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Case 3 > Therapeutics- Upper GI Tract > Flashcards

Therapeutics- Upper GI Tract Flashcards

1
Q

What are the causes of gastric ulcers

A

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.

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2
Q

What are the causes of duodenal ulcers

A

H. pylori (85%), NSAIDs (10-14%), rare causes (1%)- Zollinger Ellison, Crohn’s, stress

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3
Q

What are the causes of gastrooesophageal reflux disease

A

GORD: Food and drink, obesity, pregnancy, alcohol, smoking and NSAIDs are all risk factors which make people more prone to reflux

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4
Q

What does functional dyspepsia present with

A

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

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5
Q

What are the treatment options for functional dyspepsia

A

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

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6
Q

What is the biggest upper GI risk symptom

A

Dysphagia and anaemia, yet only 1/30 result in something bad

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7
Q

Clinical features of dyspepsia

A

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

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8
Q

Clinical features of GORD

A

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.

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9
Q

What must you do if patients have any ‘red flag’ symptoms

A

Send them for an endoscopy

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10
Q

What are red flag symptoms

A

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

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11
Q

What features are typical of dysphagia

A

The lower end of the oesophagus which is irregular, raised and has a mass lesion

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12
Q

What does it mean if there is old food in the oesophagus

A

Food is not emptying properly

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13
Q

What are the features of oesophagitis

A

Streaks of inflammation due to acid in the oesophagus

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14
Q

What happens in Barret’s oesophagus

A

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

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15
Q

What is a possible complication of a stomach ulcer

A

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.

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16
Q

What do upper gut symptoms require

A

A lifestyle treatment plan

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17
Q

What are therapeutics used

A

Not just drugs but includes lifestyle, reassurance and possibly surgery

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18
Q

What is the most common cause of GORD

A

A hiatus hernia

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19
Q

Why does a hiatus hernia result in reflux

A

Not usual to excrete excess acid, instead it is just acid moving into the oesophagus

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20
Q

What are antacids

A

Weak bases that react with gastric acid decreasing pepsin activity (inactive pH>4) resulting in having a soothing effect

21
Q

Describe H2 receptor antagonists (H2RA’s)

A

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

22
Q

What are examples of H2RA’s

A

Ranitidine/ cimetidine

23
Q

Why do H2 receptor antagonists decrease the need for surgery and the likelihood of developing a stomach ulcer

A

They have a major effect

24
Q

What are possible side effects of H2RA’s

A

Impotence, gynaecomastia (anti-androgen). Cimetidine is a cytochrome p450 inhibitor which also impairs metabolism of warfarin, phenytoin etc

25
Q

What are examples of PPIs

A

Omeprazole/ lansoprazole

26
Q

How does the proton pump inhibitor (PPI) omeprazole work

A

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

27
Q

Which are most effective out of PPIs, H2RA’s and antacids

A

PPIs

28
Q

What are side effects of PPIs

A

Diarrhoea, nausea, dizziness, headaches, there is also a possible increased risk of osteoporosis if taken long term

29
Q

What is stage I GORD

A

Occasional heartburn. Often with a known precipitant. Fewer than 2-3 episodes per week. No additional GI symptoms

30
Q

How do you treat stage I GORD

A

Lifestyle modifications, non-prescription antacids H2RA as needes

31
Q

What is stage II GORD

A

Frequent symptoms (greater than 2-3 times per week). Erosive or nonerosive GORD

32
Q

How do you treat stage II GORD

A

H2RA therapy may be adequate. PPI therapy more effective

33
Q

What is stage III GORD

A

Persistent symptoms. Immediate relapse off therapy. Oesophageal complications: stricture, Barrett’s. Oesophageal manifestations: chest pain, asthma, laryngitis

34
Q

What is treatment for GORD stage III

A

PPI therapy once or twice daily

35
Q

What are lifestyle modifications recommended in GORD

A

Not eat late at night and prop head up in bed

36
Q

Which patients require lifestyle changes

A

All, regardless of strength of treatment

37
Q

Describe anti-reflux surgery

A

Used to try and strengthen the lower end of the oesophagus

38
Q

What are the different types of anti-reflux surgery

A

270 degree wrap, Nissen, Toupet, Anterior (Dor)

39
Q

What is a possible issue of anti-reflux surgery

A

Not being able to belch which can be very uncomfortable

40
Q

What is the prevelance of Helicobacter pylori in the UK

A

20%

41
Q

How is Helicobacter pylori spread

A

By faeco-oral transmission

42
Q

What does Helicobacter pylori do

A

It infects the mucosa of the stomach -> inflammatory response -> gastritis -> increased gastrin secretion -> gastric metaplasia -> damage to mucosa -> ulceration

43
Q

Which background has higher levels of helicobacter pylori

A

Those from a deprives socio-economic backgroun

44
Q

What are the possible tests for Helicobacter pylori

A

Urea breath test, stoll antigen, serology, endoscopy

45
Q

Why is serology useless if a second infection of helicobacter pylori occurs

A

Antibodies remain positive for a whole lifetime

46
Q

What is the treatment required for helicobacter pylori

A

3 drugs, 2x a day, 1 week

47
Q

What is the efficacy of the treatment for helicobacter pylori

A

90%

48
Q

What are the drugs used for treatment of helicobacter pylori

A

PPI and two antibiotics e.g. amoxicillin, clarithromycin, metronidazole

Case 3 (9 decks)

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