Dyspepsia Flashcards
what is dyspepsia
bad digestion
epigastric pain lasting a month
can be associated wiht other upper GI symptoms as long as epigastric pain is the primary concern
2 main dyspepsia categories
organic - peptic ulcer disease, gerd, barretts esophagus, cancer
functional - no cause we can find
what is peptic ulcer disease
group of ulcerative disorders that are dependent on acid and pepsin for their production
common symptoms of peptic ulcer disease
episodic epigastric pain
heartburn
cause of PUD
imbalanc ebetween mechanisms of ijury and protection
could be injured by acid, enzymes, toxins, drugs, bacteria
complications of PUD
perforation
penetration
hemorrhage
gastric outlet obstruction
risk factors for PUD
hpylori
nsaids
PUD and GERD treatment goals
symptom relief
accelerate healing
prevent and treat complications
prevent recurrence
PUD non pharms
avoid large bedtime meals (increases acid)
avoid nsaids, smoking alcohol, caffiene affect healing
use of antacids in PUD
symptomatic relief due to compliance issues
give 1 and 3 hr post meals and at night
cautions with antacids
sodium bicarb in CHF/cirrhosis
magnesium based in dialysis
constipation, diarrhea, drug interactions
role for H2 blockers
take long to work so not much use PPI much better
should you bother increasing dose of omeprazole
no only decreases acid by further 6%
efficacy of proton pump inhibitors
gold standard for ulcers
also role in hpylori eradication
what is considered refractory PUD
fail 8 week therapu in dunodenal
12 week in gastro
usually on BID PPI for recurrence
new recommondations for eradication of hpylori is
quad based therapy becuase of clarithromycin resistance in manitoba (PPI +amox/bismuth + metronidazole + tetracycline)
use for chronic prophylaxis of PUD
maybe in patients with severe PUD complication or significant comorbidity
if another blled could be catastrophic
PPI chronic use has what effect
increases gastrin level 2x which has proliferative effects on both ECL and parietal cells causing hyperplasia and hypertrophy(rebound hypersecretion)
cancres not seen in humans
PPI adverse effects
infections - cdiff, pneumonia
fractures
interaction with clopidogrel?
what is GERD
retrograde spilling of the gastric contents into the esophagus
chronically relapsing disorder
classical symptoms of gerd
regurgitation
heartburn
dysphagia
odynophagia ( pain when swallowing)
atypical gerd symptoms
coughing wheezing globus sensation laryngitis chest pain dental erosions
gerd risk factors
pregnnacy
obesity
increased age
hiatus hernia
complications of gerd
esophagitis and esophageal bleeding
esophageal stricture
barretts esophagus - very rare
esophageal cancer - very rare
what is non erosive reflux disease
symptoms but no active imflammation
GERD and functional dyspepsia non pharms
smaller more frequent meals avoid smoking reduce alcohol and caffiene obtain ideal weight stress reduction blocks of wood at the head of the bed
use of antacids in gerd
symptom relief, breakthrough
give 1 and 3 hours post meals and at night as needed
how do prokinetics work
increase LESP and accelerate gastric emptying
recommendation for prokinetics in gerd
best agent cisapride but risk of cardiac arrythmias
metoclopramide good for nause but long term AE
gold standard for gerd
PPI
what is functional dyspepsia
dyspepsia for 3 months with no clearly identifiable pathogen
motor and sensitivity changes in GI tract?
symptom subgroups of dyspepsia
ulcer like
dysmotility like
reflux like
functional dyspepsia GOT
symptom relief
prevent recurrence
role of antacids in functional dyspepsia
limited to no benefit
role of PPI in functional dyspepsia
little more of an effect than placebo
limit to once daily dosing
best evidence for treatment of functional dyspepsia
TCAs
consider if no benefit from PPI
prokinetic role in functional dyspepsia
found more effective than placebo but risk with long term use
how long to determine benefits of therapy in functional dyspepsia
4 weeks
signs of serious GI disease
over 50 vomit, bleeding anemia weight loss dysphagia anorexia jaundonce cancer history multiple treatment failures recent dramatic changes in symptoms
cancer risk is higher where
SE asia
south america
recommend endoscopy for who
> 60 higher risk of malignancy
<60 with alarm features not recommended
treatment duration fo r h pylori
14 days
recommendation for <60with dyspepsia
test and treat for hpylori
who should be tested for hpylori eradication and how
serious GIi bleeding or other complications
urea breath test or stool antigen test
on demand dosing benefit
therapy that meets patients needs
obtain a similar outcome at less cost
potential for reduced adverse effects
on demand dosing risk
under treatment of disease (symptoms dont corelate with endoscopic findings)
long term risk of complications unknown
4 things that warrant continuing a PPI
barretts esophagus
chronic NSAID user with bleeding risk
severe esophagitis
documented history of bleeding GI ulcer
in which situations would you recommend deprescribing (decrease dose, use on demand, or stop)
mild-mod esophagitis
GERD treated for 4-8 weeks
peptic ulcer disease treated 2-12wks
ICU stress ulcer prophylaxis beyond ICU admission
uncomplicated hpyolri treated 2 wks and asymptomatic
upper GI symptoms without endoscopy asymptomatic for 3 days
what do you monitor for at 4 and 12 weeks of deprescribing
heartburn, regurgitation, dyspepsoa, epigastric pain
loss of appetite, weight loss, agitation
non drug options to assist in deprescribing
avoid meals 2 hours before bedtime
elevate head of bed
weight loss
avoid dietary triggers
alternative way to manage occasional symptoms
antacid, H2blocker
PPI, aliginate prn
what to do is symptoms relapse after deprescribing
if persist 3-7days test and treat for hpylori and consider return to previous dose
what is rebound hypersecretion
compensatory effect from PPIs blocking the proton pump
stimulastes gastrin inducing ECL and parietal cells to try produce acid
was linked to cancer in rats
how to manage rebound hypersecretion
wean over 1-3 months
are all PPIs equally effective
yes
causes of drug induced esophagitis
tetracycline doxycycline slow release potassium quinidine ASA and NSAIDs alendronate
treatment algorithm for functional dyspepsia hpylori negative
PPI —- TCA —- prokinetic —- pharmacotherapy
typical resolution of ulcer symptoms
1 week
how can nsaid use be continued after an ulcer
if duodenal can put back on NSAID after health but with gut protection
gastric ulcer try to keep off as long as possible
celecoxib and a PPI the best protection
why do we take a PPI before food
proton pumps are normally sitting back but when we eat they get to the wall of the stomach and start pumping out acid, want the PPI in board when they are in this state
