GORD/Hiatus Hernias Flashcards
What pain is Paul experiencing?
Dull pain
When does it normally occur?
After dinner
Especially if he eats late
How does it affect his everyday activities?
Stresses him- unsure about what to eat
Loses sleep
Describe the anatomical course of the oesophagus?
beginning
Neck (C6)
Continuous superiorly with the laryngeal part of the pharynx
Describe the anatomical course of the oesophagus?
middle
descends downward into the superior mediastinum
positioned between the trachea and the vertebral bodies of T1 to T4
Where does the oesophagus enter the abdomen?
Oesophageal hiatus at T10
What is the layers of the oesophagus?
Adventitia
Muscle layer
Submucosa
Mucosa
What is the adventitia?
outer layer of connective tissue
Where is there serosa rather than adventitia?
very distal and intraperitoneal portion of the oesophagus
What is the muscle layer?
external layer of longitudinal muscle and inner layer of circular muscle
What is the external layer composed of in each third?
Superior third – voluntary striated muscle
Middle third – voluntary striated and smooth muscle
Inferior third – smooth muscle
What is mucosa?
non-keratinised stratified squamous epithelium (contiguous with columnar epithelium of the stomach).
How is food transported through the oesophagus?
peristalsis
What is peristalsis?
Rhythmic contractions of the muscles, which propagates down the oesophagus
What can interfere with peristalsis?
Hardening of muscle layers can also cause dysphagia
What are oesophageal sphincters?
upper and lower oesophageal sphincters. They act to prevent the entry of air and the reflux of gastric contents respectively.
What is the upper o.s.?
anatomical, striated muscle sphincter at the junction between the pharynx and oesophagus
What produces the upper o.s.?
cricopharyngeus
What is the function of the upper o.s.?
prevent the entrance of air into the oesophagus
What is the lower o.s.?
located in the gastro-oesophageal junction
situated to the left of the T11 vertebra, and is marked by the change from oesophageal to gastric mucosa
What 4 phenomena form the lower o.s.?
The oesophagus enters the stomach at an acute angle.
The walls of the intra-abdominal section of the oesophagus are compressed when there is a positive intra-abdominal pressure.
The folds of mucosa present aid in occluding the lumen at the gastro-oesophageal junction.
The right crus of the diaphragm has a “pinch-cock” effect.
What are the four physiological constrictions in the lumen on the oesophagus?
Arch of aorta
Bronchus (left main stem)
Cricoid cartilage
Diaphragmatic hiatus
What is a physiological constriction?
Where food/foreign objects are likely to get stuck
What is Barrett’s oesophagus?
metaplasia of lower oesophageal squamous epithelium to gastric columnar epithelium
What causes Barrett’s?
hronic acid exposure as a result of a malfunctioning lower oesophageal sphincter
What is the most common symptom of Barrett’s?
long-term burning sensation of indigestion
unpleasant taste in mouth
nausea
vomiting
How can Barrett’s be diagnosed?
Endoscopy
What percentage of malignancies in the UK are oesophageal carcinomas?
2%
What are the clinical features of oesophageal carcinomas?
Dysphagia
Weight loss
What are the two types of oesophageal carcinomas?
Squamous cell carcinoma
Adenocarcinoma
What is squamous cell carcinoma?
The most common subtype of oesophagus cancer. It can occur at any level of the oesophagus
What is adenocarcinoma?
Only occurs in the inferior third of the oesophagus and is associated with Barrett’s oesophagus. It usually originates in the metaplastic epithelium of Barrett’s oesophagus
What are oesophageal varices?
abnormally dilated sub-mucosal veins (in the wall of the oesophagus) that lie within this anastomosis
When are oesophageal varices produced?
when the pressure in the portal system increases beyond normal, a state known as portal hypertension
When does portal hypertension most commonly occur?
secondary to chronic liver disease, such as cirrhosis or an obstruction in the portal vein
How do most patients with oesophageal varices present?
haematemesis (vomiting of blood)
Who is at high risk of developing oesophageal varices?
Alcoholics
What percentage of England’s working age population struggle to undertones health information that only contained text?
43%
Who faces the most difficulty when it comes to health literacy?
Older people BAME Those with low qualifications Those without English has a first language Those with low job status Those in the poverty trap
What does poor understanding lead to?
