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Clinical Approach to Dyspepsia Flashcards

1
Q

How can the site of abdominal pain indicate the underlying viscera from which it originates?

A

chest: oesophagus
upper: oesophagus, stomach, duodenum, pancreas, gall bladder, colon
mid: small intestine
lower: colon, gynae

radiation to back with severe pain: biliary tree, pancreatic pain, spinal pain

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2
Q

What can the different characters of abdominal pain indicate?

A

Acid-peptic pain: burning or dull, mild or moderately severe
Intestinal pain: colicky
Biliary colic: may be constant or colicky
Colonic pain: can be extremely severe, 10/10
Biliary and pancreatic pain; can be extremely severe

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3
Q

What are the main causes of upper abdominal pain?

A 
GORD
Functional dyspepsia
Gastric/duodenal ulcer
Cancer
Cholelithiasis 
Pancreatitis
IBS
Non-visceral: musculoskeletal, neuralgic, cardiac
Multiple causes of pain
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4
Q

What are the key exacerbating factors for oesophagitis, GORD, peptic ulcers and IBS?

A

Oesophagitis: swallowing
GORD: food/drink, lying down, bending over. Relieved by antacids, milk, sitting up
Peptic ulcers: nocturnal, worse on hunger. Relieved by food and antacids
IBS: made worse by urge to defecate and distension. Can be relieved by defecation

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5
Q

What are common associated symptoms of abdominal pain?

A

oesophageal: heartburn, regurgitation, dysphagia, odynophagia (pain when swallowing)
gastric: early satiety, post-prandial fullness, nausea
Biliary: dark urine, pale stools, jaundice
Colonic: diarrhoea, constipation, distension

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6
Q

What are 4 features of duodenal pathology?

A

Often awakens pt at night
50-80% nightly Sx
2-3 hrs after meals
More relief from meals than GU

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7
Q

What are 4 features of gastric pathology?

A

30-40% nocturnal
Non-ulcer dyspepsia 20-40%
Food/antacids – less relief
Sx shortly after meals

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8
Q

What investigations may be ordered for abdominal pain?

A

‘Test and treat’ for H. pylori (if no alarm symptoms)
Blood count, ESR, LFTs, amylase
Plain X ray, urgent CT, if acute abdomen suspected
Ultrasound
CT
Upper endoscopy

Colonoscopy- not normally indicated for abdominal pain
Lower oesophageal pH study

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9
Q

In primary care, what is dyspepsia?

A

recurrent epigastric pain, heartburn or acid regurgitation, with or without bloating, nausea or vomiting

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10
Q

What are the predictors for a positive response to a 4-week trial of PPIs?

A

Fewer days of Sx during the 1st week of treatment
Age>40
Symptoms > 3 mths
High Score for heartburn at baseline
Low Score for Epigastric Pain, bloating, diarrhoea at baseline
Low impairment of vitality at baseline

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11
Q

What are the criterial for urgent direct access referral for upper GI endoscopy 9<2weeks)?

A 
dysphagia
or aged 55 and over with weight lossandany of the following:
upper abdominal pain
reflux
dyspepsia.
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12
Q

How does the Los Angeles system of reflux oesophagitis classify cases?

A

LA Grade A: one or more mucosal breaks
< 5mm
Does not extend between the tops of 2 mucosal folds

LA grade B: one or more mucosal breaks
>5mm
Does not extend between the tops of 2 mucosal folds

LA grade C: one or more mucosal breaks that are continuous between the tops of 2 or more mucosal folds
but involve <75% of the oesophageal circumference

LA grade D: one or more mucosal breaks which involve at least 75% of the oesophageal circumference

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13
Q

When should PPIs be taken to achieve the best acid suppression?

A

Before a meal

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14
Q

What are side effects of PPIs?

A

Diarrhoea
headaches
dizziness
tiredness

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15
Q

What are the main clinical features of dyspepsia?

A 
common pathophys with IBS
altered gut motility
visceral hypersensitivity 
low grade inflammation
altered upper GI microbiome
probiotics/antibiotics/diet
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16
Q

What are the Montreal classifications of GORD?

A 
Flow diagram looking at the following categories
Oesophageal vs extra oesophageal 
symptomatic vs injury 
established vs proposed associations 
Subtypes within each
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17
Q

What are the red flag symptoms when it comes to abdominal pain and dyspepsia?

A 
anorexia
weight loss
persistent vomiting 
anaemia
haematemesis and malaena
abdominal mass
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18
Q

What are the main treatment options for GORD?

A

Lifestyle: weight loss, elevation of head of bed, smoking cessation, CBT
Medical: Antacids, alginates, H2RA, PPI, prokinetics
Surgical: Fundoplication
New endoscopic and surgical techniques

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19
Q

What is the general lifestyle advice given for dyspepsia and heartburn?

A 
avoid rich, spicy food
smoking cessation
reduce alcohol 
reduce caffeine
avoid late, large meals 
weight reduction
20
Q

What pharmacological interventions can be given for dyspepsia and heartburn?

A

Antacids: Gaviscon, Rennies

Acid suppressants: H2 receptor antagonists, proton pump inhibitors

21
Q

When should dyspepsia and heartburn be investigated further?

A

Presence of red flag or alarm symptoms

e.g. unexplained weight loss, haematemesis etc

22
Q

What is fundoplication?

