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.
How should I manage refractory or recurrent symptoms?
Assess for any new alarm symptoms
Consider alternative diagnosis
Check adherence and reinforce lifestyle advice
Consider alternative acid suppression therapy with a histamine (H2)-receptor antagonist (H2RA)
Consider the need for long-term acid suppression therapy
Consider re-testing for H pylori under special circumstances - if positive, need second line eradication therapy
May need referral for endoscopy/to gastro
Who needs urgent endoscopy under 2 week wait pathway for dyspepsia?
All patients who’ve got dysphagia
All patients who’ve got an upper abdominal mass consistent with stomach cancer
Patients aged >= 55 years who’ve got weight loss, AND any of the following:
upper abdominal pain
reflux
dyspepsia
Who needs non-urgent endoscopy for dyspepsia?
Patients with haematemesis
Patients aged >= 55 years who’ve got:
treatment-resistant dyspepsia
OR
upper abdominal pain with low haemoglobin levels
OR
raised platelet count with any of the following: nausea, vomiting, weight loss, reflux, dyspepsia, upper abdominal pain
OR
nausea or vomiting with any of the following: weight loss, reflux, dyspepsia, upper abdominal pain
What is H pylori?
Helicobacter pylori
Gram negative bacteria
What is Barrett’s oesophagus?
Columnar metaplasia of the distal oesophagus (replacing usual squamous epithelium) which has malignant potential and an 50-100x increased risk of developing oesophageal adenocarcinoma
What is short and long Barrett’s?
Short <3cm
Long >3cm
(in relation to the affected segment)
Risk factors for Barrett’s (4)
GORD
Male
Smoking
Central obesity
How is Barrett’s managed?
Endoscopic surveillance with biopsies every 3-5 years if metaplasia
High-dose proton pump inhibitor
If dysplasia then endoscopic mucosal resecction or radiofrequency ablation
Indications for upper GI endoscopy in GORD
age > 55 years symptoms > 4 weeks or persistent symptoms despite treatment dysphagia relapsing symptoms weight loss
What if endoscopy is negative in GORD?
Consider 24-hr oesophageal pH monitoring (the gold standard test for diagnosis)
Management of GORD (endoscopically proven)
Info and advice
Lifestyle measures - weight loss, avoid triggers, smaller meals etc, smoking cessation, reduce alcohol, sleep with bed raised, reducing stress
Review meds
Full dose PPI for 1-2 months
- if response then full dose treatment long-term, if no response then double-dose PPI for 1 month
What is functional dyspepsia?
Dyspepsia symptoms and normal findings on endoscopy
How do you manage functional dyspepsia?
Assess for any alarm symptoms
Offer written information and advice on the symptoms, self-care, and management options
Offer advice on lifestyle measures
Review the medication
Test the person for H. pylori infection - if positive, prescribe eradication therapy. If negative, offer low dose PPI or standard-dose H2RA for 1 month
Symptoms of GORD
Heartburn (burning, retrosternal discomfort) Belching Acid/bile regurgitation Increased salivation Odynophagia Asthma Cough Hoarseness Sinusitis Dental erosions
Define peptic ulceration
Gastric and duodenal ulceration collectively known as peptic ulcers
Define gastric ulceration
Breach in the epithelium of the gastric mucosa that penetrates the muscularis mucosae, which is confirmed on endoscopy
Define duodenal ulceration
Breach in the epithelium of the duodenal mucosa that penetrates the muscularis mucosae, which is confirmed on endoscopy
Distinguish upper and lower GI bleeding
Upper GI bleeding = proximal to the ligament of Treitz, haematemesis or melaena, hyperactive bowel sounds, raised BUN/creatinine ratio, blood on NG aspiration
Lower GI bleeding = distal to ligament of Treitz, haematochezia (fresh blood PR), normal bowel sounds and BUN/creatinine ratio, NG aspiration clear
Amoxicillin - dosing for H pylori, side effects, interactions (4), CIs, cautions
1g twice daily
S/Es - diarrhoea, nausea, vomiting, skin rash, anaphylaxis (rare)
Interactions - allopurinol (skin rashes), anticoagulants (prolongs prothrombin time), methotrexate (reduced excretion), tetracyclines
Contraindications - hypersensitivity
Caution - hypersensitivity to cephalosporins, hepatic impairment, CKD
Clarithromycin - dosing for H pylori, side effects, interactions (4), CIs, cautions
500mg twice daily
S/Es - nausea, vomiting, abdominal discomfort, and diarrhoea, taste disturbance, headache, insomnia, hyperhidrosis, hepatotoxicity, rash, pancreatitis, QT interval prolongation, arrhythmias, Stevens-Johnson syndrome, toxic epidermal necrolysis, anaphylaxis
Interactions - carbamazepine, colchicine, drugs that prolong QT interval, drugs that cause hypokalaemia, itraconazole, ketoconazole, mirabegron, omeprazole, phenytoin, sildenafil, statins, theophylline, quetiapine, warfarin, antidiabetic drugs, CCBs
Contraindications - pregnancy, breastfeeding, severe hepatic and renal impairment, hypokalaemia, history of QT prolongation
Cautions - impaired hepatic function, CKD, CHD, severe cardiac insufficiency, bradycardia, hypomagnesaemia, myasthenia gravis
Metronidazole - dosing for H pylori, side effects, interactions (4), CIs, cautions
400mg twice daily
S/Es - nausea and vomiting, anorexia, and very rarely hepatitis, jaundice, or pancreatitis. Taste disturbances, furred tongue, oral mucositis. Headache, ataxia. Thrombocytopenia, pancytopenia. Myalgia, arthralgia.
Darkening of urine. Rash, pruritus, and erythema multiforme. Drowsiness, dizziness, confusion, hallucinations, convulsions, or transient visual disorders.
Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN) or acute generalised exanthematous pustulosis (AGEP).
Common interactions - alcohol, anticoagulants, ciclosporin, cimetidine, lithium, phenytoin
Contraindications - hypersensitivity, Cockayne syndrome
Cautions - active or chronic severe peripheral and central nervous system disease, severe liver disease, alcohol dependency, pregnancy, breastfeeding
