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AIP: Abdominal pain > GORD + peptic ulceration > Flashcards

GORD + peptic ulceration Flashcards

1
Q

What is meant by dyspepsia?

A

range of symptoms arising from upper GI tract which alert doctors to consider disease of the upper GI tract

recurrent epigastric pain, heartburn or acid regurgitation, with or without bloating, nausea or vomiting

typically present for 4 weeks or more

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2
Q

After what time frame are symptoms considered to be dyspepsia?

A

4 weeks

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3
Q

What is the definition of gastro-oesophageal reflux disease?

A

symptoms of oesophagitis secondary to refluxed gastric contents

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4
Q

What are 5 things which may be included in the group of symptoms encompassed by the term dyspepsia?

A
  1. Upper abdominal pain or discomfort
  2. Heartburn
  3. Gastric reflux
  4. Nausea
  5. Vomiting
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5
Q

What is gastro-oesophageal reflux disease?

A

endoscopically determined oesophagitis or endoscopy-negative reflux disease

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6
Q

What are 4 examples of lifestyle advice to offer for a patient with dyspepsia?

A
  1. Healthy eating
  2. Weight reduction
  3. Smoking cessation
  4. Avoid known precipitants
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7
Q

What are 6 examples of precipitants for dyspesia?

A
  1. Smoking
  2. Alcohol
  3. Coffee
  4. Chocolate
  5. Fatty foods
  6. Being overweight
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8
Q

What should you recommend to patients receiving long-term treatment for dyspepsia symptoms?

A

encourage them to reduce it stepwise; use lowest effective dose, and try using as needed when appropriate

return to self-treatment with antacid and/or alginate therapy (unless underlying condition or comedication that needs continuing treatment)

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9
Q

What is the management for a patient presenting with dyspepsia together with significant acute GI bleeding?

A

refer on same day to a specialist

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10
Q

What are 6 examples of medications that could cause dyspepsia?

A
  1. Calcium antagonists
  2. Nitrates
  3. Theophyllines
  4. Bisphosphonates
  5. Corticosteroids
  6. Non-steroidal inflammatory drugs (NSAIDs)
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11
Q

Which drugs should you suspend in patients needing referral for endoscopy?

A

NSAIDs

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12
Q

What are 2 important differentials for GORD to think about?

A
  1. Cardiac disease
  2. Biliary disease
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13
Q

If patients have had a previous endoscopy and do not have any new alarm signs, what is the referral guidance for endoscopy?

A

consider continuiing management according to previous endoscopic findings

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14
Q

How often should patients needing long-term management of dyspepsia symptoms have their condition reviewed?

A

annually

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15
Q

What are 4 aspects of the management of uninvestigated dyspepsia?

A
  1. Offer empirical full-dose PPI therapy for 4 weeks
  2. Offer H. pylori ‘test and treat’
  3. If symptoms recur, step down PPI therapy to lowest dose needed to control symptoms. Discuss using treatment on ‘as needed’ basis
  4. Offer H2 receptor antagonist (H2RA) therapy if inadequate response to PPI
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16
Q

What should be done before testing for Helicobacter pylori?

A

leave a 2 week washout period after proton pump inhibitor use before testing

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17
Q

How should you manage uninvestigated ‘reflux-like’ symptoms?

A

same as uninvestigated dyspepsia (4 week full dose PPI, test for H pylori, step down tx if recurs, H2RA if still no improvement)

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18
Q

How long should patients with GORD be offered an initial PPI for?

A

4-8 weeks

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19
Q

If symptoms recur after initial treatment of GORD with a PPI what is the recommended treatment?

A

offer PPI at lowest dose possible to control symptoms

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20
Q

What is the next line treatment of GORD if there is inadequate response to a PPI?

A

H2RA

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21
Q

What is the recommended treatment for people who have had dilatation of an oesophageal stricture?

A

should remain on long-term full-dose PPI therapy

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22
Q

What is the recommended management of severe oesophagitis?

A

offer full-dose PPI for 8 weeks to heal it (take into account preference and clinical circumstances)

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23
Q

What is the next line treatment of severe oesophagitis if the initial 8 week PPI doesn’t work?

A

consider high dose the of initial PPI, switching to another full-dose PPI or switching to another high-dose PPI

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24
Q

What treatment is offered long-term to patients with severe oesophagitis?

A

offer full-dose PPI as long-term maintenance

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25
Q

When should you consider offering endoscopy to diagnose Barrett’s oesophagus in GORD?

A

don’t routinely offer it but consider

discuss pereson’s preferences and their risk factors

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26
Q

What are 7 risk factors for Barrett’s oesophagus in association with GORD?