Higher risk of emergency admission
Serious health conditions
What is reflux?
some of the acidic stomach contents come back up the oesophagus towards the mouth
What is heartburn?
a burning sensation in the chest because of the acid that’s in the stomach
Where is heartburn felt?
in the chest behind the breastbone, and it may move up towards the throat
What are other symptoms of acid reflux?
an unpleasant taste in the mouth and swallowing problems
What does GORD stand for?
Gastro-Oesophageal reflux disease
What are the treatments for reflux?
Proton pump inhibitors
4-8 week course
If it does not work a H2 blocker may be offered
What is the treatments for severe oesophagitis?
8 week PPI treatment
When is surgery appropriate for reflux?
for people who do not want to take medication long-term, or for those who have unpleasant side effects from their medication
What is the most common type of surgery for reflux?
laparoscopic fundoplication
What is laparoscopic fundoplication?
keyhole surgery technique, in which the surgeon stitches and folds the top of the stomach, just below where the oesophagus meets the stomach, to create a smaller opening
What is the aim of laparoscopic fundoplication?
reduce the amount of stomach contents re-entering the oesophagus
repait hiatus hernia
strengthen the valve at the bottom of the oesophagus
What other terms could be used for heartburn?
Acid reflux
Tummy ache
Indigestion
What is the single medical term that describes the category of symptoms Paul is describing?
Dyspepsia
What is dyspepsia?
Recurrent epicanthic pain, heartburn or symptoms of acid regurgitation, with out without bloating, nausea or vomiting
Would you use dyspepsia with a patient?
Establish good communication using familiar words
What additional symptoms might a patient experience if the cause of their dyspepsia was oesophageal reflux?
Excess salivation- water brash
What are the other symptoms one might get if the cause is gastroenteritis?
Complete later
What could cause dyspepsia?
Coeliac disease IBS Upper GI malignancy GORD Gastritis Pancreatitis Medication side effects Functional dyspepsia Gastroenteritis Stress Peptic ulcer disease Coronary heart disease
What are the most likely differentials for Paul?
GORD Gastritis Functional dyspepsia Stress Peptic ulcer disease
What is functional dyspepsia?
Suffers symptoms but investigations do not show causes
May have gastritis but it doesn’t correlate with the severity of symptoms
What can sever gastritis lead to?
Ulceration
What is the second most common endscopic finding?
Oesophagitis
What is the third most common finding?
Peptic ulcer disease
What pain is associated with biliary disease?
Colicky pain
What is colicky pain?
Intermittent, spastic pain when a hollow tube contracts to get rid of an obstruction
Why must coronary disease be considered?
Stress
Risk factors- smoking
Can present as dyspepsia
What responsibility falls upon GPs?
Making decisions of what is significant of not
Common symptoms can be indicative of mor serious, less common diseases
What is differential diagnoses?
The possibilities of diagnosis that can range from less to very dangerous
What terms is used to indicate symptoms that can indicate very serious conditions?
Red flag symptoms
Why is it important to identify red flag symptoms?
So patients with more serious symptoms are seen first and have the relevant investigations carried out urgently
What are other common presentations to the GP for which red flag features might be important?
Back pain
What can back pain be a sign of?
Spinal-cord compression
malignancy
infection
Red flags for back pain.
Previous cancer
bladder bowel dysfunction
Red flags for headaches?
Meningism
raised intracranial pressure
sudden and severe
What is the most serious differential?
Upper GI cancer
What red flag features do you think might make a doctor suspicious for Upper GI cancer?
Weight loss
Mass
Dysphagia
What is another thing to bear in mind with a red flag symptoms?
How long symptoms persist
E.g. vomiting over extended period is more relevant
Age
Other symptoms
What helps GPs decide when to refer patients?
Nice referral guidelines
What is seven further actions are most appropriate at this time? After the GP has examined Mr Miller for red flags
Testing for H pylori FBC LFTs ECG Alcohol history Weight Medication history
What should you ask when taking an alcohol history?
Units (should be 14)
Spread out
What should be included in a medical drug history?
Include over-the-counter
those that affect the oesophageal sphincter
those that affect gastric mucosa
Why test for H. Pylori?
Common any dyspepsia
gastritis peptic ulcer disease gastric malignancy
is highly prevalent
Why do a FBC?
Anaemia
How might Upper GI cancer result in anaemia?
Due to occult blood loss
Cancer cytokines can affect blood cell production
Why would you do LFTs?
Biliary disease
alcohol induced changes
opportunistic
Why is a abdominal radiograph not relevant?
Often used acutely
show perforation or obstruction
When might a rectal examination be performed?
Upper gastrointestinal bleeding
Melaena
What is Melaena?
