GERD, PUD, Dyspepsia, esophagitis. H pylori

Question 1

symptoms of dyspepsia

Answer 1

dyspepsia = epigastric pain/discomfort, post prandial fullness, early satiety

GERD = heartburn and regurgitation

Question 2

Causes of dyspepsia

Answer 2

functional (idiopathic)

GERD,

PUD,

gastric malignancy,

NSAID gastropathy

Question 3

pain that occurs on an empty stomach is due to

Answer 3

secretion of gastric acid after completion of meal digestion and suggests PUD

Question 4

Most frequent cause of dyspepsia

Answer 4

H pylori

Question 5

Who needs an EGD if they have dyspepsia?

Answer 5

Need EGD in evaluation for dyspepsia if:

>60 yrs

if <60 yrs old + they have red flag symptoms (weight loss, early satiety, unexplained Fe deficiency anemia) or GERD for >5 yrs

Question 6

Algorithm for dyspepsia

If pt has increasing progressive epigastric pain with eating for 8 months and is <60 years what do you do?

Answer 6

if pts <60 years old presenting with dyspepsia, undergo testing for H pylori (non invasive test) and eradiation therapy if positive.

Don’t give empiric PPI.

if pt is >60 yrs old presenting with dyspepsia, need EGD.

Upper EGD could be considered in pts <60 if

• have a family history of gastric cancer
• immigrated from area with increased risk for gastric cancer (Asia, Russia, S. America) .

Question 7

Side effects of PPI

Answer 7

microscopic colitis

acute interstitial nephritis

increased risk for CAP pneumonia and stress ulcer prophylaxis nosocomial pneumonia.

risk for C diff infection,

osteoporosis and osteopenia risk,

hypomagnesemia and hypocalcemia malabsorption

B12 deficiency

increased risk for CAD events.

maybe worsens renal insufficiency,

Question 8

When do we get a CT scan for work up for dyspepsia?

Answer 8

Concern for mass or palpable mass.

Question 9

H pylori serology

Answer 9

doesn’t distinguish between previous or active disease as its antibody is positive for life.

If positive, needs confirmatory testing with a stool antigen. Needs to be off PPI for at least two weeks.

Question 10

Who is high risk for complications when using NSAIDS?

Answer 10

prior complicated peptic ulcer dx history

>2 RF:

>65 yrs old,

high dose NSAID use,

previous history of uncomplicated PUD,

current use of aspirin (any dose), corticosteroids, or anticoagulation

Question 11

What makes someone use of NSAIDS moderate risk?

Answer 11

If they have one to two risk factors

>65 yrs old,

high dose NSAID use,

previous history of uncomplicated PUD,

current use of aspirin (any dose) and corticosteroids or anticoagulation

Question 12

what do guidelines recommend for anyone with high risk or moderate risk NSAID use?

Answer 12

pick a selective COX-2 inhibitor or combine NSAID with PPI or misoprostol.

Lanasoprazole is approved in US for prevention of NSAID induced ulcers.

Try to take the lowest dose NSAID for shortest period of time.

Question 13

medication induced esophagitis is from

Answer 13

drug ingestion with minimal water or at bedtime.

See localized chemical injury to the esophageal mucosa from medications that are lodged at narrow point in esophagus.

Common medications include

tetracyclines

NSAIDs

bisphosphonates,

KCL,

Fe tablets

steroids

Question 14

Clinical presentation of medication induced esophagitis

Answer 14

retrosternal burning of chest pain, odynophagia leading to dysphagia

drug ingestion with minimal water or at bedtime

Question 15

diagnosis of medication induced esophagitis

Answer 15

based on clinical presentation and upper EGD if severe symptoms

Question 16

Treatment of medication induced esophagitis

Answer 16

stop offending drug, supportive care (IVFs or pain control PRN)

Needs EGD if there’s atypical symptoms (hematemesis, weight loss) or those who STILL have symptoms after 1 week of drug withdrawal to evaluate for secondary causes

Question 17

Risk factors for medication induced esophagitis

Answer 17

abnormal esophageal anatomy

large pill size

pill ingestion while supine

inadequate fluid intake

Question 18

Prevention of medication induced esophagitis

Answer 18

drink medication with 8 oz of water

remain upright for at least 30 minutes after ingestion.

