Dyspepsia, GERD and PUD

Question 1

Differentiate between dyspepsia, GERD and PUD

Answer 1

Dyspepsia: epigastric pain or burning, more of a pain in chest
It is not a condition
It is a CARDINAL symptom of PUD

GERD: re-urgitation of acid caused by high fat meal

PUD: ulceration and erosion in mucosa of stomach causing bleeding

Question 2

What are the red flags to refer patient?

Answer 2

Age> 50 years
Persisting vomiting +/- blood
Symptoms suggesting cardiac origin
Choking
Symptoms more than 2 weeks with or without treatment
Symptoms suggesting complications such as: >5% weight loss, persistent iron deficiency, melon, dysphagia suggests esophageal obstruction, odynophagia, feeling epigastric mass

Question 3

What are the risk factors of GERD?

Answer 3

factors that cause increase in intra-abdominal pressure resulting in relaxation of the lower esophageal sphincter:
obesity; pregnancy; hiatus hernia; heavy meals; eating late at night; and carbonated beverages

factors increasing the LES tone: chocolate; alcohol; caffeine; estrogen; progestin; CCB; alpha (prazosin) and beta blockers; nitrates; benzodiazepines; opiates; smoking; theophylline; anticholinergics

other factors: age>65 yrs and stress

Question 4

What are non-pharm measures to tell the person complaining of DYSPEPSIA?

Answer 4

Do not lie down right after meals
Reduce body weight if BMI>30 kg/m2
Quit smoking; avoid alcohol and caffeine intake
Eat smaller but frequent meals

Question 5

What are non-pharm measures to tell person complaining of GERD?

Answer 5

Avoid exercise 
Avoid bending on full stomach
Avoid foods that delay gastric emptying 
such as high fat meals
Avoid foods that increase gastric exposure such as chocolate and onions
Avoid large meals 
Elevate head of bed by 10 cm
Avoid tight fitting clothes around waist
Avoid alcohol consumption
Limit use of drugs that may worsen or cause dyspepsia: bisphosphonates; corticosteroids; iron; metformin; NSAIDs; opioids; potassium salts

Question 6

What are the different management approaches of GERD?

Answer 6

if symptoms are trivial i.e <3 times/week, we go for antacids, alginates and life style measures

if symptoms are severe i.e. >3 times/ week, nocturnal, then start with standard ONCE daily dose of PPI for 8 weeks
if EFFECTIVE: stop, if symptoms recurr
1- continue with lowest effective dose
2- pulsated PPI

if INeffective, then double dose to BID for 8 weeks
if it works: stop PPI, if symptoms occur, restart PPI long term and consider endoscopy
if it does not work: further investigations required

Response to an empiric regimen of PPI BID for 8 wks indicates diagnosis of GERD or non-cardiac chest pain

Question 7

Differentiate btw PPI and H2 blockers use

Answer 7

PPI: prodrugs therefore require to be taken 30-60 min before meal
Effectiveness DOESN’T decrease with long term use
less effective if used as PRN
Effective in NSAID-induced dyspepsia
MORE effective as maintenance therapy

H2 blockers: check PharmaSpirit slide