Dyspepsia and peptic ulcers Flashcards
What is dyspepsia? (indigestion)
One or more of the following:
Postprandial fullness
Early feeling of fullness
Epigastric pain or burning
Causes of dyspepsia
Excess acid production Large volume meals Smoking and alcohol Drugs: Nitrates, CCBs and NSAIDs Obesity and pregnancy H pylori
Dyspepsia presentation
Reflux Indigestion Heartburn Acid Taste Bloating I’ve got an ulcer
What are alarm signs for GI cancer?
Unexplained weight loss Anaemia/ Evidence of GI blood loss Dysphagia Upper Abdominal Mass Anorexia Recent onset/progressive symptoms Malaena (blood in faeces)/ haematemesis
Tests for patient presenting with dyspepsia?
Endoscopy and barium swallow to test for cancer
Test and treat for H pylori (breath test or stool antigen test)
Management if cancer= referral
if GORD= PPI, lifestyle ect
If ulcer- see ulcer management
If no cause found, it is functional dyspepsia- how is this managed?
Reassurance that there’s no cancer
Dietary Review
Antidepressants (TCA/SSRI’s)
What is a peptic ulcer?
A peptic ulcer is an ulcer of the mucosa in/adjacent to an acid-bearing area
Most occur in stomach or proximal duodenum
Describe the pathophysiology of a peptic ulcer
Blood flow needed to maintain gastric mucous protection. Ischaemia to stomach mucosa—> less mucous production—> ulcer.
Increased stomach acid is produced due to h pylori or stress
Bile is also an irritant to stomach–> ulcers (reflux only occurs in pathology
How does helicobacter cause increased acid production?
Helicobacter live in mucin layer.
Attract neutrophils—> inflammation and increased acid production.
After time helicobacter may cause stomach mucosa to change to intestinal mucosa (metaplasia)
Causes of peptic ulcers
H. pylori and NSAIDs/aspirin most common cause
Less commonly: Hyperparathyroidism, Zollinger-Ellison syndrome Vascular insufficiency Sarcoidosis Crohn’s disease
Reduction of gastric mucosal resistance is main factor in Gastric Ulcers – as gastric acid secretion is reduced by damage to parietal cells.
Why is hyper secretion of acid more likely to cause duodenal ulcers?
Duodenum doesn’t secrete acid
How do NSAIDs and aspirin cause ulcers?
Inhibition of COX1 which makes prostaglandins that provide mucosal protection.
How does gastric emptying effect risk of gastric and duodenal ulcers respectively?
Increased emptying increases risk of a duodenal ulcer
Decreased emptying increases risk of a gastric ulcer
Clinical presentation of peptic ulcers
Epigastric pain often related to hunger, specific foods or time of day. Typically relieved by antacids
Bloating
Fullness after meals
Heartburn – retrosternal pain + reflux
Tender epigastrium
Differential diagnosis for dyspepsia?
Non ulcer dyspepsia GORD/ oesophagitis Gastric ulcer Duodenal ulcer GI malignancy Gastritis, duodenitis
What diagnostic tests for peptic ulcers should be carried out?
H pylori tests
Endoscopy (may not be needed)
Barium meal used to detect gastric outlet obstruction
If endoscopy is done why might biopsies need to be taken from ulcer?
To determine if it is malignant
Describe tests used to test for H pylori
13C-urea breath test
Stool antigen test – immunoassay using monoclonal antibodies
How do you treat ulcers with +ve H pylori test?
Eradication regimen E.g:
omeprazole (PPI)+ metronidazole + clarithromycin
for 1 week
No need to continue any PPIs or H2 blockers
(unless ulcer is complicated by haemorrhage or perforation)
Eradication confirmed with breath test/stool sample
How do you treat ulcers with a negative H pylori test
Stop aspirin/ NSAIDs
Treat with PPI
After healing, NSAIDs continued only with PPI prophylaxis, or NSAIDs switched for a selective cyclo-oxygenase-2 inhibitor
Complications of peptic ulcers?
Perforation
Uncommon
DUs>Gus
Treatment = surgical closure, drain abdomen
Bleeding
Malignancy
Gastric outflow obstruction
