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PMY3304 > Dyspepsia > Flashcards

Dyspepsia Flashcards

1
Q

What is Dyspepsia

A

Is a term used to describe a complex of upper GI tract symptoms typically present for four or more weeks including:
- Upper abdominal pain or discomfort (e.g. bloating, belching, a feeling of abnormal or slow digestion, early satiety)
- Heartburn, acid reflux (*more likely to be GORD if these predominate)
- Nausea and / or vomiting

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2
Q

What are the 3 causes/ triggers for Dyspepsia

A
  • underlying conditions.
  • drug induced
  • lifestyle related
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3
Q

Give some examples of underlying conditions that can cause dyspepsia

A
  • GORD
  • Peptic Ulcer Disease
  • Functional dyspepsia
  • Barrett’s oesophagus
  • Upper GI malignancy
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4
Q

Give some examples of drug induced dyspepsia.

A
  • Aspirin
  • NSAIDs
  • Corticosteroids (e.g. prednisolone
  • Beta-blockers
  • Benzodiazepines
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5
Q

Give some examples of lifestyle related tiggers

A
  • trigger foods, Binge eating, Fatty foods
  • Alcohol
  • Caffeine
  • Stress
  • Obesity
  • Smoking
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6
Q

Diagnosis - community pharmacy

A
  • Offer initial and ongoing help
  • lifestyle advice
  • help with prescribed drugs
  • OTC meds
  • advice when to see GP
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7
Q

Alarm features of dyspepsia

A
  • Dysphagia
  • Haematemesis (vomit blood) or blood in stool
  • Unexplained weight or appetite loss
  • Upper abdominal mass
  • Family history of GI malignancy
  • Patients >55 years with any of the above OR any of the following:
  • Change in bowel habit
  • Treatment-resistant dyspepsia
  • Dyspepsia with raised platelets or low haemoglobin
  • Pain radiating to jaw, back, arm - ?CV cause
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8
Q

1st line Community Pharmacy Treatment Options

A
  • Antacids: Alkaline, neutralise acid OR Alginates: Form a ‘raft’
    Cautions:
  • Care with sugar (diabetics), Care with sodium content
    (Renal impairment, hypertension /CVD, pregnancy)**
    Side-effects:
  • Aluminium-based: constipation
  • Magnesium-based: diarrhoea
    Interactions:
  • May impair absorption of other medicines
  • Can damage ‘enteric’ coat
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9
Q

2nd line Community Pharmacy Treatment Options

A
  • PPI, e.g. Nexium control (esomeprazole)
  • H2 receptor antagonists, e.g. Zantac (ranitidine) not currently available
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10
Q

Dyspepsia: Diagnosis (other settings)

A
  1. Clinical history
  2. Physical examination / investigations
  3. Referral for further specialist investigation (e.g. gastroenterologist)
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11
Q

Dyspepsia Management: Unidentified cause

A
  • Non-pharmacological - Offer lifestyle & self-care advice
    Pharmacological
  • Review existing medication, deprescribe (reduce or stop) causative drugs if appropriate
  • 1st line: Full dose proton-pump inhibitor (PPI) for 4 weeks or H. pylori test & treat
  • 2nd line: Histamine (H2) receptor antagonist (after considering further investigation)
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12
Q

How do proton pump inhibitors work?

A

Mechanism:
- Inhibits H+/K+ ATPase pump, therefore reducing gastric acid production

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13
Q

What is the PPI dosing for Dyspepsia ?

A
  • Omeprazole 20mg OD OR
  • Lansoprazole 30mg OD for 4 weeks. Step down/PRN PPI or self-care
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14
Q

What are some PPI Cautions/ side effects

A
  • elderly
  • may mask symptoms of gastric cancer
  • Diarrhoea (including C. difficile risk, microscopic colitis)
    headaches, dizziness
  • Electrolyte disturbances, especially hyponatraemia, hypomagnesia
  • Fracture risk
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15
Q

PPI interactions

A
  • clopidogrel (use lansoprazole / pantoprazole), citalopram
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16
Q

why do PPI need reviewed

A
  • Due to concerns of long-term use, should aim to step-down to minimum dose that controls symptoms & trial stopping or PRN use (are some exceptions, e.g. Barrett’s Oesophagus)
17
Q

How do istamine (H2) Receptor Antagonists work

A
  • Mechanism: binds histamine receptor preventing histamine-mediated stimulation of gastric acid secret
  • Review: as per PPI, aim to step down & where possible stop / PRN use
18
Q

