32. Dyspepsia (13%) Flashcards
1
Q
In a patient presenting with dyspepsia, include what disease in the differential diagnosis?
A
include cardiovascular disease in the differential diagnosis.
2
Q
Chez un patient qui consulte pour dyspepsie, questionnez et examinez le patient pour identifier des signes ou des symptômes plus préoccupants.
Nommez les.
A
- saignement gastro-intestinal
- perte de poids
- dysphagie
3
Q
Nommez tx H.Pylori
A
14 jrs Quad therapy
* Bismuth
* Tetracycline
* Metronidazole
* PPI
4
Q
Quand suspecter esophagite eosinophilique ?
A
- Absorbe le liquide contenu dans les aliments pour les lubrifier.
- Modifie les aliments (petits morceaux).
- Prolonge la durée des repas.
- Évite les aliments durs ou texturés (ex. : pain, viande).
- Mâche excessivement.
- Refuse les comprimés.
5
Q
Quoi faire si suspect esophagite eosinophilique ?
A
Refer to scope with biopsie
6
Q
Décrire tx esophagite eosinophilique
A
- IPP, stéroïdes topiques, Dupixent
- Orienter un diététicien pour un régime d’élimination
- Une dilatation peut être nécessaire
- En cas d’obstruction: boisson gazeuse, endoscopie en urgence
7
Q
When to screen esophageal cancer ?
A
Don’t screen even if high risk
8
Q
Name risk factor Barrett’s esophagus
A
Reflux = greatest risk factor
9
Q
Name prevention : Esophageal cancer
A
- Lifestyle
- High-dose PPI and ASA
10
Q
Name long-term PPI risks
A
- B12 deficiency
- C.Diff
- Gastric cancer
- Dementia
- Fractures
11
Q
Define : Dyspepsia (3)
A
One of the following symptoms
* Postprandial fullness
* Early satiation
* Epigastric pain
12
Q
Name Precipitating factors : Dyspepsia (4)
A
- NSAID/ASA
- smoking
- alcohol
- high fat meals
13
Q
Describe : H pylori associated with dyspepsia (5)
A
- 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)
14
Q
Name DDX : Dyspepsia ()
A
- 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
15
Q
Describe : Peptic ulcer disease (3)
A
- Upper abdominal pain prominent, back pain atypical
- Gastric worse with food, Duodenal better with food
- Postprandial belching, epigastric fullness, early satiation, N/V
16
Q
Name sx/signs : GI Malignancy
A
- Age
- Dysphagia, odynophagia
- Systemic signs (anemia, fatigue, weight loss)
17
Q
Name redflags : Dyspepsia
A
(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
18
Q
Describe physical exam : Dyspepsia (3)
A
- 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)
19
Q
Describe investigations : Dyspepsia (3)
A
- Consider CBC r/o anemia if hx of GI bleed
- H Pylori
- Consider Endoscopy if…
20
Q
When to consider H.Pylori testing ?
A
- 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)
21
Q
Describe H.Pylori testing
A
- 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
22
Q
When to consider endoscopy in dyspepsia ? (4)
A
- > 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
23
Q
Name risk factors for Barretts esophagus (5)
A
- male > 50 years old
- Caucasian
- central obesity
- smokers
- family history of BE
24
Q
Describe lifestyle tx dyspepsia (6)
A
- 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
25
Describe tx mild dyspepsia (3)
* <3 episodes/week, low intensity, short duration)
* Alginates, antacids, low-dose H2 receptors-antagonist
* Reassess after 1 month
26
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
27
Longterm, what to do with IPP?
Attempt to stop/reduce PPI yearly (except in Barrett's, esophagitis, or GI bleed), consider H2 blocker maintenance
28
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
29
When to consider endoscopy in longterm tx with IPP?
Consider endoscopy if requires >10y of treatment r/o Barrett's esophagus
30
Name risk factors : H pylori (4)
* Low SES
* Number of siblings
* Infected parents (mother)
* Born outside North America (immigrants)
31
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
32
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
33
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
34
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)
35
Describe dx : Peptic Ulcer Disease (2)
* Suspect in dyspepsia with chronic NSAID use
* Definitive diagnosis by upper endoscopy
36
Name complications : Peptic Ulcer Disease (3)
* Bleeding
* Gastric outlet obstruction
* Perforation
37
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)
38
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
39
40
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
