Gastro Duodenal Disease Flashcards
In addition to digestion what role does the stomach also play in the body?
Endocrinology
Produces intrinsic factor
What are the three types of Peptic ulcer?
Gastric Ulcers (GU) Duodenal Ulcers (DU) NSAID Ulcers
What type of peptic ulcer is most common?
Duodenal ulcers are more common than gastric ulcers.
They are more common in the elderly and there is a significant geographical variation.
What are the most common cause of peptic ulcers?
H. Pylori
Then NSAIDs/Aspirin
What is Dyspepsia?
Dys = bad, Pepsis = digestion
Pain or discomfort in the upper abdomen.
Very common: 40% of people report having had one or more dyspeptic symptoms in the previous year.
What are the symptoms of dyspepsia?
Upper abdominal discomfort Retrosternal pain if reflux Anorexia Nausea Vomiting Bloating Fullness EARLY SATIETY (alarm symptom) Heartburn
What are the less common causes of peptic ulceration?
Hyperthyroidism
Zollinger-Ellison syndrome
Vascular insufficiency Sarcoidosis
Crohn’s Disease
What are the two classifications of Dyspepsia?
Dyspepsia which is investigated can be classified as:
Organic or Functional
Functional more common
What are the causes of organic dyspepsia?
GORD +/- erosive oesophagitis Gastritis, duodenitis Peptic ulcers Gastric Cancer Liver and pancreatobiliary disease Non-GI causes (e.g. Medication, ACS)
What is functional Dyspepsia?
Non-ulcer dyspepsia.
The presence of symptoms thought to originate in the gastroduodenal region (early satiation, postprandial fullness, epigastric pain or burning) in the absence of any organic, systemic or metabolic disease that is likely to explain the symptoms.
What is FGIDs?
Functional Gastrointestinal Disorders.
Dyspepsia is one of the most common.
What is postprandial fullness?
Feeling full as soon as you start eating.
How would you approach the presentation of Dyspepsia?
Most patients do not require upper GI endoscopy.
- Review medication
- Consider non-gastro-duodenal causes
- Lifestyle advice (weight, alcohol and diet)
- Test )for H. pylori) and treat
- Trial of acid-suppressing medication (PPI)
What medications would you review in a patient presenting with dyspepsia?
- NSAIDs,
- Steroids,
- Biphosphonates (given for osteoporosis, Causes ulceration)
- Ca antagonists
- Nitrates
- Theophylline’s
What non-gastro-duodenal causes would you consider in patients presenting with dyspepsia?
Acute coronary syndrome
When should the GP refer patients who present with dyspepsia?
- Unexplained weight loss
- Iron deficiency anaemia or overt bleeding
- Progressive dysphagia
- Persistent vomiting (haemoptemesis)
- Epigastric mass
- Abnormal imaging Study
- Over 55yrs with new persistent dyspepsia
How does the stomach initiate the production of acid?
G cells located in the antrum produce gastrim.
Gastrim causes parietal cells to produce hydrochloric acid in the corpus
List the effects of NSAID related large bowel disorder
Ulceration and bleeding,
IBD like colitis,
Perforation
Diaphragm like strictures of caecum and ascending colon
Exacerbation of pre-existing IBD or precipitation of relapse
Association with collagenous colitis
What is enteropathy?
A disease of the intestine. Especially the small intestine
Define hypoalbuminuria
Condition where blood albumin levels are abnormally low
List the effects of NSAID related oesophageal disorder
Pill Oesophagitis:
Avoid NSAID digestion in the supine position (affect the oesophagus just before the stomach)
List the effects of NSAID related stomach and duodenal disorder
Gastroduodenal erosion and ulcers. Can cause GI bleeding
List the effects of NSAID related small bowel disorder
Ulceration and bleeding. Increased risk of protein and blood losing enteropathy; could lead to iron deficiency anaemia and hypoalbuminuria
Why can NSAIDs cause ulcers all over the GI tract?
They do not require acid to react so can affect everywhere
What are the clinical features of peptic ulcers?
Epigastric pain is the main feature Nocturnal/hunger pain Back pain Nausea and occasionally vomiting Weight loss and anorexia Only sign may be epigastric tenderness If the ulcer bleeds, patient may present with haematemesis and/or malaena or anaemia
What treatment may relieve epigastric pain from peptic ulcers?
Antacids (PPI)
What does back pain suggest in suspected peptic ulcer?
Penetration of a posterior DU
What investigations are performed for peptic ulcers?
Blood tests:
- H. Pylori serology
- Hb (anaemia?)
- Fasting gastrin (Zollinger-Ellison syndrome)
Urea Breath Test:
-H. Pylori
Upper GI endoscopy
- Visualisation of upper GI mucosa
- Biopsy gastic ulcers to exclude malignancy
- Biopsies for H. Pylori
Barium Studies
Why does fasting gastrin diagnose zollinger-ellison syndrome?
