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CBL_dyspepsia Flashcards

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1
Q

What is dyspepsia? (definition)

A

Dyspepsia = a range of upper gastrointestinal (GI) symptoms l_asting 4 weeks_ or more including heartburn (burning retrosternally), indigestion, upper abdominal pain or discomfort, gastric reflux, nausea or vomiting.

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2
Q

Definition of the following symptoms:

  • heartburn
  • gastric reflux
A

•Heartburn

–Typically a burning retrosternal sensation

•Gastric Reflux

–Describes the movement of stomach contents (usually acid) into the oesophagus

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3
Q

Definition of the following symptoms:

  • indigestion
  • dysphagia
  • odynophagia
A

•Indigestion

–Pain or discomfort in the stomach associated with difficulty digesting food

•Dysphagia

–Difficulty swallowing

•Odynophagia

–Painful swallowing

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4
Q

What’s functional dyspepsia?

A

Functional dyspepsia

One or more of:

  • Bothersome postprandial (after meal) fullness
  • Early satiety
  • Epigastric pain
  • Epigastric burning

And: No evidence of structural disease (including normal OGD) that is likely to explain the diagnosis

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5
Q

What’s GORD?

A

Gastro Oesophageal**Reflux Disease (GORD)

–A condition which develops when the reflux of gastric content causes troublesome symptoms

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6
Q

The differential diagnosis for dyspepsia

A

Dyspepsia differentials

  • GORD (A condition which develops when the reflux of gastric content causes troublesome symptoms)
  • Peptic/duodenal ulcer disease
  • Gastritis
  • Duodenal obstruction (e.g. pancreatic malignancy)
  • Gallbladder disease/Gallstones
  • Hiatus hernia = sliding vs oesophageal
  • Medication (NSAIDs, bisphosphonates, Ca2+ channel blockers, steroids)
  • Functional dyspepsia
  • IBS/IBD
  • Eosinophilic oesophagitis = autoimmune - allergy to precipitating foods
  • Cardiac causes
  • Cancers (oesophageal, gastric, pancreatic)
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7
Q

Initial consideration in management in the patient with dyspepsia

(3 likely scenarios)

A

Consider if:

A. Patient needs an urgent OGD (oesophago-gastroduodenoscopy) -> if there is any GI bleed: hematemesis or malena -> refer to hospital

B. Red flag symptoms -> 2 weeks referral cancer pathway

C. If not above -> consider most likely clinical diagnosis and trial of treatment

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8
Q

Who to refer for direct access (2 weeks wait) upper GI endoscopy?

A

•With dysphagia

•Aged 55 and over with weight loss and any of the following:

–Upper abdominal pain

–Reflux

–Dyspepsia

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9
Q

In what group of patients (age and symptoms) we consider non-urgent direct access upper GI endoscopy?

(2 weeks oesophageal cancer referral)

A

Patients 55 years old or more

Symptoms:

  • failed dyspepsia treatment
  • upper abdo pain + anaemia
  • raised platelets + nausea/vomiting/weight loss/reflux/dyspepsia/upper abdo pain
  • N+V + weight loss/reflux/dyspepsia/upper abdo pain
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10
Q

Dyspepsia management

  • lifestyle advice
A

Lifestyle advice:

  • No spicy, citrus foods
  • No smoking/alcohol
  • Lose weight
  • No lying down after meals
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11
Q

H. Pylori

  • type of an organism
  • transmission
A

H. Pylori:

  • gram negative bacteria (rod shaped)
  • oral-faecal or oral-oral route

-

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12
Q

H. Pylori

  • is it usually symptomatic?
A
  • 90% of patients do not have symptoms
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13
Q

What diseases does H. Pylori increase the risk of?

A
  • gastric cancer
  • doudenal ulcer
  • gastric ulcer
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14
Q

Investigations for H. Pylori

A

H. pylori testing

  • Breath test: looks at breakdown of urea in breath (urease activity by the bacteria) - requires 2+ weeks off PPI
  • Faecal antigen test
  • Biopsy on OGD (multiple biopsies)
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15
Q

Treatment for H. Pylori

A

_H. pylori treatmen_t

Triple therapy: Amoxicillin + metronidazole + PPI

for 2 weeks

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16
Q

Management of dyspepsia (pharmacological classes)

A

A. H. pylori testing -> if negative start treatment (below)

B. PPI for 4-8w

C. If symptoms reoccur - low dose PPI, H2A - PRN

D. Consider H2 receptor antagonist therapy if there is an inadequate response to PPI

*Probably should be reviewing the diagnosis and the need for endoscopy at this point

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17
Q

What are the components of Gaviscon?

