GASTRO Flashcards
what is GORD?
where acid from the stomach refluxes through the lower oesophageal sphincter and irritates the lining of the oesophagus
The oesophagus has a squamous epithelial lining making it more sensitive to the effects of stomach where as the stomach has columnar epithelial lining that is more protected against stomach acid.
what are the risk factors for GORD?
- fam history
- older age
- hiatus hernia
- obesity
what is dispepsia?
a non-specific term used to describe indigestion
what are the symptoms of GORD?
heartburn acid regurgitation retrosternal or epigastric pain bloating globus (patients may describe a lump in the throat that is present despite swallowing) nocturnal cough hoarse voice
when should a patient with symptoms of GORD be referred for endoscopy?
patients with evidence of a GI bleed need admission and urgent endoscopy
patients with symptoms suspicious of cancer should have a two week wait referral so that endoscopy is performed within two weeks
they key red flag features indicating referral are:
- dysphagia (difficulty swallowing)
- aged over 55
- weight loss
- upper abdo pain/reflux
- treatment resistant dyspepsia
- nausea and vomiting
- low Hb
- raised platelet count
how is GORD managed?
Lifestyle advice
- reduce tea, coffee and alcohol
- weight loss
- avoid smoking
- smaller lighter meals
- avoid heavy meals before bed time
- stay upright after meals rather than lying flat
Patients can take acid neutralising medication when requires - Gaviscon, Rennie
PPI - omeprazole, lansoprazole
Ranitidine (H2 receptor antagonist - antihistamine)
what effect does H.pylori have on the stomach?
it is a gram negative bacteria that lives in the stomach and causes damage to the epithelial lining of the stomach resulting in gastritis, ulcers and increasing risk of stomach cancer.
It produces ammonia to neutralise the stomach acid. The ammonia directly damages the epithelial cells.
why do people need to have H.pylori test before offering PPI?
Because PPI will effect the result of H.pylori test.
what tests can be used for H.pylori?
urea breath test
stool antigen test
rapid urease test
how is a H.pylori test treated?
the eradication involves triple therapy with a proton pump inhibitor, plus 2 antibiotics (e.g. metronidazole and clarithromycin or amoxicillin and clarithromycin)
what is barrettes oesophagus?
constant reflux of acid results in the lower oesophageal epithelium changing in a process know as metaplasia from squamous to columnar epithelium. This change is called barretts oesophagus.
other risk factors - male, smoking, central obesity
it is pre-malignant condition and is a risk factor for the development of adenocarcinoma of the oesophagus.
what is a Mallory-Weiss tear?
it is characterised by a tear or laceration often along the right border of, or near the gastro-oesophageal junction
commonly presents with haematemesis after an episode of forceful or recurrent retching, vomiting, coughing or straining .
what are the risk factors for hematemesis?
condition predisposing to retching, vomiting and/or straining chronic cough hiatal hernia retching during endoscopy significant alcohol use
what investigations should you perform for suspected mallory Weiss tear?
FBC - incase they need blood transfusion
Urea - important parameter to evaluate the severity of the bleeding - will be high in a patient with ongoing bleeding
LFTs - rule out liver disease which may predispose to varicies
INR
oesophagogastroduodenoscopy
what are some causes of upper GI bleed?
oesophageal varicies
Mallory-Weiss tear (tear of the oesophageal mucous membrane
ulcers of the stomach or duodenum
cancers of the stomach or duodenum
what scoring system is used to assess the risk of an upper GI bleed?
Glasgow-Blatchford score - used in suspected upper GI bleed on their initial presentation to help you to decide a plan and weather to discharge or not.
why does urea rise in upper GI bleed?
because they blood in the GI tract gets broken down by the acid and digestive enzymes. One of the breakdown products is the urea and this urea is then absorbed in the intestines
what is the Rockall score?
the Rocakall score is used for patients that have had an endoscopy to calculate the risk of re-bleeding and overall mortality.
how do you manage and upper GI bleed?
