4. H-Pylori & gastric disease

Question 1

What is dyspepsia?

Answer 1

Dyspepsia (bad digestion) describes a group of symptoms:
- Pain or discomfort in the upper abdomen, retrosternal pain, anorexia, nausea, vomiting, bloating, fullness, early satiety and heartburn
For 4 weeks ( 12weeks Rome criteria)

Question 2

What can cause the symptom of dyspepsia?

Answer 2

Organic vs functional dyspepsia.

Organic causes: GORD, peptic ulcer, gastritis, gastric cancer, pancreatic disease, intolerance (coeliac disease) to food and drugs, gallstones, hepatic causes, other systemic disease (metabolic, cardiac, lower GI (IBS, colonic cancer) etc.

Functional dyspepsia: no obvious organic cause, could be due to delayed gastric emptying, H. pylori infection, psychosocial factors, inflammation etc.

Question 3

What do you do if a patient presents with dyspepsia?

Answer 3

1. History and examination is key.
2. Bloods – FBC, ferritin, LFTs, U&Es, calcium, glucose, coeliac serology/serum IgA
3. Drug history – NSAIDs, steroids, bisphosphonates, Ca antagonists, nitrates, theophyllines, remember OTT
4. Lifestyle – alcohol, diet, smoking, exercise, weight reduction

Question 4

A patient presents with pain/discomfort in upper abdomen. Upon further questioning, patient says he/she has lost weight (unplanned) and has difficulty swallowing solid food. What would you do next?

Answer 4

Urgent referral for endoscopy as patient is presenting with ALARMS symptoms.

Question 5

What is an upper GI endoscopy?

Answer 5

Diagnostic and therapeutic upper GI endoscopy
Local anaesthetic (throat spray) or sedation
Day case
Fasted
Consent
Risks - 1:2000 risk perforation, bleeding, reaction to drugs given

Question 6

What is Helicobacter pylori?

Answer 6

Gram negative, spiral-shaped, microaerophilic, flagellated Gram –ve bacteria.

Question 7

Where is Helicobacter pylori found?

Answer 7

• H. pylori can only colonise gastric type mucosa
• It resides in the surface mucous layer and does not penetrate the epithelial layer
• Evokes immune response in underlying mucosa – dependent on host genetic factors

Question 8

What is the clinical outcome of H. Pylori infection?

Answer 8

Depends on site of colonization, characteristics of bacteria and host factors e.g. genetic susceptibility and other environmental factors e.g. smoking.
>80% cases = asymptomatic or chronic gastritis.
15-20% = chronic atrophic gastritis, intestinal metaplasia, gastric or duodenal ulcer
<1% = gastric cancer, MALT lymphoma

Question 9

1. What is the outcome if corpus predominant gastritis due to chronic H. Pylori infection?
2. What is the outcome if antral predominant gastritis due to chronic H. Pylori infection?
3. What is the outcome if mild mixed gastritis due to chronic H. Pylori infection?

Answer 9

1. Decreased acid > gastric atrophy. Eventually leads to gastric cancer.
2. DU disease. Increased acid, low risk of gastric cancer
3. Normal acid. No significant disease.

Question 10

How is H. Pylori infection diagnosed?

Answer 10

Non-invasive:
- serology (IgG against H. Pylori)
- Urea breath test (C13/C14 labelled CO2 used)
- Stool antigen test: ELISA. Need to be off PPI for 2wks
Invasive: requires endoscopy
- histology (gastric biopsies stained for bacteria)
- culture of gastric biopsies
- rapid slide urease test (CLO): uses ammonia. If positive = purple. If negative = yellow.

Question 11

1. Define gastritis.
2. How is gastritis diagnosed?
3. What causes gastritis?

Answer 11

1. Inflammation in the gastric mucosa
2. Histological diagnosis so need to do endoscopy (also shows clinical features).
3. Autoimmune (parietal cells), bacterial (H. Pylori infection), chemical (bile, NSAIDs)

Question 12

Peptic ulcers:

1. Which peptic ulcer is more common?
2. What causes peptic ulcers?

Answer 12

1. Duodenal ulcers > gastric ulcers
2. Majority caused by H. Pylori infection. Others = NSAIDs, smoking. Rarely caused by = Zollinger-Ellison syndrome, hyperparathyroidism, Crohn’s disease

Question 13

What symptoms are associated with peptic ulcer?

