Dyspepsia and peptic ulcer disease Flashcards
Symptoms associated with dyspepsia and peptic ulcer disease
Epigastric pain often related to hunger, specific foods, or time of day, fullness after meals, heartburn (retrosternal pain).
Tender epigastrium.
Beware alarm symptoms: anaemia (iron deficiency); loss of weight; anorexia; recent onset/ progressive symptoms; melaena/haematemesis; swallowing difficulty.
H. pylori causing dyspepsia/ peptic ulcer disease
If <55yrs old: ‘test and treat’ for H. pylori.
If positive, give appropriate PPI and 2 antibiotic combination, e.g. lansoprazole 30mg/12h PO, clarithromycin 250mg/12h PO, and amoxicillin 1g/12h PO for 1wk.
If negative, give acid suppression alone.
Refer for urgent endoscopy all with dysphagia, as well as those >55 with alarm symptoms or with treatment-refractory dyspepsia.
Duodenal ulcer: risk factors
4x more common than gastric ulcer.
Major risk factors: H. pylori (90%); drugs (NSAIDs, steroids, SSRI).
Minor risk factors: increased gastric acid secretion; increased gastric emptying (reduced duodenal pH); blood group O; smoking.
Duodenal ulcer: signs and symptoms
Asymptomatic or epigastric pain (relieved by antacids) +/- weight loss.
Epigastric tenderness.
Duodenal ulcer: diagnosis
Upper GI endoscopy.
Test for H. pylori.
Measure gastrin concentrations when off PPIs if Zollinger-Ellison syndrome is suspected.
Duodenal ulcer: differential diagnosis
Non-ulcer dyspepsia Duodenal Crohn's TB Lymphoma Pancreatic cancer
Gastric ulcers: risk factors
H. pylori (~80%) Smoking NSAIDs Reflux of duodenal contents Delayed gastric emptying Stress, e.g. neurosurgery or burns (Cushing's or Curling's ulcers)
Gastric ulcers: symptoms
Asymptomatic or epigastric pain (relieved by antacids) +/- weight loss.
Gastric ulcers: tests
Upper GI endoscopy to exclude malignancy.
Multiple biopsies from ulcer rim and base (histology, H. pylori).
Repeat endoscopy after 6-8 weeks to confirm healing and exclude malignancy.
Gastritis: risk factors
Alcohol NSAIDs H. pylori Reflux/ hiatus hernia Atrophic gastritis Granulomas (Crohn's; sarcoidosis) CMV Zollinger-Ellison syndrome Ménétrier's disease
Gastritis: symptoms
Epigastric pain
Vomiting
Gastritis: tests
Upper GI endoscopy only if suspicious features
Treatment of dyspepsia and peptic ulcer disease
Lifestyle: reduce alcohol and tobacco use.
H. pylori eradication: triple therapy is 80-85% effective at eradication.
Drugs to reduce acid: PPIs are effective, e.g. lansoprazole 30mg/24h PO for 4 (DU) or 8 (GU) wks. H2 blockers have a place (ranitidine 300mg each night PO for 8wks).
Drug-induced ulcers: stop drug if possible. PPIs may be best for treating and preventing GI ulcers and bleeding in patients on NSAID or antiplatelet drugs. Misoprostol is an alternative with different SE. If symptoms persist, re-endoscope, retest for H. pylori, and reconsider differential diagnoses (e.g. gallstones).
Surgery.
Complications of dyspepsia and peptic ulcer disease
Bleeding
Perforation
Malignancy
Reduced gastric outflow
Functional non-ulcer dyspepsia
Common.
H. pylori eradication (only after a positive result) may help.
Some evidence favours PPIs and psychotherapy.
Low dose amitriptyline (10-20mg each night PO) may help.
Antacids, antispasmodics, H2 blockers, misoprostol, pro-kinetic agents, bismuth, or sucralfate all have less evidence.