Dyspepsia Flashcards
Pain or discomfort centred at the upper
abdomen that is chronic or recurrent in nature.
Dyspepsia
Excessive wind. It includes belching,
abdominal bloating or passing excessive flatus
Flatulence
A central retrosternal or epigastric burning
sensation that spreads upwards to the throat
Heartburn
Excessive belching has been associated with?
- Common in anxious people who gulp food and drink
* Associated hypersalivation
Diagnoses to consider in dyspeptic
patients
Gastrointestinal disorders
Gastro-oesophageal reflux, including hiatus hernia
Functional (non-ulcer) dyspepsia
Oesophageal motility disorders (dysmotility)
Peptic ulcer
Upper GIT malignancies (e.g. oesophagus, stomach, pancreas)
Hepatobiliary disease (e.g. hepatitis, biliary dyskinesia, cholelithiasis)
Diagnoses to consider in dyspeptic
patients
Non GI Causes
Myocardial ischaemia Drug reaction Alcohol effect Somatisation Anxiety/stress Depression
What to exclude if excessive flatus
- malabsorption
- irritable bowel syndrome
- anxiety → aerophagy
- drugs, especially lipid-lowering agents
- lactose intolerance
Dyspepsia or indigestion is a common complaint; ______of the population will have experienced it at some time.
80%
Ten per cent of people in the community develop ____
peptic ulcer (PU) disease
The pain of _______classically occurs at night
duodenal ulcer (DU)
NSAIDs mainly cause gastric ulcers (_______, ________ and ______) with the duodenum
affected to a lesser extent
GU, gastric
antrum and prepyloric region
Dyspeptic symptoms correlate poorly with ________
NSAID associated
ulcer
_______l discomfort indicates oesophageal
disorders or angina, while__________
suggests disorders of the biliary system, stomach and
duodenum
Retrosternal
epigastric discomfort
Character of the pain
• burning pain → \_\_\_\_\_\_\_\_ • constricting pain → ischaemic heart disease or oesophageal spasm • deep gnawing pain →\_\_\_\_\_\_\_\_\_\_ • heavy ache or ‘killing’ pain → \_\_\_\_\_\_\_
gastro-oesophageal reflux (GORD)
PU
psychogenic pain
Aggravating factors:
• eating fried or fatty foods will aggravate _____
• bending will aggravate_______
• alcohol may aggravate GORD, oesophagitis,
gastritis, PU, pancreatitis
biliary disease, functional dyspepsia and oesophageal
disorders
GORD
Most DUs and about two-thirds of GUs have been attributed to________
H. pylori infection
Dx of H. pylori
(sensitivity 85–90%, specificity 90–99%); excellent for diagnosis, not for follow-up
IgC antibodies
Dx of H. pylori
urea breath test__________
(high sensitivity 97% and
specificity 96%), good for follow-up
Dx of H. pylori
stool antigen test ________
(sensitivity 96%, specificity 97%)
________during endoscopy can
detect H. pylori through histology or rapid urease testing or H. pylori culture
gastric mucosal biopsy
T or F
Regurgitation of feeds because of gastro-oesophageal reflux is an uncommon physiological event in newborn
infants.
F
common
Reflux gradually improves with time and usually ceases soon after ______
Most cases clear up completely by the age of ________, when the baby is sitting
solids are introduced into the diet.
9 or 10 months
MX of GERD in children
The infant should be placed on the left side for sleeping with the head of the cot elevated about 20– 30 degrees
Red flags for Endoscopy
- Anaemia (new onset)
- Dysphagia
- Odynophagia (painful swallowing)
- Haematemesis or melaena
- Unexplained weight loss >10%
- Vomiting
- Older age >50 years
- Chronic NSAID use
- Severe frequent symptoms
- Family history of upper GIT or colorectal cancer
- Short history of symptoms
- Usually a metaplastic response to prolonged reflux
* A premalignant condition (adenocarcinoma
Barrett oesophagus
Site for Barrett oesophagus
Lower oesophagus lined with gastric mucosa (at
least 3 cm)
Dxtics for GERD
Endoscopy
• Barium swallow and meal
• 24-hour ambulatory oesophageal pH monitoring
What drugs to avoid in GERD
anticholinergics, theophylline,
calcium-channel blockers, doxycycline
What drugs can cause Pillinduced
oesophagitis
especially with tetracyclines, slow-release potassium, iron sulphate, corticosteroids, NSAIDs
What antacid to give?
