Dyspepsia Flashcards
What is dyspepsia (7)
- Dyspepsia is a broad umbrella term for 5 conditions, covering 90% of cases
- Affects women more slightly then men
- GORD = Gastro-Oesophageal Reflux Disease (next disease state)
- Heartburn = Temporary reflux of acid up the oesophagus causing burning discomfort
- Gastritis = inflammation of the stomach
- Duodenal Ulcers
- Peptic Ulcers
What are the oesophageal causes of dyspepsia (3)
- GORD
- Hiatus hernia (leading to GORD)
- Dysphagia
What are the gastric causes of dyspepsia (2)
- Peptic ulcer
- Carcinomas
What are the inflammation or disease in other GI organs causes of dyspepsia (4)
- Crohn’s
- hepatitis
- pancreatitis
- congestive heart failure
What are the lifestyle causes of dyspepsia (5)
- Stress
- diet
- pregnancy
- smoking
- excessive caffeine and/or alcohol consumption
What are the drug-induced causes of dyspepsia (6)
- Aspirin
- NSAIDs
- Iron
- Abx
- SSRIs
- steroids
What is the most likely cause of dyspepsia
Non-ulcer dyspepsia
what are the unlikely causes of dyspepsia (3)
- ulcer
- medicine induced
- IBS
What are the least likely causes of dyspepsia (2)
- cancers
- atypical angina
What are the 2 broad categories of dyspepsia
- Pre-endoscopy
- Post-endoscopy
What are the severe symptoms post-endoscopy dyspepsia (5)
- 40% have functional dyspepsia = no ulcer
- 40% have gastro-oesophageal reflux disease (next topic)
- 3% have some form of ulcer (link to Peptic & Duodenal ulcers)
- Gastric and oesophageal cancers occurring in up to 3% of endoscopies
- Cancers are rare, but serious → Red flag symptoms…
What are the signs and symptoms of dyspepsia (8)
- Generic and hard to distinguish
- Any symptom of the upper gastrointestinal tract (GI), present for 4 weeks or more
- Upper abdominal pain or discomfort, maybe before meals or relieved by food
- Epigastric pain (upper abdomen just below ribs)
- Heartburn
- Acid reflux
- Nausea and/or vomiting
- May be relapsing/remitting
What are the red flag symptoms of dyspepsia (10)
- unintentional weight loss
- blood in vomit/stool
- GI bleeding
- Persisitant symtptoms 4-6 weeks
- sudden onset (over 55 y/o)
- progressive dysphagia (food ‘sticking’)
- symptoms after 14 days treatment
- epigastric mass/swelling
- Chest pain & feeling faint
- Suspected heart attack
What is the relevance of age with dyspepsia (2)
- Adults under 50 are likely to have symptoms for no specific pathology
- over 50 a specific pathology becomes more common
What is the relevance of the location of pain with dyspepsia (4)
- Dyspepsia is felt above the belly button and below the ribs
- Heartburn is felt in ribcage
- If a specific location is pointed to → unlikely to be dyspepsia
- IF IT RADIATES, REFER! Most urgently down left arm suspect heart attack or angina!
What is the relevance of the nature of pain with dyspepsia (3)
- Aching/discomfort → dyspepsia
- Sharp, stabbing → unlikely to be dyspepsia
- Severe → REFER
What is the relevance of other symptoms with dyspepsia (2)
- Persistent vomiting, may be ulcer or cancer → REFER
- Black, tarry stools suggest bleeding → REFER
What is the relevance of aggravating and relieving factors with dyspepsia (2)
- Pain 1-3 hours after eating and then relieved with food or antacids suggests ulcer → REFER
- Dyspepsia often bought on by ingesting certain foods and drinks such as caffeine or spice
What is the relevance of social history with dyspepsia (4)
- Binge drinking
- binge eating
- eating on the go
- eating too quickly
all associated with dyspepsia
What is the first course of action for dyspepsia (7)
- f no red flags
- Offer initial and ongoing help
- lifestyle changes
- OTC medication
- Help with Prescribed drugs
- When to see G
- Provide educational material
What are diet lifestyle advice for dyspepsia (5)
- Reduce alcohol intake- Max 14 units/week spread over 3 days
- Reduce coffee
- Reduce Chocolate
- Reduce fatty foods
- Other healthy diet promotion
What are other lifestyle advice for dyspepsia (4)
- Reduce/quit smoking
- Lose weight (if overweight) - Aided by diet and exercise
- Raise head of bed at night - lifting whole half ideally
- Avoid large meals close to bedtime
What is the second course of action for dyspepsia (10)
- Review of potential therapies that could cause symptoms
- Acarbose
- NSAIDs
- Steroids
- Antibiotics
- Antimuscarinics
- Calcium antagonists
- Nitrates
- Theophyllines
- Bisphosphonates
What is the third course of action for dyspepsia (5)
- If no drug cause and lifestyle changes not working, consider OTC therapy
- Antacids (Rennie®)
- Alginates (Gaviscom)
- Proton Pump Inhibitors (omeprazole)
- H2 receptor antagonists (famotidine)
What is the fourth course of action for dyspepsia (4)
- If none of this works or red flag refer to GP.
Typically a patient gets:
- 4 weeks full dose PPI (omeprazole)
- H. Pylori test (after 2 week PPI washout)
- Endoscopy
How are PPIs used for dyspepsia (4)
- Proton Pump Inhibitors. Inhibit proton (H+) pump in stomach parietal cells → reduced HCl production
- Most common: Omeprazole
- Typical dose: 20-40 mg ONCE a day
- Typical formulation: 20 mg Capsules
Oral omeprazole doses: low (OTC), full & double (high)
Low - 20mg OD
Full - 40mg OD
Double - 40mg BD
Oral lansoprazole doses: low (OTC), full & double (high)
Low - 15mg OD
Full - 30mg OD
Double - 30mg BD
Oral esomeprazole doses: low (OTC), full & double (high)
Low - 20mg OD
Full - 40mg OD
Double - 40mg BD
Oral pantoprazole doses: low (OTC), full & double (high)
Low - 20mg OD
Full - 40mg OD
Double - 40mg BD
Oral rabeprazole doses: low (OTC), full & double (high)
Low - 10mg OD
Full - 20mg OD
Double - 20mg BD
How are H2 receptor antagonists used for dyspepsia (4)
- Inhibit Histamine 2 receptors on parietal cells, stopping cAMP production, no activation of protein kinase → reduced H+ pump activity
- The most common: was ranitidine now famotidine
- Typical dose: 20 - 40 mg at night
- Typical formulation: 20 mg and 40 mg tablets
How are antacids used for dyspepsia (6)
- Alkaline compounds that neutralise acid producing a salt and water
- Provide short lived symptomatic relief only
- Most common: Aluminium, calcium or magnesium compounds
- Brands: Gaviscon, Rennie’s, Tums…
- Typical dose: Brand specific (see product)
- Typical formulation: suspension (also powders and chewable tablets)
How are alginates used for dyspepsia (8)
- Often added to antacids- mainly Gaviscon
- Natural polysaccharide often from seaweed
- When charged in acidic stomach:
- ↑ viscosity
- Forms physical raft
- Always use after food and drink
- Shown more effective than antacid alone
- Do not use simethicone and alginate products together