A
  1. Longer duration of symptoms
  2. Increased frequency of symptoms
  3. Previous oesophagitis
  4. Previous hiatus hernia
  5. Oesophageal stricture
  6. Oesophageal ulcers
  7. Male gender
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27
Q

What should you do if severe oesophagitis fails to respond to maintenance treatment?

A
  • carry out clinical review
  • consider switching to another PPI at full dose or high dose
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28
Q

What are 5 aspects of the management of peptic ulcer disease?

A
  1. Offer H. pylori eradication therapy if have tested positive
  2. Stop use of NSAIDs
  3. Offer full-dose PPI or H2RA therapy for 8 weeks and subsequently offer eradication therapy for H pylori if present afterwards
  4. Offer people with gastric ulcer and H pylori repeat endoscopy 6-8 weeks after beginning of treatment
  5. If peptic ulcer + H pylori, offer retesting 6-8 weeks after beginning treatment
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29
Q

How long should full dose PPI or H2RA therapy be offered to treat peptic ulcer disease?

A

8 weeks

30
Q

What should be offered to people with a gastric ulcer and H pylori?

A

repeat endoscopy 6-8 weeks after beginning treatment

depending on size of the lesion

31
Q

What should be offered to people with peptic ulcer (gastric or duodenal) and H pylori?

A

retesting fro H pylori 6-8 weeks after beginning treatment

depending on size of lesion

32
Q

For people with peptic ulcer and who have tested negative for H pylori what is the management, who are not taking NSAIDs?

A

offer full-dose PPI or H2RA therapy for 4-8 weeks, if not taking NSAIDs

33
Q

For people with peptic ulcer and who have tested negative for H pylori what is the management, who are taking NSAIDs after a peptic ulcer has healed?

A

discuss potential harm from NSAID treatment, review need for NSAIDs regularly (at least every 6 months), offer trial of use on a limited as needed basis

reduce dose/substitute with paracetamol/other alternative/lose dose ibuprofen (1.2g daily)

34
Q

For people at high risk of ulceration (e.g. previous ulcer) and for whom NSAID continuation is necessary, what management is necessary?

A

consider COX-2 selective NSAID instead of standard

always prescribe with a PPI

35
Q

What are 7 things to exclude in people with an unhealed ulcer?

A
  1. Non-adherence
  2. Malignancy
  3. Failure to detect H pylori
  4. Inadvertent NSAID use
  5. Other ulcer-inducing medication
  6. Rare causes such as Zollinger-Ellison syndrome
  7. Crohn’s disease
36
Q

If symptoms of peptic ulcer recur after initial treatment what is the management?

A

offer PPI to be taken at lowest dose possible to control symptoms

discuss treatment use on as-needed basis with people to manage their own symptoms

37
Q

What is functional dyspepsia?

A

recurring signs and symptoms of indigestion with no obvious cause

chronic disorder of sensation and peristalsis in the upper digestive tract

38
Q

How can functional dyspepsia be managed? 3 key points

A
  1. If H pylori present, provide initial eradication treatment for this
  2. Don’t routinely offer re-testing after H pylori eradication
  3. if H pylori excluded, offer either low dose PPI or H2RA for 4 weeks
39
Q

Should re-testing after eradication of H pylori in functional dyspepsia be routinely offered?

A

no, although info it provides may be valued by individual people

40
Q

What should be done if symptoms continue or recur after initial treatment for functional dyspepsia?

A

offer PPI or H2RA to be taken at lowest dose possible to control symptoms

41
Q

What should be avoided in functional dyspepsia?

A

avoid long-term, frequent dose, continuous antacid therpay - only relieves symptoms in short term rather than preventing them

42
Q

What should testing for H pylori infection involve?

A
  • Carbon-13 urea breath test OR stool antigen test
    • can use lab-based serology where its performance has been locally validated
43
Q

What type of test for H pylori should be performed for re-testing?

A

carbon-13 urea breath test

44
Q

Why should office-based serological tests for H pylori not be used?

A

inadequate performance

45
Q

What is the first-line eradication treatment for H pylori?

A

7-day, twice daily course of treatment with:

PPI and amoxicillin and either clarithromycin OR metronidazole

46
Q

What is the treatment of H pylori for people allergic to penicillin ?

A

PPI + clarithromycin + metronidazole (7 days, bd)

47
Q

What is second line treatment for H pylori, for those patients who still have symptoms after first-line eradication?

