Gastroenterology; Upper GI; Dyspepsia & GORD Flashcards
What is the most common cause of dysepsia? [1]
oesophageal cancer
State 7 red flag symptoms when asking about dyspepsia [7]
- dysphagia
- weight loss (unintentional)
- persistent vomiting
- epigastric mass
- GI bleeding
- iron deficiency
- new/ persistent unexplained symptoms > 55y
Define dyspepsia [3]
Dyspepsia is a group of symptoms that suggest upper GI disease, according to NICE. Descriptions include:
· Pain or discomfort in the epigastrium (ulcer-like)
· Heartburn/regurgitation of eaten food (GORD-like)
· Bloating, nausea, vomiting and excess wind (dysmotility-like)
A ptx presents with upper GI discomfort but after endoscopy there is no evidence of an ulcer. What is this called? [1]
Non-ulcer dyspepsia
State the 4 most common causes of dyspepsia [4]
- No lesions / non-ulcer dyspepsia (75%)
- Peptic ulcer disease (10-15%)
- Oesphagitis (15%)
- Cancer (2%)
State 6 reasons non-ulcer dyspepsia may occur [6]
· Disturbance in GI motility
· Disturbance in visceral sensation, i.e. hypersensitivity
· Decreased sense of accommodation by the stomach: stomach is sensitive so feels abnormally distended/quickly full
· Pronounced intenstino-gastric reflexes, may mimic IBS symptoms
· Gastric aid sensitivity
· Psychosocial factors
Name 4 factors that increase the likelyhood of GORD [4]
- Obesity (BMI > 30; increases intra-abdominal pressure)
- Smoking, alchohol and coffee
- Drugs (relax LOS): tricyclics, anticholinergics, nitrates, calcium channel blockers
- Fatty foods
- Pregnancy
NB: no association with H. pylori.
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Describe the pathophysiology of GORD [3]
- High intra-abdominal pressure combined with LOS relaxation and / or abnormalities causes gastric acid, bile, pepsin and pancreatin enzymes are able to reflux back into the oesophagus, causing mucosal injuries
- Often combined with decreased oesophageal motility, causing decreased oesophageal clearance
- The gastric acid levels are normal, just in the wrong place
Describe a cause of LOS dysfunction [1]
Hiatus hernia: herniation of the stomach up through the diaphragm. Causes the opening from the oesophagus to the stomach to be wider, and more stomach content can reflux into the oesophagus
State 5 causes of GORD
GORD:
- Hiatus hernia
- LOS hypotension
- obesity
- pregnancy
- smoking & alcohol
- drugs (tricyclic; anticholinergics; nitrates)
State five drug classes that can cause GORD [5]
- tricyclic
- anticholinergics
- nitrates
- CCBs
- NSAIDs
Describe symptoms of GORD [5]
Heartburn
Retrosternal discomfort after meals
Belching
Halitosis
Acid brash
Increased salivation (mouth fills with saliva)
State 3 extra-oesophageal symptoms of GORD [3]
Nocturnal asthma
Chronic cough
Laryngitis
Sinusitis
Describe the 4 different types of hiatus hernia [4]
Type 1: Sliding
Type 2: Rolling
Type 3: Combination of sliding and rolling
Type 4: Large opening with additional abdominal organs entering the thorax
What type of hernia is this? [1]
Type 3: sliding and rolling
What type of hernia is depicted? [1]
Type 4: Large opening with additional abdominal organs entering the thorax
What type of hernia is depicted? [1]
Type 1: displacement of GOJ above diaphragm
What type of hernia is depicted? [1]
Type 2: rolling - dislocation of fundus
GORD can be clinically diagnosed based on which of following isolated symptoms? [5]
State 3 atypical symptoms [3]
- Heartburn
- Belching
- Acid regurgitaton
- Water brash (xs salivation)
- Odynophagia (painful swallowing)
- Nocturnal asthma
Atypical:
- Chest pain
- Epigastric pain
- Chroic aspiration
GORD can lead to macroscopic oesophagitis.
Define macroscopic oesophagitis [1]
Ulcerations of the oesophagus
Why is GORD developing macroscopic oesophagitis clinically signfiicant? [3]
- Causes strictures
- Can cause Barrett’s oesophagus: can lead to cancer
Describe diagnostic investigations for GORD [3]
Therapeutic trial of PPI:
- i.e. 40mg of omeprazole for 2 weeks and if the symptoms are completely resolved on that and no alarm symptoms, this may be a reasonable diagnostic tes
Endoscopy (NB: ~ 50% have no lesions);
- used to create Los Angeles scoring system for oesophagitis
Oesophageal function testing:
- can monitor pH over 24 hours using a small sensor
Describe the LA Classification of oesophagitis [4]
Grade A
- At least one mucosal break, up to 5 mm, that does not extend between the tops of two mucosal folds
Grade B:
- At least one mucosal break, more than 5 mm long, that does not extend between the tops of two mucosal folds
Grade C:
- At least one mucosal break that is continuous between the tops of two or more mucosal folds but which involve less than 75% of the circumference
Grade D:
- At least one mucosal break which involves at least 75% of the esophageal circumference
State the therapeutic management for GORD
- Therapeutics [4]
- Surgery [1]
Drugs:
If no red flags: 4 week PPI course:
- omeprazole
Antiacids: Mg trisilicate
Alginates: Gaviscon
Acid suppression:
- PPIs: omeprazole and lansoprazole
- or H2 receptor antagonists: famotidine or ranitidine
Surgery:
- laparoscopic fundoplication: tying the fundus of the stomach around the lower oesophagus to narrow the lower oesophageal sphincter
Describe the usual medical strategy when someone presents with GORD [4]
- Exclude red flags
- Address potential triggers
- Offer a 1 month trial of a proton pump inhibitor
- Consider H. pylori testing
Anyone with dyspepsia is offered to be tested for which organism? [1]
Describe conditions needed to test for this organism for an accurate result [1]
H. pylori
Need 2 weeks without using a PPI before testing for H. pylori for an accurate result.
