Dyspepsia and Reflux

Question 1

Most dyspepsia is due to _______

Answer 1

Functional dyspepsia

Question 2

What is functional dyspepsia

Answer 2

Disorder of the gut-brain interaction, and no obvious cause will be found on investigation

Question 3

Is gastroscopy needed for reflux/dyspepsia

Answer 3

Gastroscopy is rarely indicated in the diagnosis or management of heartburn or dyspepsia

Question 4

Predictive value of individual alarm symptoms for upper GI cancer

Answer 4

Individual sx = low predictive value
Increased when multiple alarm features are present

Question 5

Gastric cancer often presents late with _________

Answer 5

Anaemia and epigastric pain

Question 6

Alarm symptoms

Answer 6

Progressive oesophageal dysphagia at any age
Haematemesis or melaena
Pain
Vomiting
Weight loss

Question 7

Dysphagia

Answer 7

Difficulty or pain in swallowing solids and liquids

Question 8

Globus

Answer 8

Persistent sensation of something being stuck in the throat, that does not interfere with swallowing

Question 9

Causes of oesophageal dysphagia

Answer 9

GORD
Motility disorders
Eosinophilic oesophagitis
Benign oesophageal strictures
Malignancy
Candida

Question 10

Is GORD pathological or physiological?

Answer 10

Gastro-oesophageal reflux is a normal physiological event. It is considered pathological when it causes pain, regurgitation, or oesophageal damage

Question 11

What is dyspepsia

Answer 11

Gastroduodenal symptom complex with the most common symptoms being epigastric pain or discomfort (often after meals), bothersome fullness after meals, epigastric bloating, early satiety, and nausea

Question 12

Causes of dyspepsia

Answer 12

Functional dyspepsia (most common)
Gastric irritation, e.g. secondary to NSAIDs
Peptic ulcer disease
Helicobacter infection
Coeliac disease
Malignancy

Question 13

Gastric cancer tends to occur a decade earlier in what populations?

Answer 13

Māori or Pacific people
Immigrants from high-risk countries

East Asia
Central and South America
Southern and Eastern Europe
The Caribbean
Middle Eastern, Latin American, African

Question 14

Risk factors for Helicobacter pylori infection

Answer 14

Past history of peptic ulcer
At-risk ethnicity, e.g. Māori, Pacific, Asian, Indian, African
Childhood spent in developing countries

Question 15

The likelihood of functional dyspepsia can be assessed using the ________ criteria.

Answer 15

Rome IV diagnostic criteria

Question 16

Rome IV diagnostic criteria for functional dyspepsia = one or more of the following sx

Answer 16

Bothersome epigastric pain
Bothersome epigastric burning
Bothersome postprandial fullness
Bothersome early satiation
Symptom onset ≥6 months before diagnosis
Symptoms active within the past 3 months

Question 17

Functional dyspepsia can be further subcategorised as…

Answer 17

Epigastric pain syndrome (EPS)
Postprandial distress syndrome (PDS)

Patients may present with features of both

Question 18

Epigastric pain syndrome

Answer 18

Bothersome epigastric pain or burning (sufficient to disrupt usual activities).
Induced by or relieved by meals, or onset during fasting.

Question 19

Postprandial distress syndrome

Answer 19

Bothersome postprandial fullness or early satiation

Question 20

What should you advise patients about when to do H pylori stool test (what needs to be restricted prior to doing test)

Answer 20

No antibiotics for ≥1 month before the test
No PPIs for ≥ 1 week before the test (even better 2 weeks)

Question 21

Treat with empirical standard-dose proton pump inhibitors (PPIs) for _______ (duration) if dyspepsia, and for ________ if GORD

Answer 21

Dyspepsia - 4 weeks
GORD - 4 to 8 weeks

Question 22

Side effects of PPIs

Answer 22

Headache, nausea, vomiting, diarrhoea, abdominal pain, constipation, and wind

Question 23

How to stop PPIs

Answer 23

Wean to lowest effective dose and stop
Caution the patient about rebound hyper-acidity after stopping PPI and to use PPI or antacid PRN

Question 24

Use long-term PPI in what conditions?

Answer 24

Severe oesophagitis
Oesophagitis complicated by strictures Barrett’s oesophagus

Question 25

Risk of long-term PPIs

Answer 25

Weak evidence for: Hypomagnesaemia Osteoporosis Pneumonia Increased cardiovascular risk Renal impairment in the elderly B12 deficiency Dementia

Question 26

Lifestyle management

Answer 26

Weight reduction, especially around the middle of the abdomen Stress reduction Smoking cessation Limiting alcohol Sleep position Eat slowly and chew food well Eat smaller meals Food/symptom diary for triggers

Question 27

Next steps if GORD symptoms predominate, and no response to standard-dose PPI for 8 weeks

Answer 27

Double dose of PPI for 4 to 8 weeks Add antacid

Question 28

Risk factors for Barrett's oesophagus

Answer 28

Chronic GORD > 50 yo Caucasian. Male Obesity Relative diagnosed with Barrett's oesophagus or oesophageal adenocarcinoma

Question 29

If dyspepsia symptoms predominate, and no response to empirical standard dose PPI for 4 weeks, and H. pylori eradication confirmed (or test result is negative) - next steps

Answer 29

Review reversible lifestyle factors and confirm lifestyle modification Consider further medication trial Consider the overlap with IBS

Question 30

Further medication trial after PPI

Answer 30

H2‑receptor antagonist, e.g. famotidine 40 mg once a day for 4 weeks If ineffective, add domperidone at the lowest effective dose, for not more than 4 weeks because of the risk of prolonged QT interval.

Question 31

Diagnosis of GORD

Answer 31

Therapeutic trial of PPIs in a patient with symptoms suggestive of GORD has a comparable sensitivity and specificity for diagnosing GORD as measuring the presence of oesophageal acid directly with a pH monitor in a secondary care setting

Question 32

To maximise their effect, PPIs should be taken when?

Answer 32

30 – 60 minutes before food, ideally before the first meal of the day.

Question 33

Should PPIs be given once or twice daily?

Answer 33

When increasing the dose of lansoprazole or pantoprazole it is recommended that the dose is divided to twice daily dosing, i.e. before breakfast and before dinner Omeprazole is usually dosed once daily, but a divided dose could be trialled if symptoms worsen later in the day.