Upper GI

Question 1

Why do people usually get Upper GI conditions?

Answer 1

Usually due to ACID:

• Hence acid being in the wrong location (e.g. reflux to the oesophagus or over flow to the duodenum)
• Over production of acid
• Faults with protective mechanisms (e.g. if sphinters are not working properly etc)
• Dyspepsia (indigestion, discomfort in your upper abdomen)

Question 2

What are the aims of treatment for upper GI conditions?

Answer 2

• Prevent acid from relocating
• Reduce acid production or neutralise it
• Remove cause of the underlying problems

Question 3

What factors aid in susceptibility of gastric cancer?

Answer 3

• More common in smokers and drinkers (due to reduction in protective mechanisms)
• Related to H.Pylori infection
• Increased salt intake (changes in diet)
• Less common in vegetarian
• Age (mainly over 75) and sex (males rate is double than female) are risk factors in gastric cancer

Question 4

What is the pathophysiology of gastric (stomach) secretions?

Answer 4

The Chief cells and mucus glands secrete pepsinogen. Pepsinogen breaks down proteins. For the activation of pepsinogens and pepsin activity we need acid conditions in the stomach, so we need a pH of less than 3 (very acidic).

Parietal cells secrete hydrochloric acid (gastric acid) and intrinsic factor. Parietal cells are located in the glands found in the Fundus (upper part of the stomach). HCl activates pepsinogen and kills bacteria that enters the stomach.

We need intrinsic factor for B12 absorption from the small intestines. Without it we can get problems with RBC production.

Question 5

What 3 things is acid secretion via parietal cells controlled by? (food)

Answer 5

1. Cephalic Phase - Nervous control (brain) - parasympathetic
   - Thought, smell, taste or sight of food
   - Gastric secretion is under nervous control, its the parasympathetic nervous system and occurs via the vagus nerve - and get a production of ACh
   - About 30% of acid production happens before food enters the stomach, due to the thought of food, smell, taste or sight etc - nervous control which prepares the body for eating.
2. Gastric phase - Local control (stomach) - parasympathetic
   - Distension of stomach and chemical make up and the gastric contents are stimulating receptors and release of gastrin which is involved in the production of stomach acid.
   - Around 50-60% of acid is released during this phase.
3. Intestinal phase - hormonal control (small intestines)
   - Food in duodenum (chyme) causes secretion of somatostatin which inhibits acid production - hence a negative feedback mechanism which inhibits vagal stimulation of the stomach

These phases can overlap and occur simultaneously.

Question 6

What is the physiology of gastric secretion?

Answer 6

There’s secretion of H+ ions from the parietal cells which is stimulated by histamine, gastrin and acetylcholine (ACh).

Gastrin:
- Gastrin is produced in response to vagal stimuli, a rise in pH (hence decrease in acidity - negative feedback) and ingested protein and calcium (chemical stimulation from food contents).
- Gastrin stimulates the growth of gastric mucosa hence has a protective function

Within the parietal cells, H+ is produced via the proton/protein pump, and theres exchange in H+ and K+ in the gastric lumen.

Question 7

What is gastric cytoprotection?

Answer 7

It is an important protective feature otherwise we would end up essentially eating ourselves - digesting our stomach from inside out.

AUTO-DIGESTION of the stomach is prevented by a thin layer above the mucosa surface.

• We have this complex matron of bicarbonate and mucus around pH 7 (neutral) and this is called the unstirred layer.
• So in this layer, blood flow inside the mucosa removes H+ ions that have diffused back from the lumen. Hence the build up of concentrated acid is removed and taken away by the submucosal blood flow.

If someone goes into shock and theres low blood pressure and poor blood perfusion, hence causing a decrease in blood flow, then the protection mechanism is disrupted and can lead to:
- Necrosis of the mucosa and therefore we get an increase in H+ concentration and decrease in oxygen levels.
- Stress ulcer in shocked or critically ill patients

Question 8

How does prostaglandins play a role in gastric cytoprotection?

Answer 8

Prostaglandins such as Somatostatin, increases mucus secretion, increase in bicarbonate production, increase in blood flow and DECREASE in acid production.

NSAIDs interfere with prostaglandin synthesis via the COX pathway. Hence why patients who are prescribed NSAIDs are more likely to suffer with ulcers etc hence why they need additional protection if they’re gonna be on NSAIDs longterm as we’re taking away some of the body natural protection.

