Dyspepsia and Peptic Ulcer Disease

Question 1

Rome III criteria for dyspepsia

Answer 1

one of more of the following:

postprandial fullness, early satiety, epigastric pain/burning

Question 2

Name some “alarm symptoms” for which upper GI endoscopy is indicated in the setting of new-onset dyspepsia

Answer 2

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

Question 3

Consideration for patients younger than age 50 without alarm symptoms in setting of dyspepsia

Answer 3

H pylori (IgG serology) (low cost and ease of collection)

Question 4

h2 antagonists and proton pump inhibitors have what in common

Answer 4

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

Question 5

Where are you most likely to see GI ulcers?

Answer 5

stomach and proximal duodenum

duodenal ulcers are the most common but gastric ulcers are more common in NSAID users

Question 6

Risk factors for developing peptic ulcer disease (PUD)

Answer 6

NSAID/aspirin use, smoking, h pylori, alcohol, and family history of PUD

Question 7

Classic symptoms of PUD

Answer 7

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

Question 8

On physical what differentiates PUD from dyspepsia/GERD

Answer 8

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

Question 9

The presence of what organisms is associated with 5-7 times increased risk of development of PUD

Answer 9

h pylori

Question 10

What tests can you run to evaluate for h pylori

Answer 10

serologic testing for hpylori antibodies (IgG, IgM)
stool antigen testing
urea breath testing
endoscopy with gastric mucousal biopsy (gold standard)

Question 11

What is an inexpensive, non invasive, readily available way to test for h pylori

Answer 11

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

Question 12

What is a test that you can do to evalute for eradication of hpylori post treatment

Answer 12

stool antigen (stop PPI treatment for at least 2 weeks before doing this test); good

Question 13

Good way to test for active h pylori infection

Answer 13

urea breath testing (very expensive; reserve for patients with inconclusive stool antigen testing)

Question 14

Why is endoscopy the gold standard and when to use it

Answer 14

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

Question 15

Serious complications of PUD

Answer 15

perforation, hemorrhage, or gastric outlet obstruction

Question 16

Most common cause of death from PUD

Answer 16

Upper GI bleed (perforation or rebleeding), so most common indication for surgical intervention

Question 17

Symptoms and complications of chronic GERD

Answer 17

• 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)

Question 18

Treatment for patients with Barrett’s

Answer 18

lifelong PPI therapy and should undergo surveillance for developnent of esophageal adenocarcinoma

Question 19

So a patient walks in with suspected PUD…what tests to run

Answer 19

• 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

Question 20

Patients under 50 with no alarm symptoms; how to evaluate and treat

Answer 20

“test and treat” for h pylori

if positive, initiate treatment and PPI

Question 21

Treatment therapy options for h pylori

Answer 21

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

Question 22

Approach to treating GERD

Answer 22

“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

Question 23

What lifestyle modifications can be done for GERD

Answer 23

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

Question 24

In GERD patient’s with no evidence of active infection, what and how long to treat

Answer 24

4-8 weeks of acid suppression; if symptoms resolve no further testing indicated

Question 25

Risks of chronic acid suppression therapy

Answer 25

increased risk of CAP, C diff associated diarrhea, bone demineralization, decreased abs of Ca, Mg, Fe/ferritin

Question 26

Patient’s with alarm symptoms for PUD or GERD…

Answer 26

upper GI endoscopy to exclude complications of esophageal stricture, erosive, disease, or malignancy

Question 27

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?

Answer 27

colonscopy!!!

there could be concomittant colon cancer