Dyspepsia Flashcards
(42 cards)
What are the symptoms associated with dyspepsia? (4)
Epigastric pain
Heartburn
Indigestion
Pain worse/better with eating
What are the differential diagnosis of dyspepsia? (10)
Upper GI malignancy
Gallbladder or hepatobiliary disease.
Pancreatic/Cardiac/Coeliac/Crohn’s Diseases
Gastroenteritis
IBS
Small intestine bacterial overgrowth - may also present with weight loss, chronic diarrhoea and malabsorption.
Abdominal aortic aneurysm (rare)
Explain the initial investigation for dyspepsia. (9)
Ask for alarm symptoms
Assess frequency, duration and pattern of symptoms.
Ask about family Hx of upper GI malignancy.
Ask about lifestyle factors: Obesity, trigger foods, smoking status.
Assess for stress, anxiety and depression.
Review Medications
Other clinical features
Examine person to assess for:
- Weight loss by checking serial weight and BMI measurements
- Signs of Anaemia
- Abdominal masses and tenderness.
Consider arranging a FBC to check for anaemia +/or raised platelet count.
Give e.g. of medications associated with dyspepsia. (12)
Alpha-blockers
Anticholinergics
Aspirin
BZP
Beta-blockers
Bisphosphonates
CCB
CS
Nitrates
NSAIDs
Theophylline
TCA
What are the implications of a raised platelet count? (5)
Thrombocytosis: Marker for cancer:
- Lung
- Endometrial
- Gastric = people > 55 yrs if presenting with upper abdominal pain, dyspepsia, nausea, vomiting, weight loss or reflux.
- Oesophageal = > 55 yrs if presenting with upper abdominal pain, dyspepsia, N+V, weight loss or reflux.
- Colorectal
When would you seek endoscopy referral for dyspepsia? (1)
Presenting with dyspepsia and acute GI bleeding = same day referral to specialist. (Possible cardiac or biliary disease)
What are the alarm symptoms of dyspepsia? (13)
Abdominal distension
Abdominal, pelvic or rectal mass.
Abdominal or pelvic pain
Change in bowel habit
Dyspepsia
Dysphagia
N+V
Reflux
Hamatemesis
Rectal bleeding
Weight loss
Anaemia
Raised platelet count
What are the possible cancer(s) and recommendations would be made for dyspepsia (treatment-resistant), 55 yrs and over? (2)
Possible cancer: oesophageal or stomach.
Recommendation: Non- urgent direct access upper GI malignancy.
What are the possible cancer(s) and recommendations would be made for dyspepsia with weight loss, 55 yrs and over? (2)
Possible cancer: oesophageal or stomach
Recommendation: Offer urgent direct access upper GI endoscopy (to be performed within 2 weeks)
What are the possible cancer(s) and recommendations would be made for dyspepsia with raised platelet count or N+V, 55 yrs and over? (2)
Possible cancer: oesophageal or stomach
Recommendation: Consider non-urgent direct access upper GI endoscopy.
What are the possible cancer(s) and recommendations would be made for reflux with weight loss, 55 yrs and over? (2)
Possible cancer: oesophageal or stomach
Recommendation: offer urgent direct access upper GI endoscopy (to be performed within 2 weeks)
What are the possible cancer(s) and recommendations would be made for reflux with raised platelet count or N+V, 55 yrs and over? (2)
Possible cancer: oesophageal or stomach
Recommendation: Endoscopy
What are the common elements of care for patients with dyspeptic symptoms? (5)
Lifestyle advice: healthy eating, weight reduction and smoking cessation.
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.
Addressing stress, anxiety and depression.
Encouraging people who need LT management of dyspepsia symptoms to reduce their use of Rx medication stepwise: trying ‘as needed’ use when appropriate and by returning to self-treatment with antacids +/or alginate therapy. Unless there’s an underlying condition or comedication that needs continuing tx.
Define uninvestigated dyspepsia. (1)
Patient hasn’t not undergone an endoscopy.
Explain the management process of uninvestigated dyspepsia. (2)
Offer 1 of the following strategies:
- Offer a full-dose PPI for 4 weeks
- Offer H. Pylori ‘test and treat ‘ (2 week wash out period of PPI before testing) - breath stool antigen test.
What is the first line treatment for H.pylori eradication? (2)
PPI with a combination of 2 antibiotics (accounting previous exposure of Clarithromycin or Metronidazole)
Ensure person is aware of the importance of compliance.
Give e.g. of PPI used as first line H.pylori eradication. (5)
Lansoprazole 30mg
Omeprazole 20-40mg
Esomeprazole 20mg
Pantoprazole 40mg OR
Rabeprazole 20mg
What treatment regimen is given to patients who has tested positive in the H.pylori test? (3)
Offer a 7 day triple therapy regimen of:
- PPI BD and Amoxicillin 1g BD +
- Either Clarithromycin 500mg BD OR Metronidazole 400mg BD.
What treatment regimen is given to patients who has a penicillin allergy for H.pylori eradication? (2)
Offer 7 days triple therapy regimen of:
- PPI BD + Clarithromycin 500mg BD + Metronidazole 400mg BD.
What treatment regimen is given to patients who has a penicillin allergy and has has previous exposure to Clarithromycin for H.pylori eradication? (2)
Offer 7-10 day triple therapy regimen of:
- PPI BD + Metronidazole 400mg BD + Levofloxacin 250mg BD.
What should be done before the H.pylori test? (4)
Any course of ABx need to be completed 28 days before test.
Esomeprazole, Lansoprazole, Omeprazole, Pantoprazole + Rabeprazole = stopped 14 days before test.
Cimetidine, Famotidine, Mizatidine + Ranitidine = stopped 3 days before test.
You can’t eat/drink 6 hrs prior to the test.
Explain what happens during a breath test. (3)
Test divided into 2 parts:
- Patient is asked to blow into 2 glass vials with a straw. Patient will then be asked to drink a solution of citric acid.
- A urea tablet is then dissolved in water to make the test solution. The patient drinks this and waits 30 minutes.
- Patient asked to blow into 2 more glass vials with a straw. Test is complete.
How would you manage patients with persistent/recurrent dyspepsia? (6)
Despite initial management and persisting symptoms:
- Assess for alarm symptoms
- Consider alternative diagnosis
- Check person’s adherence to initial management and reinforce lifestyle advice.
- Consider H2 antagonist
- Consider need for LT acid suppression therapy.
- Review NSAIDs/antiplatelets.
When would it be appropriate to consider H.pylori retesting? (5)
Don’t routinely offer H.pylori re-testing:
- Poor compliance to first line eradication therapy or initial test was performed within 2 weeks of PPI or 4 weeks of ABx therapy.
- Aspirin/NSAIDs indicated
- Family Hx of gastric malignancy
- Severe, persistent or recurrent symptoms.
- Person requesting re-testing (e.g. anxiety about whether H.pylori has been eradicated)
