dyspepsia

Question 1

what is dyspepsia?

Answer 1

Dyspepsia is a complex range of symptoms:
– Epigastric pain
– ‘Heartburn’
– ‘Indigestion’
– Pain worse/better with eating
– NOT a diagnosis

Question 2

what could be possible differential diagnosis of dyspepsia?

Answer 2

Upper gastrointestinal malignancy
* Gallbladder or hepatobiliary disease
* Pancreatic disease
* Cardiac disease
* Gastroenteritis
* Coeliac disease
* Crohn’s disease
* Irritable bowel syndrome
* Small intestine bacterial overgrowth —may also present with
weight loss, chronic diarrhoea, and malabsorption.
* Abdominal aortic aneurysm (rare).

Question 3

when someone presents with dyspepsia, what should be initially investigated?

Answer 3

Ask about any alarm symptoms
* Assess the frequency, duration, and pattern of symptoms, and the
impact on the person’s quality of life.
* Ask about any family history of upper gastrointestinal malignancy.
* Ask about any lifestyle factors Obesity, trigger foods, Smoking
status
* Assess for stress, anxiety, and depression
* Review the person’s medication
* Consider other clinical features
* Examine the person, to assess for:
* Weight loss by checking serial weight and body mass index (BMI)
measurements.
* Signs of anaemia.
* Abdominal masses and tenderness.
* Consider arranging a full blood count, to check for anaemia and/or a
raised platelet count

Question 4

when would a patient be refered for endoscopy?

Answer 4

For people presenting with dyspepsia together with significant acute gastrointestinal bleeding, refer them immediately (on the same day) to a specialist.

Question 5

What medications may be a possible cause of dyspepsia?

Answer 5

calcium antagonists, nitrates, theophyllines, bisphosphonates, corticosteroids and
non-steroidal anti-inflammatory drugs [NSAIDs])

Question 6

why is age important in dyspepsia?

Answer 6

refer as per nice guidelines on age

Question 7

what are the alarm symptoms of dyspepsia?

Answer 7

Abdominal distension
* Abdominal, pelvic or rectal mass
* Abdominal or pelvic pain
* Change in bowel habit
* Dyspepsia
* Dysphagia
* Nausea or vomiting
* Reflux
* Haematemesis
* Rectal bleeding
* Weight loss
* Anaemia
* Raised platelet count

Question 8

why would reflux, with weight loss and 55 yrs above be a cause for concern?

Answer 8

– Possible Oesophageal or stomach cancer
– Offer urgent direct access upper gastrointestinal
endoscopy (to be performed within 2weeks)

Question 9

what should you do if a patient has a raised platelet count or n/v, 55 and over?

Answer 9

– Possible Oesophageal or stomach
– Endoscopy

Question 10

what lifestyle advice should you give to someone with dyspeptic symptoms?

Answer 10

Lifestyle advice, healthy eating, weight reduction and smoking cessation.
* Advise people to avoid known precipitants smoking, alcohol, coffee, chocolate, fatty foods and being overweight.
* Raising the head of the bed and having a main meal well before going to bed may help some people.
* Addressing stress, anxiety and depression

Question 11

what should you encourage people who are on long term management?

Answer 11

to reduce their use of prescribed
medication stepwise: trying ‘as-needed’ use when appropriate, and by returning to self-treatment with antacid and/or alginate therapy (unless there is an underlying condition or comedication that needs continuing treatment)

Question 12

what is it classified when a patient has not undergone an endoscopy?

Answer 12

uninvestigated dyspepsia
– Common (40% of UK population)

Question 13

how should you manage uninvestigated dspepsia?

Answer 13

• Prescribe a full-dose proton pump inhibitor (PPI) for 1 month or
• Test for Helicobacterpylori infection if the person’s status is not known
  oruncertain.
  If the person tests positive forH. pylori infection,
  prescribe first-line eradication therapy.

Question 14

what should you do if symptoms persist for uninvestigated dyspepsia?

Answer 14

Switch to thealternative strategy (for example, offer a full-dose PPI for 1 month if the person has been tested forH. pylori infection and vice
versa).

Question 15

what should you do if you detect h.pylori?

Answer 15

A carbon-13 urea breath test or stool antigen test —ensure the
person has nottaken a PPIin the past 2 weeks, or antibiotics in the
past 4 weeks,

Question 16

what is first line H.Pylori eradication?

Answer 16

proton pump inhibitor (PPI) together with a combination of antibiotics (taking into account previous exposure to clarithromycin or
metronidazole).
eg lansoprazole 30mg

Question 17

what triple therapy regime should be given for h.pylori?

Answer 17

offer a 7-day triple therapy regimen of:
* A PPI twice-daily and amoxicillin 1 g twice-
daily and
* Either clarithromycin 500 mg twice-daily or
metronidazole 400 mg twice-daily.

Question 18

if a person is allergic to penicillin, what should you give in a triple therapy regime to eradicate h.pylori?

Answer 18

A PPI twice-daily and clarithromycin 500 mg
twice-daily and metronidazole 400 mg twice-
daily.

Question 19

what If the person is allergic to penicillin and has had previous exposure to clarithromycin,
offer a 7–10 day triple therapy regimen of?

Answer 19

A PPI twice-daily and metronidazole 400 mg
twice-daily and levofloxacin 250 mg twice-
daily.

Question 20

what should you do with patients with persistent or recurrent dyspepsia despite initial management?

Answer 20

• Assess for alarm symptoms
• Consider an alternative diagnosis
• Check the person’s adherence to initial management
  and reinforce lifestyle advice.
• Consider H2- antagonist
• Consider the need for long-term acid suppression
  therapy
• Review NSAIDs/antiplatelets

Question 21

when would you consider h.pylori re-testing?

