a common complaint describing a range of non-specific symptoms referring to upper GIT epigastric pain/burning, nausea, heartburn, fullness, belching patients use term 'indigestion' dyspeptic symptoms are caused by disorders of oesophagus, stomach, pancreas or hepatobiliary system

GORD and Barrett's Oesophagus Flashcards by Hamzah Niaz

What are the symptoms of gastro-oesophageal reflux?

Heartburn (major feature)
- aggrevated by bending, stooping, lying down + after meals, but relieved with antacids
Regurgitation of acids + foods into mouth (waterbrash, halitosis, enamel erosion)
Odynophagia or dysphagia (due to oesophagitis)
Belching
Nocturnal asthma/cough (due to aspiration of gastric contents on lying)

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How do you diagnose GORD?

Diagnosis is clinical + often requires no futher ix
Ambulatory 24hr pH monitoring - gold standard, a pH <4 more than 4% of the time -> abnormal
Oeseophageal manometry
Combined impedance-pH testing
OGD indicated in:
- >55y/o
- <55y/o but with alarm symptoms (weight loss, dysphagia, haematemesis, anaemia)

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Which GORD patients would you give an urgent endoscopy to?

if they have any of: ALARMS

Anaaemia
Loss of weight
Anorexia
Recent onset of progressive symptoms
Melaena / hametemesis
Swallowing difficulties

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What are the risk factors for GORD?

Hiatus hernia
Obesity
Pregnancy
Systemic sclerosis
Cigarette smoking
Fat, choc, coffee or alcohol ingestion
Drugs - antimuscarinics, Ca-ch blockers, nitrates

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What constitutes the lifestyle management for GORD?

Weight loss
Smoking cessation
Small, regular meals
Avoid eating <3h before bed
Raise the bed head
Reduce hot drinks, alcohol, caffeine, spicy foods, fizzy drinks, citrus fruits, tomatoes, onions, chocolate

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What is the pharmacological management of GORD?

Alginate-containing antacids (magnesium trisilicate, gaviscon)
Proton pump inhibitors (-prazole)
H₂-receptor antagonists (-tidine)
Dopamine antagonist prokinetic agents (metoclopramide, domperidone)

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What is the surgical management of GORD?

if symptoms unmanageable by medication or in those whose symptoms return on stopping treatment
aim is to increase resting lower oesophageal sphincter pressure
open surgery or laproscopic Nissen fundoplication - where fundus of stomach is sutured around the lower oesophagus to produce an ‘antireflux’ valve

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What is a hiatus hernia?

2 types:

Sliding hiatus hernia
- when the gastro-oesophageal jxn slides through the hiatus and lies above diaphragm, no symptoms unless associated reflux
Rolling/para-oesophageal hernia
- uncommon, where gastric fundus rolls up through the hiatus alongside oesophagus, with the gastro-oesophageal jxn remaining below diaphgram -> can give rise to complications (volvulus, bleeding + resp comps), treated surgically

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How does a hiatus hernia give rise to GORD?

A hiatus hernia can cause a weakness of the valve between the oesophagus and stomach that normally prevents acid reflux.

Therefore acid and contents are able to reflux into the oesophagus from the stomach as stomach is also sat higher.

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What is dyspepsia?

a common complaint describing a range of non-specific symptoms referring to upper GIT
epigastric pain/burning, nausea, heartburn, fullness, belching
patients use term ‘indigestion’
dyspeptic symptoms are caused by disorders of oesophagus, stomach, pancreas or hepatobiliary system

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What is the most common cause of dyspepsia?

functional dyspepsia
used to be called non-ulcer dyspepsia
refers to dyspepsia where there is no visible cause on OGD

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What are differentials for dyspepsia?

