GORD/Dyspepsia/PUD/Upper GI Bleeding Flashcards
What are the causes of GORD
1) incompetent LOS
2) Poor oesophageal clearance
3) Visceral sensitivity
What causes relaxation of LOS
Parasympathetic activity - release ACh and substance P
What are the symptoms of GORD
Heartburn Regurgitation Dysphagia Odynophagia cough Hoarse voice dyspepsia
What are the red flag symptoms
dysphagia weight loss haematemesis malena anaemia persistent vomiting Palpable mass
What are the symptoms for dyspepsia
Epigastric pain
postprandial fullness (bloating / belching)
early satiety
What are the risk factors for GORD
Smoking Alcohol Obesity Family history of GORD pregnancy NSAID Caffeine
What exacerbates heart burn
After meals
Worse when lying down or bending forward
What is odynophagia
Painful swallowing
What are the complications for GORD
Chronic oesophagitis (reflux oesophagitis) Barrett's oesophagus Oesophageal malignancy Reflex stricture Reflux dental erosions Reflux laryngitis syndrome
Why should chronic oesophagitis be detected early
Because it is reversible
If not treated early, it can develop into Barrett’s oesophagus which is non-reversible and increases risk for oesophageal malignancy
Diagnosis of GORD
pH studies
Oesophageal manometry
Gastroscopy
Who is gastroscopy reserved for in GORD
For those patients with red flag symptoms/ considered for surgery/ sympatomatic despite treatment
What is the management for GORD (first line)
Lifestyle management + full dose PPI
What are the lifestyle advices given to patients with GORD
avoid eating 2 hours before sleeping smoking cessation decrease alcohol consumption elevate level of head when lying down weight loss if obese
What type of foods should be avoided in patients with GORD
spicy / sour / caffeine
When is H2 receptor antagonist used in GORD
If the patient does not respond to PPI
What is the full dose of omeprazole
40mg once a day
Name of surgery given to GORD patients
Nissen fundoplication
When is surgery for GORD indicated
When the patient doesn’t respond to drug treatment
When the patient responds to PPI but wish to solve GORD at once
What are the foregut structures
Oesophagus stomach liver gall bladder pancreas spleen first half of duodenum
What are the 2 causes of dyspepsia
Organic causes - use of NSAID / peptic ulcer disease / gastric cancer
Functional dyspepsia - idiopathic
What is dyspepsia
A term used to describe upper GI tract symptoms
How long does dyspepsia usually occur
4 or more weeks
What should you do if a patient with dyspepsia present with other red flag symptoms
Refer them to specialists (suspect malignancy)
Management of patients with dyspepsia without red flag symptoms
Lifestyle management + antacids
What is the next step management if patients still experience dyspepsia after initial treatment
Suspect H. pylori -> test for H.pylori
If positive -> antibiotics + PPI
If negative -> if more than 55 years old -> referral
If negative -> if less than 55 years old -> PPI (treat as functional dyspepsia)
What medication should be stopped before H. pylori testing
Proton Pump inhibitors
What are the drugs used against H. Pylori
amoxicillin + clarithromycin + PPI (triple therapy)
What drugs are used against H. pylori if the patient is penicillin allergic
metronidazole + clarithromycin + PPI
What may severe GORD cause
aspiration pneumonia
What is Barett’s oesophagus
When the oesophageal mucosa undergoes metaplastic change from stratified squamous cells to simple columnar cells
What are the types of oesophagitis
Acute oesophagitis
Chronic oesophagitis (reflux oesophagitis)
Allergic oesophagitis
Which type of oesophagitis is rare
Acute oesophagitis
Which group of people is susceptible to infective acute oesophagitis (AO due to infection)
Immunocompromised individuals
What infections can cause acute oesophagitis
Herpes
CMV
candidiasis
Cause of reflux oesophagitis
Inflammation due to reflux of low pH gastric content
What are the changes in mucosa for reflex oesophagitis
basal hyperplasia and lengthening of papilla
Increase in intraepithelial neutrophils, lymphocytes and eosinophils
