Dyspepsia Peptic ulcer disease- clinical

Question 1

What are the rome III criteria for dyspepsia?

Answer 1

Epigastric pain or burning
Postprandial fullness
Early satiey

Question 2

What are the two broad categories of dyspepsia?

Answer 2

Organic causes:
Peptic ulcer disease
Drugs (especially NSAIDs and COX2 inhibitors)
Gastric cancer

Function causes:
Idiopathic
No evidence of culprit structural disease
Associated with other functional gut disorders (e.g. IBS)

Question 3

What is it important to differentiate dyspepsia from?

Answer 3

Heartburn/reflux

GORD may preexist/ predominate

Question 4

What are alarm features that accompany dyspepsia?

Answer 4

Dysphagia
Evidence of GI blood loss
Persistent vomiting
Unexplained weight loss
Upper abdominal mass

Question 5

If GORD predominates in dyspepsia, how should it be managed?

Answer 5

As GORD

Question 6

If dyspepsia is not managed as GORD, and there are no alarm features, how should it be initially managed?

Answer 6

By considering lifestyle changes, and Antacids/H2RA

Question 7

If dyspepsia symptoms are recurrent or persistent after managing lifestyle and using antacids/H2RA, what should be done?

Answer 7

Patients should be tested for H pylori.
Positive test: eradicate H pylori
Negative test: If patient is 55 or over, refer to hospital specialist
If patient is under 55, manage as functional dyspepsia

Question 8

Describe the pain in peptic ulcer disease

Answer 8

Dyspepsia, moves to back
Often nocturnal
Aggravated or relieved by eating

Question 9

a) What percentage of peptic ulcer disease is caused by H pylori?
b) What causes most of the rest of peptic ulcer?
c) what is happening to the ration of NSAID: H pylori peptic ulcers?

Answer 9

a) Approx 90% of DU
Approx 60% of GU
b) use of NSAIDs or COX 2 inhibitors
c) it is rising

Question 10

What are the 3 different outcomes of H pylori infection?

Answer 10

1. No clinical disease
2. An intense distal gastritis response which causes hypergastrinaemia, resulting in increase acid secretion.
3. There is a pan gastritis which results in gastric atrophy, and there is a reduction of acid secretion.

Question 11

Describe the pathophysiology of duodenal ulcer caused by H pylori.

Answer 11

There is increased gastrin release.
There is increased acid secretion in the stomach due to increased parietal cell mass and no body gastritis.
There is then increased duodenal acid load, which leads to gastric metaplasia, H pylori colonisation and ulceration.

Question 12

How can H pylori be diagnosed?

Answer 12

Gastric biopsy: urease test (CLO test)
histology
culture/sensitivity

Urease breath test
Faecal antigen test
Serology (IgA antibodies- not accurate with increasing patient age)

Question 13

When should the urease breath test not be used?

Answer 13

Within 2 weeks of PPI treatment or within 4 weeks of antibiotic therapy

Question 14

What is the treatment for peptic ulcer disease?

Answer 14

All should have antisecretory therapy (PPI)
All should be tested for H pylori
If H pylori is positive: eradicate and confirm
If H pylori is negative: antisecretory therapy
Withdraw NSAIDs
Lifestyle
Non H pylori and non NSAID peptic ulcers: nutrition and optimise comorbidities
No firm dietary recommendations
Surgery- infrequent

Question 15

What is the eradication therapy for H pylori?

Answer 15

Commonest therapy is triple therapy for 1 week:
PPI + amoxycillin 1g bd + clarithromycin 500mg bd
PPI + metronidazole 400mg bd + clarithromycin 250 mg bd

2 week regimens:
Higher eradication rates
Poorer compliance
quadruple therapy + culture directed therapy

Question 16

What is the follow up for peptic ulcer disease?

Answer 16

DU:
uncomplicated DU requires no follow up
Only follow up if ongoing symptoms

GU:
follow up endoscopy at 6-8 weeks
Ensure healing and no malignancy