2)Common GI/Liver Conditions

Question 1

Pathophysiology of GORD?

Answer 1

LOS dysfunction leads to reflux of gastric contents -> Oesophagitis

Question 2

Risk Factors for GORD?

Answer 2

• Hiatus Hernia
• Smoking
• Drinking
• Obesity
• Pregnancy
• Drugs (antiCh, Nitrates, CCB,TCAs)
• Iatrogenic (Hellers myotomy)
• LOS hypotension
• loss of peristaltic fx
• Gastric acide hypersectretion

Question 3

Symptoms of GORD?

Answer 3

Oesophageal

• Heartburn related to meals, worse lying down/stooping. relieved by antacids
• Belching
• Odonophagia
• Incr salivation

Extra-oesophageal

• Nocturnal Asthma
• Laryngitis
• Chronic cough
• IDA?

Question 4

Complications of GORD?

Answer 4

• Oesophagitis: heartburn
• Ulceration: rarely → haematemesis, melaena, ↓Fe
• Benign stricture: dysphagia
• Barrett’s oesophagus
  
  • Intestinal metaplasia of squamous epithelium
  • Metaplasia → dysplasia → adenocarcinoma
• Oesophageal adenocarcinoma

Question 5

DD for GORD?

Answer 5

• Oesophagitis
  
  • Infection: CMV, candida
  • IBD
  • Caustic substances / burns
• PUD
• Oesophageal Ca

Question 6

Ix for GORD?

Answer 6

Isolated symptoms dont need investigating. 
CXR may show hiatus hernia
OGD IF:
->55
-Symptoms >4wks
-Dysphagia
-Persistent symptoms despite Rx
-Wt. loss
-OGD allows grading by Los Angeles
Classification
Ba swallow: hiatus hernia, dysmotility
-24h pH testing ± manometry
-pH <4 for >4hrs

Question 7

Treatment for GORD?

Answer 7

Conservative

• Lose wt.
• Raise head of bed
• Small regular meals ≥ 3h before bed
• stop smoking and ↓ EtOH
• Avoid hot drinks and spicy food
• Stop drugs: NSAIDs, steroids, CCBs, nitrates

Medical

• OTC antacids: Gaviscon, Mg trisilicate
• 1: Full-dose PPI for 1-2mo
• Lansoprazole 30mg OD
• 2: No response → double dose PPI BD
• 3: No response: add an H2RA
• Ranitidine 300mg nocte
• Control: low-dose acid suppression PRN

Surgical
Nissen Fundoplication
-Indications: all 3 of:
-severe symptoms
-Refractory to medical therapy
-Confirmed reflux (pH monitoring)

Question 8

Complications of Nissen Fundoplication?

Answer 8

• Gas-bloat syn.: inability to belch / vomit

- Dysphagia if wrap too tight

Question 9

How is peptic ulcer disease classified?

Answer 9

Acute v Chronic

Acute: Usually due to drugs (NSAIDS/Steroids) or ‘Stress’
Chronic: Drugs, H.Pylori, Zollinger-Ellison

Question 10

Pathology of Duodenal Ulcers?

Answer 10

• 4x more common than gastric ulcers
• M>F
• First part of duodenum

Question 11

Risk factors for duodenal ulcers?

Answer 11

H. pylori (90%)

• Drugs: NSAIDs, steroids
• Smoking
• EtOH
• ↑ gastric emptying
• Blood group O

Question 12

Presentation of duodenal ulcers?

Answer 12

Epigastric pain:

• Before meals and at night
• Relieved by eating or milk

Question 13

Pathology of Gastric Ulcers?

Answer 13

• Lesser curve of gastric antrum

- Beware ulcers elsewhere as often malignant

Question 14

Presentation of Gastric ulcers?

Answer 14

Epigastric pain
-Worse on eating
-Relieved by antacids
May be weight loss

Question 15

Complications of PUD?

Answer 15

Haemorrhage
-Haematemeis or melaena
-Fe deficiency anaemia
Perforation
-Peritonitis
Gastric Outflow Obstruction
-Vomiting, colic, distension
Malignancy
- ↑ risk c¯ H. pylor

Question 16

Investigations in PUD?

Answer 16

Bloods: FBC, urea (↑ in haemorrhage)

• C13 breath test
• OGD (stop PPIs >2wks before)
• CLO / urease test for H. pylori
• Always take biopsies of ulcers to check for Ca
• Gastrin levels if Zollinger-Ellison suspected

Question 17

What are non-surgical management options for PUD?