What causes basal hyperplasia in reflux oesophagitis
low grade inflammation causes an increase in cell desquamation -> increase in proliferation to compensate
What are the complications of reflux oesophagitis
ulceration
stricture
Barrett’s oesophagus
Timeline of chronic oesophagitis
Reflux oesophagitis -> Barrett’s oesophagus (metaplasia) -> low grade dysplasia -> high grade dysplasia
What does Barrett’s oesophagus increase the risk for
Oesophageal adenocarcinoma, carcinoma
What are the treatments for low grade dysplasia (Barrett’s)
PPI + endoscopy surveillance every 6 months
What are the treatments for high grade dysplasia (Barrett’s)
Endoscopic resection - radiofrequency ablation / endoscopic mucosal resection / endoscopic submucosal resection
Features of allergic oesophagitis
Large numbers of eosinophils
Not due to acid reflux
Risk factors for allergic oesophagitis
Family history of allergies
asthma
male
common in young people
What is the treatment for allergic oesophagitis
Steroids
Montelukast
Types of oesophageal cancer
Adenocarcinoma
Squamous cell carcinoma
2 types of gastric adenocarcinoma
Intestinal
DIffuse
Where is the most common site of oesophageal cancer
lower end of oesophagus
Which oesophageal cancer is Barrett’s oesophagus most associated to
Adenocarcinoma
Risk factors for oesophageal adenocarcinoma
Barrett's oesophagus GORD obesity smoking age male
Risk factors for oesophageal squamous cell carcinoma
Oeosphagitis Hot drinks Low intake of fibres and fruits age smoking alcohol GORD Achalasia
Symptoms of oesophageal cancer
Progressive dysphagia Heart burn Vomiting / regurgitation haematemasis Weight loss Anorexia Hoarse voice
How do oesophageal tumours invade other structures
Direct local invasion - e.g. to trachea
Through blood
Lymph nodes
Diagnosis of oesophageal cancer
endoscopy and take biopsy
CT scan to stage the cancer
PET scan to check for metastases
Management of oesophageal cancer
If early (Barrett’s, high grade dysplasia) - endoscopic resection
If intermediate (no local invasion / distant metastases / lymph nodes)
- chemotherapy + surgery
- neoadjuvant chemoradiotherapy + surgery
What is the surgery for oesophageal cancer called
Oesophagectomy
Types of gastritis
Acute gastritis
Chronic gastritis
Causes of chronic gastritis
Bacterial
Chemical
Autoimmune
Which pathogen is the most common cause of bacterial gastritis
H. pylori
How does H. pylori cause chronic gastritis
Induces release of IL-8 , causing inflammatory response and chronic inflammation if not cleared
What is IL-8
A pro-inflammatory cytokine
What type of bacteria is H.pylori
Gram negative
Spiral shaped bacilli
Transmission of H. pylori
Oral to oral
Faecal to oral
When do people usually become infected with H. pylori
As a child / young adulthood
What conditions does chronic gastritis increase the risk for
Peptic ulcer disease
gastric adenocarcinoma
gastric lymphoma
What causes chemical chronic gastritis
NSAID
Alcohol
Bile reflux
What causes autoimmune gastritis
Presence of anti-parietal and anti-intrinsic factors antibodies
What are intrinsic factors for
for absorption of vitamin B12
What are the signs of vitamin B12 deficiency
Macrocytic (abnormally large RBC)
Pernicious anaemia
SACDC
What is SACDC
when myelin sheath starts to wear away
Types of gastric cancer
adenocarcinoma
lymphoma
Types of gastric adenocarcinoma
Intestinal
diffuse
Features of intestinal gastric adenocarcinoma
- better prognosis
- accounts for most of the non-cardia tumours
- increased level of HER2 protein
- most associated with H. pylori infection
Features of diffuse gastric adenocarcinoma
- poorer prognosis
- associated with genetic changes in CDH1 gene
- more in young patients
What are HER2 proteins
growth-promoting proteins; associated with breast cancer and gastric cancer
Which cancer is CDH1 gene mutation also associated to
Lobular breast cancer
Symptoms of gastric cancer
weight loss gastric reflux vomiting +/- haematemesis dyspepsia malena
How may H.pylori infection lead to gastric adenocarcinoma
