Dyspepsia, GORD and Peptic Ulcer Disease Flashcards
What is dyspepsia
A persistent or recurrent pain or discomfort in upper abdomen
British Society of Gastroenterologists definition - range of symptoms arsing from upper GI tract including upper abdominal pain or discomfort, heartburn, gastric reflux, nausea or vomiting
What are the causes of dyspepsia
Causes include:
Lifestyle factors
Medication
Diseases
What is GORD and what are the symptoms and complications?
Gastro-oesophageal reflux disease (GORD). Symptoms/complications resulting from reflux gastric contents into oesophagus, oral cavity or lung
Can cause chronic cough, laryngitis. There is a link to asthma
Can lead to complications such as stricture, Barrett’s oesophagus and oesophageal carcinoma
What causes GORD
Causes: Obesity Genetic Lifestyle Medication Age
What physiological phenomena causes gord
Lower oesophageal sphincter relaxation causing reflux of gastrix contents into oesophagus
There is also poor peristaltic movement, not enough saliva and delayed gastric emptying
What are peptic ulcers? What complication can they lead to
Open sores that develop on the inside lining of oesophagus, stomach or upper portion small intestine
Complications include upper GI bleed
What causes peptic ulcers
H Pylori (bacterial infection)
NSAIDS
Lifestyle factors
Genetic
What is the official definition of a peptic ulcer
‘ a breach in the continuity of the epithelial lining of more than 5mm in diameter, with associated inflammation’
Why do ulcers develop
Ulcers develop where there is an imbalance between the agents that protect the epithelium and those which attack
What are the symptoms of both dyspesia and GORD
Initial symptoms can include: Upper abdominal pain, tenderness, discomfort Heartburn/reflux Bloating Early satiety Nausea and vomiting
What are the generalised symptoms of gastric ulcer desease
Pain radiates to back
Mainly occurs at night
Aggravated by food
Lose weight
What are the specific symptoms of a duodenal ulcer
Epigastric pain
Anytime – empty stomach
Relieved by food/antacids
Gain weight
What are the ALARM warning signs for referral
A- Anaemia L- Loss of weight (unintentional) A- Anorexia R- Recurrent problems* M- Melaena(blood in stool)/ haematemesis S- Swallowing problems
*- Only age> 55 with unexplained & persistent recent onset dyspepsia
What does an assessment for the GI diseases include
Includes: Detailed history – medical and social *Medication review - many medicines can cause GI disturbances* NSAIDs Bisphosphonates Corticosteroids Calcium antagonists Nitrates Theophyllines Blood tests H Pylori testing – see later X-ray Endoscopy
What are the initial management steps
Identify potential causative medications and manage appropriately
Lifestyle Measures
Smoking cessation
Healthy eating
Avoid known precipitants that cause dyspepsia:
fatty, acidic or fried foods and chocolate
Reduction or exclusion of alcohol and caffeine
Avoid eating late in the evening
Weight reduction
Reduce stress
Raising the head of the bed (GORD) - reduces night time reflux
What are antacids
Medicines that neutralise acid - often used for dyspepsia
Available OTC – liquids and tablets
Simple, cheap, effective
Dose:
when required for symptoms
between meals and at bedtimes
four or more times daily
Liquids more effective than solid dosage forms, but less portable or convenient.
What are the side effects of antacids
Antacids usually contain aluminium or magnesium compounds:
Magnesium containing - laxative effect
Aluminium containing - constipating
Also look out for:
Calcium containing - possible rebound acid secretion/hypercalcaemia
Why is the sodium content important with antacids
Avoid if patient is on salt restricted diet
High sodium content undesirable in:
patients with liver, renal and cardiac conditions
hypertension
pregnancy
Definition of Low Na+
Sodium content of less than 1mmol per tablet or 10-mL dose.
What are the interactions associated with antacids
May impair the absorption of other drugs if taken at the same time
May damage enteric coatings by raising the pH
Rarely may affect pH dependent renal excretion e.g. increase excretion with possible reduction in serum levels (aspirin, lithium)
What are alginates
The are used in combination with antacid
Increase viscosity stomach contents
Some form a “raft” that floats on top of stomach contents
What do histamine H2 receptor antagonists do (give examples)
Reduce gastric acid output by blocking histamine H2-receptor blockade
Heal duodenal and gastric ulcers at higher doses.
Include Ranitidine, Cimetidine, Famotidine
Available OTC (lower doses)
Generally taken twice daily
What are histamine H2 receptor antagonists licenced for
Licensed for: GORD (less effective than Proton Pump Inhibitors) maintenance treatment (rarely used now) NSAID prophylaxis Functional dyspepsia
Also used for stress ulcer prophylaxis, peri-operatively
What are the side effects of histamine H2 receptor antagonists
Side effects include: headache, diarrhoea, dizziness, occasionally rash, altered LFTs
What do proton pump inhibitors used for (give examples)
Block final pathway in production gastric acid
Block gastric H,K-ATPase, inhibiting gastric acid secretion
Include Esomeprazole, Lansoprazole, Omeprazole, Pantoprazole, Rabeprazole
Available OTC (lower doses) for dyspepsia
Generally once-twice daily
What are the indications for PPIs (7)
Many indications including: Dyspepsia GORD Treatment of gastric and duodenal ulcers Maintenance treatment NSAID prophylaxis Excessive gastric acid secretion stress ulcer prophylaxis, peri-operatively
What are PPI side effects
Side-effects include constipation, diarrhoea, headache, dizziness
MHRA warning - subacute cutaneous lupus erythematosus (SCLE)
What does long term PPI therapy carry the risk of
Achlorhydria – low gastric acid production is associated with increased risk of:
Gastric cancer
H pylori infection (particularly the elderly)
Pneumonia
Clostridium difficile infection (PPI use was associated with a 42 per cent increase in the risk of recurrent CDI)
bacterial overgrowth and reduced calcium absorption leading to hip fracture.