Question 9

How does Oesophageal protection play a role in gastric cytoprotection?

Answer 9

The lower oesophageal sphincter is in a permanent state of tonic contraction and it relaxes to allow passage of food. Hence this part is kind of sealed of unless when were passing food into the stomach.

May experience small amount of reflux which is occasionally normal (may be due to food, alcohol etc).
- But if it becomes a regular thing then it might suggest a fault here.

Question 10

What is gastritis?

Answer 10

Gastritis is inflammation of the gastric mucosa. It is an inflammatory response to the bacteria H.Pylori. It can lead to a chronic gastritis, peptic ulcer disease and ultimately to gastric cancer.

Symptoms include dyspepsia, indigestion, burning stomach pain or a feeling of sickness etc.
But most patients are asymptomatic.

Gastritis is a precursor, is precedes (comes before) ulceration.

Question 11

What is H.Pylori bacteria? (Helicobacter Pylori)

Answer 11

H.pylori bacteria are adapted to surviving in acidic environments. They protect themselves by hydrolysing urea to produce ammonia, effectively buffer H+ ions - so they can survive in acidic environments by creating a buffer around themselves.

They colonise beneath the mucus layer in the antrum -> Leads to chronic inflammation -> Decrease in somatostatin -> Increased gastrin production -> INCREASE IN ACID PRODUCTION

So this INCREASE in acid production leads to CHRONIC INFLAMMATION in the duodenum, and H.Pylori moves (follows the acidic site) into the duodenum and reduces local protection -> DUODENAL ULCER

H.Pylori causes GASTRITIS throughout the stomach, which leads to DAMAGED cells and DECREASED acid production and DECREASED mucosa (decrease in protection), which long term leads to Gastric Ulcer and GASTRIC CANCER

Question 12

How do we identify if patient has H.Pylori?

Answer 12

Can do identified breath test or stool antigen test:

1. Give patient radio labelled urea and CO2 produced in breath - UREA BREATH TEST
   - As H.Pyloris secrete ureas to create that buffer and the urea and the CO2 can be radio labelled.
2. Stool test
   - Stools need to be stored at -20 degrees before testing.
   - Individual will need to avoid antibiotics for weeks before the test to avoid false negatives

Patients with duodenal ulcers have over 90% H.Pylori present

Patients with Stomach (gastric) Ulcer have around 70-80% H.Pylori present.

Eradication (removal) of infection improves healing rates and reduces relapse rates.

Eradication (removal) IS A CURE for H.Pylori associated ulcers.

Question 13

What is peptic ulcer disease (PUD)?

Answer 13

This is your gastric ulcers and duodenal ulcers.

Factors causing peptic ulcers:
- Age
- Gastric hyper secretion
- Reduced mucosal resistance - smokers (less natural protection)

Duodenal Ulcer - HIGHER THAN AVERAGE ACID OUTPUT

Gastric Ulcer - LOWER MUCOSAL RESISTANCE

Question 14

What are the risk fairs for Peptic Ulcer disease?

Answer 14

1. H.Pylori is the major cause of PUD
2. NSAIDs are common cause of PUD - may be due to self medication
3. More common in smokers:
   - Increase number of cigarettes in a day INCREASES peptic ulcer prevalence
   - Rate of healing slower in smokers and relapse twice as common
4. Genetic link with people with parents with PUD - 3 times more likely
5. Salty diets

Question 15

What drugs induce Dyspepsia?

Answer 15

1. NSAIDs, risks increased further if:
   - Elderly
   - History of peptic ulcer
   - Smoker
2. Sulfasalazine
3. Iron preparations
4. Corticosteroids
5. Potassium (MR forms)
6. Bisphophonates
   Etc.

1/3 of patients with RA suffer with PUD
- Ibuprofen is the safest NSAID so hence suggested if NSAID is required

Patients on low dose aspirin is also at increased risk.

NSAIDs inhibit prostaglandin synthesis via COX pathway:
- COX-1 Pathway -> Protective prostaglandins (e.g. GI mucosa)
- COX-2 Pathway -> Inflammatory prostaglandins

SAFER NSAIDs HAVE LESS INHIBITORY EFFECT ON COX-1

Celecoxib (COX 2 selective) very little COX-1 activity

Question 16

What are the signs and symptoms of Peptic ulcer disease?

