Gastro-duodenal disorders Flashcards
Define peptic ulcer disease (PUD)
Gastric and duodenal ulcers
What is the commonest cause of peptic ulcer disease?
H. pylori infection (95% of duodenal, 80% of gastric)
What type of bacteria is H. pylori?
Gram -ve aerophillic helicobacter
How can H. pylori infection be detected?
Urease breath test
Histology
Describe the pathogenesis of H. pylori induced peptic ulcer disease
H. pylori converts urea to ammonia ➔ neutralises stomach pH and is toxic to epithelium
Outline the treatment for H. pylori
Triple therapy BD for 7 days
- Omeprazole or lansoprazole
- Clarithromycin 500mg
- Amoxicillin 1g
or
- Omeprazole or lansoprazole
- Clarithromycin 250mg
- Metronidazole 400mg
How can peptic ulcers be classified?
Gastric ulcers (Type I, body and fundal)
Duodenal ulcers
Gastric ulcers (Type II, prepyloric)
Atypical ulceration
Who tends to get gastric ulcers, and where are they most commonly located?
Elderly (M>F 3:1)
Lesser curve of the stomach
Name 3 risk factors for gastric ulceration
H. pylori (80%) High alcohol intake Smoking NSAIDs Reflux of duodenal contents Normal or low acid secretion Delayed gastric emptying Stress
Describe the symptoms of gastric (type I) ulceration
Asymptomatic
Epigastric pain (burning shortly after meals)
Weight loss
Anorexia
Describe the epidemiology of duodenal and gastric (type II) ulceration
M>F 5:1
Peak age 25-30yrs
Name 3 risk factors for duodenal ulceration
H. pylori (90%) NSAIDs, steroids, SSRIs High acid secretion Increased gastric emptying Smoking
Describe the symptoms of duodenal ulceration
Asymptomatic (50%)
Epigastric pain (before meals or at night)
-Relieved by eating
Name 2 types of atypical peptic ulceration
Ectopic gastric mucosa in Meckel’s diverticulum
Zollinger-Ellison syndrome: non-beta islet cell gastrinoma of the pancreas
Differentiate between gastric and duodenal ulcerations
Gastric: Pain precipitated by food, weight loss, anorexia
Duodenal: Central back pain relieved by food, often occurs at night and early hours of morning
How is peptic ulcer disease investigated?
Gastroscopy* Barium meal Urease breath test - detect H. pylori Fasting serum gastrin levels - suspected hypergastrinaemia e.g. ZES Hypercalcaemia
Name 3 complications of peptic ulcer disease
Acute upper GI bleeding
Iron deficiency anaemia
Perforation
Gastric outlet obstruction
Outline the management of peptic ulcer disease
Lifestyle: Alcohol and smoking cessation, avoid trigger foods, stress management
Medical: Avoid NSAIDs and aspirin, H. pylori eradication if needed, low-dose PPI or standard-dose H2RA, antacids
Surgical: Pyloroplasty +- selective vagotomy, partial gastrectomy
What are the surgical indications for peptic ulcer disease?
Failure to respond to maximal medical treatment
Complications: bleeding, perforation, pyloric stenosis
Gastric outflow obstruction not responsive/suitable for balloon dilatation
Name 3 causes of acute upper GI perforation
Duodenal ulceration
Gastric ulceration (usually anterior prepyloric)
Gastric carcinoma
Traumatic injury
Ischaemia (usually secondary to gastric volvulus)
Name 3 symptoms seen in acute upper GI perforation
Acute onset upper abdominal pain
-Severe constant pain that worsens with breathing and movement, may radiate to back or shoulders
Prodrome of upper abdominal pain ➔ ulceration
Copious vomiting and distension ➔ volvulus
Prodromal weight loss, dyspepsia, anorexia ➔ carcinoma
Name 3 signs seen in acute upper GI perforation
Generalised peritonism: washboard rigidity, guarding, tenderness, Rovsing’s sign
Localised peritonism
Distension
Systemic: mild fever, pallor, tachycardia, hypotension
How can GI perforation be confirmed?
Erect CXR for pneumoperitoneum
CT scan
Outline the definitive management of upper GI perforation
Duodenal ulcer ➔ Omental patch + H. pylori eradication, partial gastrectomy +- vagotomy if recurrent
Gastric ulcer ➔ Omental patch if prepyloric (type II), local excision and sutured closure if body (type I)
Gastric carcinoma ➔ Partial gastrectomy
Traumatic ➔ Sutured closure
Ischaemic volvulus ➔ Subtotal gastrectomy
When is conservative management of upper GI perforation appropriate?
Patient declines surgery
Patient unlikely to survive surgery
Haemodynamically stable with small perforation (sealed at presentation) and no signs of peritonism
Outline conservative management of upper GI perforation
IV PPI
Limited oral intake
Active physiotherapy
H. pylori eradication
Describe the epidemiology of gastric cancer
5th commonest cancer in the world
3rd leading cause of cancer death worldwide
Name 3 types of gastric cancer
Adenocarcinoma* Leiomyosarcoma GI stromal tumour Carcinoid tumour Lymphoma
Describe the epidemiology of gastric adenocarcinoma
Commonest age >50s (95% occur in over 55s)
M>F 3:1
List 35risk factors for gastric cancer
Increasing age esp >45 Male H. pylori Diet: rich in nitrosamines, low in fruit and veg Smoking Chronic atrophic gastritis Family history Blood group A (RR 1.2)
Name 4 symptoms of gastric cancer
Dyspepsia Weight loss, anorexia, and lethargy Abdominal pain Iron deficiency anaemia Upper GI bleeding Dysphagia (uncommon unless involving gastro-oesophageal junction)
Name 2 signs of gastric cancer
Weight loss
Palpable epigastric mass
Troisier’s sign (palpable left supraclavicular LN) ➔ metastases
How is gastric cancer investigated?
FBC and LFTs
Endoscopy
Barium swallow
Where does gastric cancer commonly metastasise?
Lungs Liver Lymph nodes Oesophagus (Krukenberg tumour of the ovaries)
Indicted by Troisier’s sign
What is the prognosis of gastric cancer in the UK?
Majority of gastric cancers are metastatic or unresectable upon presentation.
Outline the management of gastric cancer
Majority unfit for surgery, treatment is palliative chemo.
If deemed curable, treatment depends on staging:
- Early: Radical gastrectomy, pre/post-op chemo
- Advanced: Pre/post-op chemo
