Week 3 - D - Gastritis (H.pylori, Autoimmune, Chemical), Dyspepsia (H.Pylori/Functional), Peptic ulcer disease (duodenal/gastric)

Question 1

There are different conditions that cause inflammatory disorders of the stomach They can usually be classified as acute or chronic gastritis What are different causes for both acute and chronic gastritis?

Answer 1

Acute gastritis cause * Irritant chemical injury * Severe trauma * Shock Chronic gastritis causes * Bacterial * Autoimmune * Chemical * Granulomas eg Crohn’s or sarcoidosis * Zollinger Ellison Synrome - gastrin secreting tumour

Question 2

Out of chemical, bacterial and autoimmune causes of chronic gastritis Which is the most common type? Which is the least common type? What are the different causes of chemical gastritis?

Answer 2

Helicobacter pylori is the most common type associated with chronic gastritis Autoimmune chronic gastritis is the rarest type Chemical gastritis is often due to NSAIDs, alcohol, bile reflux - direct injury to mucus layer which may cause erosions or ulcers

Question 3

What is the autoimmune cause of gastritis known as? What are the antibodies involved in this disease?

Answer 3

The autoimmune cause of chronic gastritis is known as Pernicious anaemia This disease occurs due to anti-gastric parietal (very sensitive but not specific) and anti intrinsic factor antibodies (very specific but not sensitive) causing autoimmune destruction of the gastric parietal cells

Question 4

What is deficient due to the autoimmune destruction of the gastric parietal cells in pernicious anaemia? What is this required for?

Answer 4

In pernicous anaemia, as the gastric parietal cells are attacked, there is a failure to secrete HCl (achlorydia) as well as a failure to secrete intrinsic factor which is required for the absorption of vitamin B12 in the terminal ileum Vitamin B12 is required for the normal production of RBCs and therefore a megaloblastic macrocytic anaemia will occur (haem notes)

Question 5

What are different causes of vitamin B12 deficiency?

Answer 5

* Decreased dietary intake - ie vegans or vegetarians * Atrophic gastritis - due to pernicious anaemia or H.pylori infection * Chronic pancreatitis - cannot produce enzymes to neutralise the acid allowing for B12 and intrinsic factor to bind in the dueodenum in alkaline conditions * PPIs or gastric bypass * Coeliac or Crohns affecting absorption in the bowel

Question 6

What are the clinical features of vitamin B12 deficiency?

Answer 6

Anaemia symptoms - pallor (skin and conjunctival), fatigue Weight loss, diarrhoea, infertility Sore tongue - glossitis(beefy tongue) and angular cheilitis Can have jaundice Developmental problems especially in children Neurological problems - paraesthesis, peripheral neuropathy,

Question 7

The B12 deficiencies may present exclusively with neurological problems and no haematological findings - may be useful to consider doing a vit B12 blood test for patients with neurological symptoms What is the neurological condition caused by vitamin B12 deficiency?

Answer 7

Subacute combined degeneration of the spinal cord a combination of peripheral sensory neuropathy with both upper and lower motor neurone signs - due to degeneration of the posterior and lateral spinal columns (dorsal column and corticospinal tracts respectively)

Question 8

How does subacute degeneration of the spinal cord present?

Answer 8

The onset is insidious (subacute) and signs are symmetrical * Combination of dorsal column medial lemnsicus tract loss - causing sensory and LMN signs * Sensory - loss of vibration, fine touch and proprioception * LMN -> absent knee and ankle jerks Corticospinal tract loss causing motor & UMN signs * Ataxia, stiffness, weakness, extensor plantars Spinothalamic tract is unaffected so pain, temperature and deep pressure sensations often still intact

Question 9

What other conditions is autoimmune gastritis linked with?

Answer 9

Linked to other autoimmune diseases Thyroid disease (hypothyroidism) Vitiligo Addison’s disease Also increased risk of malignancy - gastric carcinoma

Question 10

Chronic gastritis * H.pylori - most common type * Chemical causes - NSAIDs, Alcohol, bile.reflux disease * Autoimmune causes - pernicious anaemia How does H.pylori cause a chronic gastritis? Which interleukin is critical in Hpylori infection?

