H pylori and Gastric Disease Flashcards
Define dyspepsia
Literally - bad digestion
Pain or discomfort in the upper abdomen
Also encompasses: •retrosternal pain, anorexia, nausea, vomiting, bloating, fullness, early satiety and heartburn
What can cause the symptom of dyspepsia?
Upper GI:
- Peptic ulcer
- Gastritis
- Non ulcer dyspepsia
- Gastric cancer
Hepatic causes
Gallstones
Pancreatic disease
Lower GI (IBS, Colonic cancer)
Coeliac disease
Other systemic disease
Drugs
Psycological
When do you refer someone with dyspepsia for an endoscopy?
- Anorexia
- Loss of weight
- Anaemia – iron deficiency
- Recent onset >55 years or persistent despite treatment
- Melaena/haematemesis (GI bleeding) or mass
- Swallowing problems - dysphagia
ALARMS
What are the risks associated with endoscopy?
Bleeding, perforation and reaction to drugs given
What are the key things to do if a patient presents with dyspepsia?
History and examination
Bloods (FBC, ferritin, LFTs, U and Es, calcium, glucose, coeliac serology/serum IgA)
Drug history - NSAIDS, steroids, bisphosphonates, Ca antagonists, nitrates, theophyllines, remember OTT
Lifestyle - alcohol, diet, weight reduction, exercise,
When would an UGIE be indicated when alarm features are absent?
If the patient is over 55 years of age?
What is the follow up test for a patient after an UGI with dyspepsia?
Test for helicobacterpylori
What is the eradication therapy for helicobacter pylori?
Symptomatic treatment with PPIs or H2R antagonists and lifestyle factors
Describe helicobacter pylori
Gram negative, spiral shaped, microaerophilic, flagelated gram negative bacteria
What is the prevalence of helicobacter pylori in the world?
50% world population
What type of mucosa can helico bacter pylori colonise?
Gastric type mucosa
Resides in the surface of the mucus layer and does not penetrate the epithelial layer
What are the outcomes of helicobacter pylori?
Asymptomatic of chronic gastritis
Chronic atrophic gastritis with intestinal metaplasia
Gastric or duodenal ulcer
Gastric cancer MALT (mucosa-associated lymphoid tissue) lymphoma
(Outcome dependent on site of colonization, characteristics of bacteria and host factors e.g. genetic susceptibility & other environmental factors e.g. smoking)
Which part of the stomach is likely to cause DU disease when afflicted by helicobacter pylori?
Antrum
Infection results in predominant gastritis: increase in acid produciton
Low risk of gastric cancer
Which part of the stomach is likely to cause gastric cancer when afflicted by helicobacter pylori infection?
Corpus predominant gastritis
There is an increase in gastric atrophy
What are the non-invasive methods of H pylori infection?
What are the invasive methods of H pylori infection?
(Requiring endoscopy)
Histology: Gastric biopsies stained for the bacteria
Culture of gastric biopsies
Rapid slide urease test
What chemical is used to determine the presence of H pylori in the rapid slide urease tests?
Ammonia (produced by the H pylori urease)
What is meant by gastritis?
Inflammation in the gastric mucosa
Histological diagnosis
Clinical features seen at endoscopy
What are the causes of gastritis?
Autoimmune (parietal cells)
Bacterial (H. Pylori)
Chemical (bile/NSAIDs)
What causes the majority of peptic ulcers?
Helicobacter pylori infection
What are other causes of peptic ulcers?
NSAIDS
Smoking
•Rarely they are caused by other conditions such as Zollinger-Ellison syndrome, hyperparathyroidism, Crohn’s disease
Useful notes on peptic ulcers
Usually releived by antacids – stops acids irritating that area
Pain is sometimes worse at night/ when they haven’t eaten
Endoscopy is the best diagnosis, sometimes hard to detect signs
Biopsies important so we know if it is benign / malignant
What symptoms are associate with peptic ulcer?
- Epigastric pain is the main feature (pointing sign, may be relieved by antacids)
- Nocturnal/hunger pain (more common in DU)
- Back pain (may suggest penetration of a posterior DU)
- Nausea and occasionally vomiting
- Weight loss and anorexia
- Only sign may be epigastric tenderness
- If the ulcer bleeds, patients may present with haematemesis and/or melaena, or anaemia
Give examples of antacid therapy
•Antacid medication – proton pump inhibitors (omeprazole)or H2 receptor antagonists (ranitidine)
How are peptic ulcers treated?
Antacids
NSAIDS are to be stopped or should continue to recieve other protective agents following eradication therapy
•Surgery is only indicated in complicated PUD (Peptic ulcer disease (PUD), is a break in the lining of the stomach, first part of the small intestine, or occasionally the lower esophagus)
What is the eradication therapy of H pylori?
Triple therapy for 7 days
- Clarithromycin 500mg bd
- Amoxycillin 1g bd (or Metronidazole 400mg bd)
- Tetracycline is given if penicillin allergy
- PPI: e.g. omeprazole 20mg bd
What are the complications of a peptic ulcer?
- Acute bleeding – melaena and haematemesis
- Chronic bleeding – iron deficiency anaemia
- Perforation
- Fibrotic stricture (narrowing)
- Gastric outlet obstruction – oedema or stricture
What are the signs and symptoms of gastric outlet obstruction?
Vomiting – lacks bile, fermented foodstuffs (since food gets stored in the stomach for a long time)
Early satiety, abdominal distension, weight loss, gastric splash
Dehydration and loss of H+ and Cl- in vomit
Metabolic alkalosis
Bloods – low Cl, low Na, low K, renal impairment
What is the diagnosis of gastric outlet obstruction?
UGIE (upper GI endoscopy)
How is gastric outlet obstruction treated?
Endoscopic balloon dilatation
What is the second most common malignancy worldwide?
Gastric cancer
Majority are adenocarcinoma (epithelial cells, other types include MALT and GIST) (gastro intestinal stromal tumour)
How do patients with gastric cancer present?
Dyspepsia, early satiety, nausea & vomiting, weight loss, GI bleeding, iron deficiency anaemia, gastric outlet obstruction
What are the aetiologies of gastric cancer?
Smoking
HIgh salt diet
Foods high in nitrates
HP infection
How is a histological diagnosis of gastric cancer achieved?
Endoscopies and biopsies
How do you perform staging investigations?
•CT chest/abdo – lymph nodes and liver/lungs/peritoneum/bone marrow
What multidiscpiplinary team members are involved in the treatment of gastric cancer?
gastroenterologist, pathologist, radiologist, upper GI surgeons, oncologists, specialist nurses
What is the treatment of gastric cancer?
Surgical and chemotherapy
