GORD/Dyspepsia/PUD/Upper GI Bleeding Flashcards
(150 cards)
1
Q
What are the causes of GORD
A
1) incompetent LOS
2) Poor oesophageal clearance
3) Visceral sensitivity
2
Q
What causes relaxation of LOS
A
Parasympathetic activity - release ACh and substance P
3
Q
What are the symptoms of GORD
A
Heartburn Regurgitation Dysphagia Odynophagia cough Hoarse voice dyspepsia
4
Q
What are the red flag symptoms
A
dysphagia weight loss haematemesis malena anaemia persistent vomiting Palpable mass
5
Q
What are the symptoms for dyspepsia
A
Epigastric pain
postprandial fullness (bloating / belching)
early satiety
6
Q
What are the risk factors for GORD
A
Smoking Alcohol Obesity Family history of GORD pregnancy NSAID Caffeine
7
Q
What exacerbates heart burn
A
After meals
Worse when lying down or bending forward
8
Q
What is odynophagia
A
Painful swallowing
9
Q
What are the complications for GORD
A
Chronic oesophagitis (reflux oesophagitis) Barrett's oesophagus Oesophageal malignancy Reflex stricture Reflux dental erosions Reflux laryngitis syndrome
10
Q
Why should chronic oesophagitis be detected early
A
Because it is reversible
If not treated early, it can develop into Barrett’s oesophagus which is non-reversible and increases risk for oesophageal malignancy
11
Q
Diagnosis of GORD
A
pH studies
Oesophageal manometry
Gastroscopy
12
Q
Who is gastroscopy reserved for in GORD
A
For those patients with red flag symptoms/ considered for surgery/ sympatomatic despite treatment
13
Q
What is the management for GORD (first line)
A
Lifestyle management + full dose PPI
14
Q
What are the lifestyle advices given to patients with GORD
A
avoid eating 2 hours before sleeping smoking cessation decrease alcohol consumption elevate level of head when lying down weight loss if obese
15
Q
What type of foods should be avoided in patients with GORD
A
spicy / sour / caffeine
16
Q
When is H2 receptor antagonist used in GORD
A
If the patient does not respond to PPI
17
Q
What is the full dose of omeprazole
A
40mg once a day
18
Q
Name of surgery given to GORD patients
A
Nissen fundoplication
19
Q
When is surgery for GORD indicated
A
When the patient doesn’t respond to drug treatment
When the patient responds to PPI but wish to solve GORD at once
20
Q
What are the foregut structures
A
Oesophagus stomach liver gall bladder pancreas spleen first half of duodenum
21
Q
What are the 2 causes of dyspepsia
A
Organic causes - use of NSAID / peptic ulcer disease / gastric cancer
Functional dyspepsia - idiopathic
22
Q
What is dyspepsia
A
A term used to describe upper GI tract symptoms
23
Q
How long does dyspepsia usually occur
A
4 or more weeks
24
Q
What should you do if a patient with dyspepsia present with other red flag symptoms
A
Refer them to specialists (suspect malignancy)
25
Management of patients with dyspepsia without red flag symptoms
Lifestyle management + antacids
26
What is the next step management if patients still experience dyspepsia after initial treatment
Suspect H. pylori -> test for H.pylori
If positive -> antibiotics + PPI
If negative -> if more than 55 years old -> referral
If negative -> if less than 55 years old -> PPI (treat as functional dyspepsia)
27
What medication should be stopped before H. pylori testing
Proton Pump inhibitors
28
What are the drugs used against H. Pylori
amoxicillin + clarithromycin + PPI (triple therapy)
29
What drugs are used against H. pylori if the patient is penicillin allergic
metronidazole + clarithromycin + PPI
30
What may severe GORD cause
aspiration pneumonia
31
What is Barett's oesophagus
When the oesophageal mucosa undergoes metaplastic change from stratified squamous cells to simple columnar cells
32
What are the types of oesophagitis
Acute oesophagitis
Chronic oesophagitis (reflux oesophagitis)
Allergic oesophagitis
33
Which type of oesophagitis is rare
Acute oesophagitis
34
Which group of people is susceptible to infective acute oesophagitis (AO due to infection)
Immunocompromised individuals
35
What infections can cause acute oesophagitis
Herpes
CMV
candidiasis
36
Cause of reflux oesophagitis
Inflammation due to reflux of low pH gastric content
37
What are the changes in mucosa for reflex oesophagitis
basal hyperplasia and lengthening of papilla
