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Gastrointestinal > Dyspepsia > Flashcards

Dyspepsia Flashcards

1
Q

Definition of dyspepsia

A

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)

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2
Q

Most common causes of dyspepsia

A

-Gastro-oesophageal reflux disease (GORD).
-Peptic ulcer disease (gastric or duodenal ulcers).
-Functional dyspepsia (non-ulcer dyspepsia)

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3
Q

Questions for history in dyspepsia

A

-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

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4
Q

Drugs that can cause/ exacerbate dyspepsia

A

-Alpha-blockers
-Anticholinergics
-Aspirin
-Benzodiazepines
-Beta-blockers
-Bisphosphonates
-Calcium-channel blockers
-Corticosteroids
-Nitrates
-Nonsteroidal anti-inflammatory drugs (NSAIDs)
-Theophylline
-Tricyclic antidepressants

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5
Q

Examination assessment of dyspepsia

A

-Weight loss by checking serial weight and body mass index (BMI) measurements.
-Signs of anaemia.
-Abdominal masses and tenderness

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6
Q

Investigations in dyspepsia

A

-FBC= anaemia and/ or raised platelet count

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7
Q

Differential diagnosis of dyspepsia

A

-Upper GI malignancy
-Gallbladder or hepatobiliary disease
-Pancreatic disease
-Cardiac disease (angina)
-Gastroenteritis
-Coeliac
-Crohn’s
-IBS
-SIBO
-Abdominal aortic aneurysm

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8
Q

Why does being overweight and smoking lead to dyspepsia?

A

-Increases intra-abdominal pressure
=Relaxes the lower oesophageal sphincter
=Exposes oesophageal mucosa to gastric contents
-Smoking chronically reduces lower oesophageal pressure

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9
Q

Suspected cancer: recognition and referral pathway in dyspepsia

A

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

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10
Q

Management of undiagnosed dyspepsia

A
  1. Review medications
  2. Lifestyle advice
  3. Trial of full-dose PPI for 1 month/ test and treat H. pylori

=If symptoms persistent then alternative approach tried

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11
Q

Presentation of H. pylori

A

-Peptic ulceration, chronic gastritis: recurrent epigastric pain, relationship to food, episodic occurrence, vomiting

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12
Q

H. pylori associations

A

-Peptic ulcer disease
-Gastric cancer
-B cell lymphoma of MALT tissue (eradication of H pylori results causes regression in 80%)
-Atrophic gastritis

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13
Q

Investigations of H. pylori

A

-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.

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14
Q

Management of H. pylori

A

-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

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15
Q

Presentation of peptic ulcer disease

A

-Haematemesis
-Recurrent epigastric pain (gastric= pain eating, duodenal= pain hungry relieved by eating)
-Nausea
-Use of aspirin
-Episodic

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16
Q

Risk Factors peptic ulcer disease

A

-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?

17
Q

Investigation and management of peptic ulcer disease

A

-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

18
Q

Overview of acute bleeding in peptic ulcer disease

A

-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

19
Q

Presentation of perforated peptic ulcer

A

-Sudden, severe pain upper abdomen (epigastric) then generalised, abdominal rigidity
-Tachycardia
-Shallow respiration
-Absent bowel sounds
-Peritonitis
-Syncope

20
Q

Investigation and management of perforated peptic ulcer

A

-Free air beneath diaphragm on erect CXR/ water-soluble contrast swallow confirm leakage of gastroduodenal contents: upper pain

-Emergency surgery

21
Q

Presentation of GORD

A

-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)

22
Q

Investigation and management of GORD

A

-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

23
Q

Complications of GORD

A

-Oesophagitis
-Ulcers
-Anaemia
-Benign strictures
-Barrett’s
-Oesophageal carcinoma

24
Q

Indications for upper GI endoscopy in GORD

A

-Age >55
-Symptoms >4 weeks or persistent symptoms despite treatment
-Dysphagia
-Relapsing symptoms
-Weight loss

If endoscopy negative consider 24hr oesophageal pH monitoring

25
Q

Investigation and management of Barrett’s oesophagus

A

-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

26
Q

Presentation of hiatus hernia

A

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

27
Q

Investigation of hiatus hernia

A

-Barium swallow
-Endoscopy first line as dysphagia, often found incidentally

-Sliding: gastro oesophageal junction moves above diaphragm
-Rolling: seperate part of stomach herniates

28
Q

Management of hiatus hernia

A

-Conservative management= weight loss
-PPI
-Surgical= symptomatic paraesophageal hernia

29
Q

Presentation of gastritis

A

-Dyspepsia/ epigastric discomfort
-Nausea and vomiting, loss of appetite
-NSAID use

30
Q

Investigations of gastritis

A

-H. pylori urea breath test
-FBC
-Endoscopy: gastric erosions and /or atrophy

31
Q

Management of gastritis

A

-Anti-secretory agents
-H. pylori eradication therapy
-PPI

Gastrointestinal (48 decks)

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