106 - GORD/PUD

Question 1

Define GORD

Answer 1

Symptoms or mucosal damage produced by abnormal reflux of gastric contents into oesophagus

Question 2

Key symptoms of GORD

Answer 2

Heartburn in retrosternal area and acid regurgitation

Question 3

Physiological reflux likely if

Answer 3

Happens after eating
Short lived
Asymptomatic
Rarely occurs in sleep

Question 4

What is dysphagia

Answer 4

Problems swallowing. Red flag symptom. Long term GORD - need to rule out adenocarcinoma

Question 5

Differential diagnosis of GORD

Answer 5

Angina pectoris major differential

Stricture, ulcer, Barrett’s oesophagus, cancer. Exclude cardiorespiratory causes.

Question 6

Practically - consider GORD in all cases of

Answer 6

Chronic heartburn

Question 7

Severity and duration of GORD symptoms indicate

Answer 7

nothing about severity oesophagitis

Question 8

Prevalence of GORD

Answer 8

Can be as high as 20% in US. Varies with geography and ethnicity.

Question 9

Factors associated with GORD

Answer 9

Family history
Pregnancy
High BMI
Lower educational level
Smoking
Alcohol
Prescription medications

Question 10

Dyspepsia is

Answer 10

Pain/discomfort centred in the upper abdomen

Question 11

Causes of dyspepsia

Answer 11

25% have underlying cause
Peptic ulcer disease most common
Also biliary pain, pancreatitis, chronic abdominal wall pain, cancer, medications.

Question 12

Dyspepsia Rome III definition

Answer 12

Postprandial fullness
Early satiation
Epigastric pain/burning

Question 13

Definition of Peptic Ulcer Disease

Answer 13

PUD - surface breach of mucosal lining of GI tract due to acid & pepsin mediated damage

Question 14

Common sites of PUD

Answer 14

Duodenum (80%)

Stomach (20%)

Question 15

Causes of chronic gastritis

Answer 15

H. pylori - over 80% cases
Chemical damage (bile, reflux, drugs)
Autoimmune - Pernicious anaemia (Vit B12 malabsorption)

Question 16

Causes of acute gastritis

Answer 16

Usually due to chemical injury - alcohol/drugs

Question 17

What is gastritis

Answer 17

Inflammation of stomach lining

Question 18

Peptic ulcer symptoms

Answer 18

Wide variety or can be asymptomatic until complications start
Dyspepsia
Anorexia
Weight loss
Fatty food intolerance
Epigastric pain
Pain can radiate to back

Question 19

Duodenal ulcer symptoms generally occur

Answer 19

2-5hrs after eating on empty stomach - as acid empties into duodenum

Question 20

Gastric ulcer symptoms gennerally occur

Answer 20

soon after meals - acid in stomach

Question 21

Complications of peptic ulcer

Answer 21

Perforation leading to peritonitis
Haemorrhage due to erosion of vessel
Penetration of surrounding organ 
Obstruction due to scaring - pyloric stenosis
Cancer - VERY RARE

Question 22

PUD alarm symptoms

Answer 22

Weight loss
Persistant vomiting
Dysphagia (getting worse)
Haematemesis
Palpable abdominal mass
Unexplained anaemia
Family history of Upper GI cancer
Jaundice
Previous gastric surgery

Question 23

Common drugs that can cause PUD

Answer 23

NSAIDs

Question 24

What is Zollinger-Ellison syndrome

Answer 24

Gastrin secreting tumour in duodenum/pancreas results in increased acid production. Genetic link

Question 25

PUD risk factors

Answer 25

Male Smoker Excessive alcohol intake

Question 26

Common PUD presentation

Answer 26

``` Pain - relieved by food/antacid/milk Epigastric tenderness on palpation Nausea/vomiting Haemorrage Can be associated with GORD ```

Question 27

Investigation of suspected PUD

Answer 27

``` Test and treat approach. Stop any drugs could be causing FBC - check for anaemia H Pylori testing Endoscopy if indicated ```

Question 28

H. Pylori triple therapy

Answer 28

PPI - e.g. Omeprazole | 2 x Abx - Amoxicillin (Metronidazole if allergic) and Clarithromycin.

Question 29

H Pylori testing

Answer 29

Either stool antigen test or Urea breath test

Question 30

How does Urea breath test work?

Answer 30

Urea swallowed and is broke down by H. pylori to CO2 and NH3

Question 31

Red flags for PUD

Answer 31

``` Bleeding Iron deficiency anaemia Weight Loss Dysphagia Epigastric mass H Pylori & NSAID negative ```

Question 32

Acid-reflux defences

Answer 32

``` Lower oesophageal spincter Angle of his Mucosal flap and folds Diaphragm Peristalsis - clean reflux Bicarbonate present in saliva ```

Question 33

Pathophysiologies for GORD

Answer 33

``` Can be due to: Poor oesophageal peristalsis Incompetent lower oesophageal sphincter Hiatus hernia - stomach herniating through diaphragm and angle of his is destroyed Delayed gastric emptying ```

Question 34

GORD investigations

Answer 34

FBC - exclude anaemia Trial PPIs Barium swallow - look predisposing factors pH monitoring - exclude oesophageal/peristaltic dysfunction Endoscopy - look for Barretts

Question 35

Treatments for GORD

Answer 35

Lifestyle changes Antacids Acid suppressors - PPI (omeprazole) or H2 receptor antagonists (Ranitidine) Surgery if needed

Question 36

What is Oesophagitis? What causes it?

Answer 36

Inflammation of oesophagus due to acid and pepsins

Question 37

Complications of Oesophagitis

Answer 37

Oesophageal stricture - dysphagia | May cause Barretts Oesophagus or chronic inflammation

Question 38

Barrett's Oesophagus - What is it?

Answer 38

Normal stratified squamous epithelium is replaced with columnar epithelium. Potential to transform to adenocarcinoma.

Question 39

Stages of development of Barrett's Oesophagus

Answer 39

Damage to epithelium Metaplasia occurs during repair to acid damage. Dysplasia occurs Adenocarcinoma can occur

Question 40

Barrett's Oesophagus changes to gastric columnar epithelium - risks?

Answer 40

No malignant potential

Question 41

Barrett's Oesophagus changes to intestinal columnar epithelium - risks?

Answer 41

Malignant potential

Question 42

Barrett's Oesophagus - appearance on endoscopy

Answer 42

Finger like projections or sheets/patches of reddened epithelium.

Question 43

Risk factors for Barrett's Oesophagus

Answer 43

GORD, hiatus hernia Male Obesity Smoking/Excessive alcohol

Question 44

Impact of NSAIDS and H.Pylori in patient with Barrett's Oesophagus

Answer 44

Protective against malignant changes

Question 45

Symptoms of Barrett's Oesophagus

Answer 45

Asymptomatic - found on endoscopy

Question 46

Investigations for Barretts Oesophagus

Answer 46

Endoscopy + biopsy

Question 47

Treatment for Barrett's oesophagus

Answer 47

Acid suppression - slow progression. Endoscopy to monitor. If high grade dysplasis - ablation to burn away dysplastic epithelium or surgical resection of oesophagus.

Question 48

Alternative names for urea breath test for H. Pylori

Answer 48

Carbon 13 test CLO test (breath test) Urease test

Question 49

Surgical option for GORD

Answer 49

Nissen fundoplication | Wrap fundus of stomach around lower part of oesophagus.