Functional dyspepsia
H. Pylori infection
GORD
Peptic ulcer disease
Malignancy of oesophagus/stomach
IBS
Gastritis
Oesophagitis
Duodenitis
Coeliac disease
Drug-induced (NSAIDs)

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How do you investigate dyspepsia?

clinical history and physical examination
- help exclude non-GI causes (drugs)
- lifestyle/dietary factors identified (GORD)
bloods - anaemia, hepatobiliary/pancreatic disease
OGD + CLO if >55y/o or ALARM(s) signs - H. Pylori (invasive), malignancy, dysplasia
C-urea breath test - H. Pylori (non-invasive)

Depending on test results, it is then best to manage the underlying cause. For functional/uninvestigated dyspepsia, often will involve cutting out drugs causing dyspepsia, implementing over the counter antacids/lifestyle changes. If persistent, then can trial on PPI for 4wks.

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What is an OGD/gastroscopy?

a camera test
where doctor looks into upper part of gut
consists of oesophagus, stomach, duodenum
endoscope is a thin flexible telescope (thickness of a little finger)
it is passed through the mouth, down the oesophagus, through the stomach and to the duodenum
the endoscope has a light, camera and opening for instruments to be passed through to take biopsies
it is both diagnostic and interventional

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What happens during an OGD?

local anaesthetic sprayed to back of mouth
lay down side ways
option of light sedation with midazolam
patient must fast for ~6hrs prior to procedure
must not drive for 24hrs post-sedation
mouth guard put in place + endoscope passed through
you have to swallow it and it passes through - this is most uncomfortable part of procedure
air might be passed through to open up stomach
whole procedure only takes ~10mins

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Are there any side-effects of gastroscopy?

sore throat
slight inc risk of pneumonia
occasional damage -> bleeding, infection + perforation
small # of people have a heart attack or stroke during/soon after (however, these tend to be older ppl who are already in poor health)

What drug(s) is an example of H2 receptor antagonists?

Ranitidine

What are the indications for H₂-receptor antagonists?

Peptic ulcer disease: for treatment + prevention of gastric and duodenal ulcers and NSAID-associated ulcers, although PPIs are more effective and therefore usually preferred
GORD + dyspepsia: for relief of symptoms. PPIs are main alternative, and are preferred in more severe cases

What is the mechanism of action of H₂-receptor antagonists?

reduce gastric acid secretion
acid is normally produced by proton pump of gastric parietal cell
which secretes H⁺ into stomach lumen in exchange for drawing K⁺ into cell
proton pump is regulated by histamine
histamine released by local paracrine cells
histamine binds to H₂-receptors on gastric parietal wall
via a second-messenger system, this activates proton pump
blocking H₂-receptors therefore reduces acid secretion
however as proton pump can be stimulated by other pathways, H₂blockers cannot completely suppress gastric acid production
in this respect they differ from PPIs which tend to have a more complete suppressive effect

What are important adverse effects of H₂-receptor antagonists?

generally well tolerated w/ few side effects
bowel disturbance - diarrhoea or less often constipation
headache
dizziness

What are the warnings/contraindications for H₂-receptor antagonists?

excreted by kidneys
so dose should be reduced in those w/ renal impairment
like PPIs, they can disguise the symptoms of gastric cancer - important to investigate cause

Give examples of alginates/antacids

Gaviscon
Peptac

(trade names)

What are alginates/antacids indicated for?

GORD: for symptomatic relief of heartburn
Dyspepsia: for short-term relief of indigestion

What is the mechanism of action of alginates and antacids?

most often taken as compound preparations
containing an alginate with 1+ antacids (eg. sodium bicarb, calc carb, magnesium or aluminium salts)
antacids work by buffering stomach acids
alginates act to increase the viscosity of stomach contents, which reduces reflux of stomach acid into oesophagus
after reacting w/ stomach acid they form a floating ‘raft’
this separates the gastric contents from G-O jxn to prevent mucosal damage
some evidence suggests they also inhibit pepsin production
antacids alone (usually Al or Mg compounds) can be used for short-term relief of dyspepsia

What are the important adverse effects of alginates and antacids?

* compound alginates -\> few side effects * magnesium salts -\> diarrhoea * aluminium salts -\> constipation

What are the warnings/contraindications of alginates and antacids?

