Therapeutics- Upper GI Tract Flashcards
What are the causes of gastric ulcers
H. pylori (60%), NSAIDs (30%), carcinoma (5%), others (5%)- neoplasia, Crohn’s, stress, ZE syndrome. 75mg of aspirin daily increases the risk of developing gastric ulcers. If gastric ulcer’s don’t heal it means that they are cancerous.
What are the causes of duodenal ulcers
H. pylori (85%), NSAIDs (10-14%), rare causes (1%)- Zollinger Ellison, Crohn’s, stress
What are the causes of gastrooesophageal reflux disease
GORD: Food and drink, obesity, pregnancy, alcohol, smoking and NSAIDs are all risk factors which make people more prone to reflux
What does functional dyspepsia present with
Bloating/ belching, feeling very full after eating small amount of food, delayed gastric emptying etc. H. pylori however the NNT (number needed to treat for one patient to benefit) = 14
What are the treatment options for functional dyspepsia
PPI, prokinetic (e.g. domperidone) Prokinetic agents, or prokinetics, are medications that help control acid reflux. Prokinetics help strengthen the lower esophageal sphincter (LES) and cause the contents of the stomach to empty faster. This allows less time for acid reflux to occur, tricyclic (e.g. amitriptyline) for pain management and relaxation techniques via cognitive therapy or hypnotic techniques. Relaxation techniques are very important
What is the biggest upper GI risk symptom
Dysphagia and anaemia, yet only 1/30 result in something bad
Clinical features of dyspepsia
Peptic ulcers, reflux, cancer etc. Peptic ulcers result in epigastric pain. Acid reflux starts at the bottom of the sternum and goes to the back of the throat and is worse after meals, spicy food or when lying on your back
Clinical features of GORD
GORD is worse after a meal, after eating certain foods, whilst lying flat and during pregnancy- hormonal changes result in relaxation of the lower oesophageal sphincter.
Gastric ulcers- patient was taking ibuprofen.
What must you do if patients have any ‘red flag’ symptoms
Send them for an endoscopy
What are red flag symptoms
Hematemesis- vomiting blood; Malena- blood in stools; GI bleeding; Unintentional weight loss; Dysphagia; Persistent vomiting; Epigastric mass; >55 and persistent/ recent onset dyspepsia; Iron deficiency anaemia; Anaemia with indigestion
What features are typical of dysphagia
The lower end of the oesophagus which is irregular, raised and has a mass lesion
What does it mean if there is old food in the oesophagus
Food is not emptying properly
What are the features of oesophagitis
Streaks of inflammation due to acid in the oesophagus
What happens in Barret’s oesophagus
The gastro-oesophageal junction is in the wrong place which means that gastric mucosa is too high in the oesophagus. The two types of epithelium which occur at the junction should be near the mucosal folds. A person with Barret’s oesophagus has a higher risk of developing malignancies
What is a possible complication of a stomach ulcer
Arterial bleed in the stomach. The bleed occurs as the end of the blood vessel has been cut due to the stomach ulcer (perforation). If an arterial bleed in the stomach occurs then adrenaline is injected which results in vasoconstriction. Adrenaline wears off after 1-2 hours, therefore metal clips are used to permanently constrict the blood vessel.
What do upper gut symptoms require
A lifestyle treatment plan
What are therapeutics used
Not just drugs but includes lifestyle, reassurance and possibly surgery
What is the most common cause of GORD
A hiatus hernia
Why does a hiatus hernia result in reflux
Not usual to excrete excess acid, instead it is just acid moving into the oesophagus
What are antacids
Weak bases that react with gastric acid decreasing pepsin activity (inactive pH>4) resulting in having a soothing effect
Describe H2 receptor antagonists (H2RA’s)
H2 receptor antagonists act as inhibitors of gastric acid secretion. H2 receptor antagonists bind to Gs which prevent them from binding to histamine. They inhibit histamine-, gastrin- and acetylcholine-stimulated acid secretion, pepsin secretion also falls with the reduction in volume of gastric juice. These agents decrease both basal and food-stimulated acid secretions by 90%, also numerous clinical trials indicate that they also promote healing of duodenal uclers
What are examples of H2RA’s
Ranitidine/ cimetidine
Why do H2 receptor antagonists decrease the need for surgery and the likelihood of developing a stomach ulcer
They have a major effect
What are possible side effects of H2RA’s
Impotence, gynaecomastia (anti-androgen). Cimetidine is a cytochrome p450 inhibitor which also impairs metabolism of warfarin, phenytoin etc
What are examples of PPIs
Omeprazole/ lansoprazole
How does the proton pump inhibitor (PPI) omeprazole work
Irreversibly inhibits the H⁺/K⁺ ATPase (the proton pump), the terminal step in the acid secretory pathway. Both basal and stimulated gastric secretion is reduced. The drug is a weak base and accumulates in the acid environment of the canaliculi of the stimulated parietal cell where it is activated. The preferential accumulation means that it has a specific effect on these cells
Which are most effective out of PPIs, H2RA’s and antacids
PPIs
What are side effects of PPIs
Diarrhoea, nausea, dizziness, headaches, there is also a possible increased risk of osteoporosis if taken long term
What is stage I GORD
Occasional heartburn. Often with a known precipitant. Fewer than 2-3 episodes per week. No additional GI symptoms
How do you treat stage I GORD
Lifestyle modifications, non-prescription antacids H2RA as needes
What is stage II GORD
Frequent symptoms (greater than 2-3 times per week). Erosive or nonerosive GORD
How do you treat stage II GORD
H2RA therapy may be adequate. PPI therapy more effective
What is stage III GORD
Persistent symptoms. Immediate relapse off therapy. Oesophageal complications: stricture, Barrett’s. Oesophageal manifestations: chest pain, asthma, laryngitis
What is treatment for GORD stage III
PPI therapy once or twice daily
What are lifestyle modifications recommended in GORD
Not eat late at night and prop head up in bed
Which patients require lifestyle changes
All, regardless of strength of treatment
Describe anti-reflux surgery
Used to try and strengthen the lower end of the oesophagus
What are the different types of anti-reflux surgery
270 degree wrap, Nissen, Toupet, Anterior (Dor)
What is a possible issue of anti-reflux surgery
Not being able to belch which can be very uncomfortable
What is the prevelance of Helicobacter pylori in the UK
20%
How is Helicobacter pylori spread
By faeco-oral transmission
What does Helicobacter pylori do
It infects the mucosa of the stomach -> inflammatory response -> gastritis -> increased gastrin secretion -> gastric metaplasia -> damage to mucosa -> ulceration
Which background has higher levels of helicobacter pylori
Those from a deprives socio-economic backgroun
What are the possible tests for Helicobacter pylori
Urea breath test, stoll antigen, serology, endoscopy
Why is serology useless if a second infection of helicobacter pylori occurs
Antibodies remain positive for a whole lifetime
What is the treatment required for helicobacter pylori
3 drugs, 2x a day, 1 week
What is the efficacy of the treatment for helicobacter pylori
90%
What are the drugs used for treatment of helicobacter pylori
PPI and two antibiotics e.g. amoxicillin, clarithromycin, metronidazole
