Upper Gastrointestinal Disorders Flashcards
What is indigestion also known as?
Dyspepsia
What is indigestion?
Discomfort arising from the upper gastro-intestinal tract
What is indigestion caused by?
Overeating Caffeine Alcohol Fatty, spicy and greasy foods Chocolate Carbonated beverages
What are the symptoms of indigestion?
Heartburn Bloating Anorexia Fullness Feeling sick (nausea)
Gastrointestinal disorders associated with dyspepsia
Non-ulcer dyspepsia or functional
Gastro-oesophageal reflux disease (GORD)
Peptic ulcer dyspepsia (PUD)
Cancer
What is un-investigated dyspepsia?
No further investigation by endoscopy for patients presenting with dyspepsia
What is investigated dyspepsia?
Further investigation needed for patients presenting with dyspepsia
What is non-ulcer dyspepsia (functional dyspepsia)?
A common problem wherein patients suffer from indigestion and other symptoms suggestive of an ulcer, but no abnormality is found on investigation.
What is gastro-oesophageal reflux disease (GORD)?
A common condition in primary care. The abnormal reflux of gastric contents into the oesophagus causing irritation and severe oesophagus damage.
What is peptic ulcer dyspepsia (PUD)?
A sore in the lining of the stomach or first part of the small intestine called the duodenum.
Referral criteria for dyspepsia
- Immediate referral (same day) – patients with dyspepsia and acute significant gastrointestinal bleeding regardless of age
- Urgent referral (within two weeks) – patients with dyspepsia plus ‘ALARM’ symptoms & 55+ year old with unexplained and persistent recent-onset of dyspepsia
What does ‘ALARM’ mean?
A= Anaemia L= Loss of weight (unintentional) A= Anorexia R= Recent onset of progressive symptoms M= Melaena (blood in stool) or upper GI bleeding
Dysphagia (difficulty in swallowing
Persistent vomiting
What age group does GORD affect?
Can affect all ages
How common is GORD?
Most common disorder of oesophagus
What gender does GORD affect?
Men and women equally affected
Is GORD chronic or acute?
Chronic. (persisting for a long time or constantly recurring) & relapsing (returning)
3 types of GORD?
- Erosive oesophagitis
- Non-erosive oesophagitis (ENRD)
- Barrett’s oesophagus
What is erosive oesophagitis?
Evidence of mucosal damage
What is non-erosive oesophagitis (ENRD)?
No evidence of damage / present in more than 50% of patients / symptoms are very difficult to treat
What is barrett’s oesophagus?
Complication of GORD. Some of the cells in the oesophagus grow abnormally.
Causes of GORD
Lower oesophageal sphincter (LOS) – LOS relaxation and reduce sphincter pressure
Failure of the diaphragm pinching effect
Impaired oesophageal clearance
Impaired oesophageal mucosal resistance
Delayed gastric emptying
Hiatus hernia
2 Types of risk factors of GORD:
- Dietary factors
2. Drug factors
Dietary risk factors of GORD
- Fatty foods, chocolate, nuts, onions, spices, caffeine, citrus fruit, and tomato products
- Eating within 2 hours of bedtime
- Overeating
- Obesity BMI >30kg/m2
- Poor posture
- Advancing age
- Smoking
- NSAIDS – ibuprofen
- Bending forward
- Wearing tight clothes
- Pregnancy
Drug risk factors of GORD
- Anti-cholinergic drugs
- Nitrates
- Calcium channel blockers
- Alcohol
- Theophylline
- Progesterone
- Bisphosphonates
Mode of action of anti-cholinergic drugs
Block the action of acetylcholine by inhibiting the parasympathetic nervous system so that it cannot bind to receptors that initiate the parasympathetic response (type of neurotransmitter).
Mode of action of nitrates
Relaxing and dilate your arteries and veins so blood can flow more easier to your heart and elsewhere in the body.
Mode of action of calcium channel blockers
Lowering blood pressure. Preventing calcium from entering the cells of the heart and arteries, by blocking the calcium channel blockers this allows blood vessels to relax and open. Calcium causes the heart and arteries to contract more strongly.
