Case study: Treatment of upper GI disease

What is Dyspepsia=

• pain or discomfort in upper abdomen

• hard or difficult digestion

Causes of dyspepsia

- stress

-alcohol

- smoking

- H pylori

- medicines

- spicy foods

2 presentations of dyspepsia

• acute

• chronic

Pain right-

duodenal ulcer

When to investigate dyspepsia (endoscope)?

• if ‘alarm’ symptoms are present:

  • Dysphagia (difficulty swallowing)

  • Haematemesis (vomiting blood)

  In patients aged 55+ with weight loss plus:

  • Upper abdominal pain

  • Reflux

  • Dyspepsia

What is a Barium swallow?

• eat barium meal then x-ray, as barium is radium opaque so coats oesophagus for you to see shape

How to treat investigated dyspepsia?

treat underlying pathology but sometimes nothing found

If nothing found during investigation?

what is this called and what do we do?

• Called functional, idiopathic dyspepsia

• treat and test for H pylori

What if the H. pylori test is negative?

• Offer low dose PPI or H2RA for 4 weeks.

• h2ra ( histamine receptor antagonists).

If symptoms of investigated dyspepsia recur?

• restart PPI or H2RA at lowest dose

• People using PPIs or H2RAs should be offered an annual review

Examples of PPIs

esomeprazole, lansoprazole, omeprazole, pantoprazole, rabeprazole

Histamine receptor antagonists exmaples?

• famotidine

• histamine

• ranitidine

• cimetidine

What should you avoid doing with antacids?

long-term frequent use

Which is better PPIs or H2RAs?

PPI

How to test for H pylori?

• test for antigens in blood- not accurate or pt accepted,

• test for antigens in stool- not pt accepted,

• Urea breath test least invasive

Treatment for uninvestigated dyspepsia

• Give lifestyle advice (diet, smoking, alcohol, stress)

• Review any current medications

• Offer H. pylori test and treat, ensuring proper washout period

• If H. pylori negative, give full-dose PPI for 4 weeks

• If symptoms return, consider long-term acid suppression with PPI

• If inadequate response to PPI, try H2RA (Histamine-2 Receptor Antagonist)

Dyspepsia

too much acid in stomach

Role of antacids/anglinates

quicker response than PPIs, but the effect doesn’t last long

• They work by neutralising excess stomach acid

Oral first line therapy to eradicate h pylori for pt with no penicillin allergy

PPI + amoxicillin + clarithromycin/metronidazole (dependant on previous treatment) 7 days high dose

PPIs are used to treat

dyspepsia

Safety of long-term PPI use

- rebound hypersecretion

- osteroporotic fractures

- hypomagnesaemia

- pneumonia

What is GORD?

• retrograde passage of gastric contents from the stomach into the oesophagus

Symptoms of GORD

> heartburn

> pyrosis

> regurgitation of gastric contents into the throat

> early satiety

> belching

> hiccups

> nausea and vomiting

Therapeutic goals for treatment of GORD

> relieve symptoms

> promote oesophageal healing

> avoid long term complications

Barret's oesophagus=

pre-malignant complication of GORD in response to chronic acid exposure

What does barret's oesophagus look like?

dark red patches of tissue in lining- normal is pink

What can Barret's oesophagus develop into?

lower oesophageal cancer

Cause of GORD

abnormal relaxation of the lower oesophageal sphincter in combination with increased in stomach acid

Lifestyle modifications for pt with GORD

> avoid medication that relaxes the LOS

> avoid foods that relax the LOS

> lose weight

> avoid tight clothing

> stop smoking

> raise head of bed by 6-8 inches

> avoid eating within 3 hours of bedtime

Management of proven GORD:

- lifestyle advice

- full dose PPI for 4-8 weeks (depending on severity)

- in severe disease, consider full dose PPI long-term as maintenance-> step down where possible

Treatment for GORD if symptoms reoccur after initial treatment

offer PPI at lowest possible dose to control symptoms- even prn

Treatment in refractory cases of GORD

double dose PPI OR the addition of H2RA (taken at night) with a PPI can be tried on a short-term basis