Dyspepsia, GORD and Peptic Ulcer Disease Flashcards
What is dyspepsia?
Indigestion or functional dyspepsia
Not a disease as such, more of a symptom
A range of symptoms arising from upper GIT including upper abdominal pain or discomfort, heartburn, gastric reflux, nausea or vomiting
When can a diagnosis of dyspepsia occur?
When symptoms are persistent for more than 4 weeks
What are some of the possible causes of dyspepsia?
Lifestyle factors
Medication (e.g. NSAID’s)
Diseases
What is gastro-oesophageal reflux disease (GORD)?
Symptoms or complications resulting from reflux of gastric contents into oesophagus, oral cavity or lung caused by lower oesophageal sphincter relaxation
What can GORD cause?
Chronic cough
Laryngitis
What complications can GORD lead to?
Stricture
Barrett’s oesophagus
Oesophageal carcinoma
What are some of the causes of GORD?
Obesity Genetics Lifestyle Age Medications (e.g. CCB's, can have an effect on sphincter tone)
What is a peptic ulcer?
A breach/open sore in the continuity of the epithelial lining of more than 5mm in diameter, associated with inflammation on the inside lining of the oesophagus, stomach or upper portion of the small intestine
What complications can peptic ulcers caused?
Upper GI bleeds (often when patients present to hospital)
Peptic ulcers can be…
Gastric or duodenal
What are some of the causes of gastric ulcers?
H. pylori
NSAID’s
Lifestyle factors
Genetics
When do peptic ulcers develop?
When there is an imbalance between the agents that protect the epithelium and those which attack it
How can the symptoms of a peptic ulcer be described?
Lots of cross over between other conditions and are quite non-specific
Pain will be much more severe than with indigestion or GORD
What are the initial symptoms of a peptic ulcer?
Upper abdominal pain, tenderness and discomfort Heartburn or reflux Bloating Early satiety Nausea and vomiting
What are the specific symptoms of a gastric ulcer?
Pain that radiates to the back
Mainly occurs at night
Aggravated by food
Weight loss
What are the specific symptoms of a duodenal ulcer?
Epigastric pain (pain or discomfort right below your ribs in the area of your upper abdomen)
Occurs at any time
Relieved by food or antacids
Weight gain
What are the ALARMS warning signs or features for referral?
Anaemia
Loss of weight (unintentional)
Anorexia
Recurrent problems (only if aged over 55 with unexplained and persistent recent onset dyspepsia)
Melaena (dark sticky faeces)/haematemesis (vomiting blood)
Swallowing problems
What do the ALARM warning signs indicate?
The patient needs to be urgently referred rather than managed with OTC medicines
What would assessment of a patient experiencing one of these problems include?
Detailed medical and social history Medication review (NSAID's, biphosphonates, corticosteroids, calcium antagonists, nitrates, theophyllines) Blood tests (to rule out other causes) H. pylori testing X-ray Endoscopy
What does an endoscopy involve?
A flexible tube down the oesophagus and into the stomach
May also involve localised treatments
How are dyspepsia, GORD and peptic ulcers managed initially?
Identify potential causative medications and manage appropriately
Lifestyle measures also put in place
What lifestyle measures can be employed to help treat these conditions?
Smoking cessation Healthy eating Avoid known precipitants of dyspepsia (fatty, acidic or fried foods, chocolate, alcohol, caffeine) Avoid eating late in the evening Weight reduction Reduce stress Raising the head of the bed (GORD)
Can the same medications be used to treat al 3 conditions?
Yes, the same agents may be used but at different doses, for different indications and for different lengths of time
Several of these may be purchased OTC
How do antacids work?
Neutralise acid in the stomach
Are antacids available OTC?
Yes, as liquids and tablets
How should antacids be dosed?
When required for symptoms between meals and at bedtime
Usually 4 or more times daily
Should be take on a full stomach (digestion slows emptying and antacid can act for 2-4 hours as opposite to 20-40 minutes on an empty stomach)
Which are more effective, liquid or solid dosage forms of antacids?
Liquids, but they are less portable and convenient
When do side effects of antacids start to occur?
When you start to take the products regularly
What are some of the side effects of antacids?
Magnesium containing - laxative effect
Aluminium containing - constipating
Calcium containing - possible rebound acid secretion or hypercalcaemia
What must you be aware of when prescribing antacids?
Sodium content
Sodium bicarbonate is no longer prescribed alone but is present in some other preparations
Avoid if the patient is on a salt restricted diet
In which patient groups is a high sodium content undesirable?
Patients with liver, renal and cardiac conditions
Patients with hypertension
Pregnant women
Patients who cannot have high levels of sodium require a ‘low sodium preparation’, how is low sodium (Na+) defined?
