GI - Dyspepsia & IBD Flashcards
What is Dyspepsia
Symptom/combination of symptoms that alert to an upper GI problem. Typically…
Epigastric pain/burning Early satiety and postprandial fullness Belching Bloating Nausea Discomfort in the upper abdomen
47 year old man presents to clinic with a 3 month history of epigastric dull abdominal pain. He states that the pain is worse at night and is relieved on eating. On direct questioning, there is no history of weight loss. He is not anaemic.
Most likely cause?
A. Duodenal Ulcer B. Zollinger-Ellison Syndrome C. Gastric ulcer D. GORD E. Non-ulcer dyspepsia
Duodenal Ulcer
A 59 year old man presents with severe retrosternal burning pain. Upper GI endoscopy shows ‘metaplastic changes within the epithelium’.
Most likely cause?
A. Gastric ulcer B. Gastric carcinoma C. Oesophageal carcinoma D. GORD E. Barrett's oesophagus
Barrett’s oespophagus
A 41 year old man is referred to gastroenterology outpatients with a 3 month history of worsening epigastric pain and dyspepsia. Upper GI endoscopy confirms multiple ulcers in the stomach and duodenum. Serum gastrin is elevated.
Most likely cause?
A. Duodenal Ulcer B. Zollinger-Ellison Syndrome C. Gastric ulcer D. Gastric carcinoma E. GORD
Zollinger-Ellison Syndrome
A 40 year old woman presents with a 2 month history of burning upper abdominal pain which is worse on eating. On examination there is mild tenderness to palpation of the epigastric region.
Most likely cause?
A. Duodenal ulcer B. Zollinger-Ellison Syndrome C. Gastric ulcer D. Gastric carcinoma E. GORD
Gastric ulcer
A 37 year old overweight woman presents to the GP with burning upper abdominal pain. She says it is especially bad when she goes to bed. She also complains of a tickly cough and a funny taste in her mouth.
Most likely cause?
A. Zollinger-Ellison Syndrome B. Gastric ulcer C. Oesophageal Carcinoma D. GORD E. Non-ulcer dyspepsia
GORD
Peptic ulcer definition
A break in the superficial epithelial lining of either the stomach or the duodenum.
Peptic ulcer classifications
Duodenal vs Gastric
More common type of peptic ulcer
Duodenal
Peptic ulcer disease epidemiology
Common
Incidence increases with age
H. Pylori related in developing countries
NSAID-induced in developed countries
Peptic ulcer disease risk factors
H. Pylori NSAIDS Age Hx/FHx Smoking Alcohol Psychological stress
Rare:
Increased gastrin (e.g. Zollinger-Ellison, Gastrinoma)
Cushing’s ulcers (brain trauma), Curling’s ulcers (Burns), altered gastric emptying
Helicobacter Pylori
Gram negative flagellate
Prevalent in 80-90% of population in developing countries, 20-5-% developed countries
Mostly asymptomatic, but damage to epithelial cells can cause gastritis, peptic ulcers, gastric cancer.
Peptic ulcer disease symptoms and signs
Recurrent epigastric pain; related to eating a meal (dyspepsia) - burning/knawing pain Nausea and vomiting Early satiety Wt. loss/anorexia Sx of anaemia
Epigastric tenderness
‘Pointing sign’
Occult blood loss and iron deficiency anaemia
May be asymptomatic
Duodenal vs Gastric ulcers pain and relief
Duodenal: Pain 2-3 hrs after eating Awakens patients at night (50-80 %) Relieved by... Eating Antacids
Gastric:
Pain immediately after eating
Minimal relief with antacids
A 40 year old woman presents with a 2 month history of burning upper abdominal pain which is worse on eating.
You suspect she has a gastric ulcer. What is the most appropriate investigation?
Upper GI endoscopy Full blood count Abdominal X-Ray H. Pylori Breath Test Trial of Proton Pump inhibitor
H. Pylori Breath test
Investigation of peptic ulcer disease
<55 and no ‘alarm’ symptoms:
1. H. Pylori breath test/stool antigen test
(if symptoms and +ve H. Pylori, start treatment)
2. FBC, Stool heme test, Fasting serum gastrin level
>55/'alarm symptoms/no response to Tx: 1. UGI endoscopy --> Ulcer present: Histology to determine if neoplasia H. Pylori testing, e.g. biopsy urease testing
If gastric ulcer present, repeat endoscopy after 6-8wks to rule out malignancy
Peptic ulcer disease ‘alarm symptoms’
Wt loss Vomiting; Bleeding Anaemia; Early satiety Dysphagia
Management of Peptic ulcer disease
Lifestyle: Diet, X smoking, X NSAIDs
Pharmacological:
If H.Pylori +; triple therapy
–> 2 x Antibiotics (eradicate HP) and PPI
If H.Pylori -ve: PPI or H2 antagonist
Example Triple therapy regimen:
- Amoxicillin or Metronidazole
- Carithromycin
- Lansoprazole/omeprazole/pantoprazole
Peptic ulcer disease complications
Haemorrhage:
Endoscopy +/- endoscopic therapy (adrenaline/cauterize/clip application)
+ IV PPI
+/- Blood transfusion
Perforation:
NBM, NG tube
IV Abx
Surgery
Gastric outlet obstruction
Scarring and stricturing
Malignancy
GORD
Gastro-oesophageal Reflux Disease
Reflux of stomach contents into the oesophagus
GORD risk factors
Obesity Pregnancy Diet Smoking Drugs - anti-muscarinic, CCBs, nitrates Hiatus hernia
(also… CREST syndrome, lower oesophageal sphincter hypotension e.g. after achalasia treatment, low oesophageal peristaltic function, gastric hypersecretion, delayed gastric emptying)
GORD clinical features
Heartburn: Burning retrosternal discomfort related to food
Acid regurgitation: ‘waterbrash’ (sour taste)
Exacerbated by bending and lying flat
Relieved by antacids
(also… dysphagia, bloating, early satiety, dental erosion.
Extra oesophageal: nocturnal asthma, chronic cough, laryngitis (hoarseness, throat clearing, sinusitis)
A 37 year old overweight woman presents to the GP with burning upper abdominal pain. She says it is especially bad when she goes to bed. She also complains of a tickly cough and a funny taste in her mouth.
She has no other significant symptoms and you suspect she has GORD.
What is the most appropriate next step?
UGI endoscopy Start her on a proton pump inhibitor Barium Swallow study Start her on a H2 antagonist Oesophageal manometry
Start her on a proton pump inhibitor
GORD Investigations
Clinical Diagnosis - Ix not needed unless alarm signs present.
- Trial of PPI - diagnostic/therapeutic
- If persistent/atypical symptoms with PPI and/or alarm signs, UGI endoscopy
–>If oesophagitis or Barrett’s oesophagus - confirms reflux
–>If unrevealing, consider other tests:
Ambulatory pH monitoring
Oesophageal manometry - if suspect oesohpageal spasm/achalasia/motility disorder
Barium swallow
Oesophageal capsule endoscopy
GORD Management
Conservative: Diet - avoid precipitants, lose wt Sleep - head of the bed elevation X smoking X contributing druge
Pharmacological:
PPI (reduces acid)
Complications of GORD
Chronic exposure to acid –> injury/inflammation
Oesophagitis –> Barrett’s (metaplasia) –> Dysplasia –> Oesphageal adenocarcinoma