Dyspepsia Flashcards
What may GORD (gastro-oesophageal reflux disease) leading to oesophagitis be due to?
Obesity
Pregnancy
Drug-induced
What is peptic ulceration?
Gastric and duodenal
Can lead to anaemia
What’s Zollinger-Ellison syndrome/
Rare gastrin0secreting tumour of D-cells of the pancreas
What are the symptoms of peptic ulceration?
Precise epigastric pain
Hunger pain, relieved by eating
Night pain, relieved by food, milk or antacids
Waterbrush, appearance of water in the mouth
Nausea and sometimes vomiting
Haematemesis
What are the main causes of peptic ulceration?
Helicobacter pylori (80-90% duodenal ulcer have gram-ve infection) 70% patients have gastric ulcer, remainder mostly NSAID induced
What are the tests for H. pylori?
Urea breath test- patient given 13C and bacterial ureases convert it to 13CO2 which is absorbed and exhaled from the lungs
H. pylori antigens/antibodies in blood, saliva, stools
What symptoms are suggestive of serious disease?
Aged over 45 years Weight loss Anaemia Dysphagia Haematemesis Melaena (tarry stools) Upper abdominal masses Persistent symptoms with repeat requests for OTC remedies Onset of new symptoms
What increases acid secretions?
Histamine via H2 receptors
Gastrin
Acetylcholine via M-receptoras- M3 on parietal cells
What decreases acid secretions?
Prostaglandins (E2 and I2)
Also cytoprotective via bicarbonate and mucus release
What are the goals of treatment?
Symptomatic relief or cure
Suppression of acid release or activity, and mucosal protection
Allow natural healing and eradicate infection
What lifestyle changes can provide symptomatic relief?
Avoidance of causative drugs
Avoidance of causative foods
GORD- propping up bed, removing belts
What antacids are used?
Sodium bicarbonate
Magnesium hydroxide
Aluminium hydroxide
What are alginates?
Gaviscon
Alginic acid when combined with saliva, forms a viscous foam which floats on the gastric contents forming a raft which protects the oesophagus during reflex
What are H2 antagonists
Cimetidine (Tagamet)
Ranitidine (Zantac)
Famotidine (Pepcid)
Receptors are coupled via adenylyl cyclase to increase cAMP which activates the proton pump
What do histamine H2 antagonists do?
Reduce gastric acid secretion
Provide symptomatic relief
Best given at night
Promote ulcer healing (relapse on discontinuation)
Reduce the need for surgery in ulceration
What does cimetidine do?
Inhibits cytochrome P450 and the metabolism of other drugs
What drugs does cimetidine interact with?
Oral anticoagulants Phenytoin Carbamazepine Tricyclic antidepressants (ranitidine doesn't interact this way and is favoured)
What are PPIs (proton pump inhibitors)
Omeprazole, pantoprazole, lansoprazole
Act via irreversible inhibition of the proton pump (H+/K+-ATPase)
How do PPIs work?
Activated by acid pH
Inhibit H+ secretion by >90% may lead to achorhydia
Increased risk of campylobacter infection due to increased pH
Omeprazole is now OTC
What are pro-kinetic drugs?
Cause gastric emptying
Movement of gastric contents from stomach to duodenum- of benefit in GORD
What does domperidone do?
Increased closure of oesophageal sphincter (good for reflux disease) and opens lower sphincter
What does metocloperamide do?
Acts locally to increase gastric motility and emptying (combined with analgesics to accelerate absorption
What triple therapy is used for eradication of helicobacter pylori?
2 from: Metronidazole Amoxicillin Clarithromycin Plus PPI and/or H2 antagonist Triple therapy for 1 week then PPI alone for ulcer healing
What’s bismuth chelate?
Kills H. pylori, coats the ulcer, absorbs pepsin, increase prostaglandin production and increased HCO3- secretion
How is non-H. pylori dyspepsia treated?
Step 1: antacid and/or alginate
Step 2: H2 antagonist
Step 3: PPI
What drugs cause ulcerogenic effects?
Oral NSAIDs and corticosteroids
Ibuprofen has low incidence of GI side effects
What do cyclooxygenases (COX) exist as?
COX-1: is the physiological form, involved in gastric protection
COX-2: selective inhibitors (celecoxib) have less GI-side effects
What is celecoxib?
COX-2 selective inhibitors have less GI-side effects
How can you minimise GI damage?
Prophylaxis with PPI
H2 antagonists less or ineffective
Give in combination with misoprostol- a stable PGE1 analogue, acts on prostanoid receptors to inhibit gastric H+ secretion
