Wk 12: Dyspepsia Flashcards
What happens in the initial investigation?
- Alarm symptoms
- Assess: freq. duration + pattern
- Fx
- Lifestyle: obesity, trigger food, smoking
- Assess: stress, anxiety + depression
- Med
- Examine: weight loss (serial weight + BMI), anaemia + abdominal mass + tenderness
- FBC + platelet count: anaemia
When would you refer for endoscopy?
Dyspepsia w/ acute GI bleed
Which medications may cause dyspepsia?
- Calcium antagonist
- Nitrates
- Theophylline
- Bisphosphonates
- Corticosteroids
- NSAIDs
When referring a patient, which medication must you suspend?
NSAIDs
What are the alarm symptoms?
- Abdominal distention
- Abdominal, pelvic or rectal mass
- Abdominal/pelvic pain
- Change in bowel habit
- Dyspepsia
- Dysphagia
- Vom
- Haematemesis
- Rectal bleed
- Weight loss
- Anaemia
- Raised platelet count
What needs to be carried out if a patient has reflux with weight loss/ >55?
- Urgent direct access upper GI endoscopy w/in 2 wks
- Possible: oesophageal or stomach cancer
What needs to be carried out if a patient has reflux with raised platelet count, nausea/vom/ >55?
- Non- urgent Endoscopy
-Possible: esophageal or stomach cancer
What is the initial diagnosis if a patient has not undergone endoscopy?
Uninvestigated dyspepsia
What happens after a patient is diagnosed with uninvestigated dyspepsia?
- Prescribe full dose PPI 1 month
- Test H pylori infection, if positive offer eradication therapy
How do you test for H pylori?
- Carbon 13 urea breath test or stool antigen
- Make sure patient hasn’t taken PPI in past 2 wks or antibiotics past 4 wks
What are the PPIs offered for first line H pylori eradication in uninvestigated dyspepsia?
- Lansoprazole 30 mg
- Omeprazole 20–40 mg
- Esomeprazole 20 mg
- Pantoprazole 40 mg
- Rabeprazole 20 mg
What is given to a patient if they test positive for H pylori in uninvestigated dyspepsia?
7 day therapy:
- PPI BD + amoxicillin 1g BD
- Clarithromycin 500mg BD OR metronidazole 400mg BD
What is given to a patient if they test positive for H pylori but are allergic to penicillin in uninvestigated dyspepsia?
7 day therapy:
- PPI BD
- Clarithromycin 500mg BD
- Metronidazole 400mg BD
What is given to a patient if they test positive for H pylori but are allergic to penicillin + has had a previous exposure to clarithromycin in uninvestigated dyspepsia?
7-10 day therapy:
- PPI BD
- Metronidazole 400mg BD
- Levofloxacin 250mg BD
When would you consider retesting for H pylori?
- Poor compliance 1st therapy
- Initial test w/in 2 weeks of PPI or 4wks of antibiotic therapy
- Aspirin/NSAID indicated
- FX gastric malignancy
- Severe/persistent or recurrent symptoms
- Person request
Following an endoscopy, what are the possible diagnosis?
- Functional dyspepsia
- Gastroesophageal reflux disorder (GORD)
- Peptic ulcer disease
- Malignancy
What are the types of functional dyspepsia?
- Epigastric pain syndrome: intermittent/burning pain in epigastrium
- Postprandial distress syndrome: fullness/early satiety
What do you do if a person tests positive for H pylori in functional dyspepsia?
Prescribe 1st line eradication therapy
What do you prescribe if a person tests negative for H pylori in functional dyspepsia?
Low dose PPI OR standard dose histamine receptor antagonist for 1 month
What is GORD?
- Chronic condition
- Reflux of gastric contents into oesophagus
- Causes: heartburn + acid regurgitation
Proven GORD may be due to what?
- Oesophagitis: inflammation + mucosal erosion
- Endoscopy negative reflux disease: symptoms of GORD but endoscopy normal
What are the risk factors for developing GORD?
- Obesity, trigger food, alcohol, smoking, coffee, stress
- Drugs that dec esophageal sphincter pressure
- Pregnancy
Which drugs dec esophageal sphincter pressure?
- CCB
- Anticholinergics
- Theophylline
- Benzo
- Nitrates
What is the initial management of GORD symptoms?
- Lifestyle advice + sleeping w/ head raised
- Stop drugs that exacerbate symptoms
- Full dose PPI 4 wks for proven GORD
- Full dose PPI 8 wks for proven severe oesophagitis
What is given to patients who have recurrent symptoms with confirmed oesophagitis?
- Further 4 wks initial PPI at full dose/double dose
OR
- Add H2RA at bed
What is given to patients who have recurrent symptoms with confirmed severe oesophagitis?
- High dose initial PPI 8 wks
OR
- Switch to alt full dose
In peptic ulcer disease, what is given to a patient who has tested positive for H pylori with proven gastric/duodenal ulcer due to NSAIDS?
- Full dose PPI 2 months
- 1st line eradication therapy after PPI completion
In peptic ulcer disease, what is given to a patient who has tested positive for H pylori with proven gastric/duodenal ulcer not due to NSAIDS?
1st line eradication therapy
In peptic ulcer disease, what is given to a patient who has tested negative for H pylori with proven gastric/duodenal ulcer?
Full dose PPI therapy 4-8 wks
What are the adverse effects of PPI?
- Inc fracture risk: esp elderly + smoker
- Inc GI infection
- Masks symptoms of gastric cancer
What are the monitoring requirements of PPIs?
Magnesium before + during
- Esp if on digoxin or diuretics
- Causes hypomagnesaemia
Outline the interaction of clopidogrel + PPIs
- Clopidogrel converted into metabolites by liver cytochrome p450
- PPIs also metabolised by cytochrome p450
- PPIs inhibit isoenzymes, affecting efficacy of clopidogrel
Which PPIs can’t be given with clopidogrel?
Omeprazole + esomeprazole
Which PPIs can be given with clopidogrel?
Pantoprazole, rabeprazole + lansoprazole
Which skin disease is associated with PPIs?
Subacute cutaneous lupus erythematosus (SCLE)
What happens if a patient is on a PPI + develops lesions in sun exposed areas, accompanied by arthralgia?
- Avoid skin exposure to sun
- Stop PPI
- Symptoms resolve upon w/drawal
- If symptoms haven’t resolved: topical or systemic steroids
