GORD and dyspepsia Flashcards
Define dyspepsia
A complex of upper GI symptoms which are typically present for four or more weeks inc. upper abdo pain, heartburn, acid reflux, nausea and/or vomiting
Define gastro-oesophageal reflux disease (GORD)
A chronic condition where there is reflux of gastric contents (particularly acid, bile, and pepsin) back into the oesophagus, causing predominant symptoms of heartburn and acid regurgitation
Proven GORD = endoscopically-determined reflux disease
What causes GORD? (4)
1) Transient relaxation (reduced tone) of the lower oesophageal sphincter
2) Increased intra-gastric pressure (for example straining and coughing)
3) Delayed gastric emptying
4) Impaired oesophageal clearance of acid
Risk factors for GORD (8)
- Stress and anxiety
- Smoking and alcohol
- Trigger foods (coffee, chocolate, fatty foods)
- Obesity
- Drugs that decrease LOS pressure e.g. a-blockers, anti-cholinergics, BZDs, beta blockers, bisphosphonates, calcium-channel blockers, corticosteroids, NSAIDs, nitrates, theophyllines, and TCAs
- Pregnancy
- Hiatus hernia
- Family history
Risk factors for Barrett’s oesophagus (4)
- Male
- Long duration and/or increased frequency of GORD symptoms
- Previous oesophagitis or hiatus hernia
- Previous oesophageal stricture or ulcers
Complications of GORD
Oesophageal ulcers Oesophageal haemorrhage Anaemia due to chronic blood loss Oesophageal stricture Aspiration pneumonia Barrett's oesophagus Dental erosions, gingivitis, and halitosis
Causes for dyspepsia
GORD Peptic ulcer disease Functional dyspepsia Barrett's oesophagus Upper GI malignancy
What to ask in history of dyspepsia?
Ask about any alarm symptoms
Assess the frequency, duration, and pattern of symptoms, and the impact on QOL
Ask about any family history of upper GI malignancy
Ask about any lifestyle factors that may cause or exacerbate symptoms, such as obesity, trigger foods, pattern of eating
Ask about smoking, alcohol, stress, anxiety, depression
Review the medication
Previous episodes, meds tried, inc abx
Exam for person with dyspepsia
Weight
Signs of anaemia
Abdo masses or tenderness
Differentials for dyspepsia
Upper gastrointestinal malignancy Gallstones Cholecystitis Pancreatitis Cardiac disease/angina Gastroenteritis Coeliac disease Crohn's disease Irritable bowel syndrome Small intestine bacterial overgrowth Abdominal aortic aneurysm
Dyspepsia initial management
1) Lifestyle measures e.g. weight loss, avoiding triggers, eating smaller meals, eating 4 hours before bed, smoking cessation, reduce alcohol, help with anxiety/depression
2) Review medication - advise antacid and/or alginate for short-term symptom control
3) Offer one of the following - full dose PPI for 1 month OR test for H pylori. If positive for H pylori, prescribe 1st line eradication therapy
What if dyspepsia symptoms persist/recur following initial management?
Switch to the alternative strategy (for example, offer a full-dose PPI for 1 month if the person has been tested for H. pylori infection and vice versa)
Initial detection of H pylori infection?
A carbon-13 urea breath test or stool antigen test - ensure the person has not taken a PPI in the past 2 weeks, or antibiotics in the past 4 weeks
OR
(Laboratory serological testing if above not available)
First-line H. pylori eradication regimens
If a person tests postive for H. pylori, offer a 7-day triple therapy regimen of…
A PPI twice-daily and amoxicillin 1 g twice-daily and Either clarithromycin 500 mg twice-daily or metronidazole 400 mg twice-daily.
If pen allergic, PPI, clarithromycin, and metronidazole
If pen allergic and previous exposure to clarithromycin, PPI, metronidazole and levofloxacin 250 mg twice-daily.
Typical PPI doses
Lansoprazole 30 mg, omeprazole 20–40 mg, esomeprazole 20 mg, pantoprazole 40 mg, or rabeprazole 20 mg.
