Dyspepsia- week 9

Dyspepsia- week 9

1. Symptom not a condition, can have many causes and is not a good predictor of significant disease

2. Commonly presents as epigastric pain, bloating, heartburn

3. Very common- affects around 40% of UK population at some point

4. 4 possible diagnosis from endoscopy. 1.Functional dyspepsia (symptoms without any obvious cause) 2.Gastro-oesophageal reflux disorder (GORD) 3.Peptic ulcer disease (PUD) 4. Malignancy

5. Following medication could be causing dyspepsia: Calcium antagonsits, nitrates, theophylline, bisphosphonates, corticosteroids, NSAIDS, antiplatelets, anticoagulants

6. Endoscopy alarm symptoms: Chronic gastro-intestinal bleeding, dysphagia (difficulty swallowing), unintentional weight loss, iron deficiency anaemia (associated with blood loss), epigastric mass

7. Any patient with dyspepsia and significant acute GI bleeding refer immediately to specialist for endoscopy

8. Patients aged 55yrs and over with unexplained and persistent recent onset dyspepsia alone is enough to make an urgent referral for endoscopy

9. Patients referred for an endoscopy should not take a PPI or H2RA for two weeks beforehand as it can mask malignancies and make test ineffective. Rapuid urease test can be carried out at the same time as the endoscopy to test for H.Pylori

10. If patient does not require an endoscopy they have uninvestigated dyspepsia. This is treated with PPI therapy for four weeks. consider offering H.Pylori test and treat. If symptoms return give maintenance PPI or as required. If PPI not effective give H2RA

11. GORD - dysfunction of lower oesophageal sphincter resulting in reflux of gastric acid. Often associated with smoking, alcohol, hiatus hernia, pregnancy. Symptoms include heartburn, belching, excessive salivation, painful swallowing. Treatment- full dose PPI for 4-8 weeks and then step down to maintenance. H2RA can be given if no response.

    • Oesophagitis- often result of GORD, treatment includes full dose PPI for 8 weeks to heal, if fails switch to another PPI. Full dose PPI may be required for maintenance

12. PUD- Stop NSAID's if used! Commonly associated with H.Pylori. If patient tests positive for H.Pylori and NOT NSAID associated then use eradication therapy. If positive and NSAID associated then full dose PPI treatment for two months and then eradication therapy. If patient does not have H.Pylori then treat with full dose PPI for 1-2 months. endoscopy should then be re-done and re-tested for H.Pylori to ensure healing and eradication

13. NSAID associated ulcers- GI bleeding and ulceration can occur with NSAID use. NSAID should be withdrawn if possible when ulceration occurs. Patients at high risk of GI complications on NSAIDS include: OVER 65s, history of PUD, Patients also taking SSRI's or Antiplatlets. PPI protection should be considered in these patients if NSAID is required and lowest dose NSAID should be used in these patients. Consider misoprostol or double dose H2RA as alternative to PPI

14. Functional dyspepsia- Test and treat H.Pylori, if -ve then give low dose PPI or H2RA for four weeks

15. Treating H.Pylori will cure PUD, reduce risk of gastric cancer and may help functional dyspepsia. Does not have any effect on GORD. Tested via C13 urea breath test. Test is difficult to carry out and can give a false negative due to eating/drinking. Before testing patient should not have had any antibacterials for 4 weeks and have fasted for 6 hours

    • Triple therapy for the treatment of H.Pylori. TWICE daily for SEVEN days 1. PPI 2. Amoxicillin 3.Clarithromycin OR Metronidazole. In penicillin allergic patients give bismuth, tetracycline or quinolone instead of amoxicillin

16. PPI prescribing points: -Can increase the risk of fractures especially in elderly if used for over one year and higher risk in smokers. -Can increase the risk of GI infections such a C.Difficile. -May mask signs and symptoms of gastric cancer. Serum magnesium should be monitored and can cause hyponatraemia.

    • Esomeprazole and omperazole should NOT be taken with clopidogrel

17. Cimetidine = enzyme inhibitor of CYP450 so can increase the risk of interactions however ranitidine is not and therefore should be chosen over cimetidine as a H2RA if needed