ABCDE approach to immediate resuscitation
bloods (FBC, U&E’s, INR, LFTs, cross match 2 units of blood)
get two large bore cannulas in
transfusion
endoscopy
stop anticoagulants and NSAIDS
what is a group and save?
what is a crossmatch ?
group and save is where the lab simply check the patients blood group and keeps a sample of their blood saved incase they need to match blood to it
crossmatch is where the lab actually finds blood, tests that it is compatible and keeps it ready in the fridge to be used if necessary.
what causes stomach ulceration?
increase in stomach acid which can be caused by stress, alcohol, caffeine, smoking, spicy foods
breakdown of the protective layer of the stomach and duodenum which can be caused by medications (steroids or NSAIDs) and H.pylori
how does a peptic ulcer present?
epigastric discomfort or pain (typically if a gastric ulcer it worsens on eating and if a duodenal ulcer pain improves with eating)
nausea and vomiting
dyspepsia
bleeding causing haematemesis, coffee ground vomiting and melaena
iron deficiency anaemia due to constant bleeding
what investigations would you perform for peptic ulcer?
h pylori urea breath test or stool antigen test
upper GU endoscopy
FBC
how do you manage peptic ulcers?
PPI
what are the complications of peptic ulcer?
bleeding from the ulcer
perforation resulting in an acute abdomen and peritonitis (this requires urgent surgical repair )
scarring and strictures this can lead to pyloric stenosis
what is achalasia?
failure of oesophageal peristalsis (failure of contraction of the oesophageal muscle) and failure of relaxation of lower oesophageal sphincter due to degenerative loss of ganglia from Auerbach’s plexus which impairs oesophageal emptying
Achalasia typically presents in middle age and is equally common in men and woman
what are the clinical features of achalasia?
dysphagia of both solids and liquids
typically variation in severity of symptoms
heartburn
regurgitation of food - may lead to cough, aspiration pneumonia
what investigations would you perform for achalasia?
oesophageal manometry - the manometry will show excessive LOS tone which doesn’t relax on swallowing and absence of oesophageal peristalsis - considered the most important diagnostic test
barium swallow shows grossly expanded oesophagus, fluid level, birds beak appearance
CXR - wide mediastinum, fluid levels
upper gastrointestinal endoscopy
how do you manage achalasia?
good surgical candidate - pneumatic balloon dilatation or heller cardiomyotomy
if poor surgical candidate - CCB or nitrates can be partly effective for temporary relief, injection of botulinum A can be used but are only effective for a few months
what is the most common cause of gastritis?
and what are other causes?
H.pylori infection is the most common cause
other causes include: autoimmune gastritis, viruses and duodeno-gastric reflux, alcohol, NSAIDs, reflux/hiatus hernia, granulomas (crohn’s, sarcoidosis), CMV
how does gastritis present?
epigastric pain
vomiting
haematemesis
how do you manage gastritis?
give PPI or ranitidine
eradicate H.pylori
what are the symptoms of malabsorption?
diarrhoea weight loss lethargy steatorrhoea bloating
what is coeliac disease?
an autoimmune condition where exposure to gluten causes and autoimmune reaction in the small bowel - it usually develops in early childhood but can develop t any age
In coeliac auto-antibodies are created in response to exposure to gluten that target the epithelial cells of the intestine and lead to inflammation
what antibodies are involved in coeliac disease?
anti-tissue transglutaminase (anti-TTG) -IgA
anti-endomysial (anti-EMA) - IgA
deaminated gliadin peptide antibody (anti DGPs)
these antibodies relate to disease activity and will rise with more active disease and may disappear with effective treatment.
When you test for the antibodies, it is important to test for total immunoglobulin A levels as if they have an IgA deficiency then the coeliac test will be negative
what part of the bowel does coeliac disease effect?
inflammation affects the small bowel - particularly the jejunum
it causes atrophy of the intestinal villi which usually help with absorbing nutrients from the food passing through the intestine
the inflammation causes malabsorption of nutrients and the symptoms of the disease
