Dyspepsia Flashcards
What are the symptoms associated with dyspepsia? (4)
Epigastric pain
Heartburn
Indigestion
Pain worse/better with eating
What are the differential diagnosis of dyspepsia? (10)
Upper GI malignancy
Gallbladder or hepatobiliary disease.
Pancreatic/Cardiac/Coeliac/Crohn’s Diseases
Gastroenteritis
IBS
Small intestine bacterial overgrowth - may also present with weight loss, chronic diarrhoea and malabsorption.
Abdominal aortic aneurysm (rare)
Explain the initial investigation for dyspepsia. (9)
Ask for alarm symptoms
Assess frequency, duration and pattern of symptoms.
Ask about family Hx of upper GI malignancy.
Ask about lifestyle factors: Obesity, trigger foods, smoking status.
Assess for stress, anxiety and depression.
Review Medications
Other clinical features
Examine person to assess for:
- Weight loss by checking serial weight and BMI measurements
- Signs of Anaemia
- Abdominal masses and tenderness.
Consider arranging a FBC to check for anaemia +/or raised platelet count.
Give e.g. of medications associated with dyspepsia. (12)
Alpha-blockers
Anticholinergics
Aspirin
BZP
Beta-blockers
Bisphosphonates
CCB
CS
Nitrates
NSAIDs
Theophylline
TCA
What are the implications of a raised platelet count? (5)
Thrombocytosis: Marker for cancer:
- Lung
- Endometrial
- Gastric = people > 55 yrs if presenting with upper abdominal pain, dyspepsia, nausea, vomiting, weight loss or reflux.
- Oesophageal = > 55 yrs if presenting with upper abdominal pain, dyspepsia, N+V, weight loss or reflux.
- Colorectal
When would you seek endoscopy referral for dyspepsia? (1)
Presenting with dyspepsia and acute GI bleeding = same day referral to specialist. (Possible cardiac or biliary disease)
What are the alarm symptoms of dyspepsia? (13)
Abdominal distension
Abdominal, pelvic or rectal mass.
Abdominal or pelvic pain
Change in bowel habit
Dyspepsia
Dysphagia
N+V
Reflux
Hamatemesis
Rectal bleeding
Weight loss
Anaemia
Raised platelet count
What are the possible cancer(s) and recommendations would be made for dyspepsia (treatment-resistant), 55 yrs and over? (2)
Possible cancer: oesophageal or stomach.
Recommendation: Non- urgent direct access upper GI malignancy.
What are the possible cancer(s) and recommendations would be made for dyspepsia with weight loss, 55 yrs and over? (2)
Possible cancer: oesophageal or stomach
Recommendation: Offer urgent direct access upper GI endoscopy (to be performed within 2 weeks)
What are the possible cancer(s) and recommendations would be made for dyspepsia with raised platelet count or N+V, 55 yrs and over? (2)
Possible cancer: oesophageal or stomach
Recommendation: Consider non-urgent direct access upper GI endoscopy.
What are the possible cancer(s) and recommendations would be made for reflux with weight loss, 55 yrs and over? (2)
Possible cancer: oesophageal or stomach
Recommendation: offer urgent direct access upper GI endoscopy (to be performed within 2 weeks)
What are the possible cancer(s) and recommendations would be made for reflux with raised platelet count or N+V, 55 yrs and over? (2)
Possible cancer: oesophageal or stomach
Recommendation: Endoscopy
What are the common elements of care for patients with dyspeptic symptoms? (5)
Lifestyle advice: healthy eating, weight reduction and smoking cessation.
Avoid known precipitants: smoking, alcohol, coffee, chocolate, fatty foods and being overweight.
Raising the head of the bed and having a main meal well before going to bed may help.
Addressing stress, anxiety and depression.
Encouraging people who need LT management of dyspepsia symptoms to reduce their use of Rx medication stepwise: trying ‘as needed’ use when appropriate and by returning to self-treatment with antacids +/or alginate therapy. Unless there’s an underlying condition or comedication that needs continuing tx.
Define uninvestigated dyspepsia. (1)
Patient hasn’t not undergone an endoscopy.