Answer 21

• There has been poor compliance to first-line
  eradication therapy, or the initial test was
  performed within 2 weeks of proton pump inhibitor
  (PPI) or 4 weeks of antibiotic therapy.
• Aspirin or a NSAID is indicated
• There is a family history of gastric malignancy.
• There are severe, persistent, or recurrent
  symptoms.
• The person requests re-testing (for example if there
  is anxiety about whether H. pylorihas been
  eradicated).

Question 22

what are the possible diagnosis following endoscopy?

Answer 22

– Functional dyspepsia (Functional dyspepsiais defined as the presence of dyspeptic symptoms in the absence of an
organic cause that readily explains them)
– Gastro-oesophageal reflux disorder (GORD)
– Peptic ulcer disease (PUD)
– Malignancy

Question 23

what is functional dyspepsia?

Answer 23

(also known as non-ulcer dyspepsia) refers to people with dyspepsia symptoms
and normal findings on endoscopy (gastric or duodenal ulcer, gastric malignancy, or oesophagitis have been excluded)

Question 24

what are the two subtypes of functional dyspepsia?

Answer 24

• Epigastric pain syndrome, where intermittent or burning pain is localized to the epigastrium.
• Post-prandial distress syndrome, where there is post-prandial fullness or early satiety.

Question 25

what is GORD?

Answer 25

Gastro-oesophageal reflux disease (GORD) is usually a chronic condition where there is reflux of gastric contents back into the oesophagus, causing
predominant symptoms of heartburn and acid
regurgitation.

Question 26

what may GORD be caused by?

Answer 26

Oesophagitis, when oesophageal inflammation and mucosal erosions are seen.
* Endoscopy-negative reflux disease (or non-erosive reflux disease), when a person has symptoms of GORD but endoscopy is normal.

Question 27

what are risk factors for developing GORD?

Answer 27

Lifestyle factors, such as obesity, trigger foods, smoking, alcohol, coffee, and stress.
* Drugs that decrease the lower oesophageal sphincter pressure, such as calcium-channel blockers, anticholinergics, theophylline,
benzodiazepines, and nitrates.
* Pregnancy.

Question 28

can gord come back?

Answer 28

The annual risk of recurrence of untreated GORD symptoms is 50%,
and the lifetime risk of recurrence is 80%. GORD symptoms are more
likely to relapse in people with severe oesophagitis.

Question 29

what is the initial management of GORD?

Answer 29

• Advice on lifestyle measures and sleeping with the head of the bed raised.
• Reviewing and stopping any drugs that may be exacerbating symptoms, if possible and
  appropriate.
• Full-dose PPI for 4 weeks for proven GORD,
  to aid healing.
• Full-dose PPI for 8 weeks for proven severe
  oesophagitis, to aid healing.

Question 30

how should a patient be treated if there are refractory or recurrent symptoms of GORD?

Answer 30

• Consider alternative diagnosis
• Checking the person’s adherence to initial management.
• Reinforcing lifestyle advice.
• Prescribing a further 4 weeks of the initial PPI at full-dose or double-dose, or adding in a histamine (H2)-receptor antagonist
  (H2RA) at bedtime, for people with confirmed oesophagitis.
• Switching to an H2RA for people with confirmed endoscopy-negative reflux disease.
• Prescribing a high dose of the initial PPI for 8 weeks, or switching to an alternative full-dose or high-dose PPI for 8 weeks, if there is
  confirmed severe oesophagitis.
• Offering a full-dose PPI long-term as maintenance treatment if symptoms of severe oesophagitis are controlled.

Question 31

how should you manage a patient for h.pylori assocaited with NSAID use?

Answer 31

prescribe full-dose PPI therapy for 2 months, then prescribe first-line eradication
therapy after completion of PPI therapy.

Question 32

what are the key safety points associated with PPIs?

Answer 32

– Can increase the risk of fractures –particularly in the elderly –if used at high doses for over a year –risk increased in smokers
– Can increase the risk of GI infections –clostridium difficile
* Many secondary care trusts have a policy to withhold PPI during treatment with antibiotics
– May mask signs and symptoms of gastric cancer
* Care in those presenting with alarm symptoms –rule out malignancy before treatment is started

Question 33

how should we reduce fracture risk with PPIs?

Answer 33

Limit duration and dosage if possible to reduce risk –monitor during long term risk

Question 34

what monitoring is required for PPIs?

Answer 34

Measurement of serum magnesium
concentrations should be considered before and during prolonged treatment particularly during prolonged treatment or used with other drugs which can cause hypomagnesaemia or with digoxin
– Can also rarely cause hyponatraemia

Question 35

what drugs should be used in caution with PPIs?

Answer 35

digoxin or drugs that may cause
hypomagnesaemia (e.g.diuretics), healthcare
professionals should consider measuring
magnesium levels before starting PPI
treatment and repeat measurements
periodically during treatment.

Question 36

how do PPIs interact with clopidogrel?

Answer 36

CYP450 enzymes
All PPIs inhibit these isoenzymes to different degrees and
therefore could affect the clinical efficacy of clopidogre

Question 37

what is the MOA of clopidogrel?

Answer 37

Clopidogrel converted to active metabolite via
CYP450 enzyme system

Question 38

what should a patient on a PPI do if they develop skin lesions accompanied by arthralgia?

Answer 38

advise them to avoid exposing the skin to sunlight
* consider subacute cutaneous lupus erythematosus (SCLE) as a possible diagnosis
* consider stopping use of the PPI unless it is imperative for a serious acid-related condition; a patient who develops SCLE with a particular PPI may be at risk of the same reaction with another
* In most cases, symptoms resolve on PPI withdrawal; topical or systemic steroids might be necessary for treatment of SCLE only if there are no signs of remission
after a few weeks or months