Yr 3 - 1. Dyspepsia, Peptic Ulcers And H.pylori

Question 1

What are the possible causes of dyspepsia?

Answer 1

Gastro-oesophageal reflux disease (GORD): 15-25%
Peptic ulcer: 15-25%
Stomach cancer: 2%
The remaining 60% are classified as non-ulcer dyspepsia (NUD)e.g. gastritis/‘functional’ dyspepsia - manage as for uninvestigated dyspepsia

Rarer causes: oesophagitis from swallowed corrosives, oesophageal infection (especially in immunocompromised)

Differential diagnosis: cardiac pain, gallstone pain, pancreatitis, bile reflux

Question 2

How can H.pylori be tested for?

Answer 2

Serology
Urea breath test
Faecal antigen test

A 2wk washout period following PPI use is necessary before a breath test or stool antigen test.

Question 3

What are the options for eradication of H.pylori?

Answer 3

PAC500 regimen: full dose PPI (omeprazole 20mg bd) + amoxicillin 1g bd + clarithromycin 500mg bd for 1wk.

Or

PMC250: full dose PPI (omeprazole 20mg bd) + metronidazole 400mg bd + clarithromycin 250mg bd for 1 wk.

Question 4

What lifestyle advice would you give to a patient with dyspepsia?

Answer 4

Healthy eating
Weight loss
Smoking cessation
Avoidance of precipitating factors e.g. alcohol coffee, chocolate, fatty foods
Raising head of the bed
Have main meal well before going to bed
Promote continued use of antacids/alginates

Question 5

Describe the management of a patient with dyspepsia.

Answer 5

1. Acute GI bleed? —> admit
2. Symptoms/factors requiring referral? —> refer to endoscopy
3. Review medications for causes of dyspepsia
4. PPI (e.g. omeprazole 20 mg od)
5. Test and treat for H. Pylori
6. No response to PPI —> H2 receptor antagonist (e.g. ranitidine 150mg bd) or prokinetic (e.g. domperidone 10mg tds)

Question 6

What changes must be made to a patient’s medication prior to endoscopy?

Answer 6

Stop NSAIDs

Suspend PPI/H2 receptor antagonist for 2wk prior to the procedure

Question 7

Give examples of medications which may cause dyspepsia.

Answer 7

Ca 2+ antagonists
Nitrates
Theophyllines
Bisphosphonates
Corticosteroids 
SSRIs
NSAIDs

Question 8

What is acute gastritis?

Answer 8

Mucosal inflammation of the stomach with no ulcer.

Question 9

What are the three types of gastritis?

Answer 9

Type A: affects the entire stomach - associated with pernicious anaemia, pre-malignant
Type B: affects antrum +/- duodenum - associated with H.pylori
Type C: due to irritants e.g. NSAIDs, alcohol, bile reflux

Question 10

Describe the steps involved in management of gastritis.

Answer 10

Treat the cause where possible (e.g. vitamin B12 injections, H.pylori eradication, avoidance of alcohol)

Acid suppression - H2 receptor antagonist (e.g. ranitidine, nizatidine) or PPI (e.g. omeprazole, lansoprazole) for 4-8 wks

Re-endoscope to confirm healing

Question 11

What are the possible complications of gastritis?

Answer 11

Haemorrhage
Gastric atrophy
Gastric cancer

Question 12

What are the risk factors for peptic ulcers?

Answer 12

H.pylori
NSAID use
Smoking

Additional risk factors for gastric ulcer:
Delayed gastric emptying
Reflux from the duodenum (increased by smoking)

Additional risk factors for duodenal ulcer:
Gastric hyperacidity
Rapid gastric emptying
Stress

Question 13

How does eating food affect symptoms in gastric ulcers compared to duodenal ulcers?

Answer 13

Gastric ulcers: epigastric pain typically worsened by food

Duodenal ulcers: epigastric pain typically relieved by food

Question 14

What are the possible complications of peptic ulcers?

Answer 14

Bleeding - acute GI bleed, iron deficiency anaemia
Perforation
Pyloric stenosis in adults - duodenal stenosis secondary to scarring from chronic duodenal ulcer

Question 15

What cavities do gastric and duodenal ulcers typically perforate into?

Answer 15

Gastric ulcers - perforate posteriorly into the lesser sac

Duodenal ulcers - perforate anteriorly into the peritoneal cavity

Question 16

Which type of peptic ulcer more commonly perforates?

Answer 16

Duodenal ulcer > gastric ulcer

Question 17

Describe the presentation of a perforated peptic ulcer.

Answer 17

Sudden onset severe epigastric pain which rapidly becomes generalised.
When a GU perforated into the lesser sac symptoms may remain localised or be confined to the right side of the abdomen.
There may not be a past history of indigestion.

Examination: generalised peritonism with ‘board-like rigidity’
Management: acute surgical admission

Question 18

What surgical interventions might be used in non-healing peptic ulcers?

Answer 18

Gastrectomy
Vagotomy
Drainage

Question 19

What is a gastrinoma?

Answer 19

Gastrin secreting adenoma

Question 20

What is Zollinger-Ellison syndrome?

Answer 20

The association of peptic ulcers with gastrin secreting adenoma (gastrinoma). Gastrin excites excessive gastric acid production, which may produce multiple ulcers in the duodenum and stomach.

20% of cases are associated with multiple endocrine neoplasia type 1 (MEN1). 60% are malignant, metastases are usually found in local lymph nodes and liver.

Question 21

Where is the gastrinoma typically found in Zollinger-Ellison syndrome?

Answer 21

Adenoma is usually found in the pancreas, although it may arise in the stomach or duodenum.

Question 22

What are the symptoms of Zollinger-Ellison syndrome?

Answer 22

Abdominal pain and dyspepsia (from ulcers)

Chronic diarrhoea +/- steatorrhoea (due to inactivation of pancreatic enzymes)

Question 23

What things may epigastric pain be related to?

Answer 23

Hunger
Specific foods
Time of day
Fullness after meals
Heartburn (retrosternal pain)
Tender epigastrum

Question 24

What the the ALARM Symptoms you should be aware of in relation to epigastric pain?

Answer 24

Anaemia (iron deficiency)
Loss of weight 
Anorexia
Recent onset/progressive symptoms 
Melaena/haematemesis 
Swallowing difficulty