GERD, PUD, Dyspepsia, esophagitis. H pylori Flashcards
PUD, dyspepsia, esophagitis, H pylori and Barretts esophagus
symptoms of dyspepsia
dyspepsia = epigastric pain/discomfort, post prandial fullness, early satiety
GERD = heartburn and regurgitation
Causes of dyspepsia
functional (idiopathic)
GERD,
PUD,
gastric malignancy,
NSAID gastropathy
pain that occurs on an empty stomach is due to
secretion of gastric acid after completion of meal digestion and suggests PUD
Most frequent cause of dyspepsia
H pylori
Who needs an EGD if they have dyspepsia?
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
Algorithm for dyspepsia
If pt has increasing progressive epigastric pain with eating for 8 months and is <60 years what do you do?
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) .
Side effects of PPI
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,
When do we get a CT scan for work up for dyspepsia?
Concern for mass or palpable mass.
H pylori serology
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.
Who is high risk for complications when using NSAIDS?
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
What makes someone use of NSAIDS moderate risk?
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
what do guidelines recommend for anyone with high risk or moderate risk NSAID use?
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.
medication induced esophagitis is from
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
Clinical presentation of medication induced esophagitis
retrosternal burning of chest pain, odynophagia leading to dysphagia
drug ingestion with minimal water or at bedtime
diagnosis of medication induced esophagitis
based on clinical presentation and upper EGD if severe symptoms
Treatment of medication induced esophagitis
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
Risk factors for medication induced esophagitis
abnormal esophageal anatomy
large pill size
pill ingestion while supine
inadequate fluid intake
Prevention of medication induced esophagitis
drink medication with 8 oz of water
remain upright for at least 30 minutes after ingestion.
eosinophilic esophagitis is treated with
dietary restrictions, inhaled fluticasone spray is second line therapy
presents with chest pain and heart burn too.
Treatment of H pylori: (chart)
standard tx for H pylori infection is
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.
treatment for H pylori infection and has penicillin allergy:
PPI + clarithromycin + metronidazole for 10-14 days
When to give quadruple therapy for H pylori treatment
high macrolide or metronidazole resistance
OR treatment failure after 1 course of therapy
what is quadruple therapy for H pylori?
PPI + bismuth + metronidazole + tetracycline for 10 - 14 days.
Beware of warfarin use with tetracycline.
When to confirm erradication of H pylori?
>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.
what test is used to confirm eradication of H pylori after treatment
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.
what happens in Barret’s esophagus?
see replacement of normal esophageal stratified squamous epithelium with metaplastic columnar epithelium and this condition predisposes to the development of adenocarcinoma of the esophagus.
who gets Barrett’s esophagus?
Men, history of GERD>5 years, frequent reflux symptoms (heart burn), obesity and tobacco use
and >2 risk factors needs EGD for evaluation.
evaluation and management of Barrett’s esophagus
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
findings on EGD that show signs of Barrett’s esophagus
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.
What to do after EGD without macroscopic evidence of Barrett’s esophagus?
repeat EGD surveillance in 3-5 years
What to do after EGD if there’s signs of macroscopic evidence of Barrett’s esophagus?
needs further histological evaluation for dysplasia and should get daily PPI to decrease symptoms, heal esophagitis, and decrease progression to cancer
IF EGD shows signs of low grade dysplasia and Barrett’s esophagus, what do you do?
need EGD eradiation therapy (ablation, mucosal resection) or surveillance endoscopy every 6 to 12 months.
If EGD shows high grade dysplasia and signs of Barrett’s esophagus, what to do?
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.
Is H pylori associated with Barrett’s esophagus?
no. Only treat for H pylori if evidence for this.
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?
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.
what are features of GERD that indicate severity but do not require a EGD without PPI trial?
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.
eosinophilic esophagitis is associated with
(hear this presentation)
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.
GERD symptoms are:
heartburn and regurgitation
GERD initial treatment
lifestyle modifications with smoking and ETOH cessation,
weight loss,
decrease caffeine intake
can give PPI or H2 blocker
Esophageal PH monitoring and impedance testing should be done with
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.
GERD with continued symptoms while on PPI or H2 blocker and trying conservative lifestyle changes should get this treatment:
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
When should we get EGD for GERD?
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.
With GERD do we always test for H pylori?
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)
patients who have a bleeding peptic ulcer should get
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.
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?
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.
indications for repeat EGD after eradication of H pylori ?
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.
When to get ambulatory pH testing for GERD?
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.
indications for maintenance PPI or long term PPI use
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.
Patient who has Barrett’s esophagus and has indefinite for dysplasia biopsy? what to do next?
Optimize for GERD (PPI from once to twice daily) and then 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.
functional dyspepsia is
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.
Treatment of functional dyspepsia
trial PPI for 4 weeks
if doesn’t help then stop PPI and put pt on a TCA - more effective than SSRI or SNRI.
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
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.
What medication worsens GERD?
nifedipine and other CCB.
they decrease the lower esophageal sphincter pressure.
other medications like anticholinergic agents, alpha adrenergic antagonists, theophylline and sedatives.
what medications should be avoided together if treating someone with H pylori?
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.