Explain the management process of uninvestigated dyspepsia. (2)
Offer 1 of the following strategies:
- Offer a full-dose PPI for 4 weeks
- Offer H. Pylori ‘test and treat ‘ (2 week wash out period of PPI before testing) - breath stool antigen test.
What is the first line treatment for H.pylori eradication? (2)
PPI with a combination of 2 antibiotics (accounting previous exposure of Clarithromycin or Metronidazole)
Ensure person is aware of the importance of compliance.
Give e.g. of PPI used as first line H.pylori eradication. (5)
Lansoprazole 30mg
Omeprazole 20-40mg
Esomeprazole 20mg
Pantoprazole 40mg OR
Rabeprazole 20mg
What treatment regimen is given to patients who has tested positive in the H.pylori test? (3)
Offer a 7 day triple therapy regimen of:
- PPI BD and Amoxicillin 1g BD +
- Either Clarithromycin 500mg BD OR Metronidazole 400mg BD.
What treatment regimen is given to patients who has a penicillin allergy for H.pylori eradication? (2)
Offer 7 days triple therapy regimen of:
- PPI BD + Clarithromycin 500mg BD + Metronidazole 400mg BD.
What treatment regimen is given to patients who has a penicillin allergy and has has previous exposure to Clarithromycin for H.pylori eradication? (2)
Offer 7-10 day triple therapy regimen of:
- PPI BD + Metronidazole 400mg BD + Levofloxacin 250mg BD.
What should be done before the H.pylori test? (4)
Any course of ABx need to be completed 28 days before test.
Esomeprazole, Lansoprazole, Omeprazole, Pantoprazole + Rabeprazole = stopped 14 days before test.
Cimetidine, Famotidine, Mizatidine + Ranitidine = stopped 3 days before test.
You can’t eat/drink 6 hrs prior to the test.
Explain what happens during a breath test. (3)
Test divided into 2 parts:
- Patient is asked to blow into 2 glass vials with a straw. Patient will then be asked to drink a solution of citric acid.
- A urea tablet is then dissolved in water to make the test solution. The patient drinks this and waits 30 minutes.
- Patient asked to blow into 2 more glass vials with a straw. Test is complete.
How would you manage patients with persistent/recurrent dyspepsia? (6)
Despite initial management and persisting symptoms:
- Assess for alarm symptoms
- Consider alternative diagnosis
- Check person’s adherence to initial management and reinforce lifestyle advice.
- Consider H2 antagonist
- Consider need for LT acid suppression therapy.
- Review NSAIDs/antiplatelets.
When would it be appropriate to consider H.pylori retesting? (5)
Don’t routinely offer H.pylori re-testing:
- Poor compliance to first line eradication therapy or initial test was performed within 2 weeks of PPI or 4 weeks of ABx therapy.
- Aspirin/NSAIDs indicated
- Family Hx of gastric malignancy
- Severe, persistent or recurrent symptoms.
- Person requesting re-testing (e.g. anxiety about whether H.pylori has been eradicated)
What diagnoses is given to patients who have had an endoscopy? (5)
Functional dyspepsia
Gastro-oesophageal reflux disorder (GORD)
Peptic Ulcer Disease (PUD)
Malignancy
Define functional dyspepsia. (1)
Presence of dyspeptic symptoms in absence of an organic cause that readily explain them.
What are the main features of functional dyspepsia? (2)
People with dyspepsia symptoms and normal findings on endoscopy (gastric or duodenal ulcer, gastric malignancy or oesophagitis have been excluded)
Common diagnosis from endoscopy for dyspepsia symptoms
What are the sub-types of functional dyspepsia? (2)
Epigastric pain syndrome: Intermittent or burning pain is localised in Epigastrium.
Post-prandial distress syndrome: Where there’s post-pyramidal fullness or early satiety.
Explain the treatment regimens for functional dyspepsia. (3)
Test person for H.pylori infection
If tested H.pylori positive:
- Rx first line eradication therapy.
- Don’t arrange for routine re-testing unless there are specific clinical circumstances.
If tested H.pylori negative:
- Offer low dose PPI or standard-dose H2-receptor antagonist (H2RA) for 1 month.
