H. Pylori and Gastric Disease Flashcards
What is dyspepsia?
Describes a group of symptoms - pain or discomfort in the upper abdomen
Name the different types of symptoms that may be experienced in dyspepsia
- Upper abdominal discomfort
- Retrosternal pain
- Anorexia
- Nausea
- Vomiting
- Bloating
- Fullness
- Early satiety
- Heartburn
What are the two different types of dyspepsia?
Organic vs functional
Define organic dyspepsia
Definite pathology that can be identified, with structural abnormality being the cause
Define functional dyspepsia
Cells or structure completely normal but does not function properly
Give upper GI causes of dyspepsia
- Peptic ulcer
- Gastritis
- Non ulcer dyspepsia
- Gastric cancer
Give lower GI causes of dyspepsia
IBC, colonic cancer, coeliac disease
What are the alarms symptoms of dyspepsia which indicate you should refer to endoscopy?
- Anorexia
- Loss of weight
- Anaemia
- Recent onset > 55yrs or persistent despite treatment
- Melaena/haematemesis (GI bleeding) or mass
- Swallowing problems – dysphagia
What is melaena?
Production of dark faeces as a result of internal bleeding or swallowing of blood
What is haematemesis?
Blood in vomit
What investigations are used for dyspepsia?
Bloods:
FBC, ferritin (anaemia), LFTs, U&Es, calcium, glucose, coeliac serology/serum IgA
What do you ask in the history/examination of dyspepsia?
If patient has alarm symptoms
What do you look for in the drugs history of dyspepsia?
NSAIDs, steroids (cause inflammation), bisphosphonates, Ca antagonist, nitrates, theophyllines, remember OTT (over counter) – all these drugs can aggravate the upper GI tract
Describe the steps in the investigation of dyspepsia causes
- Alarm features?
Yes = UGIE - No = > 55yrs –> UGIE, <55yrs –> no UGIE, test for H. Pylori
What are the next steps if H. Pylori test is positive when investigating dyspepsia?
- Eradication therapy
* Symptomatic treatment with PPIs or H2R antagonists and lifestyle factors
What is a H2R antagonist?
Histamine H2 receptor blockers
What is a PPI?
Proton pump inhibitor
Describe H. Pylori
Gram negative, spiral shaped, microaerophilic, flagellated bacteria which infects 50% of the world population. It is usually acquired in childhood via faecal-oral route.
Describe the H. pylori infection
- Can only colonise in gastric type mucosa
- It resides in the surface mucous layer and does not penetrate the epithelial layer
- Evokes immune response in underlying mucosa – dependent on host genetic factors
How does H. Pylori protect itself against gastric acid?
Flagellum prevents it being stopped by the mucus layer as it helps it to burrow through. It burrows into the mucus layer to get away from the gastric acid and produces urease (enzyme) which creates a halo of alkalinity (modifies microenvironment for survival)
Name four different possible outcomes of H. Pylori Infections
- Asymptomatic or chronic gastritis
- Chronic atrophic gastritis
- Gastritis or duodenal ulcer
- Gastric cancer
What are the three divergent responses to H. pylori infection which leads to DU disease or gastric Ca?
- Antral predominant gastritis -> high acid, low risk of gastric Ca = DU disease
- Mild mixed gastritis -> normal acid = no significant disease
- Corpus predominant gastritis -> decrease acid, gastric atrophy = gastric Ca
Dependent of where the H. Pylori infection colonises in the gastric mucosa, what are the most likely outcomes?
If in antrum: more prone to ulcers in duodenum of first part of the small bowel
If in fundus: more prone to develop cancer
Describe the non-invasive approach of diagnosing H. pylori infection
- Serology: IgG against H. pylori
- C13/14 urea breath test
- Stool antigen test: ELISA (must stop PPI for 2 weeks)
Describe the invasive approach of diagnosing H. pylori infection
- Histology: gastric biopsies
- Culture of gastric biopsies
- Rapid slide urease test (CLO)
What is the CLO test for H. pylori?
The gel contains substrate which urease can break down. A biopsy is taken which is placed on the gel if the colour of the gel changes, this indicates the presence of H. pylori
What is the C13/14 urea breath test?
Carbon labelled urea is given through drink and then breathed out into a machine
Based on conversion of urea to ammonia and carbon dioxide
What is gastritis?
Inflammation of the gastric mucosa
What are the causes of gastritis?
- Autoimmune (parietal cells)
- Bacterial (H. pylori)
- Chemical (bile/NSAIDs)
What are causes of peptic ulcers?
- H. pylori
- NSAIDs (cause multiple stomach ulcers)
- Smoking
Rarely by:
Zollinger-Ellison syndrome, hyperparathyroidism, Crohn’s disease
Name the symptoms of peptic ulcers
- Epigastric pain
- Nocturnal/hunger pain
- Back pain (posterior DU)
- Nausea
- Weight loss and anorexia
- If the ulcer bleeds, can have haematemesis, melaena or anaemia
How do you treat peptic ulcers?
- Eradication therapy if caused by H. pylori
- PPI (omeprazole) or H2R antagonist (ranitidine)
- Stop NSAIDs
What is the eradication therapy for an H. pylori infection?
Triple therapy for 7 days: 2 antibiotics and a proton pump inhibitor (to reduce acid)
What medications are used in the eradication therapy of an H. pylori infection?
- Clarithromycin
- Amoxycillin (or metronidazole)
- Omeprazole (PPI)
Name some 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?
Symptoms:
• Vomiting - lacks bile
• Early satiety, abdominal distension, weight loss
• Dehydration
Signs:
• Bloods - low Cl, low Na, renal impairment
How do you diagnose gastric outlet obstruction?
UGIE and identify cause; structure, ulcer, cancer
What is the most common type of gastric cancer?
Adenocarcinoma (epithelial cells)
Other types: MALT, GIST
What is the presentation of gastric cancer?
- Dyspepsia
- Early satiety
- Nausea and vomiting
- Weight loss
- GI bleeding
- Iron deficiency anaemia
- Gastric outlet obstruction
What is the aetiology for gastric cancer
- Diet - high salt, high nitrates
- H. pylori infection
- Genetic susceptibility
- Smoking
What investigations are used to stage gastric cancer?
- CT chest/abdo - lymph nodes and liver/lungs/peritoneum/bone marrow
- MDT discussion - imaging/histological/patient fitness
What are the treatment options for gastric cancer?
Surgical and chemotherapy
