Disorders of gastric acid and ulceration

Question 1

Dyspepsia (indigestion)

The following symptoms

Answer 1

heartburn, early satiety (feeling full) , bloating + nausea often occur after eating or drinking.

Question 2

If dyspepsia is accompanied by ‘alarm features’

Answer 2

bleeding, dysphagia, recurrent vomiting or weight loss… urgent investigation is required.
- This also applies to patients over the age of 55 with unexplained, recent-onset dyspepsia that has not responded to treatment.

Question 3

Lifestyle advice

Answer 3

• Avoid excess alcohol
• Avoid aggravating foods e.g. fats
• Stop causative medications
• Weight loss
• Smoking cessation
• Raising head of the bed

Question 4

Dyspepsia Treatment

Answer 4

 Treatment of dyspepsia is a Proton Pump Inhibitor (PPI) for up to 4 weeks.
 Patients who do not respond to an initial trial of a PPI, should be tested for Helicobacter Pylori and given eradication therapy if H. Pylori is present.

Question 5

Eradication of H. pylori involves

Answer 5

acid inhibition and antibacterial treatment. Treatment should not be carried out unless presence of H. pylori is confirmed.
H. pylori can be diagnosed using a breath test, stool sample or blood test however patient cannot be tested for this if they have been on an ANTIBIOTIC in the last 4 weeks OR ANTI-SECRETORY in the last 2 weeks.

Initial treatment is a one-week triple-therapy with a PPI, clarithromycin and amoxicillin or metronidazole

This treatment usually works, but if ulceration is bad then treatment with a PPI or H2 Antagonist
may need to be continued for a further 3 weeks.

Question 6

Antacids

Answer 6

Antacids can often relieve symptoms in ulcer dyspepsia and GORD. They either contain Magnesium or Aluminium.
-  They are usually given after meals and at bedtime + liquid preparations are better.

Question 7

Antacids should not be taken at

Answer 7

the same time as other drugs, as they damage their enteric coating
- Space doses 2 hours apart from other medications

Question 8

Magnesium-containing compounds tend to act as

Answer 8

 Laxatives,

Question 9

Simeticone is sometimes included to

Answer 9

 relieve flatulence, and alginates may be included for benefit in GORD

Question 10

Aluminium-containing compounds tend to cause

Answer 10

constipation

Question 11

Antacids containing BOTH magnesium and aluminium can

Answer 11

• reduce these colonic S.E. (constipation and laxating effect)

Question 12

In renal impairment, avoid

Answer 12

antacids which contain magnesium or large amounts of sodium.

Question 13

Bismuth-containing antacids

Answer 13

are not recommended because absorbed bismuth is neurotoxic, causing encephalopathy.

Question 14

Difference between gaviscon and gaviscon advance

Answer 14

1. Gaviscon = A, B, C
   Contains Sodium Alginate, Sodium Bicarbonate, Calcium Carbonate
2. Gavison Advance:
   Contains Potassium bicarbonate, which normal Gaviscon does NOT

Question 15

Peptic ulceration

Answer 15

Duodenal and Gastric ulcers are usually due to H. Pylori or NSAIDs.

• withdraw NSAIDs where possible

Question 16

• Risk factors for NSAID associated ulcers include

Answer 16

• age >65, history of ulcers, additional co-morbidities (diabetes, CVD, renal or hepatic impairment etc.) and medicines that increase G.I. side effects.

In those at risk, a PPI should be given

• Patients who are over the age of 65 years, may be taking a DOUBLE dose of PPI if they are taking an NSAID i.e. Omeprazole 1 BD instead of 1 OD; due to being high risk of getting ulcers from NSAID’s.
• Patients who have a history of upper GI bleeding or have 3 or more risk factors, should be given a selective COX-2 inhibitor + PPI.

Treatment alternatives: H2 Antagonist e.g. Ranitidine or Prostaglandin analogue e.g. Misoprostol.

• Misoprostol can be used for the elderly who are on long-term NSAIDs e.g. Aspirin
• Misoprostol is contraindicated in pregnancy as it can induce labour or abortion.

Sucralfate may be of use in the treatment of gastric and duodenal ulcers.
- However, there have been reports of Bezoar formation (foreign body resulting from accumulation of ingested material).
Thus, CAUTION is advised in seriously ill patients, especially those receiving enteral feeds or those with delayed gastric emptying.

Question 17

GORD is a term used to describe a variety of symptoms

Answer 17

heartburn, acid regurgitation, dysphagia, ulceration and oesophagitis.

Question 18

GORD lifestyle advice

Answer 18

• Stop drinking alcohol + stop smoking

- Reduce excess weight, keep head raised up when sleeping and stop foods that might aggregate GORD e.g. Fats.

Question 19

GORD Adult treatment (mild symptoms)

Answer 19

1. Antacids (alginates): alginate-containing antacids can form a ‘raft’ to reduce acid reflux
2. Histamine H2 receptor antagonists e.g. Ranitidine
3. Proton Pump Inhibitors E.g. Omeprazole  more effective than H2 Antagonists.

If there is still no relief, then surgery may be required.

Question 20

GORD Treatment in Pregnancy

Answer 20

1. Lifestyle advice
2. If dietary/lifestyle changes fail… An antacid/alginate can be used.
3. If the above is ineffective, Ranitidine can be used
4. Omeprazole is reserved for women with severe or complicated reflux disease.

Question 21

GORD Treatment in children

Answer 21

1. Lifestyle advice: change the frequency + volume of feed: a feed thickener or thickened formula can be used.
2. Pharmacological treatment: Antacid (alginate)
3. Children who do not respond to these measures must be referred to hospital. A H2 antagonist may be used to reduce acid secretion. If the patient is resistant, Omeprazole can be used.

Question 22

Dyspepsia ALARM endoscopic referal

Answer 22

A - anemia
L - loss of weight
A - anorexia
R - recent changes, unexplained symptoms in >55y
M - Malaenia - blood in stools

Question 23

PPI MHRA alert

Answer 23

Very low risk of SCLE (Subacute cutaneous lupus erythematosus) - counsel patients to avoid sun exposure

Question 24

Omeprazole drug interactions

Answer 24

• Clopidogrel - reduced efficacy of clopidogrel

- Methotrexate - reduced clearance of MTX

Question 25

H.pylori diagnosis

Answer 25

C13 Urea Breath test

• do not use within 4 weeks of antibacterial treatment or 2 weeks of antisecretory drug