A

Sodium alginate and sodium bicarbonate

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18
Q

Mechanism of action of Gaviscon and its components

A
  • Anti-acid -> it is alkali based; neutralises the gastric acid -> symptoms relief
  • Alginate -> forms a protective layer that floats on the top of gastric content
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19
Q

Mode of action of Histamine 2 Receptor Antagonist? (in terms of dyspepsia)

Examples of H2RA drugs

A

Mode of action:

  • Histamine (H2) stimulates parietal cells to produce gastric acid
  • H2RA competitively block this receptor -> decrease in gastric acid production

Examples: Cimetidine, Ranitidine, Famotidine

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20
Q

Side effects of H2 receptor antagonists

A

Side effects:

  • Cimetidine > Ranitidine > others -> inhibit cytochrome P450 pathway
  • Diarrhoea, headache, dizziness, rash
  • Increased risk of pneumonia
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21
Q

PPI

  • mode of action
  • examples of drugs
A

Mode of action of PPI:

  • Irreversibly inhibit the proton pump (H+/K+/ATPase) of the gastric parietal cells
  • Stops H+ ions from being secreted into the gastric lumen

•Reduces acid production by 95-99%

Examples: Omeprazole, Lansoprazole, Pantoprazole

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22
Q

General side effects of PPI

A

General side effects PPI

•Nausea, vomiting, abdominal pain, flatulence, diarrhoea, constipation and headache

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23
Q

Concerns associated with PPI use

A

Specific PPI Concerns

  • Increased risk of Clostridium difficile infection (and recurrence)
  • Osteoporosis (long term use)
  • Pneumonia
  • Rebound acid hyper-secretion (after stopping)
  • Iron deficiency anaemia
  • Electrolyte disturbance (Mg/Ca/K)
  • Microscopic colitis
  • Drug induced Subacute Cutaneous Lupus Erythematosus (SCLE)

*generally PPI are safe to use, but try to minimase a long-term and large dose use

