Stomach Disorders Flashcards
What symptoms comprise dyspepsia?
- Epigastric pain or burning
- Postprandial fullness
- Early satiety
What factors make dyspepsia more common?
Helicobacter pylori infection or NSAID use
What diseases overlap with dyspepsia?
IBS and GORD
What are organic causes of dyspepsia?
Peptic ulcer disease, drugs (NSAIDs), gastric cancer
What is functional (idiopathic) dyspepsia?
The same as normal but with no evidence of structural disease
What will uncomplicated dyspepsia show on examination?
Epigastric tenderness
What will complicated dyspepsia show on examination?
Epigastric tenderness, cachexia, mass, evidence of gastric outflow obstruction, peritonism
What are the 3 steps of dyspepsia treatment?
- Check H. pylori status
- Eradicate if infected
- If negative, treat with acid inhibition
As well as dyspepsia, what can a presenting complaint of ‘indigestion’ be?
Heartburn, or problems with other organs
What are alarm features when dealing with dyspepsia?
Dysphagia, GI blood loss, persistent vomiting, weight loss, upper abdominal mass
What should be done if alarm symptoms of dyspepsia are present in a patient?
Refer to a hospital specialist
What are the first line treatments for uncomplicated dyspepsia?
Lifestyle, antacids, histamine 2 receptor antagonists
If clearing H. pylori doesn’t clear symptoms, or there is no infection in the first place, how would you manage symptoms if the patient is aged <55?
Manage as functional dyspepsia
If clearing H. pylori doesn’t clear symptoms, or there is no infection in the first place, how would you manage symptoms if the patient is aged >55?
Consider referral to hospital specialist
What can inflammatory diseases of the stomach be known as?
Gastritis
What can cause acute gastritis?
Chemicals, burns, shock, severe trauma or head injury
What are common causes of gastritis?
ABC- autoimmune, bacterial, chemical
What are rarer causes or gastritis?
Lymphocytic, eosinophilic, granulomatous
How does the stomach look endoscopically in gastritis?
Red and inflamed
What causes autoimmune gastritis?
Anti-parietal and anti-intrinsic factor antibodies
What does autoimmune gastritis cause in the body of the stomach?
Atrophy and intestinal metaplasia
Which type of chronic gastritis cause pernicious anaemia?
Autoimmune
What does autoimmune gastritis increase risk of?
Malignancy
What is the most common type of chronic gastritis?
Bacterial (H. pylori)
Where does bacteria sit in bacterial gastritis?
On the epithelia of stomach cells which attracts neutrophils
Which interleukin is important in bacterial gastritis?
IL8
What does bacterial gastritis increase risk of?
Duodenal ulcer, gastric ulcer, gastric carcinoma/lymphoma
How is bacterial gastritis treated?
Antibiotics
What causes chemical gastritis and what does this result in?
NSAIDs, alcohol or bile reflux- causes direct injury to the mucus layer by fat solvents
What can chemical gastritis produce?
Erosions or ulcers
What will be shown on stomach microscopy in chemical gastritis?
Villiform epithelium (never normal in stomach)
What is gastroparesis?
Delayed gastric emptying- build up of food causes vomiting
What are symptoms of gastroparesis?
Fullness, nausea, vomiting, weight loss, upper abdominal pain
What can cause gastroparesis?
Idiopathic, diabetes mellitus, cannabis, opiates/anticholinerginics, systemic diseases
What is the best test for gastroparesis?
Gastric emptying tests
What are management options for gastroparesis?
Remove precipitating factor, liquid/sloppy diet, eat little and often, promotility agents, gastric pacemaker
What is a temporary measure for gastroparesis?
Paralyse LOS with botox
What is peptic ulceration?
A breach in GI mucosa as a result of acid and pepsin attack
Where do peptic ulcers occur?
Stomach, first part of duodenum and end of oesophagus
What does excess acid in the duodenum cause?
Gastric metaplasia, H. pylori, inflammation, epithelial damage, ulceration
How does the stomach look (grossly) in peptic ulceration?
