Helicobacter pylori and Gastric Disease Flashcards
Dyspepsia can describe a range of symptoms. List examples
Pain/discomfort in abdomen Nausea and vomiting Bloating Retrosternal pain Anorexia Fullness, early satiety Heartburn
What is the two broad classification of causes of dyspepsia?
Organic
Functional
Groups of causes of dyspepsia
Upper GI - peptic ulcer, gastritis, non-ulcer dyspepsia, gastric cancer Hepatic causes Gallstones Pancreatic disease Lower GI - IBS, colonic cancer Coeliac Psychological Drugs Systemic disease
Symptoms that indicate a referral when patient presents with dyspepsia
ALARMS Anorexia Loss of weight (unintentional) Anaemia Recent onset and over age 55 Melaena, haematemesis Mass Swallowing - dysphagia
What investigations are used to diagnose gastric disease?
History
Examination
Upper GI Endoscopy
Bloods - FBC, ferritin, LFTs, U&Es, calcium, glucose, coeliac serology/IgA
What drugs and medications are useful in GI history?
NSAIDs Steroids Bisphosphonates Ca antagonists Nitrates Theophyllines
Which lifestyle factors need to be addressed in GI history?
Alcohol Smoking Diet Exercise Weight reduction
When presenting with dyspepsia, which factors indicate testing for H.pylori?
No ALARM symptoms
Under 55 years old
What type of bacterium is h pylori?
Gram negative, spiral, microaerophillic, flagellated
What tissue does h pylori colonise?
Gastric muscosa - burrows into mucus layer, does not penetrate epithelial layer
What substance is produced by h pylori?
Urease
4 clinical outcomes of h.pylori infection
Asymptomatic or chronic gastritis
Chronic atrophic gastritis - intestinal metaplasia
Gastric or duodenal ulcer
Gastric cancer - MALT lymphoma
Infection resulting in increased acid production will result in which type of disease?
Duodenal disease
Infection of h pylori resulting in decreased gastric acid production will result in which type of disease?
Gastric cancer - gastric atrophy
Non-invasive diagnostic investigations for h.pylori infection
Serology - IgG
13d/14c Urea Breath test
Stool Antigen test - ELISA
Invasive diagnostic investigation for h.pylori infection?
ENDOSCOPY
Biopsies
Culture
Rapid slide urease test (changes yellow to pink)
What indicates a positive result in a rapid slide urease test?
Change from yellow to pink
How is gastritis diagnosed?
Histological diagnosis
What are 3 causes of gastritis?
Autoimmune
Bacterial
Chemical
Causes of peptic ulcers
H.pylori NSAIDs Smoking Zollinger-Ellison Hyperparathyroidism Crohns
How does hyperparathyroidism lead to peptic ulcer disease?
Increased Ca
Increased Ach
Increased Gastrin
Increased gastric acid secretion –> Peptic ulcer
What is Zollinger-Ellison?
Gastrin producing neuroendocrine tumour
How does Zollinger Ellison syndrome occur?
Sporadic
MEN 1 Associated
Symptoms of zollinger ellsion
Abdominal pain Diarrhoea GO reflux weight loss bleeding nausea vomiting
Diagnostic investigations for zollinger ellison
Serum gastrin
Endoscopy
EUS
MRI liver
Treatment for zollinger-ellison syndrome
PPIs
Associated symptoms with peptic ulcer disease
Epigastric pain which is relieved by antacids Nocturnal/hunger pain Back pain Nausea, occasionally vomiting Weight loss, anorexia Epigastric tenderness Haematemesis, melaena, anaemia
Treatment of peptic ulcer disease
Eradicate h/pylori infection
Antacid medication (PPIs; omeprazole, H2 Receptor antagonists - ranitidine)
Stop NSAID uses
Surgery if complicated
What is eradication therapy for h.pylori?