best is liquid alginate/antacid mixture e.g. Gaviscon/Mylanta plus 20 mL on demand or 1–2 hours before meals and bedtime
SE of NACOs and CAcCO3 antacids
Excess is prone to cause
alkalosis—apathy, mental
changes, stupor, kidney
dysfunction, tetany
SE of
Aluminium hydroxide_______
Magnesium trisilicate:________
Constipation
Diarrhoea
SE of
Sodium bicarbonate
Alkalosis
Milk alkali syndrome
Aggravation of hypertension
SE of
Calcium carbonate:
Alkalosis
Constipation
Milk alkali syndrome
Hypercalcaemia
What to do with GERD (Step 2) if not responsive to conservative
Proton-pump inhibitor (PPI) for 4 weeks
(preferred agent) 30–60 minutes before food
H 2 -receptor antagonists (oral use for 8 weeks) famotidine 20 mg bd
Surgery is usually for young patients with severe reflux. The gold standard is a short loose_____
360-degree
fundoplication
This term applies to the 60% of patients presenting with dyspepsia in which there is discomfort on eating in the absence of demonstrable organic disease
Functional (non-ulcer) dyspepsia
Categories of Functional (non-ulcer) dyspepsia
• ulcer-like dyspepsia
or
• dysmotility-like dyspepsia
Ulcer-like dyspepsia MX
Treat as for GORD. A practical approach is to
commence with a 4-week trial of a PPI or an H 2 -
receptor antagonist and cease if symptoms resolve
WHat is the dx?
- Discomfort with early sense of fullness on eating
- Nausea
- Overweight
- Emotional stress
- Poor diet
Dysmotility-like dyspepsia
Mx of Dysmotility-like dyspepsia
• Treat as for GORD (stage 1). • Include antacids. • If not responsive: — Step 1: H 2 -receptor antagonists — Step 2: prokinetic agents
DU or GU
MC in men?
DU
NSAIDs 2–4 times increase in ______
GU and ulcer
complications
What are the different types of ulcers
— lower oesophageal
— gastric
— stomal (postgastric surgery)
— duodenal
When is PUD ‘silent’
May be ‘silent’ in elderly on NSAIDs
Investigations for PUD pts
• Endoscopy (investigation of choice) :12 92%
predictive value
• Barium studies: 54% predictive value
• Serum gastrin (consider if multiple ulcers)
• H. pylori test
MX of bleeding PUD
This can be treated with endoscopic haemostasis with ________.
Also IV omeprazole 80 mg bolus, then 8 mg/hr IV infusion for 3 days
heater probe or injection of adrenaline or both
What is the diff bet GU and DU MX
The treatment of a GU is similar to that for a DU except that GUs take about 2 weeks longer to heal and
the increased risk of malignancy has to be considered
What kind of pts do we take caution in PPI
• the elderly
• those on drugs, especially warfarin,
anticonvulsants, beta blockers
• liver disease
Associations of H. pylori
benign non-drug induced GU), gastric cancer and maltoma (a gastric lymphoma) because of mucosalinfection.
risk of gastric CA in patients with H. pylori
gastric cancer in up to 2%.
First line of Tx for H. pylori
PPI (e.g. omeprazole or esomeprazole 20 mg) plus clarithromycin 500 mg plus amoxycillin 1 g
All orally twice daily for 7 days and is the
preferred regimen
Alternatives to first line of Tx in H. pylori
PPI + clarithromycin + metronidazole 400 mg
(twice daily for 7 days)—if hypersensitive to
________
penicillin
What is the quadruple therapy
other combinations: quadruple therapy e.g.
bismuth + PPI + tetracycline + metronidazole
(for failed triple combination
Resistance to metronidazole is common
(>50%) and to clarithromycin is increasing (about 5% plus) but uncommon with __ and ____
tetracycline and
amoxycillin
When to offer Sx in pts with H. pylori/PUD
• failed medical treatment after 1 year • complications: — uncontrollable bleeding — perforation — pyloric stenosis • suspicion of malignancy in GU • recurrent ulcer after previous surgery
Prevention of NSAID of NSAID Ulcers
esomeprazole 20 mg daily or omeprazole 20 mg daily or pantoprazole 40 mg daily
This is an inflammatory condition with antibodies to
parietal cells and intrinsic factor
Autoimmune gastritis 7
Cx of Autoimmune gastritis
pernicious anaemia
SSx of Gastic CA
• Usually asymptomatic early • Consider if upper GIT symptoms in patients over 40 years, especially weight loss • Recent-onset dyspepsia in middle age • Dyspepsia unresponsive to treatment
RF for gastric CA
↑ age, blood group A, smoking,
atrophic gastritis
Tx of GAstric CA
• Surgical excision: may be curative if diagnosed early but overall survival is poor
______ is a rare but important cause of
oesophagitis
Scleroderma
Epigastric pain aggravated by any food, relieved by antacids = ______
chronic GU
A change in the nature of symptoms with a GU suggests the possibility of ______
malignant change
Avoid the long-term use of ____
water-soluble antacids