Question 19

eosinophilic esophagitis is treated with

Answer 19

dietary restrictions, inhaled fluticasone spray is second line therapy

presents with chest pain and heart burn too.

Question 20

Treatment of H pylori: (chart)

Answer 20

Question 21

standard tx for H pylori infection is

Answer 21

PPI + clarithromycin + amoxicillin for 10-14 days

(for no pencillin allergy or previous macrolide use)

Beware if pt is on warfarin because clarithromycin interacts with warfarin.

Question 22

treatment for H pylori infection and has penicillin allergy:

Answer 22

PPI + clarithromycin + metronidazole for 10-14 days

Question 23

When to give quadruple therapy for H pylori treatment

Answer 23

high macrolide or metronidazole resistance

OR treatment failure after 1 course of therapy

Question 24

what is quadruple therapy for H pylori?

Answer 24

PPI + bismuth + metronidazole + tetracycline for 10 - 14 days.

Beware of warfarin use with tetracycline.

Question 25

When to confirm erradication of H pylori?

Answer 25

\>4 weeks after initial therapy and that's when you can confirm H pylori eradication. (20% of pts fail first treatment course) If persistent symptoms after treatment or H pylori associated ulcer or gastric MALToma or early gastric cancer MUST recheck for H pylori.

Question 26

what test is used to confirm eradication of H pylori after treatment

Answer 26

_urease breath test is best_ but expensive. Can check _stool antigen or repeat EGD._ Needs to be off PPI and other medications for _at least 2 weeks_ for both urease breath test and stool antigen as these can cause false negatives.

Question 27

what happens in Barret's esophagus?

Answer 27

see replacement of normal esophageal stratified squamous epithelium with metaplastic columnar epithelium and this condition predisposes to the development of adenocarcinoma of the esophagus.

Question 28

who gets Barrett's esophagus?

Answer 28

Men, history of GERD\>5 years, frequent reflux symptoms (heart burn), obesity and tobacco use and \>2 risk factors needs EGD for evaluation.

Question 29

evaluation and management of Barrett's esophagus

Answer 29

NOTE: MKSAP says per new guidelines, **_any dysplasia (low grade or high grade) should get endoscopic ablation therapy for permanent eradication._** Need to have confirmation by second pathologist and pt is unwilling to go ablation needs annual surveillance endoscopy as alterantive. Note this is different from the chart

Question 30

findings on EGD that show signs of Barrett's esophagus

Answer 30

**ABNORMAL** see _velvety texture that is salmon colored_ (evidence of columnar epithelium) **Normal**: Squamous epithelium is _pale and glossy appearance_. any dysplasia (low or high) needs endoscopic ablation. NOT surveillance.

Question 31

What to do after EGD without macroscopic evidence of Barrett's esophagus?

Answer 31

repeat EGD surveillance in 3-5 years

Question 32

What to do after EGD if there's signs of macroscopic evidence of Barrett's esophagus?

Answer 32

needs further histological evaluation for dysplasia and should get daily PPI to decrease symptoms, heal esophagitis, and decrease progression to cancer

Question 33

IF EGD shows signs of low grade dysplasia and Barrett's esophagus, what do you do?

Answer 33

need EGD eradiation therapy (ablation, mucosal resection) or surveillance endoscopy every 6 to 12 months.

Question 34

If EGD shows high grade dysplasia and signs of Barrett's esophagus, what to do?

Answer 34

needs to be managed with endoscopic eradication therapy (ablation or mucosal resection) or esophagectomy. Preferred is endoscopic eradication as it's less invasive and preferred.