A

Surgical procedure used to treat GORD
Stomach is wrapped around the lower portion of the oesophagus (cardia) to makeshift an artificial lower oesophageal sphincter and therefore limit gastric acid reflux

23
Q

How do you treatise different LA grades non-erosive GORD?

A

LA Grade A and B:
treat symptomatically
e.g. PPIs or H2 receptor antagonist

LA Grade C and D:
long term treatment required

24
Q

What is Barrett’s oesophagus?

A

Condition where there is a metaplastic change in the mucosal cells lining the lower portion of the oesophagus

metaplastic change:
stratified squamous epithelium to simple columnar epithelium
May also see presence of interspersed goblet cells which are normally only found in the small intestine and large intestine

25
Why is Barrett's oesophagus closely monitored? How is this monitored?
0.5% annual risk of oesophageal adenocarcinoma | Surveillance endoscopy done, but this has not been proven to be cost-effective
26
What is the Laproscopic Nissen fundoplication?
most common type of surgical fundoplication used to treat GORD Performed under GA upper portion of stomach is wrapped around distal oesophagus SE: flatulence, bloating, belching, dysphagia
27
What is the Stretta procedure?
minimally invasive endoscopic procedure used to treat GORD Delivers radio frequency waves via a balloon with attached electrodes to the lower oesophageal sphincter and cardia portion of the stomach This directed energy heats the tissue causing it to swell and stiffen Efficacy is controversial and mechanism on how the stiffening is not well understood Thought that the heat mediated muscular thickening and damage to the nerves in those tissues. Damage causes tightening of LES and therefore prevents gastric acid reflux into the oesophagus
28
What is the Linx procedure?
Alternative to fundoplication minimally invasive laparoscopic implantation The device is interlinked titanium beads with magnetic cores, which prevent reflux by altering the LES barrier function
29
What are the different types of peptic ulcer?
duodenum vs gastric | uncomplicated, bleeding or perforated
30
What is the relationship between gastric acid and peptic ulcers? What does this suggest for treatment?
Proportional relationship Therefore, reducing gastric acid secretion via H2 receptor antagonists or PPIs can have beneficial impact on progression of peptic ulcers
31
What is the key main difference between gastric and duodenal peptic ulcers?
Gastric ulcers can be malignant but duodenal ulcers are not therefore need to have follow up on healing of gastric ulcers
32
What are the main causes of peptic ulcers?
H. pylori infection | Overuse of aspirin/NSAIDS
33
How do you treat peptic ulcers?
Treat underlying H. pylori or aspirin/NSAIDs Acid suppression: PPIs Follow up gastric ulcers for risk of malignancy (not necessary for duodenal ulcers) Check for eradication of H. pylori particularly if there is history of complications bleeding ulcers: maintain haemodynamic stability, can do endoscopic treatment Perforated ulcer: surgery
34
How do you identify whether someone has H.pylori infection?
Measure breath using urea breath test
35
How is H. pylori infection treated? How do people usually present with H. pylori? What is the prognosis following treatment?
treat with antibiotics most people with H. pylori present with gastritis not ulcer Some people may have dyspepsia <10% of patients will be cured by antibiotics in patients with functional dyspepsia and H. pylori
36
What is the difference between dyspepsia and functional dyspepsia?
Dyspepsia: common upper GI symptom usually includes epigastric pain, fullness, discomfort, burning, early satiety, nausea, vomiting and belching Functional dyspepsia: diagnosed only when upper GI endoscopy reveals no organic lesions that may explain dyspeptic symptoms
37
When is screening for Barrett's oesophagus justified?
``` When 3 or more of the following risk factors are present: Males Obesity Age > 50y Caucasian FHx of Barretts's or Oesophageal cancer Smoking ```
38
What is the association of Barrett's oesophagus with long term reflux according to the BSG guidelines 2014?
BO occurs in patients with longstanding reflux symptoms >10yr Screening is not routinely justified
39
Are PPIs effective in reducing risk of Barretts incidence?
Paper Kastelein et al 2013 Dutch prospective cohort study, multicentre 540 patients over 5 years PPI use reduced malignant progression (from Barrett's oesophagus) by 75%
40
Aside from PPIs, what should be recommended for a patient with Barrett's oesophagus?
regular endoscopic surveillance if lesion < 3cm in length then endoscopy should be performed every 3-5 years if lesion >= 3cm in length, then endoscopy should be performed every 2-3 years
41
Why is regular endoscopic surveillance with Barrett's oesophagus recommended?
surveillance correlates with earlier tour stage at diagnosis and improved survival from Barrett's related adenocarcinoma?
42
What is gastrin?
secreted from G cells | stimulates gastric acid production
43
What is pepsin?
protein digestion, co-secreted with gastrin
44
What is secretin?
secreted from mucosal cells in duodenum and jejunum inhibits gastric acid stimulates bile and (exocrine) pancreatic juice production
45
What is gastric inhibitory peptide?
= GIP secreted by K cells in response to FFAs inhibits gastrin release and acid secretion from parietal cells
46
What is cholecystokinin?
secreted by I cells in duodenum and jejunum in response to FFAs inhibits acid secretion from parietal cells causes gall bladder contraction and relaxation of sphincter of Oddi
47
Where is somatostatin secreted from?
D cells in pancreas and stomach SST also known as 5-HT secreted in response to FFATs, bile salt and glucose in intestinal lumen reduces: - gastric acid - pepsin - gastrin - pancreatic enzyme secretion - insulin - glucagon inhibits trophic (growth) effect of gastrin stimulates gastric mucous production

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