Sodium content of less than 1mmol per tablet or 10ml dose
Do antacids have a lot of interactions? If so, what are they?
Not really
May impair the absorption of other drugs if taken at the same time
May damage e/c by raising the pH
May affect pH dependent renal excretion (rare) e.g. increase excretion with possible reductions in serum levels (aspirin, lithium)
What are alginates and how do they work?
Given in combination with an antacid (as in Gaviscon)
Increases the viscosity of the stomach acid and creates a protective layer or ‘raft’ that floats on top of the stomach contents to prevent acid coming back up
What are histamine H2-receptor antagonists and how do they work?
Reduce gastric acid output by blocking histamine H2-receptors
Give 3 examples of histamine H2-receptor antagonists .
Ranitidine
Cimetidine (not used much in practice as it has a lot of interactions)
Famotidine
Are histamine H2-receptor antagonists available OTC?
Yes, as lower doses
How should histamine H2-receptor antagonists be dosed?
Generally twice daily (longer acting)
What can histamine H2-receptor antagonists do at high doses?
Can heal duodenal and gastric ulcers
What are histamine H2-receptor antagonists licensed for?
GORD (less effective than PPI’s)
Maintenance treatment (rarely used now)
Functional dyspepsia
What are histamine H2-receptor antagonists also used for but are not licensed for?
NSAID prophylaxis
Stress ulcer prophylaxis (for patients who are nil by mouth and need gastro protection due to a build up of acid)
What are some of the side effects of histamine H2-receptor antagonists?
Headache Diarrhoea Dizziness Rash Altered LFT's
What does Cimetidine interact with?
Warfarin - inhibits metabolism and increases INR
Phenytoin, carbamazepine, valproate and theophylline - inhibits metabolism and increases plasma concentrations
Sildenafil - increases plasma concentrations
What are proton pump inhibitors (PPI’s) and how do they work?
Block the final pathway in the production of gastric acid by blocking gastric H+, K+ ATPase and inhibiting gastric acid secretion
Name 5 examples of PPI’s.
Omeprazole Esomeprazole Lansoprazole Pantoprazole Rabeprazole
Are PPI’s available OTC?
Yes, at low doses for the treatment of dyspepsia
How should PPI’s be dosed?
Generally once or twice daily
Choice of agent depends on local formulary
Duration of treatment depends on indication
Recommend the lowest effective dose for the shortest period of time with regular review
What are the main indications of PPI’s?
Dyspepsia
GORD
Treatment of gastric and duodenal ulcers
Maintenance treatment
NSAID prophylaxis
Excessive gastric acid secretion
Stress ulcer prophylaxis peri-operatively
Which medication is most effective for the treatment of gastric and duodenal ulcers?
PPI’s as they have the most long lasting effect
What are some of the side effects of PPI’s?
Constipation
Diarrhoea
Headache
Dizziness
What MHRA warning was issued surrounding PPI’s?
Very low risk of development of subacute cutaneous lupus erythematosus (SCLE)
Long term PPI therapy is associated with…
An increased risk of adverse events such as achlorhydria (low gastric acid production) which is in turn associated with an increased risk of,
Gastric cancer
H. pylori infection (particularly in the elderly)
Pneumonia
C. difficile infection
Bacterial overgrowth and reduced calcium absorption leading to hip fracture
(The last 3 are associated with the effect long term PPI therapy has on the gut microbiota)
What are some of the interactions of PPI’s?
Antiretrovirals
Methotrexate
Citalopram
Clopidogrel (omeprazole is predicted to decrease efficacy)
What can be done if your prescribed PPI interacts with some of the patients pre-existing medications?
Could use an alternative PPI or H2-antagonist
What is Helicobacter pylori and what does it cause?
A gram-negative bacteria
Around ½ of the population colonised
Causes persistent infection in gastroduodenal mucosa
What does infection with H. pylori always lead to?
Gastritis (inflammation of the stomach lining)
H. pylori is the commonest cause of…
Peptic ulcer disease (PUD) with more than 90% of duodenal and 70% of gastric ulcers found to be infected
What is critical to the development of an ulcer in H. pylori infection?
Host co-factors
How is H. pylori transmitted?
Not totally understood
Gastro-oral or faecal-oral probable
Prevalence of H. pylori infected increases with…
Age
What is H. pylori infection linked to?
Gastric cancer
How can we detect H. pylori?
H. pylori produces an antibody response detectable in serum, saliva or urine and antigen detectable in stool
How do we test for H. pylori in patients?
Urea breath test kits - most common and can be performed in primary care, involves patient swallowing a 13C-labelled urea solution, urease activity by organism will produce labelled carbon dioxide
Stool antigen test
Mucosal biopsies - CLO (campylobacter-like organism) test, multiple should be taken, lab based serology, rarely used
What needs to be considered when testing for H. pylori in patients?