* well tolerated + safe in pregnancy * paediatric formulations are safe for use in infants * but compound alginates not to be given in combo w/ **thickened milk preparations** -\> lead to excessively thick stomach contents -\> cause bloating + abdo discomfort * sodium and potassium containing preparations should be used in pts with fluid overload or hyperkalaemia (eg. **renal failure**)

Give examples of proton pump inhibitors

* lansoprazole * omeprazole * pantoprazole

What are the indications for proton pump inhibitors?

first line treatment for: 1. prevention + treatment of **peptic ulcer disease**, including **NSAID-associated ulcers** 2. symptomatic relief of **dyspepsia + GORD** 3. eradication of ***H. Pylori* infection**, in which they are used in combo w/ antibiotic therapy

What is the mechanism of action of PPIs?

* _reduce gastric acid secretion_ * act by **irreversibly inhibiting H⁺/K⁺-ATPase in gastric parietal cells** * this proton pump is responsible for secreting H⁺ and generating gastric acid * advantage of targeting final stage of gastric acid production is that they are able to suppress acid production almost completely * in this respect, they differ from **H₂-receptor antagonists**

What are important adverse effects of PPIs?

* **GI disturbances** * **headache** * increase gastric pH -\> reduce body's host defence against infection; some evidence of inc ***C. difficile*** infection in pts taking PPIs * prolonged treatment -\> **hypomagnesaemia** -\> can lead to tetany + ventricular arrhythmia

What are the warnings/contraindications that need to be considered for PPIs?

* PPIs may **disguise symptoms of gastric cancer** * should enquire about alarm symptoms before + during treatment * can increase **risk of fracture** in elderly * caution in **osteoporosis**

What is Barrett's oesophagus?

* **squamous epithelium** (white) lining oesophagus is replaced * by abnormal specialised glandular/columnar mucosa (red) * this is a **metaplastic** change * occurs in distal oesophagus * develops due to long-standing acid reflux stimulus * diagnosed by endoscopy + biopsy

What is the management of Barrett's oesophagus?

* continuous therapy with PPIs * surveillance OGD 2yrs w/ multiple biopsies looking for dysplasia or carcinoma * if **low-grade dysplasia** -\> surveillance OGD every 6-12 months, radiofrequency ablation +/- endoscopic mucosal resection * if **high-grade dysplasia** -\> radiofrequency ablation +/- endoscopic mucosal resection, oesophagectomy

Describe the factors that influence a GP's decision to refer a patient with dyspepsia for endoscopy

Any patient with **ALARMS** symptoms of dyspepsia or is aged over 55 with unexplained + persistent dyspepsia * Anaema * Loss of weight * Anorexia * Recent onset of progressive symptoms * Melaena or haematemesis * Swallowing difficulty

What is meant by 'dysphagia'?

* **difficulty in swallowing** * should prompt urgent investigation * need to exclude malignancy * (unless of short duration + associated w/ sore throat)

What are five key questions to ask a patient presenting with dysphagia?

1. Was there difficulty in swallowing **solids *and* liquids** from the start? 2. Is it difficult to **initiate** a swallowing movement? 3. Is swallowing **painful** (odynophagia)? 4. Is the dysphagia **intermittent** or is it **constant** and getting worse? 5. Does the neck **bulge** or **gurgle** on drinking?

What is meant by 'reflux'?

Return of stomach contents into the oesophagus, mouth and potentially lungs that causes symptoms, namely heartburn

What is meant by 'achalasia'?

* motility disorder * characterised by **oesophageal aperistalsis** * and **impaired relaxation of lower oesophageal sphincter** * LOS pressure elevated in 50%+ of patients

When we swallow, why does food go into the oesophagus and not the trachea?

* when we swallow, food bolus in mouth passes back to **oropharynx** * pressure receptors stimulate centres in **medulla** * this initiates **swallowing reflexes** * **uvula** goes back and up closing off nasopharynx * simultaneously, vocal folds close + **epiglottis** covers trachea * this completely closes airways allowing food to pass into oesophagus