Dyspepsia and Reflux Flashcards
Most dyspepsia is due to _______
Functional dyspepsia
What is functional dyspepsia
Disorder of the gut-brain interaction, and no obvious cause will be found on investigation
Is gastroscopy needed for reflux/dyspepsia
Gastroscopy is rarely indicated in the diagnosis or management of heartburn or dyspepsia
Predictive value of individual alarm symptoms for upper GI cancer
Individual sx = low predictive value
Increased when multiple alarm features are present
Gastric cancer often presents late with _________
Anaemia and epigastric pain
Alarm symptoms
Progressive oesophageal dysphagia at any age
Haematemesis or melaena
Pain
Vomiting
Weight loss
Dysphagia
Difficulty or pain in swallowing solids and liquids
Globus
Persistent sensation of something being stuck in the throat, that does not interfere with swallowing
Causes of oesophageal dysphagia
GORD
Motility disorders
Eosinophilic oesophagitis
Benign oesophageal strictures
Malignancy
Candida
Is GORD pathological or physiological?
Gastro-oesophageal reflux is a normal physiological event. It is considered pathological when it causes pain, regurgitation, or oesophageal damage
What is dyspepsia
Gastroduodenal symptom complex with the most common symptoms being epigastric pain or discomfort (often after meals), bothersome fullness after meals, epigastric bloating, early satiety, and nausea
Causes of dyspepsia
Functional dyspepsia (most common)
Gastric irritation, e.g. secondary to NSAIDs
Peptic ulcer disease
Helicobacter infection
Coeliac disease
Malignancy
Gastric cancer tends to occur a decade earlier in what populations?
Māori or Pacific people
Immigrants from high-risk countries
East Asia
Central and South America
Southern and Eastern Europe
The Caribbean
Middle Eastern, Latin American, African
Risk factors for Helicobacter pylori infection
Past history of peptic ulcer
At-risk ethnicity, e.g. Māori, Pacific, Asian, Indian, African
Childhood spent in developing countries
The likelihood of functional dyspepsia can be assessed using the ________ criteria.
Rome IV diagnostic criteria
Rome IV diagnostic criteria for functional dyspepsia = one or more of the following sx
Bothersome epigastric pain
Bothersome epigastric burning
Bothersome postprandial fullness
Bothersome early satiation
Symptom onset ≥6 months before diagnosis
Symptoms active within the past 3 months
Functional dyspepsia can be further subcategorised as…
Epigastric pain syndrome (EPS)
Postprandial distress syndrome (PDS)
Patients may present with features of both
Epigastric pain syndrome
Bothersome epigastric pain or burning (sufficient to disrupt usual activities).
Induced by or relieved by meals, or onset during fasting.
Postprandial distress syndrome
Bothersome postprandial fullness or early satiation
What should you advise patients about when to do H pylori stool test (what needs to be restricted prior to doing test)
No antibiotics for ≥1 month before the test
No PPIs for ≥ 1 week before the test (even better 2 weeks)
Treat with empirical standard-dose proton pump inhibitors (PPIs) for _______ (duration) if dyspepsia, and for ________ if GORD
Dyspepsia - 4 weeks
GORD - 4 to 8 weeks
Side effects of PPIs
Headache, nausea, vomiting, diarrhoea, abdominal pain, constipation, and wind
How to stop PPIs
Wean to lowest effective dose and stop
Caution the patient about rebound hyper-acidity after stopping PPI and to use PPI or antacid PRN
Use long-term PPI in what conditions?
Severe oesophagitis
Oesophagitis complicated by strictures Barrett’s oesophagus
Risk of long-term PPIs
Weak evidence for:
Hypomagnesaemia
Osteoporosis
Pneumonia
Increased cardiovascular risk
Renal impairment in the elderly
B12 deficiency
Dementia
Lifestyle management
Weight reduction, especially around the middle of the abdomen
Stress reduction
Smoking cessation
Limiting alcohol
Sleep position
Eat slowly and chew food well
Eat smaller meals
Food/symptom diary for triggers
Next steps if GORD symptoms predominate, and no response to standard-dose PPI for 8 weeks
Double dose of PPI for 4 to 8 weeks
Add antacid
Risk factors for Barrett’s oesophagus
Chronic GORD
> 50 yo
Caucasian.
Male
Obesity
Relative diagnosed with Barrett’s oesophagus or oesophageal adenocarcinoma
If dyspepsia symptoms predominate, and no response to empirical standard dose PPI for 4 weeks, and H. pylori eradication confirmed (or test result is negative) - next steps
Review reversible lifestyle factors and confirm lifestyle modification
Consider further medication trial
Consider the overlap with IBS
Further medication trial after PPI
H2‑receptor antagonist, e.g. famotidine 40 mg once a day for 4 weeks
If ineffective, add domperidone at the lowest effective dose, for not more than 4 weeks because of the risk of prolonged QT interval.
Diagnosis of GORD
Therapeutic trial of PPIs in a patient with symptoms suggestive of GORD has a comparable sensitivity and specificity for diagnosing GORD as measuring the presence of oesophageal acid directly with a pH monitor in a secondary care setting
To maximise their effect, PPIs should be taken when?
30 – 60 minutes before food, ideally before the first meal of the day.
Should PPIs be given once or twice daily?
When increasing the dose of lansoprazole or pantoprazole it is recommended that the dose is divided to twice daily dosing, i.e. before breakfast and before dinner
Omeprazole is usually dosed once daily, but a divided dose could be trialled if symptoms worsen later in the day.