Describe the pathophysiology of H. pyorli cause gastritis, uclers and stomach cancer [3]
H. pylori goes into gastric mucosa; exposing epithelial cells below to stomach acid
H. pylori produces ammonium hydroxide; neutralises the acid around the bacteria and also produces toxins
Ammonia & toxins causes gastric mucosal damage
Describe how you investigate for H. pylori prescence [4]
- Stool antigen test
- Urea breath test using radiolabelled carbon 13 (H.pylori converts urea to ammonia: pH tested and if red: positive
- H. pylori antibody test (blood)
- Rapid urease (enzyme used by H. pylori) test performed during endoscopy (also known as the CLO test)
Which form of Which form of testing for H. pylori is used for diagnosis? [1]
The stool test is often used to diagnose Helicobacter pylori, but cannot be used to test for eradication as there is insufficient evidence for this.
Which form of testing for H. pylori is used for post-eradication therapy? [1]
Urea breath test is the only test recommended for H. pylori post-eradication therapy
Which form of testing for H. pylori is used for during endoscopy? [1]
CLO testing is a rapid urease test that is done during endoscopy to detect Helicobacter pylori and relies on the fact that the bacteria contain the urease enzyme
. It is approximately 90% sensitive, however it is an invasive test and is not recommended for eradication testing unless a patient requires an endoscopy.
Describe the treatment regime if a patient tests postive for H. pylori [6]
How long is treatment for? [1]
7 Day treament plan of triple therapy:
PPI:
- omeprazole
Antibiotics (two required):
- amoxicillin
- clathromyocin
- metronidazole (increasing resistance has limited its usefulness)
- Bismuth
- Metoclopramide
- Vasopressin
7 days
Describe the pathophysiology of Barrett’s oesophagus (BO) [2]
Chronic oesophageal injury from chronic reflux of gatstric contents; causes a change from squamous to columnar epithelium (process is called metaplasia)
Describe why BO is a clincially significant disease [2]
BO is pre-malignant; high risk of deveoping oesophageal adenocarcinoma (via reflux associated DNA damage)
There can be a stepwise progression from no dysplasia to low-grade dysplasia, high-grade dysphasia, and adenocarcinoma.
State 5 risk factors for BO
Long standing gastro-oesophageal reflux
Male sex (male-to-female ratio 2:1)
Caucasian ethnicity
Increasing age
Obesity
Smoking
Family history
Describe the treatment for
non-dysplastic BO [2]
low-grade dysplasia BO [2]
high-grade dysplasia [3]
non-dysplastic BO:
- PPI (omeprazole)
- Anti-reflux surgery (Nissen fundoplication)
low-grade dysplasia BO
- radiofrequency ablation
- consider PPI
high-grade dysplasia
- radiofrequency ablation
- consider PPI
- oesophagectomy
Describe what Eosinophilic oesophagitis (EoO) is [2]
Chronic, immune-mediated/allergen-mediated clinicopathological condition:
- oesophageal dysfunction (e.g., dysphagia and food impaction in adolescents and adults, and vomiting, regurgitation, heartburn, abdominal pain)
AND
- Histologically: eosinophilic infiltration of the oesophageal epithelium of ≥15 eosinophils
How do you diagnose EoO? [1]
How do you treat? [2]
Diagnose: biopsy
Tx: swallow inhaled steroids; exclusion diet
Describe two motility disorders that can cause dysphagia [2]
Achalasia: increased tone of LOS; can’t relax
Presbyoesophagus: elderly; peristalsis ineffective
What would indicate a patient has neurological dysphagia? [1]
More difficult to swallow liquids than solids
Describe managment for dyspepsia if H.pylori tests negative [1]
2 week PPI treatment
Tx for non-ulcer dyspepsia? [1]
PPI
State 5 extra-oesophageal manifestations of GORD [5]
- middle ear problems
- chronic sinusitis
- dental erosions
- sore throat
- cough
- astha
- aspiration pneumonia
What is the gold standard for diagnosing GORD? [2]
How do PPIs work? [1]
PPIs form the cornerstone of GORD treatment.
PPIs prevent acid production within the stomach through inhibition of H+/K+ ATPases in parietal cells.
What is the name of the surgery for GORD? [1]
Nissen fundoplication.
What is the NICE first line treatment for H. pylori? [3]
A proton pump inhibitor, plus amoxicillin, and either clarithromycin or metronidazole
Achalasia is associated with which type of oesophageal cancer? [1]
Name a significant risk factor for this cancer [1]
Squamous cell cancer
Smoking
What is the difference in location of adenocarcinoma and squamous cell carcinoma of oesophagus? [2]
Adenocarcinoma: Lower third - near the gastroesophageal junction
SSC: Upper two-thirds of the oesophagus
A 60-year-old man who is known to have Barrett’s oesophagus is reviewed with the results of his surveillance biopsies. These show high-grade dysplasia but no evidence of carcinoma. He is asymptomatic apart from his gastro-oesophageal reflux disease symptoms which are well controlled on high dose proton pump inhibitor therapy. What treatment is he most likely to be offered?
[2]
radiofrequency ablation: preferred first-line treatment, particularly for low-grade dysplasia
endoscopic mucosal resection