What are the cautions/ side effects of Histamine (H2) Receptor Antagonists

A
  • Renal impairment (dose reduction)
  • Pregnancy and breastfeeding (avoid)
  • May mask the symptoms of gastric cancer
  • Constipation, diarrhoea, dizziness, fatigue, headache, myalgia are common side effects
19
Q

H2 Receptor Antagonists interactions

A

Cimetidine is a CP450 enzyme inhibitor and will increase the levels of many drugs; care with narrow therapeutic index medicines, e.g. phenytoin, theophylline, aminophylline, warfarin

20
Q

Helicobacter pylori diagnoses and management

A
  • Diagnosis: Stool antigen test (now preferred in primary care) or urea breath test
  • Management: Aggressive triple-therapy of 2 antibiotics plus twice daily PPI for 7 days. Adherence is critical to successful eradication
  • When choosing triple therapy regimen consider
    Allergies
    Drug interactions (mainly clarithromycin)
    Previous antibiotic exposure
    Patient compliance +++++++
21
Q

What is functional Dyspepsia

A
  • Thought to be a disorder of gut:brain interaction which may lead to symptoms via alterations in processes including:
  • GI motility
  • gut microbiota composition
  • gastric acid secretion
  • Diagnosis of exclusion, patients will normally have extensive investigation, including specialist assessment, e.g. for endoscopy
22
Q

Functional dyspepsia: Management

A
  • Non-pharmacological management as per unidentified cause dyspepsia
  • H. pylori test and treat (if needed)
  • If H. pylori has been excluded and symptoms persist, offer low-dose PPI (e.g. lansoprazole 15mg OD, omeprazole 10mg OD) or H2RA for 4 weeks then on an ‘as needed’ base
  • If symptoms continue or recur after initial treatment, use PPI or H2RA at lowest dose possible to control symptoms
  • Avoid long-term, frequent dose, continuous antacid therapy (only relieves symptoms, won’t prevent)
  • May be a role for psychological therapies (e.g. CBT) or antidepressants, e.g. low dose amitriptyline
23
Q

GORD Management ?

A
  • Proven GORD’ refers to endoscopy-confirmed reflux disease. May be due to:
    - Oesophagitis = oesophageal inflammation and mucosal erosions seen on test
    - Endoscopic negative reflux disease (ENRD) = when a person has symptoms of GORD but normal endoscopy
  • Non-pharmacological management and medication review is as per other causes of dyspepsia
    - May additionally benefit from sleeping with head of bed raised (e.g. raised on blocks)
    -Specialist management may involve surgical methods, e.g. laparoscopic fundoplication
24
Q

Pharmacological management of GORD

A
  • PPI and H2RAs used
  • Higher doses used than in uninvestigated dyspepsia to promote healing (see table below)
    More severe symptoms / OGD results require more intensive treatment
  • Aim is to step down to lowest dose / PRN but some may need long-term maintenance PPI
25
Q

Symptoms of Peptic Ulcer Disease

A
  • Epigastric discomfort - Burning or gnawing (often well localised)
  • Fullness / early satiety
  • Bloating
  • Nausea
  • Heartburn
26
Q

What are Peptic Ulcer Disease Complications

A
  • Bleeding
  • Perforation
  • Obstruction
  • Chronic iron deficiency anaemia
  • Adenocarcinoma
27
Q

Peptic Ulcer Disease - Treatment - Non-pharmacological and medication review advice per previous plus

A
  • Stop NSAIDs
  • Consider reducing or stopping (if possible and appropriate) any other potential ulcer-inducing drugs, e.g. aspirin, bisphosphonates, corticosteroids, crack cocaine
  • Patients with inflammatory conditions may need to continue NSAID after ulcer healed – gastric protection and explain risks vs benefits
28
Q

Causes and Risk factors of peptic ulcer disease

A
  • Helicobacter pylori
  • Medication esp NSAIDs, corticosteroids. Co-prescribed medicines may increase risk, e.g. anticoagulants
  • Lifestyle especially alcohol intake, smoking, stress
  • Genetic component
  • Co-morbidities e.g. Crohn’s disease, Zollinger-Ellinger syndrome
29
Q

Peptic Ulcer Disease - Treatment - Pharmacological management

A
  • H. pylori test and treat
  • Full dose PPI (e.g. lansoprazole 30mg OD, omeprazole 20mg OD) for 4-8 weeks (can offer H2RA if inadequate response)
  • Follow-up 6-8 weeks after treatment – repeat endoscopy to confirm healing
  • If healed, step down / stop treatment or use at lowest dose or PRN basis to control symptoms

PMY3304 (11 decks)

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