dyspepsia and PUD

Question 1

upper abdominal pain: better with food, worse after eating
“heartburn”, nausea
full after eating (satiety)
black or bloody stool (+occult blood, may be sporadic)
anemia: pale conjunctiva, tachycardia, hypotension, orthostasis
tender epigastric region
hx DAILY NSAID use

Answer 1

bleeding peptic ulcer

Question 2

work-up for dyspepsia if

Answer 2

stat CBC (may need transfusion)
stop NSAID
if vomit/not eating: chemistry panel
if biliary or pancreatic disease suspected: liver enzymes, amylase, lipase
if possible perforation: CXR
if gallstones suspected: U/S
if possibly pregnant + ectopic pregnancy or pelvic infection: pregnancy test +/- cervical cultures
test for H. pylori: IgG serology, if + confirm with 13-C urea breath test or stool antigen test
if H.pylori +: antibiotics with PPI
if H. pylori -: treat empirically with PPI for 4-8 wks
if continue to be symptomatic, upper GI endoscopy

Question 3

reduce risk of recurrence of peptic ulcer

Answer 3

avoid NSAIDs
use PPI or misoprostol with NSAID
test for active h. pylori if on long-term nsaid tx
eradicate H. pylori

Question 4

criteria for dypepsia: rome III

Answer 4

1 or more of following:
postprandial fullness
early satiety
epigastric pain or burning

Question 5

causes of dyspepsia

Answer 5

PUD (20% cases): epigastric ab pain improves with food ingestion, pain few hours after eating, pain between 11 pm - 2am (max acid secretion), gradual onset, wks-mo sx
GERD: predominately heartburn/acid regurg
functional dyspepsia

Question 6

mucosal damage secondary to pepsin + gastric H+ secretion

Answer 6

PUD
stomach (if use NSAIDS), proximal duodenum (most common)
less common: lower esophagus, distal duodenum, jejunum (zollinger-ellison syndrome: gastrinoma, hiatal hernias, ectopic gastric mucosa in meckel diverticulum)

Question 7

early upper GI endoscopy if new onset dyspepsia + > 55 yo OR any of these alarm symptoms associated with upper GI malignancy

Answer 7

unintentional weight loss
progressive dysphagia
recurrent/persistent vomiting
odynophagia (painful swallowing)
unexplained anemia
GI bleeding/hematemesis
family hx of upper GI cancer
hx gastric surgery
jaundice

Question 8

risk factors for PUD

Answer 8

H. pylori infection
NSAID use
smoking
personal or family hx of PUD
meds: steroids, bisphosphonates, chemo drugs
stress: acute illness, multiorgan failure, ventilator
malignancy: gastric, lymphoma, lung cancer
black or hispanic

Question 9

ulcers following head injury

Answer 9

cushing ulcer

Question 10

ulcers following burn

Answer 10

curling ulcer

Question 11

inhibit H2 R on gastric parietal cells

Answer 11

H2 blocker

Question 12

inhibit HK ATPase proton pump in gastric parietal cells

Answer 12

PPI

Question 13

RUQ pain/tenderness

Answer 13

gallbladder or biliary disease

Question 14

epigastric pain radiates to back

N/V

Answer 14

pancreatitis

Question 15

NSAID-induced ulcers

Answer 15

complications more common in
elderly
co-occuring H. pylori
steroid or anticoagulant

Question 16

G- bacillus
found in 50% with PUD (5-7x increase risk of PUD)
usually maternally acquired as a child
can develop into gastric cancer

Answer 16

H. pylori

Question 17

complications of PUD

Answer 17

hemorrhage
gastric outlet obstruction
silent ulcer
more common in: elderly, NSAIDs

Question 18

if >50 yo with blood in stool OR anemia regardless of upper GI findings (ulcer or no ulcer)

Answer 18

need colonoscopy to r/o colon cancer

Question 19

preferred non-invasive test for h. pylori

Answer 19

stool antigen test:
good PPV
test post-tx for eradication
limitation: did not use PPI at least 2 weeks prior to testing

Question 20

blood screening test for h. pylori

Answer 20

IgG serology
inexpensive, non-invasive
highly sensitive for hx of infection
limitation: can’t distinguish active from a treated infection, can’t determine if have ULCERS
if +: f/u with urea test to confirm ACTIVE infection THEN treat

Question 21

urea breath test

Answer 21

inhale carbon labeled urea, metabolized by urease from h. pylori
highly sensitive + specific for ACTIVE infection
test post-tx for eradication
limitation: expensive

Question 22

gold standard for diagnosis of h. pylori

Answer 22

endoscopy with biopsy testing