Answer 10

H.pylori inhabits a niche between the epithelial surface and mucous barrier of the stomach (or dudodenum) It excites an early acute inflammatory response which will lead to chronic active inflammation if not cleared Interleukin 9 is critical in the inflammatory response

Question 11

What is produced in response to H.pylori infection? What does H.pylori gastritis increases the risk of?

Answer 11

In respons to H.pyloria, the lamina propria (in the mucosa layer) produces H.pylori antibodies This increase the risk of * Duodenal ulcers * Gastric ulcers * Gastric carcinoma * Gastric lymphoma

Question 12

What is the treatment of chronic gastritis?

Answer 12

Treat the cause Ie * if B12 deficiency, give vitamin B12 * If due to H.pylroi - treat the H.pylroi * Stop smoking and stop drinking * If drug induced eg NSAID, stop drug and give PPIs

Question 13

Dyspepsia Dyspepsia is more of a group of symptoms defined under one word however does not define the underlying pathology What are the symptoms of dyspepsia?

Answer 13

Epigastric pain or burning Postprandial fullness Early satiety

Question 14

What is the Rome IIV criteria for diagnosing dyspepsia? (basically the mentione symptoms plus how often / how long it has occurred for)

Answer 14

Presence of at least one of the following * Bothersome postprandial fullness * Bothersome early satiation * Bothersome epigastric pain * Bothersome epigastric burning AND * Occurs at least 3 days per week over the last 3 months with an onset of at least 6 months in advance

Question 15

What are the two different types of dyspepsia? Give examples of causes for both

Answer 15

Organic causes - accounts for 25% * Peptic ulcer disease * Drugs - esp NSAIDs and COX2 inhibitors * Gastric cancer Functional (idiopathic) dyspepsia- accounts for 75% * Associated with other functional gut disorders eg IBS

Question 16

What is the Rome IV criteria for diagnosing functional dyspepsia? (basically what is needed on examination/investigation)

Answer 16

Presence of at least one of the following * Bothersome postprandial fullness, Bothersome early satiation, Bothersome epigastric pain, Bothersome epigastric burning AND * Occurs at least 3 days /week over the last 3 months with an onset of at least 6 months in advance AND * no evidence of organ, systemic, structural or metabolic disease that is likely to explain symptoms (including on upper GI endoscopy)

Question 17

It is important to differentiate between dyspepsia and heartburn/reflux disease - GORD may co-exist with dyspepsia What are the differential diagnoses for dyspepsia?

Answer 17

* Non-ulcer dyspepsia * Duodenal/gastric ulcer * Duodenitis * Gastiris * Oeseophagitis/GORD * Gastric malignancy * Functional dyspepsia

Question 18

Management of dyspepsia If the symptoms is predominantly heartburn, what should it be managed as? How is dyspepsia investigated?

Answer 18

If the symptoms are predominantly heartburn, manage as GORD (antacids + PPIs, add H2RA (ranitidine, cimetidine) if not working) If the patients has dysphagia or >/=55 with ALARM Symptoms - URGENTLY REFER TO SPECIALIST (within 2 weeks) (Anaemia, loss of weight, anorexia, recent onset/progressive symptoms, malaena/haematemesis, swallowing difficulty) If these features are not present (uncomplicated dyspepsia), then do not refer

Question 19

How are patients with uncomplicated dyspepsia managed? What is carried out if these symptom fail to go away after 4 weeks?

Answer 19

Patients with uncomplicated dyspepsia 1. Review medications for possible causes of dyspepsia - eg NSAIDs 2. Lifestyle advice - stop smoking, weight loss, small regular meals 3. Give PPI If symptoms persist / recurrent symptoms - test and treat for H.pylori is advised

Question 20

How is Helicobacter pylori tested for? How long beforehand must PPIs be stopped for?