Answer 13

• Epigastric pain is the main feature (pointing sign, may be relieved by antacids)
• Nocturnal/hunger pain (more common in DU)
• Back pain (may suggest penetration of a posterior DU)
• Nausea and occasionally vomiting
• Weight loss and anorexia
• Only sign may be epigastric tenderness
• If the ulcer bleeds, patients may present with haematemesis and/or melaena, or anaemia

Question 14

How do you treat a peptic ulcer?

Answer 14

• Ulcers caused by H. pylori are treated by eradication therapy to get rid of the bacteria
• Antacid medication – proton pump inhibitors (omeprazole)or H2 receptor antagonists (ranitidine)
• If NSAIDs are also involved, these have to be stopped if possible, or should continue to receive other protective agents following eradication therapy
• Complications are treated as they arise
• Surgery is only indicated in complicated PUD

Question 15

How do you eradicate H. Pylori infection?

Answer 15

7 day triple therapy:
- Clarithromycin 500mg bd
- Amoxycillin 1g bd (or Metronidazole 400mg bd) (Tetracycline is given if penicillin allergy)
- PPI: e.g. omeprazole 20mg bd
>Resistance to antibiotics and poor compliance are the main reasons for failure
>Second line therapy protocols
>May differ dependent on local antibiotic resistance profiles
>Research – Longer time period? Other antibiotics

Question 16

What are the complications of a peptic ulcer?

Answer 16

> Acute bleeding – melaena and haematemesis
Chronic bleeding – iron deficiency anaemia
Perforation
Fibrotic stricture (narrowing)
Gastric outlet obstruction – oedema or stricture

Question 17

What are the symptoms of gastric outlet obstruction?

Answer 17

Vomiting – lacks bile, fermented foodstuffs

Early satiety, abdominal distension, weight loss, gastric splash

Dehydration and loss of H+ and Cl- in vomit

Question 18

What can gastric outlet obstruction lead to?

Answer 18

Metabolic alkalosis

Question 19

What investigation would you carry out if gastric outlet obstruction suspected?

Answer 19

Bloods – low Cl, low Na, low K, renal impairment

Diagnosis – UGIE (upper GI endoscopy) (prolonged fast/aspiration of gastric contents would be seen), identify cause – stricture, ulcer, cancer.

Question 20

How is gastric outlet obstruction?

Answer 20

Treated with endoscopic balloon dilatation, surgery, stents.

Question 21

List types of gastric tumours.

Answer 21

Majority are adenocarcinomas (epithelial cells)

Other types gastric tumour – MALT, GIST

Question 22

How does gastric cancer present in patients?

Answer 22

Dyspepsia
early satiety
nausea & vomiting
weight loss
GI bleeding
iron deficiency anaemia
gastric outlet obstruction

Question 23

List aetiological factors of gastric cancer.

Answer 23

Diet
Genetics
Smoking
H. Pylori infection
Other factors to consider – family history,  previous gastric resection, biliary reflux,  premalignant gastric pathology

Question 24

What are the subtypes of gastric cancer?

Answer 24

• Majority are sporadic (intestinal type) with no demonstrable inherited component
• <15% familial clustering, most not associated with definitive germline mutation
• 1-3% heritable gastric cancer syndromes (HDGC;
  AD, CDH-1 gene (E-cadherin))

Question 25

What is the management of a patient with gastric cancer?

Answer 25

• Endoscopy and biopsies to make a histological diagnosis
• Staging investigations: CT chest/abdo – lymph nodes and liver/lungs/peritoneum/bone marrow spread?
• MDT discussion – imaging/histology/patient fitness. Gastroenterologist, pathologist, radiologist, upper GI surgeons, oncologists, specialist nurses
• Treatment: surgical and chemotherapy