EXAM - GI CASES Flashcards
Bill, a 45 year old cis male, presents to your clinic complaining of 6 months of epigastric pain that he describes as a “burning” pain that occurs at least 4 times per week. It is worse after eating large meals and at bedtime. He has been taking TUMS daily and finds this relieves the pain about half of the time.
He denies nausea, vomiting, or significant changes in stool pattern/type.
You suspect Bill has GERD.
What alarm features will you rule out first?
“VBAD”
- Vomiting (persistent > 7 days)
- Bleeding (anemia, melena)
- Abdominal mass or unexplained weight loss (eg: 3kg or 10% body weight)
- Dysphagia (needs prompt endoscopy)
Others: jaundice, family hx of gastric/ovarian CA, prior ulcer
What lifestyle modifications will you suggest to Bill to improve his reflux?
- Minimize foods that worsen symptoms (choclate, caffeine, alcohol, spicy foods)
- Eat lighter meals & chew well
- Avoid lying down within 3 hours after eating & avoid tight clothing
- Elevate head of bed
- Weight loss if overweight
- Moderate alcohol use & smoking cessation
(these are from bottom of page 69 on Rx Files)
Can you make a diagnosis of GERD off of Bill’s symptoms alone?
A presumptive diagnosis of GERD can be established in the
setting of typical symptoms of heartburn and regurgitation.
(GERD Guidelines)
- This is confirmed with response to medical therapy (as will be discussed shortly!)
**If your assessment identified his discomfort as potential chest pain, would want to rule out cardiac causes first!
Following a physical assessment, you are confident that Bill’s pain is abdominal (not chest pain) and his symptoms reflect heartburn and regurgitation as the primary symptom. He has no alarm features.
You decide to start Bill on medication. What is the appropriate therapy?
GERD guidelines: Empiric medical therapy with a proton pump
inhibitor (PPI) is recommended in this setting
As per Rx files (p. 69):
- standard dose once daily PPI is more efficacious than H2RA
- Standard doses of PPIs: omeprazole, rabeprazole & esomeprazole 20mg daily; dexlansoprazole & lansoprazole30mg daily; pantoprazole 40mg daily
I would say Pantoprazole 40mg PO daily x 4 weeks
What important teaching will you include when you prescribe a PPI?
- take 30-60 mins before meals
- advised to take before the first meal of the day EXCEPT when issues of nocturnal symptoms, so you may advise Bill to take his PPI before dinner instead!
- Do not crush/chew
- adverse effects: nausea, headache, dizziness, somnolence, diarrhea, constipation, pruritis, sweating
- with long-term use: B12 deficiency, increased risk of # r/t Ca malabsorption, gastric bacterial or fungal infections
When will you reassess Bill’s PPI use?
Rx files pg 69:
- Reassess therapy at 4-8 weeks
GERD guidelines: An 8-week course of PPIs is the therapy of choice for symptom relief and healing of erosive esophagitis. There are no major differences in efficacy between the different
PPIs
You see Bill 4 weeks after he starts his PPI. He has been taking his PPI at night. His symptoms have partially resolved but continue to occur after lunch most days. What do you do now?
As per Rx files (p. 69)
If symptoms are partially resolved…
- ensure PPI taken 30 mins before meal
- Trial taking BID x 4-8 weeks or consider investigation
- May also want to trial a different PPI (as per BC Pathways doc)
If increasing to BID: pantoprazole 40mg PO BID (maybee????). Rx files doesn’t show BID dosing for GERD except in EE, but Pathways suggests just regular dose but BID instead of daily.
After another 4 weeks of treatment on BID panto, Bill’s symptoms have resolved. What now?
Stop PPI therapy. You fixed ‘im!
Sounds like if the person has symptoms again once you stop the PPI, you would want to put them on a maintenance dose at the lowest possible
(from “Guidelines for the Diagnosis and Management of
Gastroesophageal Reflux Disease” and Pathways)
Lynda presents with 2 months of occasional heartburn that she describes as a burning in her chest. This occurs once every 2 weeks and she describes the pain as “mild”. It often occurs at night. She currently does not take any medications for this.
