GORD, Peptic Ulcers, Upper GI bleed Flashcards
What is GORD?
Acid from the stomach (columnar epithelial lining) refluxes through the lower oesophageal sphincter
irritates the lining of the oesophagus (squamous epithelial lining)
Presentation of GORD (6)
Heartburn Acid regurgitation Retrosternal or epigastric pain Bloating Nocturnal cough Hoarse voice
When is GORD referred for endoscopy?
Used to assess for peptic ulcers, oesophageal or gastric malignancy
Evidence of a GI bleed needs admission and urgent endoscopy
Red flags indicating 2ww referral (8)
Dysphagia at any age
Aged over 55 (this is generally the cut off for urgent versus routine referrals)
Weight loss
Upper abdominal pain / reflux
Treatment resistant dyspepsia
Nausea and vomiting
Low haemoglobin
Raised platelet count
Lifestyle changes for managing GORD (6)
Reduce tea, coffee and alcohol
Weight loss
Avoid smoking
Smaller, lighter meals
Avoid heavy meals before bed time
Stay upright after meals rather than lying flat
Acid neutralising medication when required:
Gaviscon
Rennie
Proton pump inhibitors (reduce acid secretion in the stomach)
Omeprazole
Lansoprazole
What is the alternative to PPI?
Ranitidine - H2 receptor antagonist (antihistamine)
Reduces stomach acid
Surgical resolution of GORD
Laparoscopic fundoplication
Involves tying the fundus of the stomach around the lower oesophagus to narrow the lower oesophageal sphincter
What is H. pylori?
Gram negative aerobic bacteria
Causes damage the epithelial lining of the stomach resulting in gastritis, ulcers and increasing the risk of stomach cancer
Forces its way into the gastric mucosa, breaks it creates exposes the epithelial cells to acid
Produces ammonia to neutralise the stomach acid. The ammonia directly damages the epithelial cells
Who is offered test for H. pylori?
Anyone with dyspepsia
Need 2 weeks without using a PPI before testing for H. pylori
Tests for H. pylori
Urea breath test using radiolabelled carbon 13
Stool antigen test
Rapid urease test (CLO test) can be performed during endoscopy - biopsy
How does the CLO test work?
Urea is added to biopsy
If H. pylori are present, they produce urease enzymes that converts the urea to ammonia
Ammonia makes the solution more alkali giving a positive result on when the pH is tested
How is H. pylori treated?
Triple therapy for 7 days
2 Abx - Amox + Clarith
1 PPI - Omeprazole
What is Barretts Oesophagus?
Constant reflux of acid - metaplasia from a squamous to a columnar epithelium
Typically get an improvement in reflux symptoms
Barretts oesophagus is considered a “premalignant”
Risk factor for the development of adenocarcinoma of the oesophagus (3-5% lifetime risk with Barretts)
What is the treatment for Barretts/
PPI
(aspirin)
Ablation treatment can destroy the epithelium so that it is replaced with normal cells
Has a role in low and high grade dysplasia in preventing progression to cancer
What are the causes of an upper GI bleed? (4)
Oesophageal varices
Mallory-Weiss tear
Ulcers of the stomach or duodenum
Cancers of the stomach or duodenum
What is the presentation of upper GI bleed?
Haematemesis - (Coffee ground” vomit
Melaena
Haemodynamic instability occurs in large blood loss, causing a low blood pressure, tachycardia and other signs of shock (Young, fit patients may compensate well until they have lost a lot of blood)
Epigastric pain and dyspepsia - peptic ulcers
Jaundice, ascites - liver disease with oesophageal varices
What is the Glasgow-Blatchford Score?
Scoring system in suspected upper GI bleed based on initial presentation
Establishes risk of having an upper GI bleed
score > 0 indicates high risk
1 for each of the following:
Drop in Hb Rise in urea Blood pressure Heart rate Melaena Syncopy
Why is urea raised in upper GI bleed?
Blood in the GI tract gets broken down by the acid and digestive enzymes
Breakdown products is urea and then absorbed in the intestines
What is Rockall score?
Used for patients that have had an endoscopy to calculate percentage risk of rebleeding and overall mortality
Age
Features of shock (e.g. tachycardia or hypotension)
Co-morbidities
Cause of bleeding (e.g. Mallory-Weiss tear or malignancy)
Endoscopic stigmata of recent haemorrhage such as clots or visible bleeding vessels
What is the management of upper GI bleed?
A – ABCDE approach to immediate resuscitation
B – Bloods
A – Access (ideally 2 large bore cannula)
T – Transfuse
E – Endoscopy (arrange urgent endoscopy within 24 hours)
D – Drugs (stop anticoagulants and NSAIDs)
Definitive treatment is oesophagogastroduodenoscopy (OGD) to provide interventions that stop the bleeding - banding of varices or cauterisation of the bleeding vessel
What bloods are sent for in upper GI bleed?
Haemoglobin (FBC)
Urea (U&Es)
Coagulation (INR, FBC for platelets)
Liver disease (LFTs)
Crossmatch 2 units of blood
Treatment if source is oesophageal varices?
Terlipressin
Prophylactic broad spectrum antibiotics
When to transfuse in upper GI bleed?
Patients with massive haemorrhage
Platelets should be given in active bleeding and thrombocytopenia (platelets < 50)
Prothrombin complex concentrate can be given to patients taking warfarin that are actively bleeding
Where can peptic ulcers occur?
Duodenum (most common)
Stomach - gastric ulcer
How do peptic ulcers occur?
Breakdown of the protective layer of the stomach and duodenum (by H. pylori or NSAIDS)
Increase in stomach acid from: Stress Alcohol Caffeine Smoking Spicy foods
How does a peptic ulcer present? (5)
Epigastric discomfort or pain
Nausea and vomiting
Dyspepsia
Bleeding causing haematemesis, “coffee ground” vomiting and melaena
Iron deficiency anaemia (due to constant bleeding)
How are peptic ulcers managed?
Diagnosed by endoscopy (CLO test/biopsy)
PPI
Complications of peptic ulcers?
Bleeding
Perforation resulting in an “acute abdomen” and peritonitis
Scarring and strictures of the muscle and mucosa can lead to pyloric stenosis - presents with upper abdominal pain, distention, nausea and vomiting, particularly after eating
