Dyspepsia and peptic ulcer disease

Question 1

Symptoms associated with dyspepsia and peptic ulcer disease

Answer 1

Epigastric pain often related to hunger, specific foods, or time of day, fullness after meals, heartburn (retrosternal pain).
Tender epigastrium.
Beware alarm symptoms: anaemia (iron deficiency); loss of weight; anorexia; recent onset/ progressive symptoms; melaena/haematemesis; swallowing difficulty.

Question 2

H. pylori causing dyspepsia/ peptic ulcer disease

Answer 2

If <55yrs old: ‘test and treat’ for H. pylori.
If positive, give appropriate PPI and 2 antibiotic combination, e.g. lansoprazole 30mg/12h PO, clarithromycin 250mg/12h PO, and amoxicillin 1g/12h PO for 1wk.
If negative, give acid suppression alone.
Refer for urgent endoscopy all with dysphagia, as well as those >55 with alarm symptoms or with treatment-refractory dyspepsia.

Question 3

Duodenal ulcer: risk factors

Answer 3

4x more common than gastric ulcer.
Major risk factors: H. pylori (90%); drugs (NSAIDs, steroids, SSRI).
Minor risk factors: increased gastric acid secretion; increased gastric emptying (reduced duodenal pH); blood group O; smoking.

Question 4

Duodenal ulcer: signs and symptoms

Answer 4

Asymptomatic or epigastric pain (relieved by antacids) +/- weight loss.
Epigastric tenderness.

Question 5

Duodenal ulcer: diagnosis

Answer 5

Upper GI endoscopy.
Test for H. pylori.
Measure gastrin concentrations when off PPIs if Zollinger-Ellison syndrome is suspected.

Question 6

Duodenal ulcer: differential diagnosis

Answer 6

Non-ulcer dyspepsia
Duodenal Crohn's
TB
Lymphoma
Pancreatic cancer

Question 7

Gastric ulcers: risk factors

Answer 7

H. pylori (~80%)
Smoking
NSAIDs
Reflux of duodenal contents
Delayed gastric emptying
Stress, e.g. neurosurgery or burns (Cushing's or Curling's ulcers)

Question 8

Gastric ulcers: symptoms

Answer 8

Asymptomatic or epigastric pain (relieved by antacids) +/- weight loss.

Question 9

Gastric ulcers: tests

Answer 9

Upper GI endoscopy to exclude malignancy.
Multiple biopsies from ulcer rim and base (histology, H. pylori).
Repeat endoscopy after 6-8 weeks to confirm healing and exclude malignancy.

Question 10

Gastritis: risk factors

Answer 10

Alcohol
NSAIDs
H. pylori
Reflux/ hiatus hernia
Atrophic gastritis
Granulomas (Crohn's; sarcoidosis)
CMV
Zollinger-Ellison syndrome
Ménétrier's disease

Question 11

Gastritis: symptoms

Answer 11

Epigastric pain

Vomiting

Question 12

Gastritis: tests

Answer 12

Upper GI endoscopy only if suspicious features

Question 13

Treatment of dyspepsia and peptic ulcer disease

Answer 13

Lifestyle: reduce alcohol and tobacco use.
H. pylori eradication: triple therapy is 80-85% effective at eradication.
Drugs to reduce acid: PPIs are effective, e.g. lansoprazole 30mg/24h PO for 4 (DU) or 8 (GU) wks. H2 blockers have a place (ranitidine 300mg each night PO for 8wks).
Drug-induced ulcers: stop drug if possible. PPIs may be best for treating and preventing GI ulcers and bleeding in patients on NSAID or antiplatelet drugs. Misoprostol is an alternative with different SE. If symptoms persist, re-endoscope, retest for H. pylori, and reconsider differential diagnoses (e.g. gallstones).
Surgery.

Question 14

Complications of dyspepsia and peptic ulcer disease

Answer 14

Bleeding
Perforation
Malignancy
Reduced gastric outflow

Question 15

Functional non-ulcer dyspepsia

Answer 15

Common.
H. pylori eradication (only after a positive result) may help.
Some evidence favours PPIs and psychotherapy.
Low dose amitriptyline (10-20mg each night PO) may help.
Antacids, antispasmodics, H2 blockers, misoprostol, pro-kinetic agents, bismuth, or sucralfate all have less evidence.

Question 16

Differential diagnosis of dyspepsia

Answer 16

Non-ulcer dyspepsia
Oesophagitis/ GORD
Duodenal/ gastric ulcer
Gastric malignancy
Duodenitis
Gastritis