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GORD & Peptic ulcers

GORD & Peptic ulcers. Dr Alex Timperley FY2. Objectives. Aetiology Signs & symptoms Investigations Management Complications Example cases. Background. Dyspepsia. Dyspepsia. Non-specific group of symptoms related to the upper GI tract Differentials; Functional dyspepsia GORD PUD

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GORD & Peptic ulcers

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  1. GORD & Peptic ulcers Dr Alex Timperley FY2

  2. Objectives • Aetiology • Signs & symptoms • Investigations • Management • Complications • Example cases

  3. Background

  4. Dyspepsia

  5. Dyspepsia Non-specific group of symptoms related to the upper GI tract Differentials; • Functional dyspepsia • GORD • PUD • CA • Gallstones • Pancreatitis • IBS • ACS • AAA

  6. Alarm symptoms • GI bleed • Weight 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 age

  7. Endoscopy findings; • 40% functional/non-ulcer dyspepsia • 40% GORD • 13% PUD • 2% gastric cancer • 1% oesophageal cancer

  8. GORD

  9. 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 meals • Smoking, alcohol • Drugs; calcium channel blockers, anticholinergics, nitrates

  10. Symptoms • ‘heartburn’ • Epigastric or Chest pain • Acid brash & waterbrash • Odynophagia, dysphagia Extra-oesophageal; • Nocturnal asthma • Chronic cough • Laryngitis

  11. 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 fundoplication

  12. 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 adenocarcinoma

  13. Peptic ulcer disease

  14. Risk factors • H. Pylori • NSAIDs (block PGs that stimulate mucus + HCO) • Alcohol • Severe stress • Smoking • Steroids • Zollinger-Ellison syndrome Zollinger-Ellison syndrome • Gastrin secreting adenoma • Usually pancreatic • 50% malignant

  15. H. Pylori • Spiral shaped Gram negative urease secreting bacteria • 10-15% of the UK pop • Rates increase with age • bacterium converts human urea to ammonia to neutralise the acid around itself • Ammonia raises pH locally, around the pH ‘sensors’; reduces somatostatin release (usually inhibits gastrin + histamine realise)….leading to excess acid production • Chronic gastritis • Gastric carcinoma

  16. Symptoms • Asymptomatic • Epigastric pain - DU; worse when hungry & night - GU; worse when eating • Nausea • Weight loss (GU)

  17. Investigations • Bloods • ECG • 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 test

  18. Management • Lifestyle changes • Acid reduction • Eradication therapy - Test + treat; if H. Pylori +ve, triple therapy; • PPI • Clarithromycin • Amoxicillin or metronidazole

  19. Complications • Perforation • Bleeding • Gastric outflow obstruction • Malignancy

  20. 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 anaemia

  21. 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, CA

  22. 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-Ellison

  23. 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, anaemia

  24. 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

  25. References • oxford handbook of medicine • http://almostadoctor.co.uk/ • complete SAQs for medical finals – Stather, Cheshire et al. • www.patient.co.uk • Dyspepsia: Managing dyspepsia in adults in primary care, NICE Clinical Guideline (2004)

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