Dyspepsia and peptic ulcer disease

Question 1

what is dyspepsia?

Answer 1

constellation of symptoms

• epigastric pain or burning
• postprandial fullness (postprandial distress syndrome)
• early satiety (postprandial distress syndrome)

Question 2

what are the organs of the foregut? where do they cause pain?

Answer 2

oesophagus
stomach
duodenum
pancreas
gallbladder
Pain in the epigastric region

Question 3

how common is dyspepsia?

Answer 3

affects 20-40% of people globally
More common in H.pylori infection and NSAID use
PPI = most commonly prescribed drug

Question 4

what causes dyspepsia?

Answer 4

organic causes:
- peptic ulcer disease
- drugs (NSAIDs, COX2 inhibitors)
- gastric cancer
functional causes:
- idiopathic, NU dyspepsia = 75% of cases
- no evidence of culprit structural disease
- can be associated with IBS etc

Question 5

why is history important in dyspepsia?

Answer 5

differentiate between dyspepsia and reflux

Question 6

how is dyspepsia examined?

Answer 6

if uncomplicated = epigastric tenderness only
if complicated =
- cachexia
- mass
- evidence gastric outflow obstruction (crushing splash?)
- peritonism

Question 7

how is dyspepsia managed?

Answer 7

Monitor for alarm features
If ALARM features present = urgent GI referral
If ALARM features abscent = lifestyle advice , check for H. pylori infection

Question 8

what is functional dyspepsia?

Answer 8

Presence of dyspepsia symptoms with no evidence of structural disease that is likely to explain the symptoms
Complicated interaction between the gut and the brain

Question 9

what are the symptoms of peptic ulcer disease?

Answer 9

pain predominant dyspepsia (to back)
often also nocturnal
aggravated or relieved by eating (duodenal aggrevated by eating)

Question 10

is peptic ulcer disease acute or chronic?

Answer 10

chronic

relapsing and remitting

Question 11

who is peptic ulcer disease more common in?

Answer 11

lower socioeconomic groups

family history

Question 12

what is the most common cause of peptic ulcer disease?

Answer 12

H. pylori

NSAIDs cause most of the rest

Question 13

what is H. pylori and how is it acquired?

Answer 13

gram -ve microaerophilic flagellated bacillus
oral-oral/faecal-oral spread
usually acquired in infancy

Question 14

when do the consequences of H.pylori infection arise?

Answer 14

later in life

Question 15

what are the possible consequences of H. pylori infection?

Answer 15

Majority = no pathology
20-40% = peptic ulcer disease
1% = gastric cancer adenocarcinoma and lymphoma)

Question 16

what has been attributed to the lower prevalence of H.pylori in the developed world and in the young?

Answer 16

sanitation, housing, hygiene etc

Question 17

how is acid produced in the stomach?

Answer 17

food increases pH in stomach, stimulating G cels, releasing gastrin into the bloodstream which stimulated parietal cells to produce acid
When pH drops again this signal stops
Negative feedback system

Question 18

H. pylori signals the g cells to produce gastrin which causes an overproduction of acid by parietal cells = hyperacidic state = increased acid flowing into duodenum = gastric metaplasia, duodenum van get infected?

Answer 18

ability to produce acid is reduced > pH of stomach rises > G cells pump out lots of gastrin to try and compensate, this high gastrin as well as atrophy is thought to be gastric cancer risk factor

Question 19

how can you differentiate between a complicated and uncomplicated peptic ulcer?

Answer 19

uncomplicated = clear edges, yellow fuzzy centre
complicated = darker, dot in the middle indicates risk of bleeding, looks deeper, irregular edges

Question 20

what do NSAID induced ulcers look like?

Answer 20

skipping ulcers down the tract

Question 21

what are some physical signs of gastric problems?

Answer 21

acute gastritis = red inflamed ruggae
chronic gastritis = lots of little bumps
Atrophy = flat and featurless

Question 22

how is H.pyori infection diagnosed?

Answer 22

most commonly = faecal antigen testing (FAT)
urease breath test
gastric biopsy:
- urease test
- histology
- culture/sensitivity
serology (IgA antibodies)

Question 23

H.pylori decreases the pH of its environment, true or false?

Answer 23

false

increases the pH of its environment

Question 24

what does H.pylori look like histologically?

Answer 24

bacilli sitting on top of the epithelium

Question 25

how is peptic ulcer disease treated?

Answer 25

All get PPI
All are tested for H.pylori
- +ve = eradicate and confirm
- -ve = antisecretory therapy (PPI)
withdraw NSAIDs
lifestyle advice
Non H.pylori/non NSAID ulcer = nutrition and optimise comorbidities
rarely surgery

Question 26

what is first line for H. pylori?

Answer 26

Triple therapy
PPI + Amoxicillin 1g + Clarythromicin 500mg
OR
PPI + metronidazole 400mg + clarithromycin 250mg
2 week regimen
If still symptomatic - retest

Question 27

what are the possible complications of peptic ulcer disease?

Answer 27

anaemia
bleeding
perforation
gastric outlet/duodenal obstruction - fibrotic scar

Question 28

when is a duodenal ulcer follow up required?

Answer 28

only if ongoing symptoms

Not needed if uncomplicated

Question 29

when is gastric ulcer follow up required?

Answer 29

follow up endoscopy at 6-8 weeks

ensure healing and no malignancy

Question 30

what are the side effects of Hpylori triple therapy?

Answer 30

nausea

diarrhoea