Answer 16

1. Gastric symptoms:
   - Pain of eating
   - Epigastric pain (below the sternal and above the navel (belly) )
2. Duodenal symptoms:
   - Localised pain occurring between meals and at night
   - Relieved by eating (fatty foods may aggravate)
3. Other symptoms for both
   - Bloating, nausea, anorexia (eating disorder) and belching (burping)
   - Haematemesis (vomiting of blood) and melaena (dark sticky faeces containing partially digested blood) present if bleed occurred

Question 17

What is GORD?

Answer 17

Gastro-oesophageal reflux disease.

Condition where acid contents of the stomach leaks into the oesophagus.

Caused by gastric juice and occasionally duodenal contents in oesophagus

The defective lower oesophageal sphincter is the most important abnormality.

Question 18

What are the factors that can lower the pressure of the lower oesophageal sphincter?

Answer 18

1. Dietary factors (larger meals, fatty meals, energy rich foods etc)
   - Fat, chocolate, caffeine, alcohol
   These cause the sphincter to relax allowing the contents of the stomach to pass through to the oesophagus. This reflux causes symptoms of heartburn - burning sensation in your food pipe.
2. Cigarette smoking
3. Endocrine factors
   - High levels of oestrogen and progesterone
   HRT and oral contraceptive has been associated with GORD. Pregnant women experience heartburn symptoms
4. Drugs

Question 19

What is hiatus hernia?

Answer 19

When part of the stomach is pushed up through the diaphragm.

This prevents the lower oesophagus sphincter from closing properly, allowing stomach contents to escape up into the oesophagus.

Hiatus Hernia very prevalent

Majority of patients asymptomatic

May present as GORD

Question 20

Which drugs lower the lower oesophageal sphincter pressure?

Answer 20

• Anticholinergics
• Beta-2 agonists
• CCBs
• Diazepam
• Nitrates
• Alcohol
• Progesterones
• Oral contraceptives
• Theophylline

Question 21

Which drugs can cause oesophageal ulcerations?

Answer 21

• NSAIDs
• Bisphosponates
• Clindamycin
• Clotrimoxazole
• Doxycycline
• Potassium
• Theophylline
• Tetracycline

Hence why we ensure patients wash down tablets with a full glass of water so medications as such do not have prolonged contact with the oesophagus if not it can cause ulcerations.

Antibiotics are responsible for 50% of drug induced oesophagitis.

Question 22

What symptoms are seen in patients with GORD?

Answer 22

• Motility of oesophagus may be abnormal in patients with GORD
• Gastric emptying delayed in 40% of patients with GORD
• Main symptom is heartburn
• May also suffer dysphagia or odyhophagia (pain on swallowing)
• Complications of gord can include Barretts oesophagus (risk factor for cancer, and it is when the cells lining the oesophagus change to resemble that of the intestine), haemorrhage, stricture
• Endoscopy only method of diagnosis (camera tube)

Question 23

What is functional dyspepsia?

Answer 23

This is dyspepsia that has been investigated, so patients who have symptoms but no evidence of organic disease detected.

May be due to hypersensitivity to gastric acid.

Occurs in 4 groups of people:
- Ulcer like symptoms
- Dysmotility like symptoms
- Reflux like symptoms - ongoing presentation for heartburn etc
- Non-specific set of symptoms

Eradicate (eliminate) H priority if present.

Neutralise acid or prevent acid production (symptomatic relief)

Periodic monitoring - may be a precursor

Question 24

What is done in terms of management of stomach and duodenal ulcers?

Answer 24

1. Identify and eradicate (eliminate) H.Pylori bacteria

Therapy for H.Pylori would include 7 day triple therapy, which involves a proton pump inhibitor and 2 antibiotics e.g. amoxicillin and clarithromycin.

2. Stop inappropriate therapy

Such as NSAIDs. In these cases a Proton pump inhibitor or H2 antagonist for around 8 weeks. Once the ulcer is healed, we check for H.Pylori and if H.Pylori is present, we subsequently offer that eradication therapy as well.

