Dyspepsia

Question 1

What do goblet cells secrete?

Answer 1

Mucus (protects stomach lining)

Question 2

What do parietal cells secrete?

Answer 2

Gastric acid (e.g. HCl)

Question 3

What do chief cells secrete?

Answer 3

Pepsinogen (protease precursor)

Question 4

What do D cells secrete?

Answer 4

Somatostatin (inhibits acid secretion)

Question 5

What do G cells secrete?

Answer 5

Gastrin (stimulates acid secretion)

Question 6

What has positive effect on parietal cells?

Answer 6

Histamine, gastrin and ACh –> increases gastric acid production

Question 7

What is ACh released by?

Answer 7

Enteric neuron

Question 8

What is effect of somatostatin?

Answer 8

Inhibitory on gastric acid secretion (parietal cells), histamine and gastrin (G cells)

Question 9

How do proton pump inhibitors and H2 blockers reduce gastric acid secretion?

Answer 9

Inhibit pathways

Question 10

What are the different dyspepsia terms?

Answer 10

1. Dyspepsia with alarm symptoms: Dyspepsia with “red-flag” features
2. Uncomplicated (or simple) dyspepsia: Dyspepsia without “red-flag” features
3. Uninvestigated dyspepsia: Dyspepsia presenting to a physician for the first time
4. Functional (“non-ulcer”) dyspepsia: Dyspepsia, but no structural cause for symptoms at upper GI endoscopy

Question 11

What are the alarm features of dyspepsia?

Answer 11

Weight loss
Dysphagia or odynophagia
Persistent vomiting
Haematemesis or melaena
Palpable epigastric mass
Family history of gastric cancer
Dyspepsia onset over age of 45-55 years

Question 12

What are the potential causes of dyspepsia?

Answer 12

• Gastro-oesophageal reflux disease
• Peptic ulcer
• Gastric cancer

But ~80% of people with dyspepsia will have a normal endoscopy –> This is so-called functional dyspepsia

Question 13

How is dyspepsia with alarm symptoms managed?

Answer 13

Urgent endoscopy (but accuracy poor in predicting upper GI cancer)

Question 14

What are individuals with dyspepsia tested for?

Answer 14

H. pylori (eradication therapy for positives)

Question 15

How do we decide which approach to use for dyspepsia?

Answer 15

1. Prompt endoscopy:
   Is best in terms of effect on symptoms
   But, costs much more per patient
   Not cost-effective
2. “Test & treat” for H. pylori or empirical PPI therefore preferable:
   Effect on both symptoms and costs very similar
   Which to use depends on population prevalence of H. pylori
   If prevalence >10%, “test and treat” preferred

Question 16

Symptoms of peptic ulcer?

Answer 16

• Epigastric pain (May come on after eating, May be relieved by antacids, eating, or drinking milk)
• Epigastric tenderness
• Nausea
• Anorexia
• Weight loss

Question 17

What are the causes of peptic ulcers?

Answer 17

Commonest causes:
H. pylori
Non-steroidals and aspirin

Rarer causes:
Zollinger-Ellison syndrome
Crohn’s disease

Question 18

How often are peptic ulcers present in endoscopies for dyspepsia?

Answer 18

<10%

Question 19

What is H. pylori (Helicobacter Pylori)?

Answer 19

• Causally implicated in peptic ulcer disease: 60% of gastric and 80% of duodenal ulcer
• Classed as a human carcinogen by WHO:
• Strong association with gastric cancer
• 5% of dyspepsia attributable to H. pylori

Question 20

What is eradication therapy for H. pylori?

Answer 20

Proton pump inhibitor (PPI) combined with two antibiotics e.g. amoxicillin, clarithromycin, metronidazole

Question 21

How does H. pylori survive?

Answer 21

Bacterium produces urease:

1. Converts urea to ammonia and water
2. A cloud of ammonia neutralises the acidic pH of the stomach
3. Allows H. pylori to survive

Question 22

How can H. pylori be diagnosed non-invasively?

Answer 22

• Carbon urea breath test
• H Pylori serology
• H Pylori stool antigen test (can also confirm its eradication)

Question 23

How can H. pylori be diagnosed invasively?

Answer 23

• Rapid urease test

- Histological examination of biopsy specimens

Question 24

What are complications of peptic ulcer?

Answer 24

• Perforation (ulcer erodes through stomach or duodenum wall)
• Bleeding
• Gastric outlet obstruction (pyloric stenosis)

Question 25

How can bleeding caused by peptic ulcer be treated?

Answer 25

Endoscopy --> Injection of adrenaline / heat to bleeding vessel) / surgery

Question 26

How is gastric outlet obstruction (pyloric stenosis) treated?

Answer 26

Bypass procedure (surgery)

Question 27

What are the symptoms of peptic ulcer bleeding?

Answer 27

``` Haematemesis Coffee-ground vomiting Melaena Rectal bleeding Tachycardia Hypotension ```

Question 28

As H. pylori prevalence decreases, so does what?

Answer 28

Ulcer incidences