Punched out
Microscopically in peptic ulceration, the stomach has a layered appearance. What makes up the floor, base and deep layer?
Floor- necrotic debris
Base- inflamed granulation tissue
Deep layer- fibrotic scar tissue
What are complications of peptic ulcers?
Perforation, penetration, haemorrhage, stenosis, intractable pain, anaemia
Where can peptic ulcer pain radiate?
Back
With regards to timing, what can peptic ulcer pain be?
Nocturnal
What can eating cause in peptic ulcer disease?
Aggravation or relieved pain
What are causes of peptic ulcer disease?
H. pylori, NSAIDs, gastric dysmotility, outflow obstruction
When are H. pylori infections acquired?
Infancy
Describe H. pylori bacteria?
Gram - microaerophilic flagellated bacillus
What is CagA?
Cytotoxin associated gene A- oncogenic and highly antigenic
What tests can be used to detect H. pylori infection?
Gastric biopsy, urease test, histology, culture, urease breath test, faecal antigen test, serology
What does H. pylori do to the pH of its environment?
Increases it
What are the first two steps of management for peptic ulcer disease?
Anti-secretory therapies (PPIs), test for H. pylori
What is the next step of treatment in PUD when a patient has H/ pylori?
Eradicate and confirm
What is the next step of treatment in PUD when a patient is negative for H/ pylori?
PPIs, withdraw NSAIDs, lifestyle, improve nutrition, optimise co-morbidities
What is the 1st line ‘triple therapy’ for H. pylori eradication?
PPI + amoxicillin 1g bd + clarithromycin 500mg bd for 1 week
What is the 2nd line ‘triple therapy’ for H. pylori eradication?
PPI + metronidazole 400mg bd + clarithromycin 250mg bd for 1 week
What is the advantage and disadvantage of 2 week therapy for H. pylori eradication?
Higher eradication but lower compliance
What can be added to give quadruple therapy for H. pylori eradication?
Culture directed therapy
What are common side effects of antibiotics for H. pylori eradication?
Nausea and diarrhoea
Do uncomplicated duodenal ulcers require follow ups?
Not unless there are ongoing symptoms
What do gastric ulcers require as follow up?
Endoscopy at 6-8 weeks to ensure healing and no malignancy
What are examples of benign gastric tumours?
Hyperplastic polyps, cystic fundic gland polyps
What are malignant gastric tumours?
Carcinomas (majority adenocarcinoma), non-Hodgkin’s lymphoma, gastro-intestinal stromal tumours
What is the progression to gastric carcinoma?
H. pylori infection, chronic gastritis, intestinal metaplasia/atrophy, dysplasia, carcinoma
What are other gastric premalignant conditions?
Pernicious anaemia, partial gastrectomy, Lynch syndrome, Menetrier’s disease
What is Lynch syndrome?
Autosomal dominant condition which increases risk of cancers, specifically colorectal
What is Menetrier’s disease?
Massive overgrowth of mucus cells in the mucus membrane of the stomach resulting in large gastric folds
What do adenocarcinomas produce histopathologically?
Glands
Where do gastric adenocarcinomas tend to metastasise?
Other organs, peritoneal cavity, ovaries, lymph nodes, liver
What is the clinical presentation of gastric cancers?
Dyspepsia, upper GI haemorrhage, anaemia, weight loss, abdominal mass, anorexia/early satiety, vomiting
What are palliative treatment options for gastric cancer?
Chemo or radiotherapy
What are potentially curative treatment options for gastric cancer?
Surgery with or without NAC
What factors shorten 5 year survival of gastric cancer?
Metastatic disease, short history advanced age, locally advanced lesion, superficial gross appearance
What investigations would you do for gastric cancer?
Urgent upper GI endoscopy, colonoscopy
What is acholridria and what does it cause?
Absence of HCl in gastric secretions- increases risk of gastric cancer
What can cause acholridria?
Pernicious anaemia or previous gastric surgery
What can H. pylori infection produce which reduces gastric acid?
IL-1beta