Mode of action of theophylline
Xanthine Bronchodilator: helps to open your airways in your lungs so that air can flow into your lungs more feeling. Relieving symptoms such as coughing, wheezing and shortness of breath.
Mode of action of progesterone
Works by adjusting the balance of your body’s own hormone.
Mode of action of bisphosphonates
Works by slowing down the cells which break down bone (osteoclasts). Therefore, they slow down bone loss, allowing the bone building cells (osteoblasts) to work more effectively. Helping to strengthen bone and help prevent it getting any weaker.
Typical symptoms of GORD
Heart burn and acid regurgitation
Atypical symptoms of GORD
- Angina like chest pain, non-specific dyspepsia, belching, bloating, laryngitis, broncho-constriction, or worsening asthma
- Refluxed acid cause erosion of dental enamel, burning tongue & sore throat
Complicated symptoms of GORD
Dysphagia, odynophagia, bleeding, unexplained weight loss
Complications of GORD
Barrett’s oesophagus = more common in men, small but increased risk of oesophageal cancer, oesophageal lining changes (squamous to columnar), treatment with proton pump inhibitors.
Goals of treatment of GORD
Relieve symptoms and improve quality of life
Reduce frequency of reflux
Reduce duration of reflux
Heal oesophagitis
Avoid recurrence of symptoms
Reduce risk of Barrett’s oesophagus
3 treatment modalities of GORD
- Lifestyle modification – remove factors that can aggravate or provoke GORD, decrease amount of reflux which prevents reflux or improve clearance.
- Drug treatment – aim to decrease gastric acid secretion; neutralise stomach acid; prevent reflux or improve clearance; protect GI mucosa.
Drug classes to use for treatment: Antacids, H2 histamine receptor antagonists, Proton pump inhibitors - Surgical treatment – fundoplication= surgical procedure of the fundus (top of the stomach) due to fundus wrapped around the lower oesophageal sphincter (LOS) to strengthen it
How to identify peptic ulcer disease (PUD)
- Localised lesion in GI mucosa
- Ulceration anywhere in GI tract
- Gastric and duodenal ulcers - most common types
- Recurrent episodes of dyspepsia
- About 10% incidence
How to identify gastric ulcers
- Peaks at 50 - 60 years
- Men and women equally affected
- Often found between antrum and body
- Malignancy more common with gastric ulcers
How to identify duodenal ulcers
- Peaks at 45 - 64 years
- Twice as common in males than females
- Commonly found first part of the duodenum
Two factors of gastric mucosa
- Aggressive factors
2. Protective factors
Aggressive factors of gastric mucosa
- Gastric acid
- Pepsin
Protective factors of gastric mucosa
Prostaglandins regulated:
- Mucus and bicarbonate secretion
- Gastric mucosal blood flow
- Gastric emptying
Pathogenesis of PUD
Breakdown of the gastric mucosa’s protective mechanism:
- Defects in the mucosal barrier
- Abnormal rate of acid/pepsin secretion
- Inflammation caused by Helicobacter pylori
- Ulcerogenic drugs - NSAIDs, aspirin, corticosteroids
- SSRIs e.g., fluoxetine - block re-uptake of serotonin in platelets resulting in impairment of haemostatic function
- Smoking - postulated mechanisms
a. pepsin secretion, ↑acid production and ↓mucus production
b. duodenogastric reflux of bile acids
c. ↓bicarbonate & prostaglandin production - Alcohol - can cause gastritis
- Stress - can influence PUD but clear causal relationship has not been established
- Dietary factors e.g. coffee, tea, cola, beer, highly spiced foods
- may cause dyspepsia but independently do not ↑PUD
- caffeine ↑ acid secretion - Genetic predilection
Causes of PUD
- Helicobacter pylori (H.pylori)
- NSAIDs
- Stress related mucosal damage (stress ulcers)
How to identify helicobacter pylori (H.pylori)
- Gram -ve motile rod-shaped bacillus
- Major cause of PUD
- Transmitted via faecal oral route
- Increased prevalence with advancing age
- 10-20% children
Pathogenesis of H.pylori induced PUD
- Direct mucosal damage
- Alteration of host inflammatory responses
- May increase gastrin levels ↑acid secretion