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24
Q

Risk factors and associations in gastric ulcer

A

Gastric ulcers

  • Middle aged/older aged population
  • Pain worse with food
  • Gastro-toxic medications often implicated (Aspirin/NSAIDs/Steroids) & smoking
  • H.Pylori implicated in >60%
  • Malignancy must be considered 1-2%
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25
Risk factors and associations with duodenal ulcers
**Duodenal** ulcers * Younger and usually male * **Food relieves the pain** * **Nocturnal pain** more common * H.Pylori implicated in \>90% * Malignancy is very rare
26
Examples of rare ulcers
* Gastrinoma/Zollinger Ellison Syndrome * Crohn’s disease
27
Symptoms of Zollinger Ellison syndrome
refractory diarrhoea + persistent/multiple ulcers
28
What, when and why do we need to do if a gastric ulcer is identified on OGD?
Repeat OGD in 6-8 weeks It is to asses the healing of the ulcer and for malignancy
29
Management of ulcers
* **If Pylori positive** – repeat testing after treatment should be considered to confirm eradication * **Carefully consider NSAIDs** –Can they be stopped (ideally) or if not co-prescribe PPI with NSAID or COX-2 specific NSAID
30
Complications of ulcers A. Immediate B. Long term
Immediate Long term * Perforation (gastric/duodenal) * Bleeding * Obstruction/stricture * Fistula formation * Malignant transformation
31
Management of GORD - lifestyle
_Conservative/lifestyle Measures_ –Diet –Weight loss –Smoking cessation –Meal times/elevating bed
32
**Management of GORD** - medication
_Medication_ * Reviewing potentially exacerbating medications _Meds to relieve symptoms_: * Antacids * PPI’s * H2RA’s
33
**Management of GORD** - surgery
_Surgery:_ Anti-reflux surgery i.e. Laparoscopic ***Nissen Fundoplication*** ***\****fundus of the stomach is wrapped around the oesophagus -\> when stomach contracts releasing its gastric acid content -\> oesophagus closes so the acid cannot irritate it
34
**Pancreatic juice** - content - how much is secreted each day - where does it go?
**Pancreatic juice** Content: amylase, lipase, colipase and other proteases - 1.5 L a day Secreted via pancreas -\> pancreatic duct -\> ampulla of Vater -\> sphincter of Oddi -\> duodenum
35
What's the role of bile acids? How much is secreted?
Bile acids breakdown and dispose of fat and recycle products of haemolysis (e.g. bilirubin and biliverdin) 1-2 L bile secreted a day
36
Where parietal cells are located? What's their role?
Parietal cells -\> located in fundus and body of the stomach **Role:** secrete intrinsically factor and gastric HCl
37
What is the role of chief cells in the stomach?
They secrete pepsinogen, mucin and gastric lipase -\> to digest food components
38
What's the role of H2 receptors and Vagus nerve in the stomach?
* Histamine -\> H2 receptor and vagus nerve (acetylcholine) -\> stimulate acid secretion * Vagus nerve-\> stimulates the hypothalamic nuclei -\> satiety feeling when stomach is distended
39
What do cardia and pyloric regions secrete?
* Cardia and pyloric regions secrete mucus and bicarbonate ions
40
What does antrum of stomach secrete?
antrum stomach -\> gastrin secretion -\> goes via blood stream to parietal cells to stimulate HCl secretion
41
Why does the patient with GORD usually wake up around 2 AM?
* no food buffering of pH (pH is not neutralised) * lowest acidity at about 2am * lying down position may aggravate GORD Patient can wake up with heartburn.
42
What is definition of GORD?
**Gastro-oesophageal reflux disease (GORD)** refers to gastroscopy proven oesophagitis and gastric acid sometimes regurgitates into the mouth
43
Drugs that are common to cause dyspepsia
—NSAID’S —Bisphosphonates —Steroids —Metformin —Calcium antagonists —Theophylline —Nitrates
44
Red flag symptoms for 2 weeks referral for gastroscopy
* Acute GI bleeding * Progressive dysphagia * unintentional weight loss * persistent vomiting * iron deficiency anaemia * epigastric mass * aged over 55 yrs with new persistent dyspepsia
45
Management of dyspepsia algorithms (2) A. New onset - needing referral B. New onset - not needing referral
46
What cellular changes and what type of cancer is involved in ***Barrett's oesophagus***?
_Metaplasia_: squamous epithelium into columnar epithelium _Cancer type:_ oesophageal adenoma
47
Management of Barrett's oesophagus - surveillance - medication - endoscopic intervention
**'** * endoscopic surveillance with biopsies * high-dose ***proton pump inhibitor***: whilst this is commonly used in patients with Barrett's \*the evidence base that this reduces the change of progression to dysplasia or induces regression of the lesion is limited **Endoscopic surveillance** * for patients with metaplasia (but not dysplasia) endoscopy is recommended every 3-5 years **If dysplasia of any grade is identified endoscopic intervention is offered. Options include:** * endoscopic mucosal resection * radiofrequency ablation
48
