Dyspepsia and peptic ulcer disease Flashcards
Define dyspepsia and its symptoms (ALARMS)
Dyspepsia (indigestion) is a term which describes pain and sometimes other symptoms which come from your upper gut (the stomach, oesophagus or duodenum).
Epigastric pain often relates to hunger, specific foods or time of day +/- bloating, fullness after meals, heart burn (retrosternal pain +reflux) and a tender epigastrium.
ALARM symptoms associated with dyspepsia and ulcers A = Anaemia L= Loss of weight A = Anorexia R= Recent onset/progressive symptoms M = Meleana/haematemesis S = Swallowing dificulty
What are the differential diagnose associated with dyspepsia?
Non-ulcer dyspepsia Oesophagitis/GORD Duodenal /gastric ulcer Gastric malignancy Duodenitis Gastritis
What are the major and minor risk factors for duodenal ulcers?
Major: H.Pylori (90%), Drugs (NSAIDs, Steroids, SSRI)
Minor: ↑ gastric acid secretion, ↑ gastric emptying, blood group O, smoking
What are the signs and symptoms of duodenal ulcers?
Symptoms: epigastric pain typically before meals or at night, relived by eating or drinking milk. 50% are asymptomatic whilst other experience recurrent episodes
Signs: epigastric tenderness
How are duodenal ulcers diagnoses and managed?
Upper GI endoscopy (stop PPI 2 weeks before)
Test for H.Pylori
[Measure gastrin concentrations, when off PPI’s, if Zollinger-Ellison syndrome is susected]
Treatment: PPI’s or H2 blockers
How do gastric ulcer present and what are the risk factors for them?
Risk factors: H.Pylori (80%), smoking, NSAIDs, reflux of duodenal contents, delayed gastric emptying, stress,
Symptoms: asymptomatic or epigastric pain (related to meals and relieved by antacids) +/- weight loss
How do you test for gastric ulcers?
Upper endoscopy to exclude malignancy (Stop PPI 2 weeks before)
Multiple biopsies from upper rim and base (histology and H.pylori), and brushings
Repeat endoscopy to check healing
How do you manage new dyspepsia?
*flowchart
? >55 yrs or ALARM Symptoms
YES –> Do upper GI endoscopy
NO –> Stop drugs that may cause dyspepsia, lifestyle changes, OTC antacids, review in 4 weeks
? Improvement
YES –> no further action
NO —> Test for H.pylori
? Negative for H. Pylori
–> PPI’s or H2 blockers for 4 weeks
–> ? Improvement
YES –> no further action
NO –> longer-term, low dose treatment, consider
Upper GI endoscopy
? Positive for H/Pylori
–> treat to eradicate H.Pylori, review after 4 weeks
–> ? improvement
YES –> no further action
No —> Urea breath test - is H.Pylori eradicated?
YES –> Consider endoscopy
NO –> Treat to eradicated H.Pylori
How can you treat dyspepsia and ulcers?
Lifestyle: reduce stress levels, decrease alcohol and tobacco use, avoid aggravating foods
Antacids;
PPI e.g. omepraxzole, lansoprazole
H2 blockers e.g. ranitidine
Treat H.Pylori: triple therapy (2 antibiotics +PPI)
Abx - Amoxicillin and clarithromycin (twice daily, 7 days)
OR - Metronidazole, clarithromycin (twice daily, 7 days)
PPI- Omeprazole (20mg/12h) or Lansoprazole (30mg/12h)
How can you test for H.pylori?
Invasive tests:
CLO test
Histology
Culture
Non-invasive tests:
Urea-Breath test
Stool antigen
Serology
How does a Urea breath test (or C-breath test) work?
The urea breath test is based on the ability of H. pylori to break down urea, a chemical made up of nitrogen and carbon, into carbon dioxide which then is absorbed from the stomach and eliminated in the breath. (Urea normally is produced by the body from excess or “waste” nitrogen-containing chemicals and then eliminated in the urine.)
For the test, patients swallow a capsule containing urea made from an isotope of carbon (C13).
If H. pylori is present in the stomach, the urea is broken up and turned into carbon dioxide. The carbon dioxide is absorbed across the lining of the stomach and into the blood. It then travels in the blood to the lungs where it is excreted in the breath. Samples of exhaled breath are collected, and the isotopic carbon in the exhaled carbon dioxide is measured.
If the isotope is detected in the breath, it means that H. pylori is present in the stomach. If the isotope is not found, H. pylori is not present.
What are the complications of dyspepsia and peptic ulcer disease?
Bleeding
Perforation
Malignancy
Gastric outflow reduced
How does H. pylori cause ulcers?
Helicobacter pylori is a type of bacteria. H.Pylori damages the protective lining of the stomach, once this is destroyed, the protection against stomach acid is loss and acid begins to erode and damage the stomach walls to create ulcers. Eventually the ulcers can become deeper, bleed, or perforate the stomach.