Dark and offensive smelling faeces containing blood from the upper GI tract
What is a OGD?
Oesophagogastroduodenoscopy
Invasive
Internal view
What is the site of infection for H. Pylori?
Stomach
Why is It is interesting that H pylori infects the stomach?
The acid in the stomach is responsible for killing pathogen is yet H pylori is found in the stomach
Why does the acid not destroy stomach lining?
Alkaline protection from cells protect the stomach lining from acid
How is H. Pylori able to survive in the stomach?
H pylori creates a molecule that neutralises acid
What is the molecule that neutralises acid and is created by H pylori?
Urease
What does urease do?
Converts urea and water to ammonia and carbon dioxide
What does H pylori use for locomotion?
Flagella
What does H pylori use for adhesion to host?
Lipopolysaccharides
BabA
What does cagA do?
Disrupt tight junctions between cells leading to inflammation = gastritis
What does VacA do?
causes the cells in the stomach lining to undergo apoptosis and die
What is the final affect of H. Pylori toxins?
The lining cells are now exposed to the effects of hydrochloric acid
What percentage of people have H pylori in their stomach?
50%
How was Mr Mellors Heliobacterpylori diagnosed?
Stool antigen test
What are the advantages of a carbon 13 urea breath test?
Non-invasive simple,Safe
High sensitivity and specificity
Can be used for diagnosis and as a test of cure
What are the disadvantages of the carbon 13 urea breath test?
Requires specialist analysing equipment, samples may need sending away
If the patient is on antibiotics or PPIs the results might be falsely negative
Requires fasting conditions
What are the advantages of a stall antigen test?
Non-invasive, simple, safe
High sensitivity and specificity
Can be used for diagnosis and theoretically as a test of cure
What are the disadvantages of the stool antigen test?
Patience my professor of the test
Samples need refrigeration
If the patient is on antibiotics or PPIs the results might be falsely negative
Sufficient evidence is lacking for use as a test of cure
What are the advantages of a serum serology test?
Cheap and widely available
May be useful for diagnosing a patient that is newly infected
What are the disadvantages of the serum serology test?
IgM poorly sensitive for new infection
IgG does not tell you if infection is current as will remain positive after infection cleared
Cannot test for cure
What are the advantages of a CLO test?
High sensitivity and specificity
Instantaneous results
What are the disadvantages of a CLO test?
If the patient is on antibiotics or PPI is the result might be falsely negative
Invasive
How does the human body make hydrochloric acid in the stomach?
Parietal cells secrete hydrochloric acid
Cells have two sides the apical side and basolateral side
Parietal cells generate hydrogen irons
Carbon dioxide diffuse into parietal cells on basolateral side
Carbonic anhydrase catalyses the creation of carbonic acid which dissociate to give hydrogen ions
A bicarbonate chloride antiporter transports bicarbonate out of parietal cell and chloride into parietal cell
Parietal cell proton pump transports hydrogen ions to apical side
Chloride channel transports chloride ions to apical side
What receptors are involved in stimulating the process?
H to receptor initiate signalling cascade which transports hydrogen
A CH receptor
Gastrin receptor
What do you PPIs do?
Have a week antibacterial effect
have anti urease and antia ATPase prosperities
Reduces acid production
What are the three types of drugs used to treat gastritis?
Proton pump inhibitors
Antacids
H2 antagonists
Give examples of PPIs?
Lansoprazole
Omeprazole
Give examples of antacids
Aluminium hydroxide
Magnesium carbonate
Give examples of H2 antagonists
Ranitidine
Cimetidine
What other symptoms would be present if it is gastroenteritis causing the dyspepsia?
Fevers, vomiting, diarrhoea
What did the GP give Mr Muller?
Omeprazole
amoxicillin
clarithromycin
What did the GP retest Mr Muller with?
Carbon 13 breath test
How long did the GP have to wait before testing Mr Muller?
Four weeks
What does Mr. Muller have?
Treatment resistant dyspepsia
What does nice recommend for treatment resistant dyspepsia?
Endoscopy
OGD
What did Paul’s OGD find?
Sliding hiatus hernia present with evidence of moderate oesophagitis.
Oesophageal biopsies taken three times
Gastric mucosa macroscopically normal, random biopsy taken for CLO test.
Duodenum normal
What was the outcome of Paul’s CLO test?
Negative
What was recommended for Paul after the OGD?
Recommended high dose omeprazole and repeat OGD three months
When does a hiatus hernia occur?