Side effects of H2 antagonists (Cimetidine, Ranitidine) used for dyspepsia
Can cause: - diarrhoea - headache - rarely rash - liver problems - cimetidine -\> causes gynaecomastia and erectile dysfunction (probably by blocking androgen receptors)
49
***PPI*** - examples - side effects - what does long term use may cause?
***PPI*** _Examples:_ ***omeprazole, lansoprazole*** _Side effects:_ diarrhoea, nausea, vomiting, headache and abdo pain _Long term use_: hyponatraemia, increased risk of C Diff contraction, reduced Mg levels, increased fracture risk
50
What's CLO test?
***C*** ***ampylobacter*** ***like organism test*** * Rapid diagnostic test * Ability of H pylori to secrete the urease enzyme, which catalyse the conversion of urea to ammonia and carbon dioxide \*it is done during gastroscopy -\> gastric mucose is placed onto medium containing urea
51
1st and 2nd line treatment to eradicate H Pylori
**First line** ◦7 days, twice daily course of PPI, Amoxicillin & either clarithromycin or metronidazole \***Allergic to Penicillin – PPI, clarithromycin or metronidazole** **Second line** ◦7-days twice day course of PPI, Amoxicillin & clarithromycin or metronidazole (whihever was not used before) ◦ could use tetracycline or Quinolone ◦**Levofloxacin, PPI & metronidazole – Penicillin allergy**
52
Gastric vs duodenal ulcer
53
Classical signs of pancreatitis
* Classically epigastric pain radiating to the back * Grey-Turner's sign (flank ecchymoses) * Cullen's sign (peri-umbilical ecchymoses)
54
Two most common causes of pancreatitis
80% of causes: - alcohol - gallstones
55
What is used to predict the outcomes of pancreatitis?
* Marker for prognostic severity = CRP (high at 48h --\> bad prognosis) * Modified ***Glasgow*** score = pancreatitis severity scoring system
56
Markers (2) for pancreatitis - how long are they raised for?
* ***Amylase*** = can rise rapidly within 3–6 hours of the onset of symptoms, and may remain elevated for up to five days (normally 3-4 days) * ***Lipase*** = elevated for longer and more sensitive marker
57
Initial imaging in suspected acute pancreatitis
* Initial investigation in acute pancreatitis = USS -\> identification of gallstones * If diagnostic uncertainty = CT
58
Hypocalcaemia and pancreatitis - what does it tell us?
poor prognostic sign in pancreatitis --\> extensive retroperitoneal necrosis
59
Complications of pancreatitis A. before 4 weeks B. after 4 weeks
Before 4w After 4w * Peripancreatic fluid collections * Necrosis * Pseudocyst * Abscess
60
What's Courvoisier's sign?
**Courvoisier's sign:** palpably enlarged gallbladder + nontender + painless jaundice -\> the cause is unlikely to be gallstones \*possible malignancy of the gallbladder or the pancreas
61
Interpretation of AST:ALT * AST:ALT = 1 * AST:ALT \>2.5 * AST:ALT \<1
Aminotransferases (**AST, ALT)** - generally associated with **hepatocellular damage** * **AST: ALT =1** * Associated with ischaemia (CCF and ischaemic necrosis and hepatitis) * **AST: ALT \>2.5** * Associated with Alcoholic hepatitis * Alcohol induced deficiency of pyridoxal phosphate * **AST: ALT \<1** * High rise in ALT specific for Hepatocellular damage * Paracetamol OD with hepatocellular necrosis * Viral hepatitis, ischaemic necrosis, toxic hepatitis
62
What's the role of ALP and GGT?
*ALP,* *γ**GT - generally associated with cholestasis* * **ALP** primarily associated with cholestasis and malignant hepatic infiltration * Marker of rapid bone turnover and extensive bony metastasis * **GGT** sensitive to alcohol ingestion * Marker of Hepatocellular damage but non-specific * Sharpest rise associated with biliary and hepatic obstruction
63
What is Whipple's procedure?
***Whipple's procedure*** = pancreaticoduodenectomy - removal of the head of the pancreas, the first part of the small intestine (duodenum), the gallbladder and the bile duct.
64
The most common pancreatic cancer A. adults B. children
95% of pancreatic cancers are exocrine tumours A. adults: ductal adenocarcinoma B. children: pancreatoblastoma
65
What set of symptoms does need an urgent referral for endoscopy?
**Urgent (2ww endoscopy)** - dysphagia - an upper abdominal mass consistent with stomach cancer - Patients aged \>= 55 years who've got weight loss, AND any of the following: * upper abdominal pain * reflux * dyspepsia
66
**Set of symptoms for non-urgent referral for endoscopy** - all age patient + what symptoms - if a patient is \>=55 + what symptoms
**Non-urgent** Patients with haematemesis **Patients aged \>= 55 years who've got:** * treatment-resistant dyspepsia or * upper abdominal pain with low haemoglobin levels or * raised platelet count with any of the following: nausea, vomiting, weight loss, reflux, dyspepsia, upper abdominal pain * nausea or vomiting with any of the following: weight loss, reflux, dyspepsia, upper abdominal pain
67

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