Dyspepsia Flashcards
Red flag symptoms in context of dyspepsia
- ALARMS 55
Anaemia (Fe2+) Loss of weight Anorexia Recent onset, progressive Melaena/haematemesis Swalllow difficulty 55 years +
Also…
- Epigastric mass
- Persistent vomiting
Causes of dyspepsia.
a) most common
b) other causes
a) Functional (non-ulcer) dyspepsia, GORD
b) PUD, oesophagitis, oesopageal/stomach Ca
Common associated symptoms
Epigastric discomfort Fullness or bloating Excessive flatus Nausea Fatty food intolerance Reflux/heartburn (note: this is NOT dyspepsia)
Investigations for dyspepsia
- Bloods: FBC, CRP/ESR
- H. Pylori test (carbon-13 urea breath test, stool antigen test or PPI trial for 1 month)
- OGD if red flags/resistant to treatment
Peptic ulcer disease.
a) Risk factors (big 2 and some others)
b) Clinical features - gastric vs duodenal
c) Investigations
d) Complications
a) H. pylori, NSAIDs/aspirin;
- Smoking, alcohol, stress, steroids (if on NSAIDs also)
- Zollinger-Ellison syndrome: causes gastrin-secreting tumours (gastrinomas) that result in PUD
b) Epigastric pain, usually 1 to 3 hours postprandial (though duodenal ulcers may improve on eating), pain may radiate to the back if posterior, often relieved by antacids;
nausea, bloating, oral flatulence, intolerance of fatty foods (also occurs in gallstones),
c) - Bloods: FBC
- H. pylori testing: C-13 urea breath test or trial PPI for 1 month - if either test is positive, commence Rx.
- if warning signs - upper GI endoscopy
d) - Erosions may cause haemorrhage/ acute UGIB (classically erode into gastroduodenal artery)
- Perforation and acute abdomen
Management of PUD
a) General measures
b) H. Pylori -positive
c) NSAID-positive
d) H. pylori and NSAID-negative
a) Smoking cessation, limit alcohol, take NSAIDs/aspirin and other medications with food or avoid if possible
b) Triple eradication therapy (once H. pylori confirmed by breath test or one-month trial PPI):
- PPI + amoxicillin + clarithromycin/metronidazole (7 - 14 days)
- If they had an ulcer, repeat endoscopy at 6-8 weeks to see if resolution (if just dyspepsia, no need for review unless symptomatic)
c) - Stop NSAID
- 2 months of PPI
- Gastroscopy at 2 months to see resolution of ulcer
d) - Take detailed history and examine for other causes (e.g. Zollinger-Ellison syndrome)
GORD.
a) Risk factors (via 3 main mechanisms)
b) Clinical features (main 1 and others, including atypical)
c) vs. PUD
d) Investigations
e) Management
a) - Increased intra-abdominal pressure: Pregnancy.
Obesity. Tight clothes. Big meals. Hiatus hernia.
- Relaxed lower oesophageal sphincter: surgery in achalasia, systemic sclerosis, smoking, drugs (TCAs, anticholinergics, nitrates and CCBs).
- Direct mucosal damage: NSAIDs, potassium salts, bisphosphonates, alcohol
b) - Heartburn: burning feeling, rising from the stomach towards the neck, related to meals, lying down, stooping and straining. It is relieved by antacids
- Retrosternal discomfort, acid brash - regurgitation of acid or bile.
- Water brash - this is excessive salivation.
- Odynophagia/dysphagia - related to stricture secondary to reflux-associated inflammation
- Atypical: non-cardiac chest pain, cough, hoarseness, wheeze
c) Heartburn (burning retrosternal pain) vs. dyspepsia (epigastric pain or discomfort)
d) Bloods: FBC
- Imaging: CXR (hiatus hernia), barium swallow
- Upper GI endoscopy
- Special tests: oesophageal pH monitoring
e) - Conservative: weight loss, smoking cessation, reduce alcohol, raise head of bed, smaller and more frequent meals, avoid drugs that relax LOS/damage mucosa
- Medical: PPI
-
Acute upper GI bleed (UGIB): causes
- main 2 + others
Main 2: PUD, oesophageal varices;
Others:
- Gastritis, oesophagitis,
- Mallory-Weiss tear, Boerhaave syndrome,
- malignancy,
- vascular malformation
Presentation of acute UGIB:
- five ways in which bleeding may present
- Asymptomatic: found incidentally (low Hb)
- Haematemesis: bright-red, implies active haemorrhage.
- Coffee-ground vomit: bleeding that has ceased or has been relatively modest.
- Melaena: black tarry stools, usually due to acute UGIB but occasionally bleeding from the small bowel or right side of the colon.
- Haemodynamic collapse: shock, syncope, coma
Acute UGIB: management
a) Assessment
b) Investigations
c) Who to admit?
d) Do what assessment of mortality?
e) Initial management
f) Variceal bleeding
g) Non-variceal bleeding
a) - A-E: signs of blood loss (anaemia, pallor), dehydration and shock (low BP, raised HR, low urine output, prolonged CRT, confusion, reduced GCS),
- Stigmata of disease (e.g. liver disease, malignancy)
b) - Bloods: FBC (anaemia, platelets), LFTs, UEs (urea raised in UGIB), creatinine, clotting, group/save and cross-match units
- CXR (perforation)
- UGI endoscopy (gold standard)
c) Anyone >60, witnessed haematemesis, haemodynamic instability or known liver disease/varices
d) - Rockall score (eg. age, shock, comorbidities, diagnosis)
- Glasgow-Blatchford Score (eg. Hb, urea, HR, SBP, syncope, melaena, heart failure, liver disease)
f) - Terlipressin
- Band ligation
g) - OGD + mechanical clips +/- adrenaline
- PPI
- If unresponsive to medical/surgical management, insert a Sengstaken–Blakemore tube for tamponade of bleed
Oesophageal spasm.
a) Clinical features
b) Investigations
c) Management
a) Spasms of cardiac-like chest/epigastric pain (can be misdiagnosed as angina), dysphagia, reflux
b) - UGI endoscopy
- ECG / angiography to rule out cardiac cause
- Oesophageal manometry (gold-standard)
- Barium swallow - corkscrew appearance
c) Lack of evidence: can try medications to relax oesophageal tone (e.g. CCBs, nitrates), botulinum toxin, surgery (e.g. myotomy - used for achalasia)
