Oesophagus and Stomach 5 and 6 - pathology of stomach and duodenum, GI bleeding Flashcards
What are the 3 main groups of inflammatory disorders of the stomach?
Acute gastritisChronic gastritisRare
What are the causes of acute gastritis?
Irritant chemical injurySevere brunsShockSevere traumaHead injury
What are the causes of chronic gastritis?
AutoimmuneBacterial (H pylori)Chemical
Rare causes of gastritis? (3)
LymphocyticEosinophilicGranulomatous
What antibodies are related to autoimmune chronic gastritis?
Anti-parietal and anti-intrinsic factor antibodies
What will be seen on biopsy of autoimmune chronic gastritis?
Atrophy and intestinal metaplasia in body of the stomach
What type of anaemia will patients with autoimmune chronic gastritis have?
Pernicious anaemia (due to B12 deficiency)
Do patients with autoimmune chronic gastritis have an increased risk of malignancy?
Yes
What conditions do patients with autoimmune gastritis also have?
Pernicious anaemia (B12 deficiency)Often neurological symptoms
What is the most common type of chronic gastritis?
H. pylori associated chronic gastritis
How does H. pylori cause chronic gastritis?
It inhabits a niche between the epithelial cell surface and mucous barrierIf not cleared then a chronic active inflammation ensuesIL-8 is critical to this
What produces the anti-H pylori antibodies?
Lamina propria plasma cells
What causes chemical chronic gastritis?
NSAIDsAlcoholBile reflux These cause direct injury to mucus layer
What would be seen on biology of chemical chronic gastritis?
Marked epithelial regeneration, hyperplasia, contestation and little inflammation(may produce congestion and little inflammation)
How does increased acid secretion lead to duodenal ulcers?
Excess acid in duodenum produces gastric metaplasia and leads to H. pylori infection, inflammation, epithelial damage and ulceration
Why are you more likely to get ulcers in the duodenum compared with the stomach?
The duodenum is built for absorption, not protection like the stomach
What 2 factors are important in the development of chronic peptic ulcers?
Increased acid productionFailure of mucosal defence
Edges of peptic ulcers?
Clear cut - punched out
Wha are the microscopic layers of a peptic ulcer?
Floor of necrotic fibrinopurulent debrisBase of inflamed granulation tissueDeepest layer is fibrotic scar tissue
What type of cancers occur in the stomach?
Carcinomas (adencarcinoma)LymphomasGastrointestinal stromal tumours
What are 4 other premalignant conditions of the stomach, other than H pylori?
pernicious anaemiaPartial gastrectomyHNPCC/ lynch syndromeMenetrier’s disease (large folds in stomach)
What are the 2 subtypes of gastric adenocarcinoma?
Intestinal type - exophytic/ polypoid mass (easier to treat)Diffuse type - expands/ infiltrates stomach wall15% are mixed
Are gastric ulcers potentially malignant?
Yes
What is a Kruckenberg tumour?
malignancy in the ovary that metastasized from a primary site, classically the gastrointestinal tract, although it can arise in other tissues such as the breast.[1] Gastric adenocarcinoma, especially at the pylorus, is the most common source
What type of gastric lymphoma do patients get?
Mucosa associated lymphoid tissue (MALT)
What is MALT gastric lymphoma associated with?
H pylori - continuous inflammation induces an evolution into a clonal B-cell proliferation
What happens if you treat H pylori in patients with MALT?
It regresses 95% of the time
What are the most common causes of upper GI bleeding?
Duodenal ucerGastric erosionsGastric ulcerVaricesMallory-weiss tearoesophagitiserosive duodenitisNeoplasmStomal ulcerOesophageal ulcer
What is the most important initial treatment of a patient with an upper GI bleed?
Resuscitation (A, B, C) - O2, IV access, fluidsPrompt endoscopy
What is the “100 rule” for poor prognosis with a haemorrhage?
Systolic BP less than 100mmHgPulse less than 100/minHb less than 100g/LAge greater than 60Comorbid diseasePostural drop in blood pressure(be cautious of young people, diabetics and patients on beta blockers)
What is another name for an OGD?
Endoscopy
What is the purpose of performing an endoscopy in a patient with an upper GI bleed? (3)
To identify causeTherapeutic manoeuvresAssess risk of rebleeding
What scoring system is used to assess the mortality of a patient with an upper GI bleed?
Rockall risk scoring sustem
What is a screening tool to assess the likelihood that a patient with an acute upper gastrointestinal bleeding (UGIB) will need to have medical intervention such as a blood transfusion or endoscopic intervention?
The Blatchford score
Management of GI bleed if blatchford score of 0-1 (low risk)?
If no clinical concerns, the patient can be discharged without an endoscopy
Management of GI bleed if blatchford score of 2-5 (indeterminate risk)?
Monitor HbIf witnessed significant bleeding or stigmata consider IV omeprazoleIf stigmata of cirrhosis/ known liver disease give telipressinReassess to determine need for endoscopy
Management of GI bleed if blatchford score is greater than 6?
Repeat Hb at regular intervalsGive transfusion if neededIV omeprazole if witnessed bleeding or stimgmataIf cirrhosis, give telipressinReverse any coagulopathyEndscopy
Treatment of bleeding peptic ulcer?
Endoscopic treatment (high risk ulcers)Acid suppression?SurgeryH pylori eradication
Possible endoscopic treatment of a bleeding peptic ulcer? (5)
injectionheater probe coagulationCombinationsClipsHaemospray
What can be injected into a bleeding ulcer to stop it bleeding?
Adrenaline
How does haemospray work?
When it comes in contact with blood, powder absorbs water then acts both cohesively and adhesively forming a mechanical barrier over the bleeding site
What does giving an infusion of omeprazole do when a patient has a bleeding ulcer?
Reduces chance of re-bleed and death
Treatment of peptic ulcer after endoscopy stops bleeding?
Omeprazole IVH pylori eradication
Treatment of bleeding peptic ulcer if not able to be stopped by endoscopy?
Surgery
Risk factors for varies bleeding?
Portal pressure greater than 1mmHgVaries greater than 25% of oesophageal lamePresence of red signsDegree of liver failure
When should you suspect that an upper GI bleed is caused by varices?
Known history of cirrhosis with variesHistory of chronic alcohol excess, chronic viral hepatitis, metabolic or autoimmune liver disease, intra-abdominal sepsis/ surgeryStigmata of chronic liver disease
Achievement of haemostasis in patients with varcies? (5)
Telipressin (vasopressin analogue)Endoscopic variceal ligation (banding)SclerotherapySengstaken-Blakemore balloonTIPS
How is vasopressin given?
Bolus 1-2mg 4 hrly
What is sclerotherapy?
an injection of a solution (generally a salt solution) directly into the vein. The solution irritates the lining of the blood vessel, causing it to swell and stick together, and the blood to clot.
What is the sengstaken-blakemore tube?
Tube with balloon that is used when endoscopic haemostasis failsLeft in patient for 24 hours and puts pressure on bleeding varices
What does TIPS involve?
Joining of portal vein and hepatic vein
