Upper GI Pathology Flashcards
Dyspepsia definition
Group of symptoms that suggest UGI disease
Dyspepsia symptoms
Pain or discomfort in epigastrium (‘ulcer-like’)
May include:
Heartburn/regurgitation (GORD like)
Bloating, nausea, vomiting, excess wind (dysmotility like)
Dyspepsia red flag symptoms
Dysphagia Weight loss (unintentional) Persistent vomiting Epigastric mass GI bleeding Iron deficiency New/persistent unexplained symptoms >55y
Dyspepsia facts
Chronic or recurring symptoms 25-40% adults have it Only 20-25% of these seek help 5% primary care physician visits 20-40% GI consultations Billions in direct and indirect care costs
Dyspepsia- dealing with uncertainty
Often a clinical diagnosis Symptoms very non-specific Often 'no cause' found 50-75% non-ulcer dyspepsia 15-25% peptic ulcer disease 5-15% oesophagitis <2% cancer
Non-ulcer dyspepsia- Disturbances in:
GI motility Visceral sensation Gastric accommodation Intestino-gastric reflexes Gastric acid sensitivity Psycho-social factors ?Relationship with H Pylori?
Non-ulcer dyspepsia
Endoscopy is normal
Improves with time and symptomatic treatment (PPI)
GORD
Symptoms and/ore mucosal damage resulting from reflux of gastric contents into distal oesophagus
80% mild/moderate
Non-consulters, self medicate
20% consult, often GP
Few % have chronic persistent symptoms and complications
GORD prevalence
Heartburn reported in 29% age 20-69 50% US adults have used antacids 27% take>2 doses/month Mostly OTC medication PPIs are huge drug cost
GORD pathophysiology
Dysfunction of OG junction (low LOS pressure, high intra-abdo pressure) Decreased oesophageal acid clearance Delayed gastric emptying Gastric acid production normal Hiatus hernia may contribute ?Role of H Pylori?
GORD actions
Therapeutic trial of PPI Endoscopy 50% have no mucosal lesion at endoscopy Los Angeles scoring for oesophagitis 24hr pH monitoring/manometry
Some GORD endoscopy findings
Macroscopic oesophagitis in minority of patients
Complications of GORD
Stricture
Barrett’s oesophagus
Cancer
GORD Extra-oesophageal manifestations
Middle ear problems Chronic sinusitis Dental erosions and halitosis Sore throat/pharyngitis/laryngitis Cough Asthma Aspiration pneumonia
Gold standard GORD diagnosis
24hr pH monitoring
Treatment of GORD- objectives
Resolution of symptoms
Healing of oesophagitis
Prevention of complications
GORD Treatment- options
Education and explanation Lifestyle modifications Antacids and alginates Acid suppression; PPI/H2RA Endoscopic/surgical (last resort)
GORD Lifestyle modification
Eliminate triggering foods and drinks Rigorously timed meals Weight loss Eliminate smoking No pressure on stomach Sleeping in chair Inclined sleeping position
Peptic ulcer disease
Duodenal ulcer
Gastric ulcer
Peptic ulcer disease- duodenal ulcer
Pain after food (or not)
99% H pylori- related
Not malignant
Peptic ulcer disease- gastric ulcer
Symptoms not reliable to diagnose Weight loss more likely 60-70% H Pylori-related NSAIDs are significant cause 5-10% malignant
NSAID-related gastric ulcers RFS
Older patients (>70) First 3m of treatment Smokers Co-morbidity Other drugs e.g. anticoagulants
NSAID related gastric ulcers- NSAIDs cause
Dyspepsia in 60%
BUT
50% NSAID ulcers are asymptomatic
H Pylori- highly significant association with
Duodenal ulcer
Gastric ulcer and cancer
Common aetiological agent- 2 disease phenotypes are virtually mutually exclusive
H Pylori DU pathway
Antral gastritis
Increased gastric secretion
Gastric metaplasia
Duodenal ulcer
H Pylori GU pathway
Corpus gastritis
Decreased acid secretion
Gastric atrophy
Dysplasia + neoplasia
Treatment of peptic ulcer
PPI (to heal and prevent recurrence)
H. Pylori eradication therapy (PPI + antibiotics)
Always confirm H.pylori eradication (urea breath test, Hp faecal antigen test)
Stop NSAIDs
Stop smoking
Gastric ulcers malignant
Biopsy all gastric ulcers
Always re-scope for healing
Red flag symptoms gastric ulcer malignancy
Dysphagia Weight loss (unintentional) Persistent vomiting Epigastric mass GI bleeding Iron deficiency New/persistent unexplained symptoms >55y
Take home messages
Dyspepsia is commonest GI problem
NUD influences quality of life but not life expectancy
GORD is common and troublesome
PUD important and potentially serious, still common worldwide
Cancer is relatively rare but important to detect early
