Dyspepsia Flashcards
Definition of dyspepsia
Complex of upper gastrointestinal tract symptoms which are typically present for four or more weeks, including upper abdominal pain or discomfort, heartburn, acid reflux, nausea and/or vomiting.
=Predominant epigastric pain lasting at least one month (associated with other upper Gi symptoms)
Most common causes of dyspepsia
-Gastro-oesophageal reflux disease (GORD).
-Peptic ulcer disease (gastric or duodenal ulcers).
-Functional dyspepsia (non-ulcer dyspepsia)
Questions for history in dyspepsia
-Alarm symptoms for upper GI cancers
-Frequency, duration, pattern of symptoms, impact on QOL
-FHx upper GI malignancy
-Obesity
-Trigger foods and pattern of eating (coffee, alcohol, chocolate, fatty foods)
-Smoking
-Alcohol consumption
-Stress, anxiety, depression
-Medication: antacids/ antibiotics
Drugs that can cause/ exacerbate dyspepsia
-Alpha-blockers
-Anticholinergics
-Aspirin
-Benzodiazepines
-Beta-blockers
-Bisphosphonates
-Calcium-channel blockers
-Corticosteroids
-Nitrates
-Nonsteroidal anti-inflammatory drugs (NSAIDs)
-Theophylline
-Tricyclic antidepressants
Examination assessment of dyspepsia
-Weight loss by checking serial weight and body mass index (BMI) measurements.
-Signs of anaemia.
-Abdominal masses and tenderness
Investigations in dyspepsia
-FBC= anaemia and/ or raised platelet count
Differential diagnosis of dyspepsia
-Upper GI malignancy
-Gallbladder or hepatobiliary disease
-Pancreatic disease
-Cardiac disease (angina)
-Gastroenteritis
-Coeliac
-Crohn’s
-IBS
-SIBO
-Abdominal aortic aneurysm
Why does being overweight and smoking lead to dyspepsia?
-Increases intra-abdominal pressure
=Relaxes the lower oesophageal sphincter
=Exposes oesophageal mucosa to gastric contents
-Smoking chronically reduces lower oesophageal pressure
Suspected cancer: recognition and referral pathway in dyspepsia
Urgent:
-Dysphagia
-Upper abdo mass consistent with stomach cancer
->55, weight loss + upper abdo pain/ reflux/ dyspepsia
Non-urgent:
-Haematemesis
->55 + treatment resistant dyspepsia/ upper abdo pain with low haemoglobin levels/ raised platelet count with nausea or vomiting, weight loss, reflux, dyspepsia, upper abdo pain/ nausea or vomiting with weight loss or reflux, dyspepsia, upper abod pain
Management of undiagnosed dyspepsia
- Review medications
- Lifestyle advice
- Trial of full-dose PPI for 1 month/ test and treat H. pylori
=If symptoms persistent then alternative approach tried
Presentation of H. pylori
-Peptic ulceration, chronic gastritis: recurrent epigastric pain, relationship to food, episodic occurrence, vomiting
H. pylori associations
-Peptic ulcer disease
-Gastric cancer
-B cell lymphoma of MALT tissue (eradication of H pylori results causes regression in 80%)
-Atrophic gastritis
Investigations of H. pylori
-Breath urase (not performed within 4 weeks treatment with antibacterial or 2 weeks of antisecretory like PPI)
-Monoclonal stool antigen: gram-negative
-Serology (IgG, cannot distinguish between current and past infection) if failed.
-2 weeks after stopping PPI and 4 weeks after antibiotics as suppresses bacteria and causes false negative results.
-Biopsy?
=Test if uncomplicated dyspepsia unresponsive to lifestyle changes and antacids, following month of PPR without alarm symptoms.
=History of ulcer.
=Unexplained iron deficiency anaemia.
Management of H. pylori
-PPI
-Amoxicillin + clarithromycin/ metronidazole.
-PPI + metro + clarithro if penicillin allergic
Tetracycline hydrochloride or levofloxacin.
-No need to check for test of cure if symptoms have resolved, if repeat testing required urea breath test
Presentation of peptic ulcer disease
-Haematemesis
-Recurrent epigastric pain (gastric= pain eating, duodenal= pain hungry relieved by eating)
-Nausea
-Use of aspirin
-Episodic
Risk Factors peptic ulcer disease
-H. pylori
=95% duodenal
=75% gastric
-Drugs
=NSAIDs
=SSRIs
=Bisphosphonates
=Corticosteroids
-Zollinger-Ellison syndrome: rare cause characterised by excessive levels of gastrin, usually from gastrin secreting tumour
-Alcohol and smoking?