Hiatus hernia is a car when part of the abdominal viscera herniate through the oesophageal opening in the diaphragm
What are the risk factors for hiatus hernias?
Male gender Obesity Age Pregnancy Genetic predisposition
What does a hiatus hernia occur due to?
Widening of the diaphragmatic hiatus
Pulling up of the stomach e.g Due to oesophageal shortening
Or pushing up of the stomach e.g. due to intra-abdominal pressure
What occurs during a hiatus hernia?
Function of the lower oesophageal sphincter is compromised and the anti-reflux barrier is lost
Allow stomach contents to reflux into the oesophagus
What are hiatus hernia is a common cause of?
GORD
What are the two variants of hiatus hernia is?
Sliding and Rolling
What is a sliding hiatus hernia?
85 to 95% of cases
GOJ moves upwards
Predominantly causes symptoms of GORD
What is a rolling hiatus hernia?
5 to 15% of cases
GOJ remains in place
A portion of the stomach, bowel, pancreas or spleen herniates into the chest next to the GOJ
What are the constituents of the refluxed material?
Stomach acid and indigested food
What is the pH of the refluxed material?
Acidic
Why might the PPI not work?
Functional dyspepsia
Non-acid reflux
Hiatus hernia
What does gaviscon do?
Foamy barrier created on top of the stomach contents
What was causing Mr Mellors presenting complaint heartburn?
GORD as a result of his hiatus hernia
What is Barretts oesophagus?
Complication of GORD
Precondition for oesophageal cancer
What percentage of people with GORD develop Barretts oesophagus?
10 percent
What percentage of people with Barratts oesophagus develop oesophageal cancer?
1 to 5%
How can the nature of tissue change a long continuous system?
Different tissue types along the track
Oesophagus has squamous epithelium stomach has columnar
All epithelia lined with mucus
Oesophageal configuration changes for something else
Why does cell type change?
Exposure to gastric contents
What is the phenomena when cells change from one type to another called?
Metaplasia
What is the histological difference between a healthy and Barratts oesophagus?
more Red and velvety
What is a precursor for intestinal metaplasia?
Cardiac metaplasia
What are Barrett cells vulnerable to?
Architectural changes leading to dysplasia
Which can be considered low or high grade depending on the characteristics of the cells
What can a high grade dysplasia that has not invaded neighbouring tissues be also known as?
Carcinoma in situ
Intraepithelial neoplasia
Stage zero cancer
What does high grade dysplasia run the risk of?
Developing into invasive cancer
How often will a patient with GORD have an OGD?
Every few years or more often depending on the situation
How can invasive adeno carcinoma be treated?
Surgically with an oesophagectomy
What was Mr Miller’s diagnosis of Heliobacter pylori?
Red herring
What does the GP to recommend to Mr Maller?
How are you do is 20 mg of omprezole oral twice a day
Lifestyle changes
What lifestyle elements should be incorporated to ease acid reflux and heartburn?
Eat smaller, more frequent meals
Raise one end of your bed 10 to 20 cm by putting something under your bed or mattress
Make it so your chest and head are above the level of your waist so stomach acid does not travel up towards your throat
Try to lose weight if you’re overweight
Try to find ways to relax
What lifestyle elements should be avoided to ease heartburn and acid reflux?
Do you not have food or drink that triggers your symptoms
Do not eat within three or four hours before bed
Do you not wear clothes that are tight around your waist
Do not smoke
Do you not drink too much alcohol
Do not stop taking any prescribed medicine without speaking to a doctor 1st
What lifestyle changes are especially relevant to Paul?
Raising his bed
Avoiding eating within 3 to 4 hours of bed
Try to lose weight
Try to find ways to relax
How can stress exacerbate acid reflux?
Ulcerations of the brain gut excess
How can smoking exacerbate acid reflux?
Nicotine relaxes the lower oesophageal sphincter
How does alcohol exacerbate GORD?
Chronic alcohol excess is associated with GORD
Inhibition of gastric emptying
Affect the functioning of the lower oesophageal sphincter are
Contributes to gastric mucosal damage
What are common trigger foods?
Spicy food
Acidic food
Coffee
How does tight clothing exacerbate reflux?
Increases abdominal pressure
What are risk factors for reflux?
Overweight Smoke Drink to much alcohol Eat spicy, acidic to fatty foods Hiatus hernia
What is a EMR?