Zollinger-Ellison syndrome = gastrin secreting tumour in pancreas.
Normal G cells stimulated by Vagus (parasympathetic)
During fast shouldn’t produce much gastrin
Do you biopsy ulcers in duodenum?
No because they are always benign.
Biopsy gastric ulcers always to rule out cancer
When would a barium study be carried out?
Patient may be unfit for invasive test like endoscopy.
May have severe dysphagia and cannot fit scope down
As a GP what tests could you carry out suspecting peptic ulcers?
Blood tests
Urea breath test
Describe Helicobacter pylori
Gram negative, spiral shaped, microaerophilic bacterium
Commonest chronic bacterial infection world wide
Uniquelly adapted to survive in the harsh gastric environment
Acquired in childhood
Why is H. Pylori acquired in childhood but not in adulthood?
Acid secretion is lower when you are young compared to the adult stomach.
This allows the bacterium to spread by the focal oral route and establish in the less acidic stomach
What are the clinical associations with H. Pylori?
Gastritis (acute and chronic)
Peptic Ulcer Disease
Gastric Neoplasia (adenocarcinoma and MALT lymphoma)
Non-Ulcer dyspepsia (small proportion of patients)
Describe the non invasive tests for H. Pylori Infection
Serology: IgG against H. Pylori
^13C/^14C Urea Breath Test
Why is ^13C used over ^14C?
^14C is radioactive
Describe the Invasive Test for H. Pylori infection
Endoscopy
Gastric biopsies taken for histology
Gastric biopsies are also cultured
Rapid slide urease test (CLO)
how does the Urease Breath Test work?
Give drink with urea.
Carbon marked ^13C.
If H. Pylori urea will be broken down and CO2 and ammonia released as products.
If the CO2 you breath out is marked then you know H. Pylori is present
How does the CLO test work?
Put gastric biopsy in CLO well. pH change detected and H. Pylori can be detected
What mucosa can H. Pylori colonise?
Gastric type only.
It doesn’t penetrate the epithelium and resides in the mucous layer.
What kind of reaction does H. Pylori cause in the body?
Induces a powerful inflammatory reaction, which becomes chronic (Chronic gastritis)
What are the outcomes of H. Pylori infection?
There are 3 outcomes
Antral Predominant Gastritis:
- This causes an increased acid production
- There is a low risk of gastric cancer
- Causes duodenal ulcers
Mild Mixed Gastritis:
- Normal acid
- No significant disease
Corpus Predominant Gastritis:
- Decreased acid production
- Gastric atrophy
- Gastric cancer
What is the pathophysiology of duodenal ulcer disease?
Antrum is infected.
G cells produce extra gastrin because they are tricked into thinking stomach is more alkali than it is.
Acid enters duodenum
Duodenum trie stop protect itself by changing cells from duodenal to gastric cells.
Duodenum wall is weakened as a result
Ulcers occur
How can you cure DU?
Eradication of H. Pylori will nip the condition in the bud.
Ulcers can be treated to heal and won’t return
What is the management of peptic ulcers?
Ulcers caused by H. Pylori are simply treated by eradication therapy.
If NSAIDs are also involved these have to be stopped if possible (or should receive other protective agents following eradication therapy)
Complications are treated as they arise
Surgery only indicated in complicated PUD
What is the eradication treatment for H. Pylori?
Triple therapy for 7 days.
Acid inhibitor along with 2 antibiotics at least.
Clarithromycin 500mg bd (twice daily)
Amoxycillin 1g bd (or metronidazole 400mg bd)
-Tetracyclin if penicillin allergy
PPI (omeprazole 20mg bd)
This is effective in 90% of cases.
Resistance to antibiotics and poor compliance main reasons for failure
What are the indications for H. Pylori eradication?
Peptic ulcer disease
MALT lymphoma
Following curative resection of primary gastric cancer
Non ulcer dyspepsia (no sinister signs)
FDR of gastric cancer patient
Long term use of PPI therapy
What are the complications of peptic ulcers?
Gastric outlet obstruction (scarring in tight junction)
Acute bleeding
Perforation
Give a brief introduction to gastric cancer
Second commonest GI malignancy
Large geographical variation
Predicted increase in incidence due to population growth
Very poor prognosis (5yr survival
What are the clinical features of gastric cancer?
Symptoms similar to PUD: Epigastric pain
N&V, anorexia, weight loss
Dysphagia with proximal tumours
Sign’s:
Epigastric mass, weight loss, hepatomegaly if metastatic, Virchow’s node
Investigation:
Endoscopy and biopsy
CT scan of abdomen
What is virchow’s node?
Lymph node in the left supraclavicular fossa.
Will be visibly enlarged