3. Reduce acid production to reduce gastritis and enable mucosa to repair
   - Block H2 (H2 antagonist) or Proton Pump inhibitor for 4-8 weeks

If the patient presents later and the ulcer is unhealed, this may be due to:

• Adherence:- With triple therapy for example have they completed the course, taken the medications appropriately for example.
• NSAIDs:- Have they stopped the NSAIDs or have carried on with them due to pain or they’ve stopped the prescribed NSAIDs but they’ve been using OTC NSAIDs etc.
• Other disease present:- E.g. Chrohns disease or malignancy.

Question 25

What is the management of GORD?

Answer 25

1. Remove the causative agent - Anything that lowers the lower oesophageal sphincter pressure. - Non-pharmacological advice 2. Use of rafting products - E.g. Gaviscon They reduce acid production enabling the recovery of the oesophageal mucosa

Question 26

What non-pharmacological management advice is given for GORD?

Answer 26

1. Diet - Eat small meals (less pressure in the stomach hence preventing reflux) - Avoid food which lowers the lower oesophageal sphincter pressure (e.g. chocolate, alcohol, fatty rich foods, caffeine etc) - Avoid fatty foods - slows gastric motility which can aggravate symptoms 2. Avoid eating within 4hrs and drinking within 2hrs of going to bed 3. Avoid drugs which lower the LOS pressure 4. Avoid tight fitting clothes (lessen pressure) 5. Lose weight 6. Attention to posture - Avoid bending from the waits, instead better to square (knees) hence reducing pressure on the stomach contents. - Do not lie down after eating - As this increases exposure of food to the oesophageal lining - which will aggravate the inflammation and make symptoms worse. - Nocturnal heartburn (night time) symptoms raise the head of the bed (15-23cm) 7. Stop smoking 8. Reduce alcohol intake

Question 27

What can be done for the management of dyspepsia?

Answer 27

For symptomatic management: - Neutralise acid - Reduce flatulence (gas production) - Prevent dislocation of acid All treatments are available over the counter.

Question 28

What are antacids and how are they used for the treatment of upper GI conditions?

Answer 28

Antacids are salts such as aluminium, magnesium, sodium and calcium salts. - When these are taken they combine with stomach acid/HCl and a carbon dioxide bi product is released. - This neutralises the acid - Gives a sense of relief - eructation (may bring up that gas like burp) - Increase in LOS pressure - bought about by gastric alkalisation - Mucosal protection - through the stimulation of prostaglandin synthesis Antacids have an effect on gastro release by increasing gastro release in response to the increased pH (more alkali) after taking the antacid and this results in an acid rebound. Available in tablets and liquid form but liquids work quicker but shorter acting - but liquids have a greater neutralising capacity because of their smaller particle size and surface area. However tablets are more convenient - chew/break them up for best effect. There's rapid relief of symptoms of heartburn and indigestion. Best taken 1hr after a meal, when gastric emptying is slow so they remain the stomach for longer. Avoid long term, frequent, continuous use - Only relieves symptoms in the short term, rather than prevention Examples: Rennies

Question 29

What are the side effects of antacids?

Answer 29

- Constipation with aluminium based salts - Diarrhoea with magnesium based salts - Aluminium binds to phosphate in the gut which can lead to Osteoporosis - Aluminium may be absorbed which can lead to Neurotoxicity. - You can get acid rebound, rebound gastric acid secretion with prolonged use. - Be careful around sodium content and try avoid excessive sodium In patients with hypertension and CVD problems Important drugs interactions to consider, for example: - Enteric coatings on certain medications. If we lose that protective effect, the drug will be destroyed by the stomach contents. - Reduced absorption - you may get binding of things such as tetracycline and iron based tablets Antacids are generally safe in pregnancy - Be mindful of sodium content as it can contribute to fluid retention.

Question 30

What are Alginates and how are they used for the treatment of upper GI conditions?

Answer 30

Alginates: - Most common alginate is Gaviscon - The alginate is combined with an antacid Mechanism of action - When alginates hit the contents of the stomach, they form a high pH viscid mass (raft) and this traps air bubbles and that's why they are formulated with antacids and that reaction results in a release of CO2 that is trapped in the raft. That then floats on top of the stomach contents and protects the oesophagus from contact of the stomach contents if they are to rise to the oesophagus through reflex

Question 31

What is Dimethicone and how are they used in the treatment of Upper GI conditions?