Endoscopic mucosa resection
What is the aim of an EMR?
remove the affected area of the oesophagus lining, without damaging the rest of the oesophagus
How is the EMR performed?
surgeon removes the affected area using a thin wire called a snare
the snare is put through an endoscope into the body
What is RFA?
Radiofrequency ablation
What does RFA do?
Uses heat to destroy abnormal cells
What are the side effects of RFA?
Mild pain
Discomfort
Generally unwell
Possible temperature
What is a oesophagectomy?
surgeon removes the part of the oesophagus that contains the abnormal cells then join the stomach to the remaining part of the oesophagus
When is someone offered a oesophagectomy?
you have a high-grade dysplasia
you have a high-grade dysplasia that cannot be removed using an endoscope
What happens after a oesophagectomy?
ICU
Drip until they can eat or drink again
Possible NG tube
Feeding tube
What does a NG tube do?
Removes digestive fluids
Helps area heal
Prevents nausea
What are the new treatment methods for Barrett’s that are being researched?
Multipolar electrocoagulation
Cryotherapy
When are antacids best given?
when symptoms occur or are expected, usually between meals and at bedtime
What makes antacids suitable?
Aluminium- and magnesium-containing antacids
relatively insoluble in water, are long-acting if retained in the stomach
What are potential side effects of antacids?
Magnesium-containing antacids tend to be laxative whereas aluminium-containing antacids may be constipating
Why are bismuth containing antacids not recommended?
absorbed bismuth can be neurotoxic, causing encephalopathy; they tend to be constipating
Why are calcium containing antacids not recommended?
an induce rebound acid secretion
prolonged high doses also cause hypercalcaemia and alkalosis, and can precipitate the milk-alkali syndrom
What is simeticone?
added to an antacid as an antifoaming agent to relieve flatulence.
useful for the relief of hiccup in palliative care.
What are alginates?
added to an antacid as an antifoaming agent to relieve flatulence. These preparations may be useful for the relief of hiccup in palliative care.
What are potential adverse effects associated with long term PPI use?
hypergastrinemia pneumonia dementia drug interactions risk of fractures hypomagnesemia Clostridium difficile–associated diarrhea vitamin B12 deficiency acute interstitial nephritis (AIN), cutaneous and systemic lupus erythematosus events
What causes hypergastrinemia?
Gastric acid suppression
What does hypergastrinemia cause?
hyperacidity; after discontinuing PPI therapy, patients may experience worsening GORD symptoms
parietal cells to hypertrophy and enterochromaffin-like cells (ECL) to undergo hyperplasia
Increase risk of gastric cancer
What can be done to avoid hypergastrinemia?
PPIs should be slowly tapered
How does PPI use cause pneumonia?
Acid suppression leads to an increase in gastric pH, allowing for the overgrowth of non-Helicobacter pylori bacteria in gastric juices, gastric mucosa, and the duodenum.2 This can potentially lead to microaspiration and lung colonization
Why may PPIs cause fractures?
there may be as much as a 41% reduction in calcium absorption after 14 days of omeprazole therapy
What are symptoms of hypomagnesemia?
muscle weakness and cramps, tetany, convulsions, arrhythmias, and hypotension
Why might PPIs cause vitamin B12 deficiency?
atrophic gastritis and achlorhydria, promoting bacterial overgrowth that allows for the increased digestion of cobalamin
What are the symptoms of acute interstitial nephritis?
nausea, vomiting, fatigue, fever, and hematuria
Why may PPIs cause dementia?
PPIs may increase the production and degradation of amyloid and bind to tau
What is DILE?
Drug-induced lupus erythematous
Lupus-like syndrome that usually resolves after discontinuation of the medication
What is the most common form of DILE?
SCLE
Drug-induced subacute cutaneous lupus erythematous
Who is at risk of developing SCLE?
Women of childbearing age, those with drug allergies or previous episodes of SCLE, photosensitive skin, exposure to ultra-violet radiation, and family history
Give examples of drugs that interact with PPIs
itraconazole, ketoconazole, isoniazid, oral iron supplements, and several protease inhibitors
What pathways can the brain and gut communicate via?
neural pathway (vagus nerve and enteric nervous pathway) Endocrine pathway Immune pathway
What hormones are involved in communication?
Cortisol
Adrenaline
both influence immune cytokines
What can influence the composition of our GI bacteria?
Stress
Altered levels of glucocorticoid hormones leads to modulates immune response
What is the modulated immune response?
Increased levels of proinflammaotory cytokines
Change in the levels of neuroactive molecules
Influences brain function
