GORD & Peptic ulcersDr 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• CA• Gallstones• Pancreatitis• IBS• ACS• AAA

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

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

GORD

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

Symptoms• ‘heartburn’• Epigastric or Chest pain• Acid brash & waterbrash• Odynophagia, dysphagia

Extra-oesophageal;• Nocturnal asthma• Chronic cough• Laryngitis

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

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

Peptic ulcer disease

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

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

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

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

Management• Lifestyle changes• Acid reduction• Eradication therapy - Test + treat; if H. Pylori +ve, triple

therapy;1. PPI2. Clarithromycin3. Amoxicillin or metronidazole

Complications• Perforation• Bleeding• Gastric outflow obstruction• Malignancy

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.a) Give 2 red-flag symptoms you would ask? weight loss, dysphagia, melena, symptoms of anaemia

b) Name 4 risk factors for GORDSmoking, 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

Case 2Greg 78, several months Hx worsening epigastric pain, worse when eating, partly relieved by antacids.a)What is the most likely diagnosisGastric ulcer disease

b)Give 3 causesH.pylori, NSAIDs, alcohol, smoking, Zollinger-Ellison

c) Give 2 methods to identify H.pyloriUrea 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 complicationsPerforation, haemorrhage, CA, pain, GOO, pain, anaemia

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

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)