Dyspepsia

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Created by
Megan Vann

Cards (41)

  • Dyspepsia is a symptom. It includes upper abdominal pain, heartburn, acidity, nausea and/or vomiting, fullness and belching
  • Dyspepsia is commonly caused by peptic ulcer disease, H. Pylori, gastritis and GORD. Can also be caused by oesophageal or gastric cancer.
  • Lifestyle factors that cause dyspepsia:
    • Alcohol
    • Smoking
    • Fatty foods
    • NSAIDs
    • Steroids, SSRIs and antibiotics
  • Any patient presenting with dysphagia warrants an urgent 2WW referral for oesophageal/gastric cancer
  • H. pylori infection is a common cause of dyspepsia, leading to inflammation of the stomach lining.
  • A patient over 55 with weight loss + reflux / dyspepsia needs an urgent upper GI 2WW referral for a direct access endoscopy
  • Consider non urgent direct access upper GI endoscopy for oesophageal/gastric cancer in patients with haematemesis
  • ALARM Symptoms:
    A = anaemia
    L = loss of weight
    A = anorexia
    R = recent onset or progressive symptoms
    M = melena / haematemesis
    S = swallowing difficulties
  • management of dyspepsia in a patient under 55 with no ALARM Symptoms:
    1. lifestyle modification / stop contributing medication
    2. H.Pylori test (before PPI) + full dose PPI for 1 month
    3. H2 receptor antagonist
    4. referral to gastroenterology if persistent symptoms or H.Pylori eradication unsuccessful
  • Helicobacter Pylori is a gram negative bacteria found in the stomach. It is associated with peptic ulcers and gastric cancer
  • H. Pylori ”test and treat” = test in patients under 55 with no ALARM Symptoms and treat if positive
  • A stool antigen test is most commonly performed for the detection of H. Pylori. Patients need a wash out period of no PPI for 2 weeks and no antibiotics for 4 weeks.
  • Treatment of H. Pylori is triple therapy with PPI + 2 antibiotics for 7 days
    1. PPI + amoxicillin + clarithromycin / metronidazole
    2. PPI + amoxicillin + the other antibiotic that wasn’t given as first line
  • Peptic ulcer disease describes an ulcer in the stomach and/or the duodenum
  • Peptic ulcers are caused by factors that disrupt the mucus barrier or increase acid.
    Factors that disrupt the mucus barrier - H. Pylori and NSAIDs
    Increase stomach acid - stress, alcohol, caffeine, smoking and spicy foods
    Medications such as NSAIDs and aspirin increase the risk of bleeding from peptic ulcers
  • Patients with PUD typically present with epigastric pain, nausea and/or vomiting and dyspepsia
  • Signs of upper GI bleeding from PUD:
    • Haematemesis (can be coffee ground)
    • Malena
    • Low Hb - chronic microscopic bleeding causes low Hb, low MCV and low ferratin
  • Eating typically causes temporary relief for duodenal ulcers, so these patients tend to maintain or gain weight
  • Eating typically worsens pain from gastric ulcers therefore these patients tend to lose weight due to fear of eating
  • A patient under 55 years with no ALARM Symptoms + typical PUD symptoms need no investigation. Can be referred for non-urgent direct access endoscopy if haematemesis is present.
  • Patients presenting with PUD symptoms should be tested for H. Pylori if PPIs are ineffective
  • Un-investigated PUD should be treated the same as dyspepsia
    1. Life style modification / stop drugs
    2. H. Pylori + 1 month full dose PPI
    3. H2 receptor antagonist
    4. referral
  • All gastric ulcers will be biopsied to exclude malignancy - repeat endoscopy to ensure healing
    Repeat endoscopy should be performed 6-8 weeks after starting PUD treatment
  • GORD is the reflux of gastric acid, pepsin, bile and duodenal contents back into the oesophagus
  • The squamous epithelial lining of the oesophagus makes it more sensitive to stomach acid
  • Patients with GORD typically present with:
    • Dyspepsia that is worse when lying down
    • Pain in the epigastric region that is relieved by antacids
    • Nocturnal cough
    • Acid and water brash in the mouth
    • Odynophagia - painful swallowing
  • Risk factors for GORD:
    • Obesity / pregnancy
    • Over eating / large meals
    • Alcohol
    • Smoking
    • NSAIDs
    • Hiatus hernia
  • Patients under 55 with no ALARM Symptoms presenting with typical GORD symptoms usually need no investigation
    If an OGD shows oesophagitis or Barrett's oesophagus then GORD is confirmed
  • Management of un-investigated GORD is the same as dyspepsia:
    1. Life style modification / stop drugs
    2. H. Pylori testing and 1 month full dose PPI
    3. H2 receptor antagonist
    4. Referral
  • A prolonged course of PPI is used to treat oesophagitis
  • Complications of GORD:
    • Peptic stricture - can cause dysphasia
    • Ulcers
    • Oesophagitis
    • Barrett's oesophagus
  • Barrett's oesophagus is a pre-cancerous condition of the oesophagus
    The normal squamous epithelium of the oesophagus is replaced by metaplastic columnar mucosa which can progress to adenocarcinoma
  • Complications of PUD:
    • Haemorrhage
    • Perforation
    • MALT lymphoma
    • Gastric cancer
  • Achalasia is a rare condition where the lower oesophageal sphincter does not relax. A "birds beak" appearance is seen on a barium swallow. Most patients present with dysphagia from solids and liquids.
  • Metronidazole is one of the antibiotics used to treat H. Pylori infections. Is it extremely unsafe to use this antibiotic with alcohol as it causes a toxic accumulation in the body
  • NSAIDs cause mucosal injury to the GI tract due to cyclo-oxygenase 1 inhibition, this causes:
    • Reduction of cytoprotective mucosal prostaglandins
    • Reduction in secretion of protective mucus barrier in stomach and small bowel
  • Lansoprazole and omeprazole are examples of proton pump inhibitors
    They inhibit gastric secretions by blocking gastric H+/K+ ATPase
    Enables healing of PUD, GORD and Barrett's oesophagus
  • Histamine type 2 receptor antagonists bind to H2 receptors on the basolateral surface of gastric parietal cells and interfere with acid production / secretion
  • Oesophageal structures are abnormal narrowing of the oesophageal lumen. symptoms include: progressive dysphasia to solid food, food impaction, painful swallowing, weight loss. Most common cause is benign peptic strictures from long standing GORD.
  • A perforated peptic ulcer will cause free air under the diaphragm on a chest x-ray - pneumoperitoneum