Triple therapy
Clarithromycin
Amoxicillin (Metronidazoles)
PPI
Complications of peptic ulcer disease
Acute bleeding Chronic bleeding Perforation Fibrotic stricture Pyloric stenosis Gastric outlet obstruction
Signs of Gastric outlet obstruction
Vomiting Early satiety Abdominal distension Weight loss Gastric splash Dehydration Metabolic alkalosis Bloods - low Cl, low Na, low K, renal impairment
Diagnostic investigations of Gastric outlet obstruction
UGIE
Treatment of gastric outlet obstruction
Endoscopic balloon dilatation
Surgery
5 year survival rate of gastric cancer
Less than 20%
Most common type of gastric cancer
Adenocarcinoma
GI stromal tumor
Mucosa associated lymphoid tumour
Signs of gastric cancer
Dyspepsia Early satiety Nausea & vomiting Weight loss GI bleeding Iron deficiency anaemia Gastric outlet obstruction
What is the Correa hypothesis?
Most sporadic cancers are of intestinal type
What perrcentage of gastric cancers are heritable?
1-3 %
Hereditary Diffuse Gastric Cancer
Mode of inheritance of Hereditary Diffuse Gastric Cancer
Autosomal dominant CDH1 gene (E-cadherin)
Management of gastric cancer
Endoscopy and biopsy - Histological diagnosis
Staging investigation - CT chest/abdo
MDT
Treatment - surgery and chemotherapy
What is a peptic ulcer?
A break in the lining of the GI tract to the muscularis mucosa
Most common location of peptic ulcers
lesser curvature of the proximal stomach or the first part of the duodenum.
Which type of ulcers present earlier?
Duodenal - around 20 years
How do NSAIDs cause peptic ulcer formation?
Inhibit prostaglandin synthesis - reduces glycoprotein, mucous and phospholipid secretion
Lining loses protection from acid
What are curling’s ulcer and cushing’s ulcer?
Physiological stress- risk factor for peptic ulcer disease
Curling’s - from burns
Cushing’s from head trauma
What is the NICE criteria for urgent referral for upper GI Endoscopy (OesophagoGastroDuodenoscopy) ?
New onset
Over 55 with weight loss and upper abdominal pain, reflux or dyspepsia
New onset dyspepsia not responding to PPI
Classic differentiation between gastric and duodenal ulcers
any pain from a gastric ulcer is exacerbated by eating, whilst duodenal ulcers are worse 2-4 hours after eating or even alleviated by eating
Differential diagnoses for peptic ulcer disease
ACS GORD Gallstone Gastric malignancy Pancreatitis
Risk factors for gastric cancer
Male H pylori Smoking Increasing Age Alcohol consumption
Salt in diet
Family history
Pernicious anaemia
What is trosier sign?
Palpable left supraclavicular node - Virchow’s
Indicates metastatic abdominal malignancy
Other signs of metastatic disease
Ascites
Hepatomegaly
Jaundice
Acanthosis nigricans
What should biopsies be sent for testing in suspected gastric cancer?
Histology – for classification and grading of any neoplasia present
CLO test – for the presence of H. Pylori
HER2/neu protein expression – this will allow for targeted monoclonal therapies if present
What imaging is needed for TNM staging of gastric cancer?
Diagnosis on biopsy from OGD
CT Chest Abdo Pelvis
Laparoscopy
What assessment and support is essential in definitive management of gastric cancer?
Nutritional status - support with feeding
Dietician will assess
Curative treatment for gastric cancer
Surgery and perioperative treatment - 3 cycles neoadjuvant and 3 cycles adjuvant
Surgical options for gastric cancer
Proximal - Total gastrectomy
Distal - subtotal gastrectomy (antrum or pylorus)
Most common reconstruction method in alimentary pathology
Roux en Y
Which surgical option may be offered to patients with T1a gastric cancer?
Endoscopic Mucosal Resection
Complications of gastrectomy
Death Anastomotic leak Re-operation Dumping syndrome Vitamin B12 deficiency
Palliative management of gastric cancer
Chemotherapy
Best Supportive
Stenting
Complications of gastric cancer
Perforation
Iron deficiency anemia
Malnutrition
Gastric Outlet Obstruction
Types of gastrectomy
Subtotal
Total with Roux en Y reconstruction
Open gastrectomy
Laparscopic distal gastrectomy
