32. Dyspepsia (13%) Flashcards
In a patient presenting with dyspepsia, include what disease in the differential diagnosis?
include cardiovascular disease in the differential diagnosis.
Define : Dyspepsia (3)
One of the following symptoms
* Postprandial fullness
* Early satiation
* Epigastric pain
Name Precipitating factors : Dyspepsia (4)
- NSAID/ASA
- smoking
- alcohol
- high fat meals
Describe : H pylori associated with dyspepsia (5)
- but treatment does not necessarily improve symptoms
- Incidence 20-40% in Canada
- Higher in First Nations (>50%)
- Lower in children born in Canada.
- Risk of ulcer (10-20% vs. 1-2%) and gastric cancer (33% relative reduction)
Name DDX : Dyspepsia ()
- Functional/IBS (no organic cause) - 60%
- Peptic ulcer disease - 25%
- GERD
- GI Malignancy
- Drug-induced dyspepsia (NSAIDs and COX-2 inhibitors)
- Other: Celiac, chronic pancreatitis, gastritis, Crohn’s, cardiac
Describe : Peptic ulcer disease (3)
- Upper abdominal pain prominent, back pain atypical
- Gastric worse with food, Duodenal better with food
- Postprandial belching, epigastric fullness, early satiation, N/V
Name sx/signs : GI Malignancy
- Age
- Dysphagia, odynophagia
- Systemic signs (anemia, fatigue, weight loss)
Name redflags : Dyspepsia
(VWBAAAD)
- Vomiting
- Weight Loss (Involuntary)
- Blood loss (melena, hematemesis, anemia)
- Age >50
- Anemia
- Abdominal mass or lymphadenopathy
- Dysphagia, odynophagia, early satiety
- Family history of upper GI cancer
Describe physical exam : Dyspepsia (3)
- Carnett’s sign: Abdominal tenderness on muscle tensing (positive test), suggests abdominal wall pain rather than viscera
- Lymphadenopathy (left supraclavicular, periumbilical)
- Palpable abdominal mass (hepatoma), jaundice (liver mets), pallor (anemia)
Describe investigations : Dyspepsia (3)
- Consider CBC r/o anemia if hx of GI bleed
- H Pylori
- Consider Endoscopy if…
When to consider H.Pylori testing ?
- Consider in <50yo with dyspepsia but no red flags (especially if family history of peptic ulcer or cancer)
- Note: Not necessary to screen nonulcer dyspepsia with GERD prominent symptoms (heartburn/regurgitation)
Describe H.Pylori testing
- Urea breath test (stop PPI 2w prior to test, antacids PRN)
- Stool antigen test can be considered if UBT not available
- IgG antibody testing helpful if negative (but does not distinguish cleared infection if positive). Could be acceptable in documented PUD given high pretest probability
When to consider endoscopy in dyspepsia ? (4)
- > 50yo with new-onset dyspepsia
- Atypical features or red flags
- No response (or limited) after 4-8w of adequate PPI
- Consider in chronic GERD with 3 risk factors for Barrett’s esophagus
Name risk factors for Barretts esophagus (5)
- male > 50 years old
- Caucasian
- central obesity
- smokers
- family history of BE
Describe lifestyle tx dyspepsia (6)
- Weight loss if overweight
- Stop smoking, excessive alcohol
- Stop NSAID/ASA
- Avoid food/drinks that trigger (Alcohol, fried foods, spicy foods, garlic/onion, orange/citrus, chocolate/peppermint, coffee/caffeine, tomatoes)
- Eat smaller meals
- Elevate head of bed, avoid meal 2-3h before bedtime if nocturnal GERD
Describe tx mild dyspepsia (3)
- <3 episodes/week, low intensity, short duration)
- Alginates, antacids, low-dose H2 receptors-antagonist
- Reassess after 1 month
How to reassess dyspepsia tx with IPP ? (5)
- Reasssess in 4-8w
- If good response, trial of D/C (20% remain asymptomatic, consider antacid or H2 Blocker PRN)
- If symptoms relapse = Return to previous PPI dose, can prescribe on-demand (take during periods needed)
- Inadequate can try to double dose, BID, or switch PPI -> Reassess in 4w
- Endoscopy if no response after adequate trial
Longterm, what to do with IPP?
Attempt to stop/reduce PPI yearly (except in Barrett’s, esophagitis, or GI bleed), consider H2 blocker maintenance
Name risks of IPP (4)
- Hip fracture (0.4% vs. 0.18%)
- C Diff (OR 1.96)
- Pneumonia (OR 1.73, NNH 226)
- Low: Vit B12, iron, magnesium, calcium, parathyroid
When to consider endoscopy in longterm tx with IPP?
Consider endoscopy if requires >10y of treatment r/o Barrett’s esophagus
Name risk factors : H pylori (4)
- Low SES
- Number of siblings
- Infected parents (mother)
- Born outside North America (immigrants)
Name Indications for Testing H.Pylori (4)
- Dyspepsia (consider endoscopy if >50yo or alarm features). GERD-prominent symptoms do not require testing
- Active/previous peptic ulcer disease
- Low-grade gastric mucosa-associated lymphoid tissue lymphoma (MALT) or history of gastric cancer resection, or family history of gastric cancer
- Longterm NSAIDs
Describe tx : H. Pylori (3)
Standard Triple Therapy (PAC) x 14d
* PPI, eg. Lansoprazole 30mg PO BID
* Amoxicillin 1g PO BID
* Clarithromycin 500mg PO BID
Describe tx In areas of clarithromycin resistance: H. Pylori (3)
Non-Bismuth Quadruple (PAMC) x 14d
- PPI, eg. Lansoprazole 30mg PO BID
- Amoxicillin 1g PO BID
- Metronidazole 500mg PO BID
- Clarithromycin 500mg PO BID
What to do after tx of h.pylori ?
- ACG 2017 recommends testing all patients ≥ 4 weeks after antibiotic completed and 1-2 weeks after proton pump inhibitor (PPI) withheld
- Symptomatic after treatment (UBT after 28d of antibiotic, 3d PPI)
- H. pylori positive gastric/duodenal ulcer or gastric cancer (endoscopy)
Describe dx : Peptic Ulcer Disease (2)
- Suspect in dyspepsia with chronic NSAID use
- Definitive diagnosis by upper endoscopy
Name complications : Peptic Ulcer Disease (3)
- Bleeding
- Gastric outlet obstruction
- Perforation
What to stop/avoid : Peptic Ulcer Disease (3)
- Smoking, alcohol
- NSAIDs
- Foods that cause symptoms (although no evidence that foods increase the risk of ulcers)
Quels éléments, si présents à l’anamnèse, vous pousseraient à rechercher la présence de H. Pylori ? (4)
- Satiété précoce
- Douleur épigastrique uniquement
- Douleur chronique et récidivante
- Nausée
Quelles sont les risques potentiels associés à la prise d’inhibiteur des pompes à protons à long terme?
- Fracture de hanche
- Pneumonie
- C difficile
- Hypovitaminose B12
