GORD & Peptic
ulcers
Dr Alex Timperley FY2
Objectives
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Aetiology
Signs & symptoms
Investigations
Management
Complications
Example cases
Background
Dyspepsia
Dyspepsia
Non-specific group of symptoms related to the upper GI tract
Differentials;
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Functional dyspepsia
GORD
PUD
CA
Gallstones
Pancreatitis
IBS
ACS
AAA
Alarm symptoms
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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;
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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;
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Hiatus hernia
Pregnancy/obesity
Large meals
Smoking, alcohol
Drugs; calcium channel blockers, anticholinergics, nitrates
Symptoms
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‘heartburn’
Epigastric or Chest pain
Acid brash & waterbrash
Odynophagia, dysphagia
Extra-oesophageal;
• Nocturnal asthma
• Chronic cough
• Laryngitis
Investigations
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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
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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
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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
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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. PPI
2. Clarithromycin
3. Amoxicillin or metronidazole
Complications
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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 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
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
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
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
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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)