6. Gastric acid disorders and ulceration Flashcards
Dyspepsia symptoms
- Upper abdominal pain
- Heartburn
- Gastric reflux
- Belching/gas
- Bloating/feeling full
- Nausea/vomiting
Dyspepsia Red flag symptoms
- Gastro-intestinal bleeding (may caused by peptic ulcer)
The below symptoms may be a sign of oesophageal or stomach cancer:
* Unexplained weight loss
* Dysphagia
* 55+ years and with dyspepsia
Causes of dyspepsia
- Peptic ulcers
- GORD
- Cancer
- Drugs: NSAIDs, Nitrates, Bisphosphonates, CCB’s, corticosteroids (side effect)
Uninvestigated Dyspepsia treatment
- PPI for 4 weeks
- H.pylori test. If the test comes out positive eradication therapy should follow
‘High-risk’ patients (e.g elderly, north africans and certain areas) must be tested first OR in parallel with a PPI course
Functional dyspepsia treatment
- PPI or H2 receptor antagonist for 4 weeks
AND - test for H.pylori, if symptoms come out positive eradication therapy should follow
If symptoms come back, use treatment on an as needed basis
Gastro-oesophageal reflux disease
When gastric content is regurgitated back into the oesophagus. As the oseophagus sphincter becomes weaker
Has two types: erosive and non-erosive
Erosive: where oesophageus is inflammed
Non-erosive
GORD causes
NSAIDs, Nitrates, Bisophosphonates, Calcium-channel blocker, corticosteroid, alpha-blocker, antimuscarinic, beta-blocker, TCA
GORD symptoms
- Heartburn
- Unpleasant sour taste in the mouth
GORD treatment
- Uninvestigated GORD: 4 weeks with a PPI
-
Diagnosed GORD with endoscopy: PPI 4 or 8 weeks
If there is no response, a H2 receptor antagonist can offered.
The lowest effective dose can be taken on an as needed basis - Severe oesophagitis: PPI for 8 weeks. If this fails, try an higher dose or switch to another PPI
GORD treatment in pregnancy
1st line: Diet and lifestyle advice
2nd line: Antacid
For severe symptoms
3rd line: Omeprazole
P
Peptic ulcers
An open sore in the mucosal lining of the stomach or the duodenum
Causes of peptic ulcer
- NSAIDs
- h. pylori
Patients at risk of peptic ulcer
History of complicated ulcer
or have at least 2 of the following risk factors:
* 65+ years
* High dose and prolonged use
* Drugs which increase the risk of GI bleeding, e.g SSRI’s
* Serious co-morbidity e.g CVD, HT, diabetes
* Excessive alcohol
* NSAID adverse reaction
Peptic ulcer symptoms
- Burning abdominal oain
- Dyspepsia
- Heartburn
- Nausea
- Bloating
- Apetite loss
- Weight loss
Types of peptic ulcer
- Gastric ulcers
- Duodenal ulcers
NSAID-induced ulcer treatment
- PPI or H2 receptor antagonist for 8 weeks
- Conduct a H.pylori test, if positive, start eradication therapy.
- Stop NSAID, (can swicth to paracetamol, may not be possible in chronic conditions e.g rheumatoid arthritis).
Can switch to COX-2 selective inhibitor (as they cause less GI side effects but have a higher risk of cardiovascular events) + Gastro-protection (like PPI, H2 receptor antagonist, misoprostol)
consider other co-morbidities the patient will have
Peptic ulcers treatment (not caused by NSAID or h.pylori)
PPI or h2 receptor antagonist 4 to 8 weeks
Diagnosing h.pylori infection
Urea breath test and Stool antigen test
The test should not be performed within 2 weeks of a PPI OR 4 weeks of an antibiotic as this may causen a false negative
H.pylori eradication therapy
Treatment lasts for 7 days:
1st line: PPI + amoxicillin + clarithromycin OR metronidazole
PAC/PAM
if penicillin allergy: PPI + metronidazole + clarithromycin
PMC
2nd line: if PAC was used first line use PAM and vice versa
if penicillin allergy: PPI + metronidazole + levofloxacin
PML
If patient has recently used an antibiotic for an unrelated infection, it cannot be given again to reduce the risk of resistance
Antacid mechansims of action
Neutralises gastric acid. Provides relief within 15-30 minutes
Alginates mechanism of action
Forms a viscous gel raft ontop of the stomach contents. This prevents it from being regurgitated
Types of antacids and alginates
Antacids
Magnesium salt - laxative effects
Aluminium salt - constipative effects
Alginates
* alginic acid
* sodium alginate
Gaviscon contains both antacid and alginates
Liquid formulations are more effective than tablets
Antacids/alginates caution
Many preparations of antacids and alginates are high in Na+ content, take caution in:
- Hypertension (increases fluid retention)
- Heart, Liver, Kidney failure (increases fluid retention)
- Lithium (as sodium-restricted diet must be followed)
Antacids counselling
Should be taken after each meal, at bedtime or prn