Answer 17

Conservative

• Lose wt.
• Stop smoking and ↓ EtOH
• Avoid hot drinks and spicy food
• Stop drugs: NSAIDs, steroids
• OTC antacids

Medical

• OTC antacids: Gaviscon, Mg trisilicate
• H. pylori eradication: PAC500 or PMC250
• Full-dose acid suppression for 1-2mo
• PPIs: lansoprazole 30mg OD
• H2RAs: ranitidine 300mg nocte
• Low-dose acid suppression PRN

Question 18

What are the surgical options for PUD?

Answer 18

Vagotomy (truncal or selective)
Antrectomy +/- vagotomy
Subtotal gastrctomy (for zollinger ellison)

Question 19

What are the physical complications of PUD surgery?

Answer 19

Stump leakage

• Abdominal fullness
• Reflux or bilious vomiting (improves c¯ time)
• Stricture

Question 20

What are the metabolic complications of PUD surgery?

Answer 20

Dumping syndrome

• Abdo distension, flushing, n/v
• Early: osmotic hypovolaemia
• Late: reactive hypoglycaemia

Blind loop syndrome → malabsorption, diarrhoea

• Overgrowth of bacteria in duodenal stump
• Anaemia: Fe + B12
• Osteoporosis

-Wt. loss: malabsorption of ↓ calories intake

Question 21

What is dyspepsia?

Answer 21

Non specific group of symptoms:

• Epigastric pain
• Bloating
• Heartburn

Question 22

What are alarm symptoms in dyspepsia?

Answer 22

Anaemia
Loss of wt.
Anorexia
Recent onset progressive symptoms
Melaena or haematemesis
Swallowing difficulty

Question 23

What are the causes of dyspepsia?

Answer 23

• Inflammation: GORD, gastritis, PUD
• Ca: oesophageal, gastric
• Functional: non-ulcer dyspepsia

Question 24

What is the management of new onset dyspepsia?

Answer 24

OGD if >55 or ALARMS
 Try conservative measures for 4 wks
 Stop drugs: NSAIDs, CCBs (relax LOS)
 Lose wt., stop smoking, ↓ EtOH
 Avoid hot drinks and spicy food
 OTC
 Antacids: magnesium trisilicate
 Alginates: gaviscon advance
 Test for H. pylori if no improvement: breath or serology
 +ve → eradication therapy
 Consider OGD if no improvement
 -ve → PPI trial for 4wks
 Consider OGD if no improvement
 PPIs can be used intermittently to control
symptoms.

Question 25

Management of proven GORD?

Answer 25

Full dose PPI for 1-2mo | Then, low-dose PPI PRN

Question 26

Management of proven PUD?

Answer 26

Full dose PPI for 1-2mo H. pylori eradication if positive Endoscopy to check for resolution if GU Then, low-dose PPI PRN

Question 27

What is H Pylori eradication therapy?

Answer 27

``` 7 day course NB PPIs and cimetidine → false –ve C13 breath tests and antigen tests t/f stop >2wks before. PAC 500  PPI: lansoprazole 30mg BD  Amoxicillin 1g BD  Clarithromycin 500mg BD PMC 250  PPI: lansoprazole 30mg BD  Metronidazole 400mg BD  Clarithromycin 250mg BD ```

Question 28

What is the failure rate of eradication therapy?

Answer 28

95% success rate, failure mainly due to poor compliance. Can add bismuth (make stool black)

Question 29

What is barretts and how is it graded?

Answer 29

Distal oesophageal epithelium undergoes metaplasia from squamous to columnar. - Gastric metaplasia is low risk - Intestinal metaplasia is 2 yrly surveillance - Low grade dysplasia= 90% chance of Ca at 6yr - High Grade dysplasia+ half will already have adenocarcinoma

Question 30

What is the classification system in GORD?

Answer 30

``` LA classification 1- mucosal break <5mm 2- mucosal break >5 mm 3- large mucosal break but <75% of circumference 4- mucosal break > 75% of circumference ```

Question 31

What are the two types of hiatus hernia? which gives yu reflux?

Answer 31

Sliding and rolling Sliding gives you reflux as sphincter is in chest and becomes less competent Rolling rarely gives reflux as sphincter is in abdomen, needs repair though as more likely to strangulate= bad