Answer 20

Test for H. pylori using a * carbon-13 urea breath test or * a stool antigen test, * serology (IgA antibodies) where performance is locally validated.- inaccurate with increasing age To improve the accuracy of Helicobacter pylori (H pylori) testing it is important to have a 2-week washout period after using a proton pump inhibitor (PPI). Improving the accuracy of the test will ensure that treatment for H pylori infection is given only if needed

Question 21

If the H.pylori test comes back as negative, what is the treatment? If the H.pylori test comes back as positive, what is the treatment? If symptoms persist in either case what should happen?

Answer 21

If H.pylroi testing comes back as negative- prescribe PPIs for 4 weeks If H.pylori test comes back as positive - triple therapy is advicated (LAC PPI(lansoprazole) + Amoxicillin+ Clarithromycin or Metronidazole) (if pen allergic, PPI+Clar+Met) If symptoms persist despite treatment and patient: * /=55 - refer for urgent upper GI endoscopy

Question 22

What is the management of functional dyspepsia?

Answer 22

Management Prescribe patient with PPI - they may also require psycotherapy Patient may benefit from low dose-amitryptilline

Question 23

Peptic ulcer disease Peptic ulcer disease is a common cause of organic dyspepsia What is a peptic ulcer? What are the common sites for a peptic ulcer to occur?

Answer 23

Peptic ulceration is a breach in the gastrointestinal mucosa as a result of acid/pepsin attack and due to failure of the mucosal site * Duodenal ulcers are the most common (1st part usually) * Gastric ulcers (junction of body and antrum) * Oeseophago-gastric junction ulcers * Stomal ulcers - occurring after gastrojejunostomy in the jejunal mucosa near the opening (stoma) between the stomach and the jejunum.

Question 24

What are the major risk factors for peptic ulcers? Name some other risk factors?

Answer 24

Helicobacter pylori is associated with the majority of peptic ulcers: 95% of duodenal ulcers 75% of gastric ulcers Other risk factors * Drugs - mainly NSAIDs, also SSRIs, corticosteroids, biphosphonates * Zollinger Ellison syndrome * Smoking and alcohol

Question 25

What is the pathogenesis of peptic ulcers?

Answer 25

There is increased attack due to increased acid secretion There is also failure of epithelial defence mechanisms

Question 26

What are the complications of peptic ulcers?

Answer 26

* Haemorrhage * Perforation * Stensosis * Gastric cancer - adenocarcinoma or low grade B-cell gastric lymphomas (mucosal associated lymphoid tissue lymphoma)

Question 27

H.pyloria is by far the most common cause of peptic ulcers What type of bacteria is it? How is it acquired?

Answer 27

Helicobacter is a gram-negative, helically-shaped, microaerophilic bacterium usually found in the stomach Infection is usually acquired in children (oral-oral spread or faecal oral spread) Majority of people never experience symptoms however some experiences consequences of the infection later in life such as peptic ulcer disease

Question 28

What are the symptoms of gastric or duodenal ulcers? - remember a key feature to differentiate between the two

Answer 28

Symptoms epigastric pain nausea
duodenal ulcers more common than gastric ulcers
epigastric pain when hungry, relieved by eating
gastric ulcers * epigastric pain worsened by eating

Question 29

What are the investigations carried out in patients with suspected peptic ulcer disease?

Answer 29

Upper GI endoscopy and gastric biopsy to exclude malignancy if dysphagia, or >/=55 with ALARM Symptoms IF not then test and treat for H.pylori Carbon 13 urea breath test a stool antigen test, serology (IgA antibodies) where performance is locally validated.- inaccurate with increasing age

Question 30

What is the treatment of peptic ulcer disease? If both H.pylori negative and positive

Answer 30

H.pylori negative - Give antacids and PPIs until ulcer is healed H.pylori positive - triple therapy to eradicate for 1 week * PPI(lansoprazole)+Amoxicillin + clarithromycin or metronidazole if pen allergic- PPI + Clarithromycin + Metronidazole

Question 31

Is any post-therapy follow up carried out in peptic ulcer disease?

Answer 31

Duodendal ulcer * No follow up is required if good response to treatment * Only if ongoing symptoms Gastric ulcer * Follow up Upper GI endoscopy is recommended at 6-8 weeks to ensure healing and no malignancy