Answer 31

Dimethicone is an anti-foaming agent. - Available as a chewable tablet - It works by reducing surface tension of intragastric air bubble - Hence it breaks down that bubble and allows the bubbles to escape and reduces that feeling of bloating

Question 32

How are H2 receptor antagonists used in the treatment of Upper GI conditions?

Answer 32

Examples :- Cimetidine, Famotidine, Nizatidine and Ranitidine They work by competing for the H2 receptor on the parietal cells. They have a longer duration/onset of action compared to antacids. A powerful stimulus such as a large meal will override that blockade on the H2 receptor. Peptic Ulcer Disease (PUD): - Theres a higher healing rate if you use a H2 receptor antagonist but no reduction in relapse, as we need to consider whether H.Pylori has been eradicated. GORD: - You can treat with a H2 receptor antagonist but only use if theres an inadequate response to PPI. - After 12 weeks, 80-90% of patients with mild oesophagitis improved - Not effective in moderate to severe GORD Ranitidine - Available over the counter: - Symptomatic relief of heartburn, dyspepsia and hyperacidity - Maximum dose of 2 tablets within 24 hours - 6 days continuous treatment maximum - Patients use them prophylactically, so patients take them before food when they know it's going to precipitate a problem.

Question 33

What are the side effects of H2 antagonists?

Answer 33

Generally very safe - Headaches and dizziness - Cimetidine - Gynaecomastia, impaired libido (sex drive) - Nizatidine - sweating, abnormal dreams - State of confusion in elderly Interactions: - Cimetidine binds to P450 e.g. Phenytoin, theophylline, warfarin etc

Question 34

How are proton pump inhibitors used in the treatment of Upper GI conditions?

Answer 34

Examples :- Omeprazole, Lansoprazole, Pantoprazole, Esomeprazole These are enteric coated preparations because they are absorbed in the small intestine. They usually take a day or two to take effect so patients prescribed a PPI will be also given an antacid for a few days whilst waiting for the PPI to take effect. Mechanism of action: - Works by blocking the hydrogen-potassium ATPase enzyme - They have a very prolonged suppression on acid secretion - 20mg omeprazole causes 80% reduction of acid secretion for 24hrs, 40mg causes 100% reduction They heal ulcers more rapidly than H2 antagonists, but their healing rate is the same at 8 weeks. Considered the MOST effective medication for heartburn. PPIs are the SUPERIOR in the treatment of relfux/GORD.

Question 35

What are the side effects of PPIs?

Answer 35

Short term side effects: - Nausea - Diarrhoea - Flatulence - Epidastric pain - Dry mouth - Headache Some patients suffer from Athralgia and Myalgia, so muscle pains. As they are so effective in acid suppression, there are concerns about bacterial overgrowth; may increase the risk of salmonella or helicobacter Lansoprazole should be taken before food as it can reduce food bioavailability. May be rebound acid Use on lowest dose to control patients condition or use it on an as needed basis.

Question 36

Are PPIs available over the counter?

Answer 36

Yes Omeprazole 10mg and 20mg available OTC. Indicated for reflex symptoms in adult patients, >18 year olds. Swallowed whole with water 20mg daily until symptoms improves then reduced to 10mg. Refer to GP: - If after 2 weeks still mo relief - If treatment required continuously for 4 weeks them refer - Patient is over 45 and presents with new or changed symptoms (may be gastric cancer)

Question 37

Which treatment is suggested when for different upper GI condition?

Answer 37

1. Functional dyspepsia, Gastritis or PUD: - Need to prioritise removing any causative agents - Dietary changes - Symptomatic management H2 ANTAGONISTS OR PROTON PUMP INHIBITORS 2. GORD: - Lifestyle and dietary changes ALGINATE PRODUCTS OR PROTON PUMP INHIBITORS (NOT H2 Antagonists - only of inadequate response to PPI)

Question 38

When do we refer patients presenting with upper GI symptoms?

Answer 38

- Patient is over 45 with a new/changed symptoms of heartburn or dyspepsia - Continuous dyspepsia - Increasing severity - Weight loss, loss appetite, sign of anaemia - Pain on exercise - cardiac origin? - Pregnant or breastfeeding? - Dysphagia (unexplainable pain on swallowing) - Blood in vomit or stools