Tutorial #38: Dyspepsia Flashcards
What is the Rome IV criteria of dyspepsia?
The presence of any of the following:
- bothersome postprandial fullness
- bothersome early satiety
- bothersome epigastric pain/burning
What is the Rome IV criteria of functional dyspepsia?
The presence of any one of the following symptoms:
- bothersome postprandial fullness
- bothersome early satiety
- bothersome epigastric pain/burning
These symptoms have to be recurrent in the last 3 months AND the onset of the symptoms are greater than 6 months ago
AND
There is no evidence of organic, systemic, metabolic or structural disease that can better explain the symptoms.
What is the CR2 suggested approach to patients with undiagnosed dyspepsia? (5 steps)
- Perform a focused initial history, physical examination
- determin if the pathology is likely in the upper GI tract
- Identify patients who require endoscopy
- Identify patients with H.pylori
- Empiric treatment (if required)
In patients < 60, what are 4 criteria that indicate a patient experiencing dyspepsia require an upper GI endoscopy?
- Clinically significant weight loss (>5% of body weight over 6 to 12 months)
- Overt GI bleeding
- > 1 alarm feature
- Rapidly progressive alarm features
Alarm features include:
- unintentional weight loss
- progressive dysphagia
- odynophagia
- unexplaiend iron deficiency anemia
- persistent vomiting
- palpable mass or lymphadenopathy
- family history of upper GI cancer
What are the “alarm features” you should look for in investigating a patient with dyspepsia? (x7)
- unintenional weight loss
- progressive dysphagia
- odynophagia
- unexplained iron deficiency anemia
- persistent vomiting
- palpable mass or lymphadenopathy
- family history of upper GI cancer.
In a patient who is > 60 years old with univestigated dyspepsia, what is recommended in regards to performing an upper GI endoscopy?
In patients > 60 years old, the recommendation is to perform upper endoscopy with gastric biopsy in ALL patients
What are two ways to non-invasively test for H.Pylori?
- urea breath test
- Serum testing
Urea breath testing is often recommended because of superior sens. and spec, and also because serum testing does not distinguish between current and past infections.
What is the the recommended therapy for patients experiencing dyspepsia and are H.pylori positive?
14 day course of: PPI + clarithromycin + metronidazole OR amoxicillin
*Some resistent strains of H.pylori in Canada have made quadruple therapy a reasonable first-line therapy:
*Bismuth qudruple therapy: PPI + bismuth + metronidazole + tetracycline (ex. doxycycline)
OR
*Non-bismuth qudruple therapy: PPI + amoxicillin + metronidazole + clarithromycin
In a patient who is experiencing dyspepsia, and you have determined that they do not need an endoscope AND they are h.pylori negative and/or symptoms persist after H.pylori is eradicated, what is the next best step?
Trial proton pump inhibitor for 4-8 weeks
In a patient who is experiencing dyspepsia, and you have determined that they do not need an endoscope AND they are h.pylori negative and/or symptoms persist after H.pylori is eradicated AND their symptoms persist after initiating a PPI for 4-8 weeks, what is the next best step?
Discontinue PPI and trial tricyclic antidepressant for 8-12 weeks
You have started empiric treatment for a patient with dyspepsia. After trialing a PPI (4-8 weeks, then discontinued), and a tricyclic antidepressant (8-12 weeks) and symptoms continue to persist, what is the next best step?
Discontinue tricyclic antidepressant and trial a prokinetic for 4 weeks
example of prokinetic agent include metoclopramide
You have started empiric treatment for a patient with dyspepsia. After trialing a PPI (4-8 weeks, then discontinued), and a tricyclic antidepressant (8-12 weeks), the symptoms have subsided. What is the next best step?
continue tricyclic antidepressant for 6 months and then discontinue
resume tricyclic antidepressant if symptoms reoccur
You have started empiric treatment for a patient with dyspepsia. After trialing a PPI (4-8 weeks, then discontinued), a tricyclic antidepressant (8-12 weeks, discontinued), and a prokinetic agent (4 weeks) and symptoms continue to persist, what is the next best step?
4 items on the answer of this card
- Re-evaluate symptoms
- perform an upper endoscopy if not preevious performed
- assess gastric emptying in patients with nasea and vomiting predominant symptoms
- trial of psychotherapy in patients with functional dyspepsia
You have started empiric treatment for a patient with dyspepsia. After trialing a PPI (4-8 weeks, then discontinued), a tricyclic antidepressant (8-12 weeks, then discontinued), and a prokinetic agent (4 weeks), the symptoms have subsided. What is the next best step?
Discontinue prokinetic agent. Repeat 4 week course if symptoms reoccur.
What is the most likely diagnosis in a patient who has retrosternal/epigastric burning pain that becomes worse after lying down or after meals?
GERD
What lab findings suggest peptic ulcer disease as a cause of dyspepsia?
- microcytic anemia (or overt GI bleeding)
- Positive H.pylori testing
What is the treatment for peptic ulcer disease?
- Eradicate H.pylori if present
- acid suppression therapy (ex. PPI)
- avoidance of NSAIDs, OR use of a COX-2 selective NSAID if NSAID use is unavoidable
For point 3, please see picture. Basically non-selective NSAIDs inhibit COX-1 as well, which is responsible for producing prostaglandins that initiate GI cell protection (in addition to increasing platelet activity).
Patient presents with RUQ pain that radiates to the scapula/right shoulder, and usually occurs after eating. The pain maximizes in intensity for at least 1 hour and then gradually resolves. This pain does not last more than 6 hours. What is the most likely diagnosis?
Biliary colic
What is the confirmatory test for biliary colic?
The presence of gall stones with abdominal ultrasound
