Dyspepsia and peptic ulcer disease

• Dyspepsia is a non specific group of symptoms involving epigastric pain (possible related to hunger, eating specific foods, time of day) and heartburn (retrosternal pain with demonstratable acid reflux

ALARM Symptoms

• Anaemia
• Loss of weight
• Anorexia
• Recent onset of progressive symptoms
• Melaena or haematemesis
• Swallowing difficulties

Management

• If <55 test for H. pylori (13C breath test)
• Treat if necessary – triple therapy, PPI, clarithromycin and either metronidazole or amoxicillin for 7days
• If >55 and new dyspepsia isn’t accounted fro by NSAID use then refer urgently for endoscopy

Duodenal ulcers

• 4 times more common than gastric ulcers
• Risk factors – H. pylori infection, drugs (aspirin, NSAIDs, steroids)
• Epigastric pain typically occurs before meals and is relieved by food or drinking milk

Gastric ulcers

• Occur mainly in the elderly on the lesser curve. Ulcers elsewhere are more likely to be malignant
• Risk factors – H. pylori, GORD, smoking, drugs (NSAIDs)
• Stress can causes ulcers – Cushing’s ulcers following neurosurgery and Curling ulcers following burns

Management

• Lifestyle – stop smoking, avoid exacerbating foods
• H.pylori eradication – triple therapy is 85% effective at eradication
• Drugs to reduced acid – PPIs are the most effective

Complications

• Bleeding
• Perforation
• Malignancy
• Gastric outflow obstruction

Gastro-oesoghageal reflux disease

• Dysfunction of the lower oesophageal sphincter

• Associated with;
  • Smoking
  • Alcohol
  • Hiatus hernia
  • Pregnancy
  • Obesity
  • Drugs – tricyclics, anticholinergics, nitrates, calcium channel blockers
  • Systemic sclerosis
  • H. pylori

Symptoms

• Heartburn
• Belching
• Acid brash (acid or bile regurgitation)
• Waterbrash (excessive salivation)
• Odynophagia (painful swallowing)
• Nocturnal asthma

Complications

• Oesophagitis
• Ulcers
• Benign stricture
• Barrett’s oesophagitis
• Oesophageal adenocarcinoma
• Iron deficiency anaemia

Tests

• Indications for urgent endoscopy – age >55, symptoms >4wk, dysphagia, persistent symptoms despite treatment, weight loss
• Endoscopic classification
  • Los Angeles classification
    • Use the term mucosal breaks rather than ulceration. 4 grades;
      • 1 – one or more mucosal breaks <5mm long, not extending beyond 2 mucosal fold tops
      • 2 – mucosal break >5mm long, limited to between 2 mucosal fold tops
      • 3 – mucosal break continuous with 2 or more mucosal fold tops but which involves <75% of the oesophageal circumference
      • 4 – mucosal break involving >75% of the oesophageal circumference

Management

• Lifestyle – encourage patient to lose weight, stop smoking, small regular meals. Avoid hot drinks, alcohol and eating <3hr before going to bed.
  • Avoid drugs affecting oesophageal motility or that damage the mucosa (e.g. NSAIDs, bisphosphonates)
• Drugs – antacids or alginates. PPI or prokinetic drugs e.g. metachlopromide
• Surgery – Nissen fundoplication if patient has severe symptoms and is refractory to medication

Hiatus hernia

• When the proximal stomach herniates though the diaphragm into the thorax
• Can be divided into;
  • Sliding hiatus hernia
    • 80%
    • Where the gastro-oesophageal junction slides into the chest
  • Rolling hiatus hernia
    • When the gastro-oesophageal junction remains in the abdomen but a bulge of the stomach herniates into the thorax next to the oesophagus
• The barium swallow is the best diagnostic test
• Management
  • Lose weight
  • Treat reflux symptoms
  • Surgery for intractable symptoms