What would be appropriate pharmacologic therapy?
- First r/o cardiac cause! Then consider as GERD…
For mild and infrequent symptoms, offer nonpharmacologic advise +/- H2RA, alginate or antacid (all taken PRN).
H2RAs offer good relief as needed and last longer than antacids. They are also great for nocturnal symptoms!
(rx files p. 70 and BC pathways “enhanced primary care: GERD” doc)
John is a 65 year old man who reports new onset of frequent heartburn, bloating, and indigestion for the last two months.
Without knowing anything else, what are you concerned about?
- Cardiac cause
- Also age! “Patients would require prompt investigation and assessment if alarm features are present or if they are >50 years of age with new onset or worsening of symptom severity or frequency” (CPS under “patient assessment” in GERD/dyspepsia). Need investigations to r/o esophageal/gastric CA.
Martha, a 72 year old woman, presents with complaints of a “gnawing” sensation in her stomach for the last week that improves with meals. She denies vomiting but confirms she had melena stool yesterday. No dizziness or syncope.
A urea breath test confirms Martha has an H. Pylori infection. Due to her red flags (age >60, signs of bleeding), she is referred for endoscopy, which confirms there is nothing more ominous going on (such as CA) and she is diagnosed with with a duodenal ulcer (PUD).
What is the appropriate initial treatment? She has no allergies.
Priority is eradicating the H. Pylori
p. 71 in Rx Files - quadruple tx options are first line (I would be surprised if she asked us for these but just wanted to be sure we know where to find them!)
Also in CPS: The Canadian Association of Gastroenterology guidelines recommend quadruple therapy for 14 days as first-line management in the eradication of H. pylori infection.[24] The recommended quadruple therapy regimens include:
- any of the PPIs, amoxicillin, metronidazole and clarithromycin BID for 14 days
- any of the PPIs BID, bismuth subsalicylate QID, metronidazole TID–QID and tetracycline QID for 14 days
CPS states “In patients with complicated ulcers (e.g., bleeding, perforation, severe symptoms) or severe PUD-related complications, continue therapy with PPIs until eradication of H. pylori is confirmed”
After Martha’s initial treatment, she is feeling much better. Does she need confirmation of H. Pylori eradication if she’s asymptomatic??
Yes because she has a complicated duodenal ulcer.
If things weren’t so complicated, it’s not routinely indicated.
(criteria of those who need confirmation of eradication is on Rx files p. 71 on right-hand side)
Dylan is a 45 year old male who takes NSAIDs daily for the last 10 years since his diagnosis of rheumatoid arthritis. He also drinks 3 beers/day and smokes a pack a day. He comes to your clinic complaining of intermittent abdominal discomfort, bloating, early satiety and nausea. He was previously diagnosed with a gastric ulcer 3 years ago. His symptoms worsen when he eats.
These symptoms describe “dyspepsia”, which is the cardinal sign of PUD.
He has no alarm symptoms.
What is your treatment plan to address the NSAID-induced PUD?
- Stop NSAIDs (only low dose NSAIDs for thrombosis prevention should be continued)
- Test for H. Pylori (treat if positive)
Treat PUD in those using ASA or NSAIDs with standard-dose PPIs. (H2RAs and misoprostol are less-effective alternatives) - CPS
- Looks like PPI treatment duration is typically 4 weeks for duodenal ulcers and up to 8 weeks for gastric ulcers. The fact that the pain is worse with eating was meant to hint that it’s a gastric ulcer.
Treatment may be stopped 8 weeks after discontinuation of ASA or NSAIDs.
Treatment examples could be:
Omeprazole 20mg po daily ac x 4 weeks (for DU) or 4-8 weeks (for GU)
Pantoprazole po daily ac (duration same as above)
May also want to consider misoprostol? According to Susan’s slide “Misoprostol can reduce the incidence of NSAID-induced ulcers to less than 3% and the incidence of ulcer complications by 50%.”
(pg 70 in rx files & CPS)
