Dyspepsia

Question 1

What is Dyspepsia?

Answer 1

Indigestion

Question 2

What is GORD?

Answer 2

Gastro-Oesophageal Reflux Disease

Leads to Oesophagitis

Question 3

What can cause GORD?

Answer 3

Obesity
Pregnancy
Drug-induced

Question 4

What is Peptic Ulceration?

Answer 4

Damage to lining of alimentary tract
Gastric/Duodenal
Erosion, damage, bleeding

Question 5

What is Zollinger-Ellison syndrome?

Answer 5

Gastrin secreting tumour of D-cells (pancreas)

Question 6

What is Gastritis?

Answer 6

Inflammation of the stomach

Question 7

What effect can NSAIDs/oral steroids have on the alimentary tract?

Answer 7

Damage ie. ulceration

Question 8

What are the signs/symptoms of Peptic Ulceration?

Answer 8

Epigastric pain, precisely located
Hunger pain (relieved by eating)
Night pain (relieved by food, milk, antacids)
Warterbrash
Nausea/vomiting (esp. blood)

Question 9

What is the most common cause of duodenal/gastric ulcers?

Answer 9

H. pylori (G-) infection
80-90% Duodenal
70% Gastric

Question 10

What is the pathogenesis of ulcers due to H. pylori infection?

Answer 10

Infection leads to chronic inflammation leads to gastric damage leads to ulceration

Question 11

What tests are available for H. pylori infection?

Answer 11

Urea breath test - pt given 13C urea, bacterial ureases convert it to 13CO2, exhaled
H. pylori antigens/antibodies (blood, saliva, stool)

Question 12

What are the warning signs for serious alimentary disease?

Answer 12

Age >45
Weight loss
Anaemia
Dysphagia
Haematemesis
Melaena
Upper abdominal masses

Question 13

What factors increase acid secretion?

Answer 13

Histamine (H2 receptors)
Gastrin (CCK receptors)
AcH (M3 receptors, parietal cells)

Question 14

What factors decrease acid secretion?

Answer 14

Prostaglandins (E2/I2) - also cyytoprotective (bicarbonate/mucus release)

Question 15

What are the goals of treatment for Dyspepsia?

Answer 15

Symptomatic relief

Question 16

What are the main methods of treatment for Dyspepsia?

Answer 16

Lifestyle changes (avoid causative drugs, foods, prop up in bed, remove belts)
Suppression of acid release
Mucosal protection

Question 17

What is required for long term cure of Dyspepsia?

Answer 17

Suppression of acid release

Allows natural healing AND H. pylori infection

Question 18

What is a further negative effect of H. pylori infection?

Answer 18

Development of gastric carcinomas

Question 19

What are the most common antacids?

Answer 19

Sodium bicarbonate

Magensium/Aluminium Hydroxide

Question 20

How do antacids work?

Answer 20

Alkaline bases, react w/ acid to produce salt and water - RAISE pH

Question 21

What are alginates?

Answer 21

A type of anti-dyspepsia medication often combined with antacids

Question 22

How do alginates work?

Answer 22

Alginic acid combines w/ saliva
Forms viscous foam, floats on gastric contents
Protects oesophagus during reflux

Question 23

How do Histamine H2 antagonists work?

Answer 23

Antagonise H2 receptors

H2 receptors coupled via adenylyl cyclase - increase cAMP - activates proton pump

Question 24

Give examples of Histamine H2 antagonists

Answer 24

Cimetidine
Ranitidine
Famotidine

Question 25

Which Histamine H2 antagonist is more complicated to treat with?

Answer 25

``` Cimetidine - inhibits CP450, many drug interactions -Oral anticoagulants -Phenytoin -Carbamazepine -TCAs RANITIDINE FAVOURED ```

Question 26

How do Proton Pump Inhibitors work?

Answer 26

Irreversible inhibition of the proton pump

Question 27

Give examples of Proton Pump Inhibitors

Answer 27

Omeprazole Pantoprazole Lansoprazole

Question 28

What negative effects can treatment with PPIs have?

Answer 28

Inhibit H+ secretion >90% - leads to achlorhydria | Increased risk of Campylobacter infection

Question 29

What are prokinetic drugs?

Answer 29

Drugs that cause gastric emptying

Question 30

Give examples of prokinetic drugs

Answer 30

Domperidone - closure of oesophageal sphincter, opens lower sphincter Metocloperamide - increases gastric motility/emptying

Question 31

What is Metocloperamide combined with?

Answer 31

Analgesics, accelerates absorption

Question 32

What is the most effective treatment for H. pylori eradication?

Answer 32

Antibiotic (2 from Metronidazole, Amoxicillin, Clarithromycin) PPI/H2 antagonist TRIPLE THERAPY for 1 wk PPI alone for ulcer healing

Question 33

What is Bismuth Chelate?

Answer 33

Antacid that kills H. pylori

Question 34

How does Bismuth Chelate work?

Answer 34

Kills H. pylori Coats ulcer Absorbs pepsin Increases prostaglandin production AND HCO3- secretion

Question 35

What is the treatment for Dyspepsia in the absence of H. pylori infection?

Answer 35

Staged approach

Question 36

What is stage 1 Dyspepsia treatment?

Answer 36

Antacid OR Alginate/Antacid

Question 37

What is stage 2 Dyspepsia treatment?

Answer 37

H2 antagonist

Question 38

What is stage 3 Dyspepsia treatment?

Answer 38

PPI

Question 39

How do NSAIDs/oral steroids have their ulcerogenic effect?

Answer 39

Inhibit prostaglandin production - NSAIDs inhibit COX - Steroids inhibit PLA2

Question 40

What are COX enzymes?

Answer 40

Cyclooxygenases

Question 41

What are the two isoforms of COX enzymes?

Answer 41

COX-1 - physiological form, gastric protection | COX-2 - pathological, inflammation

Question 42

What is Celecoxib?

Answer 42

COX-2 selective inhibitor, fewer GI side effects

Question 43

How can GI damage be minimized?

Answer 43

Prophylaxis w/ PPI | H2 antagonists less effective, give w/ Misoprostol

Question 44

What is Misoprostol?

Answer 44

Stable PGE1 analogue

Question 45

How does Misoprostol work?

Answer 45

Acts on prostanoid receptors, inhibits gastric H+ secretion