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