What are the PPI drug interactions
Interactions include:
Antiretrovirals
Methotrexate
Citalopram
Omperazole is predicted to decrease efficacy Clopidogrel – manufacturer advises avoid
Clinical significance is debatable!
Recommendations include using an alternative PPI or an H2 Antagonist
What does H. pylori do
Causes persistent infection in gastroduodenal mucosa
Infection always causes gastritis
Commonest cause PUD - > 90% of duodenal and > 70% of gastric ulcers are found to be infected.
Prevalence increases with age
Linked to gastric cancer
How does H pylori get transmitted
Transmission unclear – gastro-oral and faeco-oral probable
How do we detect h. pylori infection
H pylori produces an antibody response detectable in serum, saliva or urine and antigen detectable in stool
Testing:
Urea breath test kits
Patient swallows 13C-labelled urea solution
Urease activity by organism produces labelled carbon dioxide.
Stool antigen test
Mucosal biopsies
CLO test - multiple biopsies of mucosa should be taken
Lab based serology (locally validated)
What are the specifics around antimicrobials and H. pylori infection
Antibiotics/bismuth salts – may supress H pylori growth and give false negative
Achlorhydria (due to the presence of antacid therapy) – can give false positive
Testing should not be performed within 4 weeks of treatment with antibacterials or 2 weeks with PPI/antisecretory drugs
Retest using urea breath test if required
How do we eradicate H. pylori
Triple therapy - 7 day, twice-daily course of a PPI plus two antibiotics
Check allergy status and confirm previous antibiotic exposure
If PUD and H pylori positive- timing of eradication will depend on if PUD also associated with NSAID
Which drugs do we use to get rid of h. pylori (first line)
First Line – Triple therapy, twice daily for 7 days
PPI full dose BD, Amoxicillin 1g BD, Clarithromycin 500mg BD or Metronidazole 400mg BD
Penicillin allergic – PPI full dose BD, Clarithromycin 500mg BD and Metronidazole 400mg BD
*PPI choice depends on the hospital trust
What is a second line treatment for h pylori
Alternative regimens available if penicillin allergic and previous clarithromycin exposure or treatment failure
These contain full dose PPI BD plus a combination of two or more of the following antibacterials: Bismuth Tetracycline Quinolone e.g ciprofloxacin Metronidazole Clarithromycin
What is the pharmacists role in the treatment of h. pylori (5)
Patient education – adherence to regimen and importance of completing course as prescribed
Counsel on side-effects
Interactions e.g.
Clarithromycin + Statins
Metronidazole + alcohol
Ensure regimens prescribed correctly – can be confusing
Appropriate referral if ALRAM symptoms, recurrence
What link is there between nsaids and GI disturbances
NSAIDs can cause a variety of GI injuries including PUD, bleeding and ulceration
NSAIDs are one of the common causes of PUD
What are the risk factors for NSAID bleeds
Risk factors for NSAID bleed include: Age > 60 Multiple NSAIDs Smoker (increased risk PUD) H pylori infection (increased risk PUD) Concurrent medication including steroids, anticoagulants (which also affect GI tract) Higher dose/longer duration
How do NSAIDS cause ulcers (both directly and indirectly)
Direct mechanisms: Inhibition of prostaglandin synthesis impairs mucosal defences – erosive breach of epithelial barrier allows acid to enter
Acid attack deepens breach into frank ulceration
Low pH encourages passive absorption of NSAID so trapped in mucosa
Indirect mechanisms of NSAID damages include:
Reduce gastric blood flow
Reduce mucus and bicarbonate production
Leads to decreased cell repair
How do we manage NSAID-induced PUD
Stop NSAID if possible (sometimes not possible for things like arthritis)
Test for H pylori
Treat with full dose PPI (or H2-receptor) antagonist for 8 weeks
If H pylori also present – give eradication therapy after above treatment
What steps do we take if the NSAIDS need to be continued after the peptic ulcer has healed
Discuss potential harm
Regular review (at least 6 monthly) appropriateness
Reduce dose, Rx PRN, switch to Ibuprofen
Alternative agent e.g. cyclooxygenase-2-selective NSAID
Prescribe gastroprotection
(Gastroprotection:
PPI
H2-receptor antagonist
Misoprostol)
What is Misoprostol
Effective at preventing NSAID induced PUD (although less effective than PPIs in preventing duodenal ulcers)
Prostaglandin analogue - antisecretory and cytoprotective effects.
Less well tolerated than PPIs. Side-effects include diarrhoea
Contra-indicated in pregnancy (uterine stimulant)
won’t be examined Dyspepsia and GORD in Pregnancy: what are the management steps we can take
Dyspepsia in pregnancy commonly due to GORD – mechanical and hormonal factors
Symptoms include heartburn and acid reflux
Management can include:
Dietary and lifestyle changes – first line
Antacid or alginate (avoid preparations containing sodium bicarbonate or magnesium trisilicate)
If symptoms severe or persist – Ranitidine or Omeprazole
won’t be examined GORD and Reflux in Infants and Children: what are the management steps we can take
Change frequency and volume of feed Feed thickener or thickened formula feed Use an alginate instead of thickened feeds H2-receptor antagonist Proton pump inhibitor (nb, it is common in 12-18 month olds)
