Dyspepsia

Question 1

Definition of dyspepsia

Answer 1

One or more of:

Epigastric/retrosternal burning

Early satiety

Post-prandial fullness

Question 2

Alarm symptoms for dyspepsia

Answer 2

Anaemia

Lossof weight

Anorexia

Recent onset/progressive

Melaena/haematemesis OR mass

Swallowing difficulty

Question 3

Indications of Upper GI endoscopy

Answer 3

Dysphagia

OR

>55 yrs and refractory/alarm symptoms

Question 4

Main differentials for dyspepsia

Answer 4

Non-ulcer dyspepsia (majority!)

GORD aka oesophagitis

Gastritis/duodenitis

Gastric/duodenal ulcer

Gastric malignancy

Pancreatic cancer if epigastric pain

Crohn’s

Zollinger-Ellison syndrome (gastrin levels off PPI)

Question 5

Screening for H. pylori options

Answer 5

¹³C breath test (most accurate non-invasive)

Stool antigen

both above need 2-week PPI washout

Urease test (CLO test) - most accurate invasive

Histology/culture of biopsy

Question 6

Treatment of H. pylori

Answer 6

1/52 course of:

PPI - e.g. lansoprazole 30mg BD

2 abx - e.g. clarithromycin + amoxicillin

Question 7

Risk factors for duodenal ulcers

Answer 7

4x more common than gastric ulcer

MAJOR: H. pylori, drugs

MINOR: smoking, high acid secretion, increased gastric emptying

Question 8

Drugs contributing to gastric/duodenal ulcers

Answer 8

Steroids

SSRIs

Bisphosphonates

NSAIDs (incl. OTC)

Question 9

Risk factors for gastric ulcers

Answer 9

Drugs

Smoking

Surgery/burns (Cushing’s and Curling’s)

Delayed gastric emptying

H. pylori

Question 10

Utility of endoscopy for ulcers

Answer 10

Biopsy ulcer + histology/culture

repeat after 6-8w to ensure healing and exclude malignancy

Question 11

Most common anatomical location of gastric ulcers

Answer 11

Lesser curve

Elsewhere - higher risk of malignancy

Question 12

Risk factors for gastritis

Answer 12

Alcohol, NSAIDs

H. pylori, CMV

Zollinger-Ellison syndrome

Reflux, hiatus hernia

Granulomas (e.g. Crohn’s, sarcoid)

Question 13

First-line management of dyspepsia

Answer 13

Stop drugs causing/exacerbating

Lifestyle - smoking, alcohol, triggers, weight loss

OTC antacid for 4 weeks

?Trial PPI - full dose for 4 or 8 weeks

R/V in 4 weeks

Question 14

Management of non-ulcer dyspepsia

Answer 14

Lifestyle factors (incl. stress/mood)

Low-dose PPI (lowest possible)

Upper GI endoscopy to exclude disease

Low dose TCA e.g. amitryptilline

Question 15

Complications of ulcers/gastritis

Answer 15

Bleeding

Malignancy

Perforation

Gastric outflow obstruction (e.g. pyloric stenosis) –> vomiting

Question 16

2nd and 3rd line management of dyspepsia

Answer 16

If PPI fails

Test + treat H. pylori

Consider H2RA e.g. ranitidine

Question 17

Criteria for routine referral to GI endoscopy

Answer 17

No alarm symptoms

High risk of gastric cancer/anxiety

Previous gastric ulcer/surgery

Continuing need for NSAIDs