H pylori and Gastric Disease

Question 1

Define dyspepsia

Answer 1

Literally - bad digestion

Pain or discomfort in the upper abdomen

Also encompasses: •retrosternal pain, anorexia, nausea, vomiting, bloating, fullness, early satiety and heartburn

Question 2

What can cause the symptom of dyspepsia?

Answer 2

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

Question 3

When do you refer someone with dyspepsia for an endoscopy?

Answer 3

• 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

Question 4

What are the risks associated with endoscopy?

Answer 4

Bleeding, perforation and reaction to drugs given

Question 5

What are the key things to do if a patient presents with dyspepsia?

Answer 5

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,

Question 6

When would an UGIE be indicated when alarm features are absent?

Answer 6

If the patient is over 55 years of age?

Question 7

What is the follow up test for a patient after an UGI with dyspepsia?

Answer 7

Test for helicobacterpylori

Question 8

What is the eradication therapy for helicobacter pylori?

Answer 8

Symptomatic treatment with PPIs or H2R antagonists and lifestyle factors

Question 9

Describe helicobacter pylori

Answer 9

Gram negative, spiral shaped, microaerophilic, flagelated gram negative bacteria

Question 10

What is the prevalence of helicobacter pylori in the world?

Answer 10

50% world population

Question 11

What type of mucosa can helico bacter pylori colonise?

Answer 11

Gastric type mucosa

Resides in the surface of the mucus layer and does not penetrate the epithelial layer

Question 12

What are the outcomes of helicobacter pylori?

Answer 12

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)

Question 13

Which part of the stomach is likely to cause DU disease when afflicted by helicobacter pylori?

Answer 13

Antrum

Infection results in predominant gastritis: increase in acid produciton

Low risk of gastric cancer

Question 14

Which part of the stomach is likely to cause gastric cancer when afflicted by helicobacter pylori infection?

Answer 14

Corpus predominant gastritis

There is an increase in gastric atrophy

Question 15

What are the non-invasive methods of H pylori infection?

Answer 15

Question 16

What are the invasive methods of H pylori infection?

Answer 16

(Requiring endoscopy)

Histology: Gastric biopsies stained for the bacteria

Culture of gastric biopsies

Rapid slide urease test

Question 17

What chemical is used to determine the presence of H pylori in the rapid slide urease tests?

Answer 17

Ammonia (produced by the H pylori urease)

Question 18

What is meant by gastritis?

Answer 18

Inflammation in the gastric mucosa

Histological diagnosis

Clinical features seen at endoscopy

Question 19

What are the causes of gastritis?

Answer 19

Autoimmune (parietal cells)

Bacterial (H. Pylori)

Chemical (bile/NSAIDs)

Question 20

What causes the majority of peptic ulcers?

Answer 20

Helicobacter pylori infection

Question 21

What are other causes of peptic ulcers?

Answer 21

NSAIDS

Smoking

•Rarely they are caused by other conditions such as Zollinger-Ellison syndrome, hyperparathyroidism, Crohn’s disease

Question 22

Useful notes on peptic ulcers

Answer 22

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

Question 24

What symptoms are associate with peptic ulcer?

Answer 24

• 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

Question 25

Give examples of antacid therapy

Answer 25

•Antacid medication – proton pump inhibitors (omeprazole)or H2 receptor antagonists (ranitidine)

Question 26

How are peptic ulcers treated?

Answer 26

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)

Question 27

What is the eradication therapy of H pylori?

Answer 27

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

Question 28

What are the complications of a peptic ulcer?

Answer 28

• Acute bleeding – melaena and haematemesis
• Chronic bleeding – iron deficiency anaemia
• Perforation
• Fibrotic stricture (narrowing)
• Gastric outlet obstruction – oedema or stricture

Question 29

What are the signs and symptoms of gastric outlet obstruction?

Answer 29

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

Question 30

What is the diagnosis of gastric outlet obstruction?

Answer 30

UGIE (upper GI endoscopy)

Question 31

How is gastric outlet obstruction treated?

Answer 31

Endoscopic balloon dilatation

Question 32

What is the second most common malignancy worldwide?

Answer 32

Gastric cancer

Majority are adenocarcinoma (epithelial cells, other types include MALT and GIST) (gastro intestinal stromal tumour)

Question 33

How do patients with gastric cancer present?

Answer 33

Dyspepsia, early satiety, nausea & vomiting, weight loss, GI bleeding, iron deficiency anaemia, gastric outlet obstruction

Question 34

What are the aetiologies of gastric cancer?

Answer 34

Smoking

HIgh salt diet

Foods high in nitrates

HP infection

Question 35

How is a histological diagnosis of gastric cancer achieved?

Answer 35

Endoscopies and biopsies

Question 36

How do you perform staging investigations?

Answer 36

•CT chest/abdo – lymph nodes and liver/lungs/peritoneum/bone marrow

Question 37

What multidiscpiplinary team members are involved in the treatment of gastric cancer?

Answer 37

gastroenterologist, pathologist, radiologist, upper GI surgeons, oncologists, specialist nurses

Question 38

What is the treatment of gastric cancer?

Answer 38

Surgical and chemotherapy