Gastric Diseases Flashcards
What is GORD
Gastro-oesophageal reflux disease
What characteristics define GORD
- Reflux of gastric contents is normal but when there is prolonged contact of gastric contents with mucosa this results in clinical symptoms
What three disease can be caused by prolonged reflux
- Oesophagi’s
- Stricture
- Barrett’s Oesophagus
What conditions can cause GORD
- Lower oesophageal sphincter hypotension
2. Loss of oesophageal peristaltic function
How do hiatus hernias result in GORD
- Sliding: Where gastro-oesophageal junction + part of the stomach slides up into the chest via the hiatus so it lies above the diaphragm
- Rolling: Where gastro-oesophageal junction remains in the abdomen but part of the funds of the stomach prolapses through the hiatus alongside the oesophagus
Other causes of GORD
- Abdo obesity
- Gastric acid hyper secretion
- Slow gastric emptying
- Overeating
- Smoking
- Alcohol
- Pregnancy (results in increased abode pressure)
- Fat, chocolate, coffee or alcohol ingestion
- Drugs
- Systemic sclerosis
Why does reflux not happen in rolling hiatus
Because the gastro-oesophageal junction remains intact
In GORD, what muscles are relaxed between swallows and which are not
Muscles of oesophagus are relaxed
Upper + Lower oesophageal sphincters
When does the LOS open
Relaxes when swallowing is initiated
What happens to the LOS in GORD
Some random relaxation is normal but reduced tone in GORD allows gastric acid to flow back into the oesophagus
When do clinical features of GORD appear
When anti-reflux mechanisms fail, allowing acid gastric contents to make prolonged contact with lower oesophageal mucosa
Difference between how the LOS and UOS work
LOS relaxes when swallowing is initiated
UOS is released independently of a swallow
What four factors contribute to GORD
- Increased mucosal sensitivity to gastric acid
- Reduced oesophageal clearance of acid
- Delayed gastric emptying
- Prolonged post-prandial (after-eating)
- Nocturnal reflex
How does a hiatus hernia contribute to GORD
Impairs anti-reflux mechanism
Clinical presentation of GORD
- Heartburn
- Belching
- Food/Acid brash (food, acid or bile regurgitation)
- Water brash (Increased salivation )
- Odynophagia (painful swallowing)
How do you tell if someone has heartburn
- Aggravates by bending, stooping or lying down which promotes acid exposure
- Relieved by antacids
- Worse with hot drinks or alcohol
- Seldom radiates to arms
Four extra-oesophageal symptoms of GORD
- Nocturnal asthma
- Chronic cough
- Laryngitis (hoarseness and throat clearing)
- Sinusitis
Differential diagnosis of GORD
- CAD
- Biliary colic
- Peptic ulcer disease
- Malignancy
How can GORD be diagnosed
- Only if alarm bell signs:
- Endoscopy
- Barium swallow
When is an endoscopy done for GORD
- Symptoms for more than 4 weeks
What are alarm bell signs of GORD
- Dysphagia
- Weight Loss
- Haematemesis
- Persistent vomiting
- GI bleeding
- Palpable mass
- Over 55
- Symptoms despite treatment
Role of Barium Swallow in GORD
Hiatus Hernia
Role of endoscopy
Assesses oesophagi’s and hiatal hernia
What two conditions have reflux
Barrett’s oesophagus and oesophagitis
How is reflux controlled
24hr oesophageal pH monitoring is helpful in diagnosing GORD when endoscopy is normal or just prior to surgery to confirm reflux
or PPIs don’t work
What classification do we use when doing endoscopy to gauge extent of damage
Los Angees classification of GORD
How is GORD treated
- Encourage weight loss
- Smoking cessation
- Small,regular meals
- Avoid: Hot drinks, alcohol, citrus fruits and eating less than 3 hours before bed
What antacid is given for GORD
MAGNESIUM TRISILICATE MIXTURE
Effects of MAGNESIUM TRIPLICATE MIXTURE
Relieves symptoms by forming a gel or foam raft with gastric contents to reduce reflux
Side-effect of MAGNESIUM TRIPLICATE MICTURE
Cause diarrhoea due to Mg
Treatment for GORD
- Antacids
- Alignates
- PPI