| Increase in intraepithelial neutrophils, lymphocytes and eosinophils
38
What causes basal hyperplasia in reflux oesophagitis
low grade inflammation causes an increase in cell desquamation -> increase in proliferation to compensate
39
What are the complications of reflux oesophagitis
ulceration
stricture
Barrett's oesophagus
40
Timeline of chronic oesophagitis
Reflux oesophagitis -> Barrett's oesophagus (metaplasia) -> low grade dysplasia -> high grade dysplasia
41
What does Barrett's oesophagus increase the risk for
Oesophageal adenocarcinoma, carcinoma
42
What are the treatments for low grade dysplasia (Barrett's)
PPI + endoscopy surveillance every 6 months
43
What are the treatments for high grade dysplasia (Barrett's)
Endoscopic resection - radiofrequency ablation / endoscopic mucosal resection / endoscopic submucosal resection
44
Features of allergic oesophagitis
Large numbers of eosinophils
| Not due to acid reflux
45
Risk factors for allergic oesophagitis
Family history of allergies
asthma
male
common in young people
46
What is the treatment for allergic oesophagitis
Steroids
| Montelukast
47
Types of oesophageal cancer
Adenocarcinoma
| Squamous cell carcinoma
48
2 types of gastric adenocarcinoma
Intestinal
| DIffuse
49
Where is the most common site of oesophageal cancer
lower end of oesophagus
50
Which oesophageal cancer is Barrett's oesophagus most associated to
Adenocarcinoma
51
Risk factors for oesophageal adenocarcinoma
```
Barrett's oesophagus
GORD
obesity
smoking
age
male
```
52
Risk factors for oesophageal squamous cell carcinoma
```
Oeosphagitis
Hot drinks
Low intake of fibres and fruits
age
smoking
alcohol
GORD
Achalasia
```
53
Symptoms of oesophageal cancer
```
Progressive dysphagia
Heart burn
Vomiting / regurgitation
haematemasis
Weight loss
Anorexia
Hoarse voice
```
54
How do oesophageal tumours invade other structures
Direct local invasion - e.g. to trachea
Through blood
Lymph nodes
55
Diagnosis of oesophageal cancer
endoscopy and take biopsy
CT scan to stage the cancer
PET scan to check for metastases
56
Management of oesophageal cancer
If early (Barrett's, high grade dysplasia) - endoscopic resection
If intermediate (no local invasion / distant metastases / lymph nodes)
- chemotherapy + surgery
- neoadjuvant chemoradiotherapy + surgery
57
What is the surgery for oesophageal cancer called
Oesophagectomy
58
Types of gastritis
Acute gastritis
| Chronic gastritis
59
Causes of chronic gastritis
Bacterial
Chemical
Autoimmune
60
Which pathogen is the most common cause of bacterial gastritis
H. pylori
61
How does H. pylori cause chronic gastritis
Induces release of IL-8 , causing inflammatory response and chronic inflammation if not cleared
62
What is IL-8
A pro-inflammatory cytokine
63
What type of bacteria is H.pylori
Gram negative
| Spiral shaped bacilli
64
Transmission of H. pylori
Oral to oral
| Faecal to oral
65
When do people usually become infected with H. pylori
As a child / young adulthood
66
What conditions does chronic gastritis increase the risk for
Peptic ulcer disease
gastric adenocarcinoma
gastric lymphoma
67
What causes chemical chronic gastritis
NSAID
Alcohol
Bile reflux
68
What causes autoimmune gastritis
Presence of anti-parietal and anti-intrinsic factors antibodies
69
What are intrinsic factors for
for absorption of vitamin B12
70
What are the signs of vitamin B12 deficiency
Macrocytic (abnormally large RBC)
Pernicious anaemia
SACDC
71
What is SACDC
when myelin sheath starts to wear away
72
Types of gastric cancer
adenocarcinoma
| lymphoma
73
Types of gastric adenocarcinoma
Intestinal
| diffuse
74
Features of intestinal gastric adenocarcinoma
- better prognosis
- accounts for most of the non-cardia tumours
- increased level of HER2 protein
- most associated with H. pylori infection
75
Features of diffuse gastric adenocarcinoma
- poorer prognosis
- associated with genetic changes in CDH1 gene
- more in young patients
76
What are HER2 proteins
growth-promoting proteins; associated with breast cancer and gastric cancer
77
Which cancer is CDH1 gene mutation also associated to
Lobular breast cancer
78
Symptoms of gastric cancer
```
weight loss
gastric reflux
vomiting +/- haematemesis
dyspepsia
malena
```
79
How may H.pylori infection lead to gastric adenocarcinoma
