule out H .pylori
Endoscopy + biopsy
FBC
Type C gastritis treatment
Stop NSAIDs/alcohol
Hydrogen receptor blockers - ranitidine
PPI - omeprazole
Complications of gastritis
Chronic gastritis
Peptic ulcer disease
Vitamin B deficiency
Achlorhydria - decreased/absent gastric acid production
What is gastric outlet obstruction
Obstruction of pylorus –> DELAYED gastric emptying
Gastric outlet obstruction causes (3)
Fibrotic stricture from healing of gastric ulcer
Tumour - gastric cancer, pancreatic cancer (in the head)
Pyloric stenosis
Gastric outlet obstruction symptoms (3) and signs (2)
Symptoms:
Postprandial nausea/vomiting –> alkalosis
Epigastric pain
Early satiety
Signs:
Abdominal distension/bloating
Weight loss
Gastric outlet obstruction investigations
- bloods (2)
- imaging (3)
U+Es - low K+ due to prolonged vomiting
RFTs (impaired) - creatine may be high due to abnormal renal function, low albumin
UGIE - to see any mechanical obstruction, i.e. pyloric stenosis or tumour
Abdo XR - to see if there’s any SI obstruction
Gastric emptying scintigraphy - assesses for how much food is retained in stomach after 4 hours; would indicate GASTROPARESIS
Gastric outlet obstruction treatment
- medical (2)
- surgical (2)
Pro-kinetics - promote GI motility so faster gastric emptying
Anti-emetics
Endoscopic balloon dilation - if stricture present from a healed ulcer or pyloric stenosis
Surgery - antrectomy/gastrectomy/gastrojejunostomy if serious
Gastric cancer is usually what type of tumour
Adenocarcinoma
Gastric cancer pathophysiology (3)
From chronic gastritis, cancer can develop through phases of intestinal metaplasia –> intestinal dysplasia –> carcinoma
Loss of tumour suppressor genes (e.g. p53)/ Overexpression of oncogenes
Gastric cancer risk factors (5)
Chronic H pylori infection
Pernicious anaemia - from B12 deficiency
High nitrate diet
Smoking
Family history of gastric cancer
Gastric cancer symptoms (3) and signs (4)
-usually asymptomatic until ADVANCED
Symptoms:
Dyspepsia - epigastric pain
Nausea/vomiting
Dysphagia - not as common; more so if proximal tumour
Signs: Weight loss/anorexia Acute bleeding -haematamesis -melaena Chronic bleeding -Iron deficiency anaemia
Gastric cancer diagnostic investigation + staging investigations (4)
UGIE + BIOPSY
Staging
- EUS,
- CXR,
- CT chest/abdo/pelvis,
- PET CT (more sensitive than plain CT for metastases)
Gastric cancer treatment
- curative (1)
- non-surgical candidate (1)
- palliative for advanced/metastatic
Gastrectomy
+/- perioperative/postoperative chemotherapy (given depending on stage of cancer at diagnosis)
Non-surgical - chemoradiotherapy
Chemoradiotherapy
Complications of gastric cancer (4)
Malnutrition
Gastric obstruction - may obstruct pylorus
GI bleed
Gastric perforation - tumour can erode through wall –> peritonitis
4 ways that gastric cancer can spread
Direct
Lymphatic
Blood
Transcoelomic (spreads into peritoneal cavity)
5 places gastric cancer spreads to
Lymph nodes
Liver
Peritoneum
Lungs
Bone marrow
Prognosis of gastric cancer
5 year survival rate less than 20%
Differentials of haematemesis (5)
Peptic Ulcer
Gastric/oesophageal carcinoma
Oesophageal varices
Mallory Weiss Tear
Benign disorders of the oesophagus (3)
GORD
Peptic ulceration (can get this in lower oesophagus)
Barrett’s oesophagus
Does H. pylori increase or decrease gastric acid secretion in patients with
- duodenal ulcers
- gastric cancer
DU - increases acid secretion
Gastric cancer - decreases acid secretion
Organic v functional dyspepsia
Organic - definitive pathological cause
Functional - abnormal function but normal structure
If ALARM features indicate dyspepsia, what investigation should be done
UGIE
Describe the characteristics of H.pylori (4)
Gram negative, spiral shaped, microaerophilic, flagellated
H. pylori only resides where
Gastric surface MUCOSA layer, doesn’t penetrate epithelium below
What characteristics of H.pylori allows it to escape from the toxic gastric acid around it (2)
Its tail (flagellated) allows it to burrow into the mucous layer (but doesn’t burrow through epithelium)
It produces urease which creates a halo of alkalinity around the bacteria
H. pylori typically has to to chronically infect what part of the stomach to cause gastric cancer
Body
H. pylori typically has to to chronically infect what part of the stomach to cause duodenal disease
Antrum
How does the urea breath test detect H.pylori
swallow urea labelled with radioactive carbon
If isotope-labelled CO2 detected in exhaled breath then indicates that the urea swallowed was split by urease (produced by H pylori) into ammonia and CO2 (UREASE DEPENDENT TEST)
What enzyme does H.pylori produce
Urease
Invasive investigations of H.pylori (non invasive = serology, urea breath test, faecal H.pylori antigen test) (2)
Gastric biopsy
Rapid slide urease test - gastric biopsy placed onto gel, the urease produced by H pylori (if present) will break down the yellow gel and turn it pink (UREASE DEPENDENT TEST
What is a fundoplication + what is it done for
Wrapping fundus of stomach around lower oesophagus to create a valve around the LOS to tighten it –> reduces reflux
Done for severe GORD
Name a common approach used in total gastrectomy
Roux en Y
Treatment of acute bleeding peptic ulcer (4)
Endoscopic therapy
- injecting adrenaline - constricts ulcer area
- cautery to burn/scar bleeding vessel
- endoclip
PPI
Duodenal ulcers are relieved after what
Meals
Gastric ulcers tend to WORSEN after meals
If peptic ulcer has perforated and caused bleeding, what are the 2 signs of the bleeding
Overt bleeding (visible)
- Haematemesis - coffee ground vomit
- Melaena - dark foul smelling stool
Occult bleeding
-stool haem test +ve
What is gastroparesis (similar to gastric outlet obstruction but not exactly the same)
NON-MECHANICAL OBSTRUCTION of pylorus (i.e. not due to a physical abnormality like pyloric stenosis or a tumour or ulcer) –> DELAYED gastric emptying
Paraneoplastic complication/manifestation of gastric cancer on the skin
SEBORRHOEIC KERATOSES (‘stuck on’ lesions)