H. pylori infection -> chronic gastritis -> intestinal metaplasia (glandular cells become intestinal cells) -> dysplasia
Type of epithelium in duodenum
simple columnar cell with crypts of lieuberkuhn between villi
Type of epithelium in stomach
simple columnar cells with gastric glands
Type of epithelium in oesophagus
stratified squamous cells
What causes gastric lymphoma
Due to H.pylori
Continuous inflammation induces an evolution into a clonal B cell proliferation -> low grade lymphoma -> high grade lymphoma
What lymphoid tissue does gastric lymphoma affect
mucosa associated lymphoid tissue (MALT)
Where is MALT found
Lamina propria (where the mucosal immunity is)
Metastases of gastric cancer
Lymph nodes of greater omentum
through blood - to liver first
transcolaemic - to organs in peritoneal cavity , ovaries
Can low grade gastric lymphoma disappear completely
Yes, if H. pylori is eradicated
Management of early gastric cancer
Endoscopic resection - radiofrequency ablation / endoscopic mucosal resection / endoscopic submucosal resection
Management of intermediate gastric cancer
Perioperative chemotherapy (FLOT regime) + surgery
Management of late gastric cancer
Chemotherapy + targetted molecular therapy (e.g. targetting HER2)
Types of peptic ulcer
Gastric ulcer
Duodenal ulcer
4 parts of duodenum
Superior
Descending
Inferior
Ascending
Where does duodenal ulcer usually occur
Superior part of duodenum
Compare between gastric and duodenal ulcer
Gastric - equal gender distribution - incidence increases with age Duodenal - associated with H. pylori - more common in males - more common than gastric ulcer
Causes of peptic ulcer
H. pylori
NSAID
What conditions are H. pylori associated to
Chronic gastritis
Gastric intestinal adenocarcinoma
Gastric lymphoma
Peptic ulcer disease (esp. duodenal)
How does H. pylori cause peptic ulcers
1) cause hypergastrinemia by increasing gastrin production and reducing somatostatin
2) damages mucous producing goblet cells and epithelial cells
3) this causes an increase in gastric acid secretion and decrease in protective mucous
4) allows H. pylori to enter stomach lining and damage deeper layers
5) acid enters, causing ulcer
Which cell produces gastrin
G cells
When is gastrin normally released
In response to distention of stomach
presence of amino acids / peptides
increase in pH
Does everyone with H. pylori infection develop into peptic ulcer
No, only 20-40%
How does NSAID cause peptic ulcers
NSAID inhibit COX1, COX2, PGE2 (prostaglandin E2)
COX1 and COX2 produce PGE2
PGE2 stimulates mucous production and inhibits gastric acid secretion
so decrease in COX1, COX2, PGE2 leads to increase in acid secretion and decrease in protective mucous
Examples of NSAID
aspirin
ibuprofen
naproxen
What type of NSAID is aspirin
non-selective; blocks COX1 and COX2 but weakly more selective to COX1
Use of aspirin
as an antiplatelet to prevent arterial thromboembolism
Where does H. pylori usually colonize
antrum
Symptoms of peptic ulcer
Epigastric pain
dyspepsia
nausea
heartburn
Complications of peptic ulcer
perforation upper gi bleed gastric outlet obstruction (prevents gastric emptying) Duodenal obstruction Peritonitis
Which artery is usually eroded by duodenal ulcers
gastroduodenal artery
Diagnosis of peptic ulcer
H. pylori testing
Bloods
Endoscopy
Tests for H. pylori
Stool antigen test
Urease test
serology
culture
Which 2 tests are the most common for H.pylori testing
Stool antigen test
Urease test
How is urease test done and why is it done
done by taking a biopsy via endoscopy
It is done because H. pylori produces urease to increase pH of its environment
What drug should be taken off from patients before H.pylori testing
PPI because PPI can give false negative results
Why is serology not really used for H.pylori
Because it is not accurate with increasing patient age
Management of peptic ulcer
Lifestyle management + Drug treatment
What are the lifestyle advices for peptic ulcer disease
Avoid spicy / sour foods / caffeine
decrease alcohol consumption
smoking cessation
stop using NSAID
What are the drug treatments