H. pylori infection -> chronic gastritis -> intestinal metaplasia (glandular cells become intestinal cells) -> dysplasia
80
Type of epithelium in duodenum
simple columnar cell with crypts of lieuberkuhn between villi
81
Type of epithelium in stomach
simple columnar cells with gastric glands
82
Type of epithelium in oesophagus
stratified squamous cells
83
What causes gastric lymphoma
Due to H.pylori
Continuous inflammation induces an evolution into a clonal B cell proliferation -> low grade lymphoma -> high grade lymphoma
84
What lymphoid tissue does gastric lymphoma affect
mucosa associated lymphoid tissue (MALT)
85
Where is MALT found
Lamina propria (where the mucosal immunity is)
86
Metastases of gastric cancer
Lymph nodes of greater omentum
through blood - to liver first
transcolaemic - to organs in peritoneal cavity , ovaries
87
Can low grade gastric lymphoma disappear completely
Yes, if H. pylori is eradicated
88
Management of early gastric cancer
Endoscopic resection - radiofrequency ablation / endoscopic mucosal resection / endoscopic submucosal resection
89
Management of intermediate gastric cancer
Perioperative chemotherapy (FLOT regime) + surgery
90
Management of late gastric cancer
Chemotherapy + targetted molecular therapy (e.g. targetting HER2)
91
Types of peptic ulcer
Gastric ulcer
| Duodenal ulcer
92
4 parts of duodenum
Superior
Descending
Inferior
Ascending
93
Where does duodenal ulcer usually occur
Superior part of duodenum
94
Compare between gastric and duodenal ulcer
```
Gastric
- equal gender distribution
- incidence increases with age
Duodenal
- associated with H. pylori
- more common in males
- more common than gastric ulcer
```
95
Causes of peptic ulcer
H. pylori
| NSAID
96
What conditions are H. pylori associated to
Chronic gastritis
Gastric intestinal adenocarcinoma
Gastric lymphoma
Peptic ulcer disease (esp. duodenal)
97
How does H. pylori cause peptic ulcers
1) cause hypergastrinemia by increasing gastrin production and reducing somatostatin
2) damages mucous producing goblet cells and epithelial cells
3) this causes an increase in gastric acid secretion and decrease in protective mucous
4) allows H. pylori to enter stomach lining and damage deeper layers
5) acid enters, causing ulcer
98
Which cell produces gastrin
G cells
99
When is gastrin normally released
In response to distention of stomach
presence of amino acids / peptides
increase in pH
100
Does everyone with H. pylori infection develop into peptic ulcer
No, only 20-40%
101
How does NSAID cause peptic ulcers
NSAID inhibit COX1, COX2, PGE2 (prostaglandin E2)
COX1 and COX2 produce PGE2
PGE2 stimulates mucous production and inhibits gastric acid secretion
so decrease in COX1, COX2, PGE2 leads to increase in acid secretion and decrease in protective mucous
102
Examples of NSAID
aspirin
ibuprofen
naproxen
103
What type of NSAID is aspirin
non-selective; blocks COX1 and COX2 but weakly more selective to COX1
104
Use of aspirin
as an antiplatelet to prevent arterial thromboembolism
105
Where does H. pylori usually colonize
antrum
106
Symptoms of peptic ulcer
Epigastric pain
dyspepsia
nausea
heartburn
107
Complications of peptic ulcer
```
perforation
upper gi bleed
gastric outlet obstruction (prevents gastric emptying)
Duodenal obstruction
Peritonitis
```
108
Which artery is usually eroded by duodenal ulcers
gastroduodenal artery
109
Diagnosis of peptic ulcer
H. pylori testing
Bloods
Endoscopy
110
Tests for H. pylori
Stool antigen test
Urease test
serology
culture
111
Which 2 tests are the most common for H.pylori testing
Stool antigen test
| Urease test
112
How is urease test done and why is it done
done by taking a biopsy via endoscopy
| It is done because H. pylori produces urease to increase pH of its environment
113
What drug should be taken off from patients before H.pylori testing
PPI because PPI can give false negative results
114
Why is serology not really used for H.pylori
Because it is not accurate with increasing patient age
115
Management of peptic ulcer
Lifestyle management + Drug treatment
116
What are the lifestyle advices for peptic ulcer disease
Avoid spicy / sour foods / caffeine
decrease alcohol consumption
smoking cessation
stop using NSAID
117
What are the drug treatments
```
If H.pylori positive
