1. GORD & Peptic ulcers Dr Alex Timperley FY2

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

3. Background

4. Dyspepsia

5. 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. ‘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 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 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; 1.PPI 2.Clarithromycin 3.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. a)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) Dyspepsia: Managing dyspepsia in adults in primary care