Tutorial #38: Dyspepsia

Question 1

What is the Rome IV criteria of dyspepsia?

Answer 1

The presence of any of the following:
- bothersome postprandial fullness
- bothersome early satiety
- bothersome epigastric pain/burning

Question 2

What is the Rome IV criteria of functional dyspepsia?

Answer 2

The presence of any one of the following symptoms:
- bothersome postprandial fullness
- bothersome early satiety
- bothersome epigastric pain/burning

These symptoms have to be recurrent in the last 3 months AND the onset of the symptoms are greater than 6 months ago

AND

There is no evidence of organic, systemic, metabolic or structural disease that can better explain the symptoms.

Question 3

What is the CR2 suggested approach to patients with undiagnosed dyspepsia? (5 steps)

Answer 3

1. Perform a focused initial history, physical examination
2. determin if the pathology is likely in the upper GI tract
3. Identify patients who require endoscopy
4. Identify patients with H.pylori
5. Empiric treatment (if required)

Question 4

In patients < 60, what are 4 criteria that indicate a patient experiencing dyspepsia require an upper GI endoscopy?

Answer 4

• Clinically significant weight loss (>5% of body weight over 6 to 12 months)
• Overt GI bleeding
• > 1 alarm feature
• Rapidly progressive alarm features

Alarm features include:
- unintentional weight loss
- progressive dysphagia
- odynophagia
- unexplaiend iron deficiency anemia
- persistent vomiting
- palpable mass or lymphadenopathy
- family history of upper GI cancer

Question 5

What are the “alarm features” you should look for in investigating a patient with dyspepsia? (x7)

Answer 5

• unintenional weight loss
• progressive dysphagia
• odynophagia
• unexplained iron deficiency anemia
• persistent vomiting
• palpable mass or lymphadenopathy
• family history of upper GI cancer.

Question 6

In a patient who is > 60 years old with univestigated dyspepsia, what is recommended in regards to performing an upper GI endoscopy?

Answer 6

In patients > 60 years old, the recommendation is to perform upper endoscopy with gastric biopsy in ALL patients

Question 7

What are two ways to non-invasively test for H.Pylori?

Answer 7

1. urea breath test
2. Serum testing

Urea breath testing is often recommended because of superior sens. and spec, and also because serum testing does not distinguish between current and past infections.

Question 8

What is the the recommended therapy for patients experiencing dyspepsia and are H.pylori positive?

Answer 8

14 day course of: PPI + clarithromycin + metronidazole OR amoxicillin

*Some resistent strains of H.pylori in Canada have made quadruple therapy a reasonable first-line therapy:

*Bismuth qudruple therapy: PPI + bismuth + metronidazole + tetracycline (ex. doxycycline)

OR

*Non-bismuth qudruple therapy: PPI + amoxicillin + metronidazole + clarithromycin

Question 9

In a patient who is experiencing dyspepsia, and you have determined that they do not need an endoscope AND they are h.pylori negative and/or symptoms persist after H.pylori is eradicated, what is the next best step?

Answer 9

Trial proton pump inhibitor for 4-8 weeks

Question 10

In a patient who is experiencing dyspepsia, and you have determined that they do not need an endoscope AND they are h.pylori negative and/or symptoms persist after H.pylori is eradicated AND their symptoms persist after initiating a PPI for 4-8 weeks, what is the next best step?

Answer 10

Discontinue PPI and trial tricyclic antidepressant for 8-12 weeks

Question 11

You have started empiric treatment for a patient with dyspepsia. After trialing a PPI (4-8 weeks, then discontinued), and a tricyclic antidepressant (8-12 weeks) and symptoms continue to persist, what is the next best step?

Answer 11

Discontinue tricyclic antidepressant and trial a prokinetic for 4 weeks

example of prokinetic agent include metoclopramide

Question 12

You have started empiric treatment for a patient with dyspepsia. After trialing a PPI (4-8 weeks, then discontinued), and a tricyclic antidepressant (8-12 weeks), the symptoms have subsided. What is the next best step?