- amoxicillin + clarithromycin + PPI (omeprazole)
If penicillin allergic
- metronidazole + clarithromycin + PPI
If H.pylori negative
- PPI for 4-8 weeks
```
118
What dosage of PPI should be given to PUD patients
full dose ; omeprazole - 40mg a day
119
Why is there poor compliance to triple therapy
Side effects: nausea, diarrhea
120
Drug treatment if first line H.pylori eradication fails
amoxicillin + clarithromycin + tetracycline + PPI
If penicillin allergic
metronidazole + tetracycline / levofloxacin + bismuth + PPI
121
Follow up management for PUD
Gastric ulcer - endoscopy after 6 - 8 weeks of PPi
duodenal ulcer - if no more symptoms - low dose PPI ; if symptoms persist - suspect malignancy / antibiotic resistance / rarer causes
122
What are the causes of acute upper GI bleed
```
peptic ulcer disease
gastric erosions
varices
oesophagitis
malignancy
Mallory weiss tear
```
123
Which peptic ulcer disease most commonly causes upper GI bleed
duodenal ulcer
124
What is mallory weiss tear
tear of lower oesophagus due to violent coughing or vomiting
125
Symptoms of Upper GI bleed
Haematemesis
Malena (black, tarry stool)
signs of shock
syncope / confusion
126
What is the 100 rule
```
Represents symptoms that indicate poor prognosis for upper gi bleed
HR = <100 bpm
systolic BP = <100mmHg
Hb = <100 g/l
age = > 60
comorbidities
```
127
What does systolic hypotension mean for shock
There has been loss of more than 30% of total blood volume, causing compensatory mechanisms to not function anymore
128
Why should you keep an eye on young patients with upper GI bleed
They can compensate well initially but crash suddenly
129
Upper GI bleed patients on beta blockers
will not show signs of tachycardia
130
Upper GI bleed patients with diabetes
Poor autonomic response so may not show the signs
131
Management of Upper GI bleed
Resuscitation
Endoscopy
treat underlying cause
132
What are the resuscitation methods for upper GI bleed
ABCDE
IV fluid
blood transfusion
133
Management for bleeding peptic ulcer
endoscopic treatment to attempt to stop bleeding
IV omeprazole
134
What are the endoscopic treatments for bleeding peptic ulcers
Injection of adrenaline + Heater probe coagulation
Clips +/- adrenaline
Haemospray
135
What solution of adrenaline should be used for injection in bleeding peptic ulcer
1 in 10000
136
Effect of adrenaline
reduces blood flow to the area
137
How does haemospray stop the bleeding
Soaks up water in the area, increasing concentration of coagulation factors
forms a barrier
138
How many times should endoscopic treatment be attempted before surgery in bleeding peptic ulcers
2 times
Endoscopy -> IV omeprazole -> Endoscopy
139
Post bleeding PUD management
Eradication of H. pylori if indicated
| oral PPI
140
What causes oesophageal varices
Portal hypertension (hypertension in the liver)
Portal hypertension makes it harder for blood to enter the liver then IVC so blood finds another way to flow back, which is through oesophageal vessels
This causes oesophageal vessels to dilate and become fragile
141
What is the common cause of portal hypertension
Cirrhosis
142
Resuscitation for bleeding oesophageal varices
ABCDE
| IV fluids and blood transfusion
143
Why should central venous pressure be monitored in bleeding oesophageal varices
It directly reflects the portal pressure. Needs to be monitored while giving fluid and blood to avoid raising the portal pressure
144
How to stop the bleeding oesophageal varicse
Endoscopic variceal ligation (banding)
Sengstaken Blakemore tube
TIPSS
145
Which scoring methods are used to assess the severity of haemorrhage
Blatchford
| Rockall
146
Effect of IV terlipressin
Causes sphlanchic vasoconstriction (vasoconstriction of sphlanchic vessels - SMA / IMA ..etc) to decrease blood flow
147
When is TIPSS indicated
If endoscopic variceal ligation is ineffective
148
When is Blatchford scoring used
After resuscitation of (first line assessment recommended by NICE)
149
When is Sengstaken Blakemore indicated
If endoscopic haemostasis cannot be achieved or endoscopy is not availble
But this is not a definite treatment so if endoscopy fails, use TIPSS instead of this
150
What is the first line method to stop variceal bleeding
Endoscopic variceal ligation (banding)
