Clinical Approach to Dyspepsia Flashcards
How can the site of abdominal pain indicate the underlying viscera from which it originates?
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
What can the different characters of abdominal pain indicate?
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
What are the main causes of upper abdominal pain?
GORD Functional dyspepsia Gastric/duodenal ulcer Cancer Cholelithiasis Pancreatitis IBS Non-visceral: musculoskeletal, neuralgic, cardiac Multiple causes of pain
What are the key exacerbating factors for oesophagitis, GORD, peptic ulcers and IBS?
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
What are common associated symptoms of abdominal pain?
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
What are 4 features of duodenal pathology?
Often awakens pt at night
50-80% nightly Sx
2-3 hrs after meals
More relief from meals than GU
What are 4 features of gastric pathology?
30-40% nocturnal
Non-ulcer dyspepsia 20-40%
Food/antacids – less relief
Sx shortly after meals
What investigations may be ordered for abdominal pain?
‘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
In primary care, what is dyspepsia?
recurrent epigastric pain, heartburn or acid regurgitation, with or without bloating, nausea or vomiting
What are the predictors for a positive response to a 4-week trial of PPIs?
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
What are the criterial for urgent direct access referral for upper GI endoscopy 9<2weeks)?
dysphagia or aged 55 and over with weight lossandany of the following: upper abdominal pain reflux dyspepsia.
How does the Los Angeles system of reflux oesophagitis classify cases?
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
When should PPIs be taken to achieve the best acid suppression?
Before a meal
What are side effects of PPIs?
Diarrhoea
headaches
dizziness
tiredness
What are the main clinical features of dyspepsia?
common pathophys with IBS altered gut motility visceral hypersensitivity low grade inflammation altered upper GI microbiome probiotics/antibiotics/diet
What are the Montreal classifications of GORD?
Flow diagram looking at the following categories Oesophageal vs extra oesophageal symptomatic vs injury established vs proposed associations Subtypes within each
What are the red flag symptoms when it comes to abdominal pain and dyspepsia?
anorexia weight loss persistent vomiting anaemia haematemesis and malaena abdominal mass
What are the main treatment options for GORD?
Lifestyle: weight loss, elevation of head of bed, smoking cessation, CBT
Medical: Antacids, alginates, H2RA, PPI, prokinetics
Surgical: Fundoplication
New endoscopic and surgical techniques
What is the general lifestyle advice given for dyspepsia and heartburn?
avoid rich, spicy food smoking cessation reduce alcohol reduce caffeine avoid late, large meals weight reduction
What pharmacological interventions can be given for dyspepsia and heartburn?
Antacids: Gaviscon, Rennies
Acid suppressants: H2 receptor antagonists, proton pump inhibitors
When should dyspepsia and heartburn be investigated further?
Presence of red flag or alarm symptoms
e.g. unexplained weight loss, haematemesis etc
What is fundoplication?
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
How do you treatise different LA grades non-erosive GORD?
LA Grade A and B:
treat symptomatically
e.g. PPIs or H2 receptor antagonist
LA Grade C and D:
long term treatment required
What is Barrett’s oesophagus?
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
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
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
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
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
What are the different types of peptic ulcer?
duodenum vs gastric
uncomplicated, bleeding or perforated
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
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
What are the main causes of peptic ulcers?
H. pylori infection
Overuse of aspirin/NSAIDS
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
How do you identify whether someone has H.pylori infection?
Measure breath using urea breath test
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
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
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
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
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%
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
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?
What is gastrin?
secreted from G cells
stimulates gastric acid production
What is pepsin?
protein digestion, co-secreted with gastrin
What is secretin?
secreted from mucosal cells in duodenum and jejunum
inhibits gastric acid
stimulates bile and (exocrine) pancreatic juice production
What is gastric inhibitory peptide?
= GIP
secreted by K cells in response to FFAs
inhibits gastrin release and acid secretion from parietal cells
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
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
