2- dyspepsia & peptic ulcer disease Flashcards
what is functional dyspepsia?
= sensation that things aren’t being digested properly (indigestion)
what is rome IV criteria for classifying functional dyspepsia?
-Bothersome:
- epigastric pain
-epigastric burning
- postprandial fullness
- early satiation
- Symptom onset at least 6 months prior to diagnosis
- Symptoms active within the last 3 months
- And, no evidence of structural disease (including at upper endoscopy) likely to explain the symptoms
what is postprandial fullness?
Sensation of being excessively and uncomfortably full for a prolonged time after a normal-sized meal
what are subtypes of functional dyspepsia?
epigastric pain syndrome, postprandial distress syndrome
what is criteria for diagnosis of epigastric pain syndrome? *important criteria
Must include one or both of the following symptoms at least 1 day a week:
- Bothersome epigastric pain or epigastric burning
what is supportive criteria for diagnosis of epigastric pain syndrome?
- Pain may be induced or relieved by ingestion of meal or occur whilst fasting
- Postprandial epigastric bloating, belching and nausea can also be present
- Persistent vomiting likely suggests another disorder
- Heartburn not a dyspeptic symptoms, but may often coexist
- The pain does not fulfil biliary pain criteria
- Symptoms that are relieved by evacuation of faeces or gas generally not considered as part of dyspepsia
- Other digestive symptoms (GORD or IBS may co-exist)
what is must criteria for diagnosis of postprandial distress syndrome? *important criteria
Must include one or both of the following symptoms at least 3 days a week:
- Bothersome postprandial fullness
- Bothersome early satiation (severe enough to prevent finishing a regular sized meal)
what is supportive criteria for postprandial distress syndrome?
- Postprandial epigastric pain or burning, epigastric bloating, excessive belching, and nausea can also be present
- Vomiting warrants consideration of another disorder
- Heartburn is not a dyspeptic symptom, but may often coexist
- Symptoms that are relieved by evacuation of faeces or gas should generally not be considered as part of dyspepsia
- Other individual digestive symptoms or groups of symptoms (GORD/IBS) may co-exist with PDS
what are risk factors for functional dyspepsia?
- younger people
- female
- high levels of somatoform type symptoms (physical complaints that cannot be attributed to organic diseases or injuries and are often associated with psychological distress or dysfunction)
- IBS
- psychological comorbidity
- enteric infection
- high BMI
- NSAIDs
- h.pylori
what are some important things to ask about when taking a clinical history for dyspepsia?
- duration & nature of symptoms
- ask about all upper GI symptoms including red flags
- enquire about epigastric pain or burning, early satiation, postprandial fullness, heart burn, nausea, haematemesis, belching, regurgitation, dysphagia
- changes in diet, medications
what are alarm features that suggest referral for urgent endoscopy to assess gastro-oesophageal cancer?
- people of any age with dysphagia
- people ≥ 55 years with weight loss and any of dyspepsia, upper abdominal pain, reflux
what are alarm features that suggest referral for non-urgent endoscopy to assess gastro-oesophageal cancer?
- people with haematemesis
- people ages ≥ 55 with treatment resistant dyspepsia, dyspepsia with raised platelet count or nausea or vomiting, upper abdominal pain with low haemoglobin, raised platelet count or nausea or vomiting
what is treatment for functional dysphagia?
= no cure but aim to improve symptoms, quality of life, social functioning etc
- regular aerobic exercise + avooid dietary triggers
- acid suppression (proton pump inhibitor or H2 receptor antagonist)
- prokinetic
- gut brain neuromodulator (tricyclic antidepressant)
= Referral for specialist treatments: anti-psychotics, CBT, hypnotherapy, stress management
what is peptic ulcer disease and why is it related to dyspepsia?
= ulcers in stomach, duodenum pr oesophagus
- common cause of organic dyspepsia (dyspepsia caused by identifiable structural or biochemical abnormality in GI tract)
*it’s a painful dyspepsia that is often worse at night and aggravated or relieved by eating
what are causes of peptic ulcers?
- h.pylori = colonises and disrupts stomach mucosa by reduced mucous and increased acid →damage
- NSAIDs = can irritate stomach lining by inhibiting prostaglandins so increased acid + decreased mucous →damage
- conditions that involve Gastric dysmotility, outflow obstruction →can have increased exposure of stomach lining to acid
- medications used in combination with NSAIDS/aspirin with SSRIs, corticosteroids, aldosterone antagonists or anticoagulants → increase risk of upper GI bleeding + ulcer formation
- Psychological stress associated with increase incidence
what are the 2 different outcomes for h.pylori infection?
- no atrophy which means just as many normal cells like gastrin cells etc so increased gastric acid →increased likelihood of ulcer
- atrophy which means less normal cells like gastrin secreting acid so less gastric acid →gastric cancer
what is the CLOtest?
h.pylori (helicobacter) increases pH and secretes urease which catalyses conversion of urea to ammonia
urease test changes acid to ammonium bicarbonate
pink =positive
orange = negative
what is treatment for peptic ulcer disease?
- proton pump inhibitor (to reduce acid)
- stop any NSAIDs
if h.pylori +ve = eradicate
if h.pylori -ve = antisecretory therapy (PPI)
what is treatment to eradicate h.pylori infection?
triple therapy for 1 week = PPI, amoxicillin and clarithromycin or metronidazole
what are complications for peptic ulcer disease?
- Anaemia
- Bleeding
- Perforation
- Gastric outlet/duodenal obstruction/fibrotic scar
what is follow up required for
a) duodenal ulcer?
b) gastric ulcer?
a) if uncomplicated - no follow up, only if ongoing symptoms
b) gastric ulcer - follow up endoscopy at 6-8 weeks to ensure healing + no malignancy
what is gastroperesis?
delayed gastric emptying
what are causes of gastroparesis?
- diabetes (main cause - mostly type 1)
- neurological conditions - multiple sclerosis, parkinson’s disease
- connective tissue conditions - diffuse systemic sclerosis
- post surgery
- medications = opiates
- idiopathic
what investigations can be done for gastroparesis?
- thorough history
- oesophago-gastro-duodenoscopy = to exclude pyloric stenosis or structural cause
- gastric emptying studies
what is treatment of gastroparesis?
- dietary modification
- glycaemic control
- stop any offending medications
- pro-kinetics: metoclopramide + domperidone
- gastric pacemaker
- newer treatments - prucalopride, botox, G-POEM