Answer 12

continue tricyclic antidepressant for 6 months and then discontinue

resume tricyclic antidepressant if symptoms reoccur

Question 13

You have started empiric treatment for a patient with dyspepsia. After trialing a PPI (4-8 weeks, then discontinued), a tricyclic antidepressant (8-12 weeks, discontinued), and a prokinetic agent (4 weeks) and symptoms continue to persist, what is the next best step?

4 items on the answer of this card

Answer 13

1. Re-evaluate symptoms
2. perform an upper endoscopy if not preevious performed
3. assess gastric emptying in patients with nasea and vomiting predominant symptoms
4. trial of psychotherapy in patients with functional dyspepsia

Question 14

You have started empiric treatment for a patient with dyspepsia. After trialing a PPI (4-8 weeks, then discontinued), a tricyclic antidepressant (8-12 weeks, then discontinued), and a prokinetic agent (4 weeks), the symptoms have subsided. What is the next best step?

Answer 14

Discontinue prokinetic agent. Repeat 4 week course if symptoms reoccur.

Question 15

What is the most likely diagnosis in a patient who has retrosternal/epigastric burning pain that becomes worse after lying down or after meals?

Answer 15

GERD

Question 16

What is the treatment for GERD? (x2)

Answer 16

1. lifestyle modification
2. PPI

Question 17

What are the risk factors for peptic ulcer disease? (x2)

Answer 17

1. Presence of H.pylori
2. NSAID use

Question 18

How does eating affect the symptoms of peptic ulcer disease?

Answer 18

Depends on whether it is a gastric or duodenal ulcer -> duodenal ulcer will be relieved with eating, gastric ulcer is worse with eating.

(Therefore patients with duodenal ulcers will eat more and have weight gain, and vice versa)

(ngl I do not know the pathophys behind this, I wish I did haha)

(dumb memonic I came up with is that there are more U’s in duodenal ulcer than gastric ulcer, so weight goes Up in duodenal ulcers…)

Question 19

What lab findings suggest peptic ulcer disease as a cause of dyspepsia?

Answer 19

1. microcytic anemia (or overt GI bleeding)
2. Positive H.pylori testing

Question 20

What is the confirmatory test for peptic ulcer disease?

Answer 20

Endoscopy

Question 21

What is the treatment for peptic ulcer disease?

Answer 21

1. Eradicate H.pylori if present
2. acid suppression therapy (ex. PPI)
3. avoidance of NSAIDs, OR use of a COX-2 selective NSAID if NSAID use is unavoidable

For point 3, please see picture. Basically non-selective NSAIDs inhibit COX-1 as well, which is responsible for producing prostaglandins that initiate GI cell protection (in addition to increasing platelet activity).

Question 22

What are 5 positive predictors for gastric cancer as the cause of dyspepsia?

Answer 22

1. Progressive weight loss (>5% of usual bodyweight over 6-12 months)
2. UGI bleeding OR microcytic anemia
3. Dysphagia/odynophagia
4. palpable mass or lymphadenopathy
5. Fhx of GI malignancy

This is similar to the alarm features in the “endoscopy for uninvestigated dyspepsia” treatment algorithm.

Question 23

What is the confirmatory test for gastric cancer?

Answer 23

Endoscopy and biopsy

Question 24

Patient presents with RUQ pain that radiates to the scapula/right shoulder, and usually occurs after eating. The pain maximizes in intensity for at least 1 hour and then gradually resolves. This pain does not last more than 6 hours. What is the most likely diagnosis?

Answer 24

Biliary colic

Question 25

What is the confirmatory test for biliary colic?

Answer 25

The presence of gall stones with abdominal ultrasound

Question 26

Most likely diagnosis in 65y/o japanese man with fatigue, dyspepsia, weight loss, and lymphadenopathy?

Answer 26

Gastric cancer

Question 27

Most likely diagnosis in 42F presenting w/ 6mo hx of dyspepsia, epigastic pain, and early satiety which is interfering with her day to day life. Occurs 3-4 times a week. Smoker. Previous h pylori testing and endoscopy have been -ve.

Answer 27

Functional Dyspepsia (idea is that once you've ruled out most other things, FD is your diagnosis of exclusion afaik)