GORD,achalasia Flashcards
What are some of the causes and triggers for GORD?
Greasy and spicy foods
Coffee and tea
Alcohol
NSAIDs
Stress
Smoking
Obesity
Hiatus hernia
What is the lining of the oesophagus?
Squamous epithelial
What type of bacteria is H.Pylori?
Gram-negative aerobic
What does H.pylori bacteria do to the stomach and the stomach lining?
It creates gaps in the gastric mucosa, exposing the epithelial cells underneath to be damaged from the stomach acid.
H.pylori also produces ammonium hydroxide which neutralises the stomach acid and produces toxins which lead to gastric mucosal damage.
What investigations do you do for H.pylori?
Stool antigen test
Urea breath testusing radiolabelled carbon 13
H. pylori antibody test (blood)
Rapid urease testperformed during endoscopy (also known as theCLO test)
What is the eradication regime if a patient has H.pylori?How long?
Triple therapy with a PPI and 2 antibiotics (e.g. amoxicillin and clarithromycin) for 7 days
What is the only test recommended for H.pylori POST-eradication therapy?
The urea breath test
When is the stool antigen test recommended in H.pylori investigation?
For the diagnosis of GASTRO-DUODENAL infection with H.pylori
What is the urea breath test?
- patients consume a drink containing carbon isotope 13 (13C) enriched urea
- urea is broken down by H. pylori urease
- after 30 mins patient exhale into a glass tube
- mass spectrometry analysis calculates the amount of 13C CO2
- should not be performed within 4 weeks of treatment with an antibacterial or within 2 weeks of an antisecretory drug (e.g. a proton pump inhibitor)
What is the rapid urease test?
Rapid urease test involves taking a small biopsy of the stomach mucosa and adding it to urea liquid.
H.pylori produces urease enzymes that convert urea —→ ammonia
Ammonia makes the solution more alkaline. So when there is a colour change, that gives a positive result (PINK means a + test)
What is Barrett’s oesophagus?
It is when the lower oesophageal epithelium changes from squamous to columnar epithelium (is called metaplasia meaning a change in cell type)
What is Barrett’s oesophagus caused by?
Chronic acid reflux into the oesophagus
What are the risk factors for GORD?
- gastro-oesophageal reflux disease (GORD)is the single strongest risk factor
- male gender (7:1 ratio)
- smoking
- central obesity
How do you treat Barrett’s oesophagus (is usually diagnosed via endoscopy when pts are investigated for dyspepsia)?
High dose PPI (reduces progression to dyspepsia)
Endoscopic monitoring from progression to adenocarcinoma
Endoscopic ablation (radiofrequency ablation to destroy the abnormal columnar epithelial cells and precancerous cells. Treatment for low and high-grade dysplasia)
What is Zollinger-Ellison syndrome?
A rare condition where excessive amounts of gastrin are secreted by gastrin secreting tumours in the duodenum and pancreas. more gastrin means more stomach acid causing dyspepsia, diarrhoea and peptic ulcers
What genetic condition may Zollinger-Ellison be associated with?
MEN type 1 syndrome (an autosomal genetic condition) which can cause hormone-secreting tumours of the parathyroid and pituitary glands.
What can cause a hiatus hernia?
Increased abdominal pressure due to obesity, pregnancy, straining from constipation, coughing, heavy lifting
Muscle elasticity is reduced (from aging) which can cause weaker diaphragm/sphincters
Trauma from seatbelt injury
Previous surgeries
What may a hiatus hernia be misdiagnosed as and why?
Asthma (as pts may present with a nocturnal cough/wheeze)
MI (Due to chest pain and dyspnoea)
What are the 4 different types of hiatus hernias?
1.Sliding (where the gasrto-oesophageal junction moves up into the thorax)
2.Rolling (a part of the stomach, like the fundus, protrudes through the hiatus rather than the junction itself)
3.Combination of rolling and sliding
4.Herniation of other contents in bowel like spleen/pancreas/bowel
How do you investigate a hiatus hernia?
Chest X-ray
CT scan
Endoscopy
Barium swallow test
Manometry (measures pressure and constriction of muscles in the oesophagus)
How do you treat a hiatus hernia?
If asymptomatic (no treatment needed)
If symptoms persist —> use PPI
You can use antacids (like H2 receptor blockers like ranitidine)
In severe cases, surgery is needed
What is a critical red flag if someone has GI problems?
DYSPHAGIA
(needs an urgent 2-week wait referral for an endoscopy)
What are some presentations if someone has GORD?
- Heartburn
- Acid regurgitation
- Retrosternal or epigastric pain
- Bloating
- Nocturnal cough
- Hoarse voice
What is the management of GORD?
Lifestyle changes
Reviewing medications(e.g. stop NSAIDs)
Antacids(e.g. Gaviscon, Pepto-Bismol and Rennie) – short-term only
Proton pump inhibitors(e.g. omeprazole and lansoprazole)
Histamine H2-receptor antagonists (e.g. famotidine)
Surgery
What is Achalasia?
Is failure of oesophageal persitalsis and of relaxation of the lower oesophageal sphincter due to degenerative loss of ganglia from Auerbach’s plexus.
How might someone present if they have achalasia?
Dysphagia of BOTH liquids and solids
Heartburn
Regurgitation of food (may lead to cough, aspiration pneumonia)
What investigations do you do if you suspect someone has achalasia?
Oesophageal manometry (MOST IMPORTANT diagnostic test)
Barium swallow (Bird’s beak appearance)
Chest X-ray (would see widened mediastinum)
If a patient does a barium swallow test for achalasia, what sign would you see radiographically?
BIRD’S BEAK APPEARANCE (dilated oesophagus but constricted lower oesophageal junction)
What is the FIRST-LINE and preferred treatment option for someone who has achalasia (without multiple comorbidities)?
Pneumatic (balloon) dilation
In this procedure, an air-filled cylinder-shaped balloon disrupts the muscle fibres of the lower oesophageal sphincter (which is too tight in patients with achalasia)
If achalasia is persistent or recurrent, what surgical intervention can you do?
Heller cardiomyotomy
