S/Sx 1 - Dyspepsia, N/V, Singultus, Gas

Question 1

Define dyspepsia. What is not dyspepsia?

Answer 1

EPIGASTRIC pain or burning
Early satiety
Postprandial fullness

Dyspepsia is not heartburn

Question 2

When is dyspepsia clinically relevant?

Answer 2

After 1 month

Question 3

75% of patients have what type of chronic dyspepsia?

Answer 3

Functional. It is the most common CHRONIC cause… Think psychosocial

Question 4

What are the two most commen organic causes of dyspepsia?

Answer 4

GERD - 20%

PUD 5-15%

Question 5

What are the “Alarm Signs” associated with dyspepsia?

Answer 5

Weight loss
Dysphagia
Recurrent vomiting
Evidence of GI bleed
Anemia

Question 6

When should you order an EGD for a dyspepsia patient?

Answer 6

If s/sx suggest other etiology (ulcers, malignancy etc…)

Failure to respond to therapy after 6 weeks

• • All patients 60 or older with new onset
• • All patients with alarm signs

Question 7

When should you pursue emperic treatment of Dyspepsia?

Answer 7

All patients under 60 years with no alarm symptoms

Question 8

What is Empiric treatment of dyspepsia?

Answer 8

H. Pylori testing (fecal antigen also post and Carbon -13 urea breath test)

PPI X 4 week (trial)

Question 9

If an H. Pylori test is postive, what are our two options to treat?

Answer 9

Standard Triple Therapy

1. PPI PO BID
2. Clarithromycin PO BID
3. Amoxicillin (or metro if allergic)

Standard Quad therapy

1. PPI PO BID
2. Bismuth sub
3. Tetracycline
4. Metro

Question 10

If you have excluded all organic causes of dyspepsia, what doe this patient have? What do you do?

Answer 10

Functional dyspepsia

1. Lifestyle
2. Pharm - Antisecretory, Antidepress, Metoclopromide
3. Therapy

Question 11

List 4 causes of vomiting

Answer 11

1. Afferent vagal fibers from GI viscera (think serotonin 5-HT3 receptors)
2. Stim vestibular system fibers
3. Amygdala (high CNS) - sights/sounds/ thoughts
4. Chemoreceptor trigger zone - acids n shit

Question 12

Compare causes of N/V without and with pain

Answer 12

Without - Food poisoning, Acute gastroenteritis, systemic illness

With - Peritoneal irritation, acute obstruction, Gastroparesis (delayed? emptying)

Question 13

How do you interpret tilt test (orthostatic hypotension)

Answer 13

3 minutes after standing = subtract your two values.

A decline of 20+mmhg systolic or 10+mmhg diastolic = ortho hypo

HR increase of 30 may suggest hypovolemia

Question 14

Are labs neccessary during N/V workup?

Answer 14

Not always… CBC and BMP/CMP for labs can be used.

Imaging not indicated unless exam suggests focal cause

Question 15

What are some complications of vomiting?

Answer 15

Dehydration
Hypokalemia
Met. Alkalosis
Aspiration
Boerhaave
Mallory - Weiss

Question 16

How do we treat N/V?

Answer 16

Typical = Sip some fluid, BRAT, Ginger, **Profile/work note

Antiemetics =

Serotonin 5- HT3 antagonist = Ondansetron

Dopamine antag = Promethazine, procloperazine

Antihistimine = Meclizine, Dimenhydrinate, Diphenhydramine, Scopalamine

Question 17

Persistant intractable hiccups warrant what?

Answer 17

Full Hx and PE

Question 18

What are some of the Tx for hiccups?

Answer 18

TSP sugar
Stim nasopharynx
Valsalva
Rebreathing
Scaring
Relieve gastric distention
Chlorpromazine for persistant***

Question 19

Eructation is what? When does it typically occur? What is the main cause?

Answer 19

Belching/ Involuntary or voluntary release of gas from stomach or esophagus. Usually after meals…. Usually due to aerophagia.

Question 20

Flatus (farting) typically is derived from what two sources?

Answer 20

Swallowed air (nitrogen)
Bacterial fermentation of undigested carbs. 

*Foul smell = sulfur, ammonia, methane

Question 21

What are FODMAPS? Why should we give a shit?

Answer 21

Short chain carbs

Lactose, fructose, polypols, fructans

Question 22

How do we workup and treat Flatus?

Answer 22

1. investigate malabsorption syndromes
2. food diary (avoid FODMAP)
3. Beano and simethicone