Question 35

Is H pylori associated with Barrett's esophagus?

Answer 35

no. Only treat for H pylori if evidence for this.

Question 36

1st step with dyspepsia is: Age that EGD should be recommended in if they lack GERD symptoms? What alarm features require EGD if below this age?

Answer 36

find out if they use NSAIDS and ETOH and GERD symptoms (retrosternal pain and regurgitation) can trial acid suppression with dyspepsia alone. BUT IF over \>60 years old with new onset dyspepsia or no GERD symptoms just dyspepsia (epigastric pain, early satiety and postprandial fullness) they need an EGD. \<60 years alarm features are: family history of gastric cancer, unitended weight loss, dysphagia, GI bleeding, Fe deficiency anemia.

Question 37

what are features of GERD that indicate severity but do not require a EGD without PPI trial?

Answer 37

extraesophageal manifestations (coughing and wheezing), nocturnal symptoms (acid regurgitation), belching nausea and dry cough non cardiac chest pain Can also have a lump in throat while swallowing. _NO symptoms of **dyspepsia** (epigastric pain, early satiety, post prandial fullness, and weight loss)_ Tx with **_lifestyle changes and PPI trial._**

Question 38

eosinophilic esophagitis is associated with (hear this presentation)

Answer 38

**dysphagia**, centrally located chest pain and **food impaction** (food getting stuck) and **refractory heart burn** and upper abdominal pain. Also seen in people with allergic disorders like asthma, food allergies, and atopic dermatitis.

Question 39

GERD symptoms are:

Answer 39

heartburn and regurgitation

Question 40

GERD initial treatment

Answer 40

lifestyle modifications with smoking and ETOH cessation, weight loss, decrease caffeine intake can give PPI or H2 blocker

Question 41

Esophageal PH monitoring and impedance testing should be done with

Answer 41

pts who have GERD symptoms that don't respond to 4-8 weeks of twice daily PPI therapy. rule out extra-gastrointestinal manifestations of GERD like laryngopharynx reflux which can cause chronic cough.

Question 42

GERD with continued symptoms while on PPI or H2 blocker and trying conservative lifestyle changes should get this treatment:

Answer 42

switch to different PPI or change to a twice daily PPI can consider a GI consult GERD with refractory to initial once daily PPI is seen in 10-40% of pts

Question 43

When should we get EGD for GERD?

Answer 43

if once daily PPI or twice daily PPI has ALARM FEATURES - can skip PPI trial and go to EGD if there is _weight loss, GI bleeding, dysphagia or odynophagia._ **EGD is the gold standard** for ruling out for upper GI _structural causes of dyspepsia_.

Question 44

With GERD do we always test for H pylori?

Answer 44

no. GERD = heartburn and regurgitation Only if there's **dyspepsia** (meaning p_ostprandial fullness, early satiety, and **epigastric pain**)_, "**test and treat approach"** to H pylori doesn't have a clear role in management for GERD)

Question 45

patients who have a bleeding peptic ulcer should get

Answer 45

**tested for H pylori with biopsy** in EGD Pts who have evidence for infection should get treatment _beware that is high false negative results_ for H pylori in **GI bleeding, with PPI, bismuth, and antibiotics**.

Question 46

pt has GI bleed and gets EGD. has 2 cm duodenal ulcer with visible vessel at the base (high risk ulcer). _Ulcer biopsy is done and negative for H pylori._ What is the next step in evaluation regarding treatment for H pylori infection?

Answer 46

pt should get **outpatient urea breath test** and **stool antigen.** Can test for it after 1-2 weeks of stopping PPI. serology is _less effective_ because cannot differentiate betwen active and prior infection. There is a **_high FALSE negative rate for H pylori in biopsies during active GI bleeds, antibiotics, PPI, and bismuth._**

Question 47

indications for repeat EGD after eradication of H pylori ?

