Dyspepsia and Peptic Ulcer Disease Flashcards
Define dyspepsia
Indigestion
What are some of the symptoms of dyspepsia
Epigastric pain or burning
Postprandial fullness
Early satiety
Combination or separate symptoms
What are the structures of the foregut and where does it start and end
Oesophagus Stomach Duodenum Pancreas Gallbladder Starts at the cricopharyngeus to the ampulla of Vater
Describe the epidemiology of Dyspepsia
Very common (20-40% global) No consistence association with sex/age/ socioeconomic status/ smoking or alcohol More common if H pylori infected More common if using NSAIDs Overlap with IBS / GORD
What are the 2 main classes of causes of Dyspepsia and how common is each one
Organic (25%) and Functional (75%)
What are some of the organic causes?
Peptic ulcer disease
Drugs (NSAIDs, COX2 inhibitors)
Gastric cancer
What are some of the functional causes?
Idiopathic
Associated with other functional gut disorder such as IBS
No evidence of culprit structural disease
What is it really important to differentiate between in diagnosing dyspepsia
Heartburn, reflux or dyspepsia
What is the only examination finding in dyspepsia
Epigastric tenderness only
If the dyspepsia is complicated, what else can it cause
Cachexia
Mass
Evidence of gastric outflow obstruction
Peritonism
How do we manage a patient with no alarm symptoms
Non invasive test and treat strategy
Test for H pylori
If a patient is H pylori positive what course of action should be taken?
Prescribe course of antibiotics
If H pylori negative what course of action should be taken?
Use PPI and other acid suppression and monitor the patient symptomatically if under 55
If the patient is over 55, we use ore active treatment and consider a referral to specialist
What other factors can affect functional dyspepsia?
Visceral hypersensitivity (MAIN CONTRIBUTOR) Disrupted gut-immune interactions Abnormal upper GI motor and reflex functions Psychosocial factors (gut changes with stress) Genetic factors Altered brain-gut interactions
What is peptic ulcer disease
Peptic ulcer disease refers to painful sores or ulcers in the lining of the stomach or first part of the small intestine, called the duodenum
What are the common syptoms of peptic ulcer disease?
Pain radiating to the back Nocturnal pain Aggrevated or relieved by eating Relapsing and remitting chronic illness More common in lower socio-economic groups Past family history
What are the 2 main causes of peptic ulcers
H pylori and NSAIDs
What is happening to the ratio of NSAID: H pylori?
It is rising
Describe H pylori
Acquired in infancy
Gram negative microaerophilic flagellated bacillus
Oral-oral/ faecal oral spread
Consequences of infection do not arise until later in life
What are the 2 main consequences of H Pylori
Peptic Ulcer disease
Gastric cancer
Describe the prevalence of H Pylori around the world
In the developing world, the prevelance is very high at an early age
In the Western world, there is a greater prevalence as the age increases. Older generations were brought up in a less clean and more poorly sanitised environments.
There is a higher prevalence of H pylori in lower social economic areas
What are the 2 different outcomes of an H Pylori infection
An increase in acid secretion of a decrease in acid secretion.
An increase causes an increased risk of duodenal ulcer
A decrease causes atrophy which results in Gastric Cancer
What is a typical endoscopic finding of a duodenal NSAID induced ulcer
Multiple white erosions all on one side of the tube
What do we need to worry about if an ulcer is irregular in shape and deep with raw edges?
Cancer - biopsy is required!
What is a typical sign of a gastric ulcer?
Raw edges on an ulcer
What 4 ways can we diagnose H pylori infection?
Gastric Biopsy
Urease Breath Test
Faecal Antigen test
Serology (IgA antibodies)
What might give you a false reading of H pylori?
If the patient is taking PPIs
What does H pylori do?
Increases the pH of its microenvironment
What would H pylori look like in terms of histology?
Black dots in the crypt area of the stomach
How can we treat Peptic Ulcer Disease (PUD)
Antisecretory Therapy (PPI)
Test for presence of H pylori
Withdraw NSAIDs
Surgery
Is the peptide ulcer likely to be organic or functional if symptoms persist in the young?
Functional
What do we do if symptoms persist in a patient over 55
Refer for an endoscope
What are the 2 main groups of drugs used to treat ulcers? and give examples of both
H2RAs - Ranitidine or nizatidine
PPIs - Omeprazole or lansoprazole
Why is omerprazole better than H2RAs in Duodenal ulcers?
It heals duodenal ulcers faster
Why are H2RAs better than omeprazole in Duodenal Ulcers?
Therapy after four weeks is higher
What is the disadvantage of antacids such as Gaviscon ?
They take much longer and the patient is more likely to lose compliancy
What is the first line treatment of H Pylori
Triple therapy - 1 week of:
PPI + amoxycillin 1g bd + clarithromycin 500mg bd
PPI + metronidaxole 400mg bd + clarithromycin 250mg bd
What happens if the treatment of H pylori has not improved the symptoms
Biopsy may be required
What are the main side effects that occur during the treatment of H Pylori
Nausea, diarrhoea
Name 4 complications of peptic ulcer disease?
Anaemia
Bleeding
Perforation
Gastric outlet / duodenal obstruction
What follow up treatment is required for duodenal ulcers?
No follow up
Confirmation of helicobacter free
Rarely forms malignancy
What follow up treatment is required for Gastric Ulcers
Follow up endoscopy in 6-8 weeks
Ensure healing and no malignancy has formed which is common
What are some of the symptoms /risks of gastric cancer?
Dyspepsia and alarm symptoms such as weight loss, anaemia, mass, recurrent vomiting
Family history of gastric cancer
Achlorhydria (production of gastric acid in the stomach is absent or low, respectively)
What is the overall end result of H pylori infection regardless of the increase or decrease in acid
An increase in Gastrin