A careful drug history needs to be taken (acid suppression therapy important)
Antibiotics/bismuth salts may supress H. pylori growth and give a false negative
Achlorhydria can also give a false positive
Testing should not be performed within 4 weeks of treatment with antibacterials or 2 weeks with PPI’s/antisecretory drugs
If the patient has to be retested, which test should be used?
Urea breath test
How can H. pylori be eradicated?
Triple therapy has the highest eradication rates and involves a 7 day, twice-daily course of a PPI plus 2 antibiotics
What should be checked before H. pylori eradication?
Allergy status
Previous antibiotic exposure
If a patient has peptic ulcer disease and tests positive for H. pylori, which should be treated first?
Timing of eradication will depend on if the PUD is also associated with NSAID use
Give examples of standard triple therapy treatments.
PPI full dose BD, amoxicillin 1g BD, Clarithromycin 500mg BD, or Metronidazole 400mg BD Full dose PPI, Esomeprazole 20mg BD Lansoprazole 30mg BD Omeprazole 20-40mg BD Pantoprazole 40mg BD Rabeprazole 20mg BD
What if the patient is still H. pylori positive after the first course, penicillin allergic or have previous clarithromycin exposure?
There are alternative regimens available
These contain full dose PPI BD plus a combination of 2 or more of the following antibacterials,
Bismuth
Tetracyclines
Quinolone e.g. Ciprofloxacin
Metronidazole
What is a pharmacists role in these conditions?
Patient education (ensure adherence to regimen and emphasise the importance of completing the course as prescribed)
Counsel on side-effects
Make patients aware of interactions e.g.
Clarithromycin and statins
Metronidazole and alcohol
Ensure regimens have been prescribed correctly (can be confusing)
Ensure appropriate referral if ALARM symptoms are present
NSAID’s can cause…
A variety of GI injuries including PUD, bleeding and ulceration
One of the comments causes of PUD
What are the risk factors for an NSAID bleed?
Age >60 Multiple NSAID's Smoker (increases PUD risk) H. pylori infection (increases PUD risk) Concurrent medication including steroids, anticoagulants Higher dose Longer duration
How do NSAID’s cause NSAID-induced ulcers?
NSAID’s inhibit prostaglandin synthesis, this impairs mucosal defences leading to an erosive breach of the epithelial barrier
Acid attack deepens the breach into a frank ulceration
The low pH encourages passive absorption of NSAID and so it becomes trapped in the mucosa
By which indirect mechanisms does NSAID damage occur?
Reduces gastric blood flow
Reduces mucus and bicarbonate production
Leads to decreased cell repair
How can we manage NSAID-induced PUD?
Stop NSAID if possible (even if just for a short period of time)
Test for H. pylori (if present, give eradication therapy after treating the ulcer)
Treated with full dose PPI or H2-receptor antagonist for 8 weeks
What should be put in place if the patient has to continue NSAID after the peptic ulcer has healed?
Discuss potential harm
Regular review of appropriateness (at least 6 monthly)
Reduce dose
Rx as PRN
Switch to ibuprofen
Alternative agent e.g. cyclooxygenase-2-selective NSAID
Prescribe gastroprotection
Which agents can be prescribed as gastroprotection?
PPI
H2-receptor antagonist
Misoprostol
How does Misoprostol work?
A prostaglandin analogue
Has antisecretory and cytoprotective effects
What can Misoprostol be used for?
Effective at preventing NSAID induced PUD (although less effective than PPI’s in preventing duodenal ulcers)
Which is better tolerated, PPI’s or Misoprostol?
PPI’s
Name 1 side effect of Misoprostol.
Diarrhoea
When is Misoprostol contraindicated and why?
Pregnancy
It is a uterine stimulant
How is Misoprostol available?
As combination products with Diclofenac Sodium e.g. Arthrotec
What is dyspepsia in pregnancy usually due to?
GORD, caused by mechanical and hormonal factors
What are some of the symptoms of dyspepsia in pregnancy?
Heart burn
Acid reflux
How is dyspepsia managed in pregnancy?
Dietary and lifestyle changes as first line
Antacid or alginate (avoid preparations containing sodium bicarbonate or magnesium trisilicate)
If symptoms persist or are severe, can use Ranitidine or Omeprazole
GORD and reflux is also common in which other patient group?
Infants and children
Usually resolves by 12-18 months of age
How is GORD and reflux managed in infants and children?
Change frequency and volume of feed Feed thickener Use an alginate H2-receptor antagonist PPI Support and reassurance is especially necessary here as this can be a very distressing time for parents
