H Pylori and Gastric Disease

Question 1

what contents are in the upper GI tract

Answer 1

oesophagus

stomach

Question 2

what contents are in the lower GI tract?

Answer 2

small intestin and large

Question 3

functions of stomach

Answer 3

Food storage, initial digestive processes, acidic environment –defence , secretion – gastric acid, gut hormones, intrinsic factor, pepsin

Question 4

what is dyspepsia?

Answer 4

Pain or discomfort in the upper abdomen
upper abdominal discomfort, retrosternal pain, anorexia, nausea, vomiting, bloating, fullness, early satiety and heartburn

Question 5

what can cause the symptom of dyspepsia in the upper GI?

Answer 5

GORD
Peptic ulcer
Gastritis
Non ulcer dyspepsia
Gastric cance

Question 6

what can cause symptoms in the lower GI?

Answer 6

IBS

Colonic cancer

Question 7

what can cause symptoms of dyspepsia

Answer 7

drugs
psychological
coeliac disease

Question 8

what do you do if a patient has dyspepsia?

Answer 8

Bloods – FBC, ferritin, LFTs, U&Es, calcium, glucose, coeliac serology/serum IgA

Drug history – NSAIDs, steroids, bisphosphonates, Ca antagonists, nitrates, theophyllines, remember OTT

Lifestyle – alcohol, diet, smoking, exercise, weight reduction

Question 9

when to refer to endoscopy

Answer 9

Anorexia
Loss of weight
Anaemia – iron deficiency
Recent onset >55 years or persistent despite treatment
Melaena/haematemesis (GI bleeding) or mass
Swallowing problems - dysphagia

Question 10

what is an upper GI endoscopy?

Answer 10

Diagnostic and therapeutic upper GI endoscopy

Local anaesthetic (throat spray) or sedation

Question 11

what is helicobacter pylori?

Answer 11

Gram negative, spiral-shaped, microaerophilic, flagellated Gram –ve bacteria

Question 12

where does the H.pylori infect?

Answer 12

It resides in the surface mucous layer and does not penetrate the epithelial layer

Question 13

what is the outcome of H.pylori dependent on?

Answer 13

Outcome dependent on site of colonization, characteristics of bacteria and host factors e.g. genetic susceptibility & other environmental factors e.g. smoking

Question 14

diagnosing H.pylori

Answer 14

Non-invasive
Serology: IgG against H. pylori
13C /14C Urea Breath Test
Stool antigen test – ELISA - need to be off PPI for 2 weeks

Invasive: requires endoscopy
Histology: gastric biopsies stained for the bacteria
Culture of gastric biopsies
Rapid slide urease test (CLO)

Question 15

what is gastritis?

Answer 15

Inflammation in the gastric mucosa
Histological diagnosis
Clinical features seen at endoscopy

Question 16

causes of gastritis

Answer 16

Autoimmune (parietal cells)
Bacterial (H. pylori)
Chemical (bile/NSAIDs)

Question 17

what is the more common ulcer

duodenal or gastric

Answer 17

duodenal

Question 18

what are the majority of peptic ulcers caused by?

Answer 18

H.pylori

Question 19

what symptoms are associated with peptic ulcers?

Answer 19

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 20

how do you treat a peptic ulcer?

Answer 20

Ulcers caused by H. pylori are treated by eradication therapy to get rid of the bacteria

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

If NSAIDs are also involved, these have to be stopped if possible, or should continue to receive other protective agents following eradication therapy

Complications are treated as they arise

Surgery is only indicated in complicated PUD

Question 21

how do you eradicate H.pylori?

Answer 21

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 (2 times a day)

Question 22

what are the complications of a peptic ulcer?

Answer 22

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

Question 23

what does gastric outlet obstruction cause?

Answer 23

Vomiting – lacks bile, fermented foodstuffs

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 24

how do you diagnose gastric outlet obstruction

Answer 24

UGIE (prolonged fast/aspiration of gastric contents), identify cause – stricture, ulcer, cancer

Question 25

treatment of gastric outlet obstruction?

Answer 25

endoscopic balloon dilatation, surgery

Question 26

what is the second commonset malignancy worldwide?

Answer 26

gastric cancer

Question 27

presentation of gastric cancer

Answer 27

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

Question 28

aetiology of gastric cancer

Answer 28

smoking
genetic
smoking
ulcers
H.pylori
diet

Question 29

management of a patient with gastric cancer

Answer 29

Endoscopy and biopsies to make a histological diagnosis

Staging investigations – has it spread elsewhere?
CT chest/abdo – lymph nodes and liver/lungs/peritoneum/bone marrow

MDT discussion – imaging/histology/patient fitness

MDT discussion – imaging/histology/patient fitness
Who is present? gastroenterologist, pathologist, radiologist, upper GI surgeons, oncologists, specialist nurses

Treatment – surgical and chemotherapy