Investigation and management of peptic ulcer disease
-Endoscopy, H. pylori testing (urea breath test/stool antigen), FBC (microcytic anaemia or high platelet count for malignancy)
-PPI: if H.pylori -ve, until ulcer healed
-H2 antagonist
-H. pylori eradication if +ve
-Low-dose aspirin
Overview of acute bleeding in peptic ulcer disease
-Most common complication (75%)
-Gastroduodenal artery: significant source
-P: haematemesis, melena, hypotension, tachycardia
-M: ABC, IV proton pump inhibitor, endoscopic intervention, failure= urgent interventional angiography with transarterial embolisation or surgery
Presentation of perforated peptic ulcer
-Sudden, severe pain upper abdomen (epigastric) then generalised, abdominal rigidity
-Tachycardia
-Shallow respiration
-Absent bowel sounds
-Peritonitis
-Syncope
Investigation and management of perforated peptic ulcer
-Free air beneath diaphragm on erect CXR/ water-soluble contrast swallow confirm leakage of gastroduodenal contents: upper pain
-Emergency surgery
Presentation of GORD
-Heartburn (retrosternal burning, chest pain?)
-Regurgitation (acid in mouth)
-Dyspepsia (discomfort related to eating, bloating nausea, pain, indigestion)
-Dysphagia (secondary to oesophagitis may indicate stricture)
-Chronic cough (nocturnal asthma)
-Hoarseness (irritation of vocal cords by gastric reflux, worse in morning)
Investigation and management of GORD
-Heartburn and regurgitation
-Endoscopy, oesophageal pH monitoring, PPI trial
-Antacids/ alginates/ full dose and maintenance dose PPI / weight loss/ avoid trigger foods/ avoid late meals/ smoking cessation. Anti-reflux surgery
-Endoscopically proven
=Full dose PPI 1-2 months
=If response then low dose treatment required
=No response double dose PPI 1 month
-Not proven
=Full dose PPI 1 month
=Response then low dose treatment on as required basis
=No response then H2RA or prokinetic for 1 month
Complications of GORD
-Oesophagitis
-Ulcers
-Anaemia
-Benign strictures
-Barrett’s
-Oesophageal carcinoma
Indications for upper GI endoscopy in GORD
-Age >55
-Symptoms >4 weeks or persistent symptoms despite treatment
-Dysphagia
-Relapsing symptoms
-Weight loss
If endoscopy negative consider 24hr oesophageal pH monitoring
Investigation and management of Barrett’s oesophagus
-Pre-malignant condition: squamous to columnar mucosa (metaplasia), chronic GORD. Increased risk of adenocarcinoma
-RF: GORD, male (7:1), smoking, central obesity
-Endoscopy with multiple biopsy= metaplasia of distal oesophagus. Short (<3cm) and long (>3cm)
-Oesophagectomy or endoscopic therapy (surveillance every 3-5 years for metaplasia)/ radiofrequency ablation of Barrett’s mucosa first if dysplasia, resection/ high dose PPI
Presentation of hiatus hernia
Herniation of part of stomach above diaphragm
-Sliding: 95%- gastroesophageal junction
-Rolling: separate part through oesophageal hiatus
-RF: obesity, increased abdo pressure ascites, multiparity)
-Heartburn
-Dysphagia
-Regurgitation
-Chest pain
Investigation of hiatus hernia
-Barium swallow
-Endoscopy first line as dysphagia, often found incidentally
-Sliding: gastro oesophageal junction moves above diaphragm
-Rolling: seperate part of stomach herniates
Management of hiatus hernia
-Conservative management= weight loss
-PPI
-Surgical= symptomatic paraesophageal hernia
Presentation of gastritis
-Dyspepsia/ epigastric discomfort
-Nausea and vomiting, loss of appetite
-NSAID use
Investigations of gastritis
-H. pylori urea breath test
-FBC
-Endoscopy: gastric erosions and /or atrophy
Management of gastritis
-Anti-secretory agents
-H. pylori eradication therapy
-PPI