Answer 47

the _repeat biopsy of ulcer after treatment with EGD after 6 weeks of treatment_ is to **rule out possibility of gastric cancer along with H pylori.** - repeat ulcer biopsy - inadequate sample - unclear if there was cancer - if pt was from endemic area (Russia, Asia, S. America) - may have longer standing H pylori and so therefore increased risk for gastric mucosa associated lymphoid tissue lymphoma (MALT) - no recent NSAID use - so likely more related to longstanding H pylori - family hx of gastric cancer - age \>50 yrs - large ulcers - higher risk for cancer - absent duodenal ulcers - require higher acid secretion and lower risk for gastric cancer.

Question 48

When to get ambulatory pH testing for GERD?

Answer 48

helpful for diagnosing GERD in suspected extraesophageal manifestation of GERD, laryngopharyngeal reflux resulting in persistent cough **Extraesophageal symptoms of GERD:**- asthma, globus sensation, hoarseness, throat clearing, chronic laryngitis. _Laryngopharynx is more sensitive to erosive effects of acid_ and small amount of reflux can cause this. Thus ambulatory pH testing is good to evaluate this. **Don't get esophageal manometry -** only used for people who have an _underlying motility disorder with peristalsis or lower esophageal sphincter dysfunction_ - **if no dysphagia don't get it.**

Question 49

indications for maintenance PPI or long term PPI use

Answer 49

_maintenance PPI recommended_ for pts who have - **GERD who continue to have symptoms after initial course of PPI is discontinued**. - **erosive esophagitis** **- Barrett's esophagus** Try to use the _lowest effective dose possible_ and consideration should be given to _reducing or stopping PPI therapy at least once a year._ Risk for PPI \>1 yr use: increased risk for hip, wrist, and spine fractures.

Question 50

Patient who has Barrett's esophagus and has indefinite for dysplasia biopsy? what to do next?

Answer 50

Optimize for GERD (PPI from once to twice daily) and t**hen repeat EGD.** Guidelines don't specify a time to repeat EGD but 6 months to 1 year after antisecretory therapy would be reasonable. If repeat EGD at 1 year is normal then can go to 3-5 year surveillance with EGD.

Question 51

functional dyspepsia is

Answer 51

**epigastric pain syndrome that is characterized by:** - bothersome post prandial fullness - early satiety - epigastric pain and epigastric pain for at least 3 days per week _symptoms starting for at least 6 months prior ot diagnosis_ and no evidence of structural disease to make the symptoms. Evaluation should show _normal EGD, normal gastric and small bowel biopsies and normal lab testing and no alarm symptoms and negative H pylori tests. Did not respond to PPI._

Question 52

Treatment of functional dyspepsia

Answer 52

trial PPI for 4 weeks if doesn't help then stop PPI and put pt on a TCA - more effective than SSRI or SNRI.

Question 53

what to order next for GERD evaluation if: = GERD refractory to PPI and already had EGD with no erosive changes and H pylori biopsies are negative

Answer 53

**Get a 24 hr ambulatory reflux monitoring.** Don't get barium swallow or esophragm or upper GI series because only for dysphagia or pre or post surgical evaluation of people who had anti-reflux surgery.

Question 54

What medication worsens GERD?

Answer 54

**nifedipine and other CCB.** they decrease the **lower esophageal sphincter pressure.** other medications like anticholinergic agents, alpha adrenergic antagonists, theophylline and sedatives.

Question 55

what medications should be avoided together if treating someone with H pylori?

Answer 55

**colchicine and clarithromycin** Check to make sure pt who is going to get clarithromycin isn't also on colchicine. - **coadministration of colchicine and clarithromycin can result in fatal colchicine toxicity** that manifests as **rhabdomyolysis, AKI** and **pancytopenia** Colchicine is metabolized in the liver by CYP3A4 cytochrome and should be avoided in tps taking CYP3A4 inhibitors like clarithromycin there are fatal outcomes with both given at the same time. ok to resume colchicine after recovery.