- H2 receptor antagonist
What alienate is given and why
GAVISCON (relieves symptoms)
What PPI is given for GORD
LANZOPRAZOLE
What H2 receptor antagonist is given for GORD
CIMETIDINE
How does CIMETIDINE work
Blocks histamine receptors on parietal cells
Surgical intervention for GORD
- Nissen fundoplication
Aim of nissen fundoplication
Aims to laparoscopically increase resting LOS pressure (SEVERE GORD)
Complications of Nissen fundoplication
Dysphagia and bloating
Complication of GORD
- Peptic stricture
2. Barrett’s Oesophagus
What is Peptic stricture pathophysiology
- Inflammation of oesophagus results form gastric acid exposure resulting in narrowing and stricture of oesophagus
Where do peptic strictures occur
Patients over 60
Clinical presentation of peptic stricture
- Presents as gradually worsening dysphagia
How is peptic stricture treated
Endoscopic dilatation
Long-term PPI therapy
What is always present in Barret’s oesophagus caused by GORD
Hiatus hernia
What is the risk of having Barrett’s oesophagus
Risk of progression to oesophageal cancer
What is mallory-weirs tear
Linear mucosal tear occurring at oesophagogastric junction and produced by a sudden increase in intra-abdominal pressure
What usually causes mallory-weirs tears
- Bouts of coughing or retching
- Alcoholic ‘dry heaves’
- Forceful vomiting
- Male
- NSAID abuse
Clinical features of Mallory-Weiss Tear
- VOMITING
- HAEMATEMESIS AFTER VOMITING
3 .RETCHING - POSTURAL HYPOTENSION
- DIZZINESS
Differential diagnosis of Mallory-Weiss tear
- Gastroenteritis
- Peptic ulcer
- Cancer
- Oesophageal varices
How is mallory-weirs tear diagnosed
Endoscopy
How is mallory-weirs tear treated
- Minor bleeds and heal in 24 hours
- Haemorrhages tend to stop
- Surgery involves sewing the tear (not common)
What characterises dyspepsia
- Postprandial (after-eating) fullness
- Early satiation
- Epigastric pain or burning for more than 4 weeks
Define dyspepsia
Describes a number of upper abode symptoms (e.g. heart, epigastric pain or discomfort)
What is the most common form of dyspepsia
Functional dyspepsia
What causes dyspepsia
Peptic Ulcers
Clinical presentation of dyspepsia
- Reflux when lying flat
- Heartburn
- Acid taste (due to reflux)
- Bloating
- Indigestion (feeling full and can’t sleep after a heavy meal)
What are red flag alarm symptoms for cancer and not dyspepsia
- Unexplained weight loss
- Anaemia
- Evidence of GI bleeding (malaena)
- Dysphagia
- Upper abdo mass
- Persistent vomiting
- Over 55 (increased risk)
What is melaena
Dark tar like black stools
Differential diagnosis of dyspepsia
- Heartburn/Rurgitation/Cough
- Alarm symptoms
- Acute vs Chronic
Differential diagnosis if early postprandial pain is involved
Gastritis, GORD or gastric carcinoma
Differential diagnosis if postprandial pain is involved
Gastric ulcer
Differential diagnosis if pain is relieved by milk
Gastric ulcer
How is dyspepsia managed
- Reassurance
- Dietary review
- Antidepressants
- Look for helicobacter pylori using faecal antigen testing or breath test
- Endoscopy to find a clear picture of whats going on
Name an antidepressant given for dyspepsias
CITALOPRAM (reduces sensitivity of the gullet
How many layers does the duodenum have
Two smooth muscle layers
outer longitudinal and inner smooth
What structure does the duodenum connect to
Jejunum
What cells are found in the upper two thirds of the stomach
- Parietal cells (secrete HCL)
- Chief cells (produce pepsinogen and initiate proteolysis - the digestion of proteins)
- ECL cells - release histamines (stimulate acid release)
What cells are found in the antral part of the stomach
- Mcuus secreting cells (secrete mucin and bicarbonate)
- G cells (secrete gastrin = acid release)
3, D cells (secrete somatostatin that surpasses acid secretion)
Role of prostaglandins in the stomach
Stimulate the secretion of mucus
Role of Brunner’s gland sin the duodenum
Secrete alkaline mucus