-
Define GORD. (1)
Chronic condition where there’s reflux of gastric contents back into the oesophagus causing predominant symptoms of heartburn and acid regurgitation.
What is proven GORD? (1)
Endoscopically-determined reflux disease.
What causes proven GORD? (2)
Oesophagitis = oesophageal inflammation and mucosal erosions are seen.
Endoscopy-negative reflux disease (or non-erosive reflux disease) = person has GORD symptoms but normal endoscopy.
What are the risk factors of GORD? (3)
Lifestyle factors: Obesity, trigger foods, smoking, alcohol, coffee, stress.
Drugs that reduce the lower oesophageal sphincter pressure e,g, CCB, anticholinergics, theophylline , BZP and Nitrates.
Pregnancy
What is the initial management of GORD? (4)
Advise on lifestyle measures and sleeping with the head of the bed raised.
Reviewing and stopping any drugs that may be exacerbating symptoms if possible and appropriate.
Full dose PPI for 4 weeks for proven GORD to aid healing.
Full dose PPI for 8 weeks for proven severe oesophagitis to aid healing.
Explain the management of refractory/recurrent GORD. (7)
Consider alternative diagnosis.
Checking person’s adherence to initial management.
Reinforce lifestyle advice.
Rx 4 weeks of initial PPI at full dose or double dose or adding H2RA at bedtime for people with confirmed oesophagitis.
Switching to H2RA for people with confirmed endoscopy-negative reflux disease.
Rx high dose of initial PPI for 8 weeks or switch to alternative full dose or high dose PPI for 8 weeks if confirmed severe oesophagitis.
Offer a full dose PPI LT as maintenance tx if symptoms of severe oesophagitis are controlled.
Explain the management of peptic ulcer disease. (5)
Test person for H.pylori infection:
- If person tests H.pylori positive with proven gastric or duodenal ulcer which is:
- Associated with NSAIDs use = Rx full-dose PPI therapy for 2 months then Rx first line eradication therapy after completion of PPI therapy.
- Not associated with NSAIDs use = Rx first line eradication therapy.
If person tests H.pylori negative with proven gastric or duodenal ulcer:
- Rx full dose PPI therapy for 4-8 weeks depending in clinical judgement.
What safety points do you need to consider for PPI? (5)
Can increase fracture risk (elderly if used at high doses, higher risk in smokers)
Increased GI infections (C.Diff = withhold PPI if present)
Can masks s/s of gastric cancer (rule out malignancy pre-tx.)
Patient’s on PPI may develop stomach cancer = increase their doses to manage acid reflux and dyspepsia further masking red flag symptoms.
Symptoms can become resistant or alter in character i.e. manifesting as pain rather than burning.
Higher risk of developing subacutecutaneous lupus erythematosus (SCLE)
What actions is considered to reduce the fracture risk when taking PPI? (2)
Limit duration and dosage.
Monitor for long term risk
What counselling points is given to patients regarding the development of lesions with arthralgia when taking PPI? (5)
Avoid skin exposure to sunlight.
Consider SCLE as a diagnosis.
Consider stopping use of PPi unless it’s imperative for a serious acid-related condition. Patient develops SCLE with a specific PPI may be at risk of the same reaction with another.
Symptoms resolve on PPI withdrawal, topical or systemic steroids may be used for SCLE tx only if there’s no signs of remission after a few weeks/months.
What are the monitoring requirement for PPI? (2)
Serum Mg (before and during prolonged tx or used with other drugs which can cause hypomagnesemia or with digoxin.)
Rarely cause hyponatraemia.
Severe hypomagnesemia reported in PPI use.
For patients expected to be on prolonged tx and those taken PPI with digoxin or drugs that may cause hypomagnesemia (e..g diuretics), HCP should consider measure Mg levels before starting PPI and repeat measurements periodically during tx.
What is a common drug interaction with PPI? (1)
Clopidogrel (Antiplatelet)
Explain the interaction between PPI’s and Clopidogrel. (3)
- PPI’s affect the efficacy of clopidogrel.
- Omeprazole and Esomeprazole = Avoid with clopidogrel.
- Use Pantoprazole (least likely to interact), Lansoprazole and Rabeprazole (good alternatives).
