Dyspepsia

Question 1

Describe the clinical problems that can cause dyspepsia ‘indigestion’?

Answer 1

GORD
Peptic ulcers
Gastritis
Zollinger- Ellison syndrome (rare gastrin secreting tumour of the D cells of the pancreas)

Question 2

Describe the goals of treatment in a patient with dyspepsia?

Answer 2

Symptomatic relief, including lifestyle advice (such as causative foods, sitting up in GORD)

Treat cause: peptic ulcer reduce acid eradicate H.pylori if positive.

Question 3

List the different types of pharmaceuticals used to treat the symptom of dyspepsia and give examples?

Answer 3

Antacids: (HCO3-, Mg(OH)2, Al(OH)3) aka gaviscon

Alginates

Histamine H2 Antagonists aka cimetidine, ranitidine

Proton Pump Inhibitors aka omeprazole, lansoprazole

Prokinetic drugs (increase gastric emptying and therefore increased closure of the oesophageal sphincter) aka Domperidone

Question 4

Describe the mechanism of action of alginates?

Answer 4

Alginic acid combines with saliva to form a viscous foam which floats on the gastric contents forming a raft which protects the oesophagus during reflux.

Question 5

Describe the mechanism of action of H2 antagonists?

Answer 5

When H2 receptors (on parietal cells) are stimulated by histamine they produce cAMP which increase the cativity of the proton pump and therefore more acid is secreted.

These receptors are anatgonised therefore reducing the quantity of secreted acid.

Question 6

Describe some important prescribing points for H2 antagonists and the general reasons for use?

Answer 6

Best given at night.
Cimetidine is a CyP450 inhibitor therefore check DI.
Ranitidine does not do this (its right as rain).

Used as it:
Provides symptomatic relief by reducing gastric acid secretion.
Promotes ulcer healing.

Question 7

Describe the mechanism of action of PPI’s any adverse effects and the general reasons for use?

Answer 7

PPI’s inhibit the proton pump in parietal cells and therefore greatly reduce gastric acid secretion >90% less secretion.

Adverse effect: the patient is more prone to Campylobacter infection (food poisoning)

Reasons for use:
Symptomatic relief
Promotes ulcer healing
Prophylactically with NSAIDs

Question 8

Describe the reason why NSAIDs are associated with peptic ulcers?

Answer 8

NSAIDs are COX inhibitors:

COX1 is involved in the production of prostaglandins which are gastric protective.
COX2 is involved in the production of leukotrienes which are involved in the pain response and inflammation.

NSAIDs block both Coxs.

Note: some selective COX2 inhibitors such as celecoxib which is a good alternative as it has less GI s/e’s

Question 9

Describe how you would test for H.pylori and treat it?

Answer 9

Urease H.pylori breath test.
Urinary testing.
Bloods.

Treat with a triple therapy for 1 week:

Clarithromycin + amoxocillin OR metronidazole + a PPI.

Continue with PPI for ulcer healing.

Question 10

Describe how you would treat a non h.pylori ulcer?

Answer 10

Stop any NSAIDs (commonest cause for non h.pylori ulcers)

Stepped approach: go up and down as appropriate

Step 1: Antacid +/- alginate
Step 2: H2 receptor antagonist
Step 3: PPI

Question 11

What are the warning signs in a patient with dyspepsia if any of these are present what should you do?

Answer 11

Anaemia
Weight Loss
Dysphagia
Persistent Vomiting
FH/PMH of cancer
New onset symptoms over the age of 50

Refer for urgent endoscopy