Gastro-duodenal disorders

Question 1

Define peptic ulcer disease (PUD)

Answer 1

Gastric and duodenal ulcers

Question 2

What is the commonest cause of peptic ulcer disease?

Answer 2

H. pylori infection (95% of duodenal, 80% of gastric)

Question 3

What type of bacteria is H. pylori?

Answer 3

Gram -ve aerophillic helicobacter

Question 4

How can H. pylori infection be detected?

Answer 4

Urease breath test

Histology

Question 5

Describe the pathogenesis of H. pylori induced peptic ulcer disease

Answer 5

H. pylori converts urea to ammonia ➔ neutralises stomach pH and is toxic to epithelium

Question 6

Outline the treatment for H. pylori

Answer 6

Triple therapy BD for 7 days

• Omeprazole or lansoprazole
• Clarithromycin 500mg
• Amoxicillin 1g

or

• Omeprazole or lansoprazole
• Clarithromycin 250mg
• Metronidazole 400mg

Question 7

How can peptic ulcers be classified?

Answer 7

Gastric ulcers (Type I, body and fundal)
Duodenal ulcers
Gastric ulcers (Type II, prepyloric)
Atypical ulceration

Question 8

Who tends to get gastric ulcers, and where are they most commonly located?

Answer 8

Elderly (M>F 3:1)

Lesser curve of the stomach

Question 9

Name 3 risk factors for gastric ulceration

Answer 9

H. pylori (80%)
High alcohol intake
Smoking
NSAIDs
Reflux of duodenal contents
Normal or low acid secretion
Delayed gastric emptying
Stress

Question 10

Describe the symptoms of gastric (type I) ulceration

Answer 10

Asymptomatic
Epigastric pain (burning shortly after meals)
Weight loss
Anorexia

Question 11

Describe the epidemiology of duodenal and gastric (type II) ulceration

Answer 11

M>F 5:1

Peak age 25-30yrs

Question 12

Name 3 risk factors for duodenal ulceration

Answer 12

H. pylori (90%)
NSAIDs, steroids, SSRIs
High acid secretion
Increased gastric emptying
Smoking

Question 13

Describe the symptoms of duodenal ulceration

Answer 13

Asymptomatic (50%)
Epigastric pain (before meals or at night)
-Relieved by eating

Question 14

Name 2 types of atypical peptic ulceration

Answer 14

Ectopic gastric mucosa in Meckel’s diverticulum

Zollinger-Ellison syndrome: non-beta islet cell gastrinoma of the pancreas

Question 15

Differentiate between gastric and duodenal ulcerations

Answer 15

Gastric: Pain precipitated by food, weight loss, anorexia

Duodenal: Central back pain relieved by food, often occurs at night and early hours of morning

Question 16

How is peptic ulcer disease investigated?

Answer 16

Gastroscopy*
Barium meal
Urease breath test - detect H. pylori
Fasting serum gastrin levels - suspected hypergastrinaemia e.g. ZES
Hypercalcaemia

Question 17

Name 3 complications of peptic ulcer disease

Answer 17

Acute upper GI bleeding
Iron deficiency anaemia
Perforation
Gastric outlet obstruction

Question 18

Outline the management of peptic ulcer disease

Answer 18

Lifestyle: Alcohol and smoking cessation, avoid trigger foods, stress management

Medical: Avoid NSAIDs and aspirin, H. pylori eradication if needed, low-dose PPI or standard-dose H2RA, antacids

Surgical: Pyloroplasty +- selective vagotomy, partial gastrectomy

Question 19

What are the surgical indications for peptic ulcer disease?

Answer 19

Failure to respond to maximal medical treatment
Complications: bleeding, perforation, pyloric stenosis
Gastric outflow obstruction not responsive/suitable for balloon dilatation

Question 20

Name 3 causes of acute upper GI perforation

Answer 20

Duodenal ulceration
Gastric ulceration (usually anterior prepyloric)
Gastric carcinoma
Traumatic injury
Ischaemia (usually secondary to gastric volvulus)

Question 21

Name 3 symptoms seen in acute upper GI perforation

Answer 21

Acute onset upper abdominal pain
-Severe constant pain that worsens with breathing and movement, may radiate to back or shoulders
Prodrome of upper abdominal pain ➔ ulceration
Copious vomiting and distension ➔ volvulus
Prodromal weight loss, dyspepsia, anorexia ➔ carcinoma

Question 22

Name 3 signs seen in acute upper GI perforation

Answer 22

Generalised peritonism: washboard rigidity, guarding, tenderness, Rovsing’s sign
Localised peritonism
Distension
Systemic: mild fever, pallor, tachycardia, hypotension

Question 23

How can GI perforation be confirmed?

Answer 23

Erect CXR for pneumoperitoneum

CT scan

Question 24

Outline the definitive management of upper GI perforation

Answer 24

Duodenal ulcer ➔ Omental patch + H. pylori eradication, partial gastrectomy +- vagotomy if recurrent
Gastric ulcer ➔ Omental patch if prepyloric (type II), local excision and sutured closure if body (type I)
Gastric carcinoma ➔ Partial gastrectomy
Traumatic ➔ Sutured closure
Ischaemic volvulus ➔ Subtotal gastrectomy

Question 25

When is conservative management of upper GI perforation appropriate?

Answer 25

Patient declines surgery Patient unlikely to survive surgery Haemodynamically stable with small perforation (sealed at presentation) and no signs of peritonism

Question 26

Outline conservative management of upper GI perforation

Answer 26

IV PPI Limited oral intake Active physiotherapy H. pylori eradication

Question 27

Describe the epidemiology of gastric cancer

Answer 27

5th commonest cancer in the world | 3rd leading cause of cancer death worldwide

Question 28

Name 3 types of gastric cancer

Answer 28

``` Adenocarcinoma* Leiomyosarcoma GI stromal tumour Carcinoid tumour Lymphoma ```

Question 29

Describe the epidemiology of gastric adenocarcinoma

Answer 29

Commonest age >50s (95% occur in over 55s) | M>F 3:1

Question 30

List 35risk factors for gastric cancer

Answer 30

``` Increasing age esp >45 Male H. pylori Diet: rich in nitrosamines, low in fruit and veg Smoking Chronic atrophic gastritis Family history Blood group A (RR 1.2) ```

Question 31

Name 4 symptoms of gastric cancer

Answer 31

``` Dyspepsia Weight loss, anorexia, and lethargy Abdominal pain Iron deficiency anaemia Upper GI bleeding Dysphagia (uncommon unless involving gastro-oesophageal junction) ```

Question 32

Name 2 signs of gastric cancer

Answer 32

Weight loss Palpable epigastric mass Troisier's sign (palpable left supraclavicular LN) ➔ metastases

Question 33

How is gastric cancer investigated?

Answer 33

FBC and LFTs Endoscopy Barium swallow

Question 34

Where does gastric cancer commonly metastasise?

Answer 34

``` Lungs Liver Lymph nodes Oesophagus (Krukenberg tumour of the ovaries) ``` Indicted by Troisier's sign

Question 35

What is the prognosis of gastric cancer in the UK?

Answer 35

Majority of gastric cancers are metastatic or unresectable upon presentation.

Question 36

Outline the management of gastric cancer

Answer 36

Majority unfit for surgery, treatment is palliative chemo. If deemed curable, treatment depends on staging: - Early: Radical gastrectomy, pre/post-op chemo - Advanced: Pre/post-op chemo