If H.pylori positive - amoxicillin + clarithromycin + PPI (omeprazole) If penicillin allergic - metronidazole + clarithromycin + PPI If H.pylori negative - PPI for 4-8 weeks
What dosage of PPI should be given to PUD patients
full dose ; omeprazole - 40mg a day
Why is there poor compliance to triple therapy
Side effects: nausea, diarrhea
Drug treatment if first line H.pylori eradication fails
amoxicillin + clarithromycin + tetracycline + PPI
If penicillin allergic
metronidazole + tetracycline / levofloxacin + bismuth + PPI
Follow up management for PUD
Gastric ulcer - endoscopy after 6 - 8 weeks of PPi
duodenal ulcer - if no more symptoms - low dose PPI ; if symptoms persist - suspect malignancy / antibiotic resistance / rarer causes
What are the causes of acute upper GI bleed
peptic ulcer disease gastric erosions varices oesophagitis malignancy Mallory weiss tear
Which peptic ulcer disease most commonly causes upper GI bleed
duodenal ulcer
What is mallory weiss tear
tear of lower oesophagus due to violent coughing or vomiting
Symptoms of Upper GI bleed
Haematemesis
Malena (black, tarry stool)
signs of shock
syncope / confusion
What is the 100 rule
Represents symptoms that indicate poor prognosis for upper gi bleed HR = <100 bpm systolic BP = <100mmHg Hb = <100 g/l age = > 60 comorbidities
What does systolic hypotension mean for shock
There has been loss of more than 30% of total blood volume, causing compensatory mechanisms to not function anymore
Why should you keep an eye on young patients with upper GI bleed
They can compensate well initially but crash suddenly
Upper GI bleed patients on beta blockers
will not show signs of tachycardia
Upper GI bleed patients with diabetes
Poor autonomic response so may not show the signs
Management of Upper GI bleed
Resuscitation
Endoscopy
treat underlying cause
What are the resuscitation methods for upper GI bleed
ABCDE
IV fluid
blood transfusion
Management for bleeding peptic ulcer
endoscopic treatment to attempt to stop bleeding
IV omeprazole
What are the endoscopic treatments for bleeding peptic ulcers
Injection of adrenaline + Heater probe coagulation
Clips +/- adrenaline
Haemospray
What solution of adrenaline should be used for injection in bleeding peptic ulcer
1 in 10000
Effect of adrenaline
reduces blood flow to the area
How does haemospray stop the bleeding
Soaks up water in the area, increasing concentration of coagulation factors
forms a barrier
How many times should endoscopic treatment be attempted before surgery in bleeding peptic ulcers
2 times
Endoscopy -> IV omeprazole -> Endoscopy
Post bleeding PUD management
Eradication of H. pylori if indicated
oral PPI
What causes oesophageal varices
Portal hypertension (hypertension in the liver)
Portal hypertension makes it harder for blood to enter the liver then IVC so blood finds another way to flow back, which is through oesophageal vessels
This causes oesophageal vessels to dilate and become fragile
What is the common cause of portal hypertension
Cirrhosis
Resuscitation for bleeding oesophageal varices
ABCDE
IV fluids and blood transfusion
Why should central venous pressure be monitored in bleeding oesophageal varices
It directly reflects the portal pressure. Needs to be monitored while giving fluid and blood to avoid raising the portal pressure
How to stop the bleeding oesophageal varicse
Endoscopic variceal ligation (banding)
Sengstaken Blakemore tube
TIPSS
Which scoring methods are used to assess the severity of haemorrhage
Blatchford
Rockall
Effect of IV terlipressin
Causes sphlanchic vasoconstriction (vasoconstriction of sphlanchic vessels - SMA / IMA ..etc) to decrease blood flow
When is TIPSS indicated
If endoscopic variceal ligation is ineffective
When is Blatchford scoring used
After resuscitation of (first line assessment recommended by NICE)
When is Sengstaken Blakemore indicated
If endoscopic haemostasis cannot be achieved or endoscopy is not availble
But this is not a definite treatment so if endoscopy fails, use TIPSS instead of this
What is the first line method to stop variceal bleeding
Endoscopic variceal ligation (banding)
