GASTRIC ACID DISORDERS + ULCERATION Flashcards
Dyspepsia
Upper abdominal pain
heartburn
gastric reflux
bloating
nausea and vomiting
Dyspepsia - red flags
- Gastrointestinal Bleeding
- Aged 55 Years +
- Unexplained Weight Loss
- Dysphagia
GAUD
Uninvestigated dyspepsia
describes symptoms in patients who have not had an endoscopy.
Uninvestigated Dyspepsia - Treatment
- PPI for 4 weeks first
- Test for H. pylori if PPI didn’t work - treat if positive
Functional Dyspepsia (investigated but no cause present)
Test for H. pylori - treat if positive
Not infected: 3 weeks of PPI or H2 receptor antagonist
H.Pylori
Most common causes of peptic ulcer disease
H.pylori - when do you test pt?
- uncomplicated dyspepsia who are unresponsive to lifestyle changes and antacids, following 4 week PPI
- high risk of H. pylori infection (such as older people, individuals of North African ethnicity, and those living in a known high risk area)
- Previously untested patients with a history of peptic ulcers or bleeds;
- Prior to initiating NSAIDs in patients with a prior history of peptic ulcers or bleeds;
- Patients with unexplained iron-deficiency anaemia after endoscopic investigation has excluded malignancy, and other causes have been investigated.
H.Pylori - diagnosis
Urea (13C) breath test
Stool Helicobacter Antigen Test (SAT)
PPI stopped 2 weeks before test
Abx stopped 4 weeks before test
H.Pylori - triple therapy treatment
Treated with Triple Therapy (PPI and 2 of the antibiotics):
- PPI: BD
- Amoxicillin: 1000mg BD
- Clarithromycin: 500mg BD
FOR 7 DAYS
- Metronidazole: 400mg BD
PAC
PAM
PCM
GORD
Gastro-Oesophageal Reflux Disease
GORD - risk factors
Increased with:
* Consuming Fatty Foods
* Pregnancy
* Hiatus Hernia
* Family History
* Stress And Anxiety
* Obesity
* Drug Side-effects
* Smoking, Alcohol
GORD - red flags
SAME URGENT REFERRAL
CRITERIA AS DYSPEPSIA
GORD - which drugs have a side effect of GORD?
a/b-blockers, CCBs, anticholinergics, benzos, bisphosphonates, corticosteroids, NSAIDs, nitrates, and TCAs, alendronic acid
GORD - non-drug treatment
1st line: lifestyle advice
Healthy eating
Weight loss (if obese)
Avoiding any trigger foods
Eating smaller meals
Eating the evening meal 3-4 hours before going to bed
Raising the head of the bed
Smoking cessation
Reducing alcohol consumption
uninvestigated GORD - treatment
Medicine review if taking a drug that exacerbates GORD
* PPI for 4 weeks first
* Test for H. pylori if PPI didn’t work - treat if positive
Confirmed GORD - treatment
treated with 4-8 weeks of PPI
Dyspepsia - pregnancy
Dyspepsia symptoms in pregnancy are commonly due to gastro-oesophageal reflux disease (GORD)
Dyspepsia in pregnancy - treatment
- 1st line: Dietary and lifestyle advice
- No response = an antacid or an alginate can be used.
- If this is ineffective or symptoms are severe omeprazole or ranitidine (unlicensed)
Antacids - examples
Magnesium-containing antacids: Laxative
Aluminium-containing antacids: Constipating
Calcium-containing antacids: Induces rebound acid secretion
Simeticone (antifoaming agent) added to antacid →
relieves flatulence
Alginates + antacid
increases the viscosity of stomach content
form a viscous gel (‘raft’) that floats on the surface of the stomach contents
Antacids Interactions
- Increase the stomach pH (more alkali) meaning enteric coated capsules are damaged before reaching the intestine
- Check sodium content of antacid - not to be taken with lithium / in hypertension
> Low sodium: co-magaldrox - Antacids not to be taken with other drugs due to impairing absorption
Bisphosphonates, Tetracyclines, Ciprofloxacin
Antacids and enteric coated capsules
Increase the stomach pH (more alkali) meaning enteric coated capsules are damaged before reaching the intestine
Antacids and sodium
- Check sodium content of antacid - not to be taken with lithium / in hypertension
> Low sodium: co-magaldrox
Antacids and other drugs
Antacids not to be taken with other drugs due to impairing absorption
Bisphosphonates, Tetracyclines, Ciprofloxacin
Proton Pump Inhibitors - examples
Omeprazole Esomeprazole Lansoprazole Rabeprazole
PPI - side effects
Osteoporosis - risk of bone fractures due to low B12
Increased risk of C.diff
Masks symptoms of gastric cancer
- Hyponatraemia and hypomagnesaemia
- CAP
PPI - osteoporosis
Increase risk of fractures / osteoporosis
* Due to hypomagnesaemia and low B 12
PPI - interactions
INTERACTION:
Es/omeprazole/ omeprazole + Clopidogrel
(use lansoprazole instead)
Increase conc of methotrexate, phenytoin, warfarin and digoxin
Eso/ omeprazole + clopidogrel
- Suitable alternatives: pantoprazole least likely to interact and lansoprazole and rabeprazole also suitable
Important safety information for PPIs
SCLE
Advise to avoid exposing the skin to sunlight
Consider SCLE
Consider STOP PPI
Symptoms should resolve on PPI withdrawal
Symptoms of SCLE
- lesions – especially in sun exposed areas of the skin
- accompanied by arthralgia
H2 Receptor Antagonists - examples
Ranitadine Cimetidine Famotidine Nizatidine
H2 receptor antagonists - Side effects
Diarrhoea, headache, dizziness, rash, and tiredness
H2 receptor antagonists - cancer
Caution: may mask symptoms of gastric cancer
Rule out alarm features of cancer before treatment
H2 receptor antagonists - Interactions
Reduced absorption of -azole antifungals
Cimetidine
CYP450 enzyme inhibitor
CKS guidelines for suspected cancer pathway referral (for an appointment within 2 weeks) if:
- aged 40 and over with unexplained weight loss and abdominal pain
- aged 50 and over with unexplained rectal bleeding
- aged 60 and over with either iron-deficiency anaemia or changes in their bowel habit
- Tests show occult blood in their faeces. §
