Dr Alex Timperley FY2 Objectives Aetiology Signs amp symptoms Investigations Management Complications Example cases Background Dyspepsia Dyspepsia Nonspecific group of symptoms related to the upper GI tract ID: 177760
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Slide1
GORD & Peptic ulcers
Dr Alex Timperley FY2Slide2
Objectives
AetiologySigns & symptoms
Investigations
Management
Complications
Example casesSlide3
BackgroundSlide4
DyspepsiaSlide5
Dyspepsia
Non-specific group of symptoms related to the upper GI tract
Differentials;
Functional dyspepsia
GORD
PUDCAGallstonesPancreatitisIBSACS
AAASlide6
Alarm symptoms
GI bleedWeight loss
Dysphagia
Iron deficiency anaemia
Persistent vomiting
Epigastric mass
(Suspicious barium meal)**if any of the above refer for urgent (2ww) endoscopy for patients of ANY ageSlide7
Endoscopy findings;
40% functional/non-ulcer dyspepsia40% GORD
13% PUD
2% gastric cancer
1%
oesophageal
cancerSlide8
GORDSlide9
GORD
‘condition which develops when reflux of the stomach contents causes troublesome symptom/complications’
*dysfunction of the lower oesophageal sphincter
Risk factors;
Hiatus hernia
Pregnancy/obesity
Large mealsSmoking, alcoholDrugs; calcium channel blockers, anticholinergics, nitratesSlide10
Symptoms
‘heartburn’Epigastric or Chest pain
Acid brash & waterbrash
Odynophagia, dysphagia
Extra-oesophageal;
Nocturnal asthma
Chronic coughLaryngitisSlide11
Investigations
ECG; if retrosternal/chest pain
Bloods
OGD; mucosal break or normal (ENRD)
24 hour oophagia pH monitoring +/- manometry
Treatment
Life style changes
Drugs; Antacids, PPIs, H2 antagonists, prokinetic
Surgical; Nissen fundoplicationSlide12
Complications
Oesophagitis
Benign stricture
Barrett’s oesophagus
Barrett’s oesophagus
Normal oesophageal squamous epithelium is replaced by gastric columnar epithelium; metaplasia
Premalignant
~ 40 fold increase risk of adenocarcinomaSlide13
Peptic ulcer diseaseSlide14
Risk factors
H. Pylori
NSAIDs (block PGs that stimulate mucus + HCO)
Alcohol
Severe stress
Smoking
SteroidsZollinger-Ellison syndromeZollinger-Ellison syndromeGastrin secreting adenomaUsually pancreatic
50% malignantSlide15
H. Pylori
Spiral shaped Gram negative urease secreting
bacteria
10-15% of the UK
pop
R
ates increase with agebacterium converts human urea to ammonia to neutralise the acid around itselfAmmonia raises pH locally, around the pH ‘sensors’; reduces somatostatin release (usually inhibits gastrin + histamine realise)….leading to excess acid production
Chronic gastritis
Gastric carcinomaSlide16
Symptoms
AsymptomaticEpigastric pain
- DU; worse when hungry & night
- GU; worse when eating
NauseaWeight loss (GU)Slide17
Investigations
BloodsECG
CXR, AXR
Stool test; H. Pylori antigen
Urea breath test; swallow urea labelled with C13, measure CO2.
Serological IgG for H. Pylori (not for eradication)
OGD; biopsy + urease testSlide18
Management
Lifestyle changesAcid reduction
Eradication therapy - Test + treat; if H. Pylori +ve, triple therapy;
PPI
Clarithromycin
Amoxicillin or metronidazoleSlide19
Complications
PerforationBleeding
Gastric outflow obstruction
MalignancySlide20
Case 1
Sally 49, 2/12 Hx of epigastric discomfort; worse on lying down, bending & especially bad after her am coffee. Her weekly trips to the Indian restaurant have stopped + she has had to change her diet.
Give 2 red-flag symptoms you would ask?
weight loss, dysphagia, melena, symptoms of anaemiaSlide21
b) Name 4 risk factors for GORD
Smoking, ETOH, obesity, pregnancy, hiatus hernia, spicy foods
c) All Ix are normal. Suggest 2 medical Rx for GORD.
Gaviscon (alkali), Ranitidine, Omeprazole, Metoclopramide
d
) Give 2 complications of GORD
Stricture, Barrett’s, CASlide22
Case 2
Greg 78, several months Hx worsening epigastric pain, worse when eating, partly relieved by antacids.
a)What is the most likely diagnosis
Gastric ulcer disease
b)Give 3 causes
H.pylori, NSAIDs, alcohol, smoking, Zollinger-EllisonSlide23
c) Give 2 methods to identify H.pylori
Urea breath test, stool antigen, OGD + histology, serological test for IgG abs
d)What is the Rx for H.pylori?
PPI + clarithromycin + amoxicillin/metronidazole
e)Give 3 complications
Perforation, haemorrhage, CA, pain, GOO, pain, anaemiaSlide24
My hints for finals
Learn pharmacology well!
Practice with patients!!
Practice all exams…including; ankle, ophthalmology, developmental examination, squint!
Its all about the process!!! Don’t worry if you don’t know the diagnosis Slide25
References
oxford handbook of medicine
http://almostadoctor.co.uk
/
complete SAQs for medical finals – Stather, Cheshire et al
.
www.patient.co.ukDyspepsia: Managing dyspepsia in adults in primary care, NICE Clinical Guideline (2004)