Dyspepsia and Peptic Ulcer Disease Flashcards
Rome III criteria for dyspepsia
one of more of the following:
postprandial fullness, early satiety, epigastric pain/burning
Name some “alarm symptoms” for which upper GI endoscopy is indicated in the setting of new-onset dyspepsia
age older than 50 or risk factors for GI malignancy
- uninentional weightloss
- progressive dysphagia/odynophagia
- recurrent/persistent vomiting
- unexplained anemia; GI bleeding/hematemesis
- family hx of cancer; specifically upper GI
- jaundice
- hx of gastric surgery
Consideration for patients younger than age 50 without alarm symptoms in setting of dyspepsia
H pylori (IgG serology) (low cost and ease of collection)
h2 antagonists and proton pump inhibitors have what in common
REDUCE GASTRIC ACID BY ACTING ON GASTRIC PARIETAL CELLS
h2 antagonists - block acid secretion pathway by blocking receptor
ppi - irreversibly inhibit H/K ATPase pump
Where are you most likely to see GI ulcers?
stomach and proximal duodenum
duodenal ulcers are the most common but gastric ulcers are more common in NSAID users
Risk factors for developing peptic ulcer disease (PUD)
NSAID/aspirin use, smoking, h pylori, alcohol, and family history of PUD
Classic symptoms of PUD
epigastric abdominal pain that is improved with eating or pain that develops a few hours AFTER eating
- gradual in onset, may present for weeks/months
- can have nighttime symptoms too
On physical what differentiates PUD from dyspepsia/GERD
Dyspepsia and GERD usually have unremarkable abdominal exams; PUD may have mild to moderate epigastric tenderness
may also positive FOBT (but not always, so negative doesn’t rule out PUD)
will show signs of anemia if bleeding ulcer is significant
The presence of what organisms is associated with 5-7 times increased risk of development of PUD
h pylori
What tests can you run to evaluate for h pylori
serologic testing for hpylori antibodies (IgG, IgM)
stool antigen testing
urea breath testing
endoscopy with gastric mucousal biopsy (gold standard)
What is an inexpensive, non invasive, readily available way to test for h pylori
serologic testing
however, this can’t distinguish between active and past infection; if you get one positive result, you’ll be positive for the rest of your life
What is a test that you can do to evalute for eradication of hpylori post treatment
stool antigen (stop PPI treatment for at least 2 weeks before doing this test); good
Good way to test for active h pylori infection
urea breath testing (very expensive; reserve for patients with inconclusive stool antigen testing)
Why is endoscopy the gold standard and when to use it
it can visualize bacteria, ulcers, evaluate for presence of malignancy in esophagus, stomach, or duodenum;
only use when there is high suspicion for esophageal or gastric complcations of PUD or GERD rather than just hpylori
Serious complications of PUD
perforation, hemorrhage, or gastric outlet obstruction
Most common cause of death from PUD
Upper GI bleed (perforation or rebleeding), so most common indication for surgical intervention
Symptoms and complications of chronic GERD
- heartburn and regurgitation on a monthly basis
- erosive esophagitis (but can have nonerosive GERD also; aka NERD)
- Barrett’s esophagus -> esophageal adenocarcinoma
esp in smokers, alocohol and Caucasian men with chronic GERD)
Treatment for patients with Barrett’s
lifelong PPI therapy and should undergo surveillance for developnent of esophageal adenocarcinoma
So a patient walks in with suspected PUD…what tests to run
- CBC for baseline HgB; repeated every 6-8 hours to monitor for bleed
- liver transaminases and amylase/lipase if biliary of panreatic disease suspected
- ECG to rule out ACS
- chest xray to rle out abdominal visceral perf (seen by free air under diaphragm)
- pregnancy test in all reproductive age women
- abominal U/S if chole is suspected
Patients under 50 with no alarm symptoms; how to evaluate and treat
“test and treat” for h pylori
if positive, initiate treatment and PPI
Treatment therapy options for h pylori
TRIPLE THERAPY (7-14 DAYS)
bismuth subsalicylate + metro + tetracycline
ranitidine bismuth + tetra cycline + clarithromycin/metro
omeprazole + clarithromycin + amox/metro
QUAD THERAPY (10-14 days) omerpazole, bismuth, metronidazole, tetracycline
Approach to treating GERD
“test and treat” starts with lowest possible doe of H2 antagonist once daily to contorl symptoms then increasing frequency/potency to PPI if symptoms not adequately controlled
What lifestyle modifications can be done for GERD
avoid smoking, alcohol, spicy foods, citrus foods, fatty foods, large meals, fatty meals, chocoalte, peppermint,, eat at least 3-4 hours before lying down
can also elevate the head of bed and avoiding tight clothing
also avoid NSAIDS
In GERD patient’s with no evidence of active infection, what and how long to treat
4-8 weeks of acid suppression; if symptoms resolve no further testing indicated
Risks of chronic acid suppression therapy
increased risk of CAP, C diff associated diarrhea, bone demineralization, decreased abs of Ca, Mg, Fe/ferritin
Patient’s with alarm symptoms for PUD or GERD…
upper GI endoscopy to exclude complications of esophageal stricture, erosive, disease, or malignancy
Even though you’re pretty sure it’s upper GI bleeding and you’ve seen an ulcer, what should you always do in patients over 50 anyway?
colonscopy!!!
there could be concomittant colon cancer