A

7-day, twice daily course of treatment with:

  • PPI +
  • amoxicillin +
  • calrithryomycin OR metronidazole - whichever wasn’t used the first time
48
Q

When should larparoscopic fundoplication be offered? 2 situations

A
  1. Confirmed diagnosis of acid reflux and adequate symptom control with acid suppression therapy, but don’t wish to continue with therapy long term
  2. Confirmed diagnosis of acid reflux and symptoms are responding to PPI, but can’t tolerate acid suppression therapy
49
Q

When should you consider referral to a specialist service for people with GORD? 3 situations

A
  1. Gastro-oesophageal symptoms that are non-responsive to treatment or unexplained
  2. With suspected GORD who are thinking about surgery
  3. With H. pylori that has not responded to second-line eradication therapy
50
Q

When should you offer surveillance to people with Barrett’s oesophagus?

A

if confirmed diagnosis of Barret’s by endoscopy and histopathy, taking into account presence of dyspepsia, individual preference, risk factors

51
Q

What shoudl you emphasise for a patient considering surveillance for Barrett’s oesophagus?

A

harms of endoscopic surveillance may outweigh benefits in people at low risk of progression to cancer (e.g. stable non-dysplastic Barrett’s oesophagus)

52
Q

What are 6 possible complications of GORD?

A
  1. Oesophagitis
  2. Ulcers
  3. Anaemia
  4. Benign stricture
  5. Barrett’s oesophagus
  6. Oesophageal carcinoma
53
Q

What is the link between endoscopy appearance and GORD?

A

poor correlation between the two

54
Q

What are 5 indications for upper GI endoscopy?

A
  1. age > 55 years
  2. symptoms > 4 weeks or persistent symptoms despite treatment
  3. dysphagia
  4. relapsing symptoms
  5. weight loss
55
Q

If endoscopy is negative for GORD, what is the gold standard test for diagnosis to perform following this?

A

24-hr oesophageal pH monitoring

56
Q

What key risk factor is associated with the majority of peptic ulcers? What proportion are associated with it?

A

Helicobacter pylori

  • 95% of duodenal ulcers
  • 75% of gastric ulcers
57
Q

What are 4 risk factors for peptic ulcer disease?

A
  1. Helicobacter pylori
  2. Drugs: NSAIDs, SSRIs, corticosteroids, bisphosphonates
  3. Zollinger-Ellison syndrome
  4. Blood group O (duodenal ulcers)
  5. Potential role of alcohol and smoking (unclear)
58
Q

What are 4 key examples of drugs which increase the risk of peptic ulcer disease?

A
  1. NSAIDs
  2. SSRIs
  3. Corticosteroids
  4. Bisphosphonates
59
Q

What is Zollinger-Ellison syndrome?

A

excessive levels of gastrin, usually from a gastrin secreting tumour in pancreas or duodenum

excessive gastrin causes stomach to produce too much acid

60
Q

What are 2 clinical features of peptic ulcers?

A
  1. Epigastric pain
  2. Nausea
61
Q

Which type of peptic ulcer is more common?

A

duodenal ulcers

62
Q

What is the nature of the pain from duodenal ulcers?

A

epigastric pain when hungry which is relieved by eating

63
Q

What is the nature of the pain from gastric ulcers?

A

epigastric pain worsened by eating

64
Q

What is the key investigation to perform in suspected peptic ulcers?

A

H pylori testing with either carbon-13 urea breath test or stool antigen test

65
Q

What is the management of peptic ulcers if they are H pylori negative?

A

PPIs given until the ulcer is healed

66
Q

What is the management of peptic ulcers if they are H pylori positive?

A

eradication therapy for H pylori

67
Q

What are 3 key features of the symptoms of perforation of a peptic ulcer?

A
  1. typically develop suddenly
  2. initially develop suddenly then become more generalised
  3. patients may describe syncope
68
Q

What is the recommended first form of imaging in suspected peptic ulcer disease perforation?

A

plain x-rays: upright (erect) chest x-ray if present with acute upper abdo pain

69
Q

Why is an upright (erect) CXR the first line imaging in patients with a perforated peptic ulcer?

A

75% will have a perforated peptic ulcer under the diaphragm

70
Q

What are 8 aspects of lifestyle advice to give to manage peptic lcer disease?

A
  1. stop smoking
  2. cut down alcohol
  3. regular, smaller meals at eat 4 hr before bed
  4. avoid acidic foods, coffee, fatty or spicy foods
  5. encourage weight loss if obese
  6. try to avoid stress
  7. avoid NSAIDs/steroids/bisphosphonates/SSRIs/potassium supplements/crack cocaine
  8. try over the counter antacids

AIP: Abdominal pain (20 decks)

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