Peptic Ulcer Disease – BC Guideline

Dyspepsia is a symptom

1 In a patient presenting with dyspepsia, include cardiovascular disease in the differential diagnosis.

DDx:

  • Cardiac: CAD/MI/PE/Pericarditis/Myocarditis/Aortic dissection/Tamponade
  • Boerhaves
  • Hepatobiliary, colonic, Celiac, Achalasia, MSK, esophageal stricture / scleroderma
  • Dyspepsia: GERD, gastric cancer (Zollinger-Ellison), esophageal cancer, pancreatic cancer, gallstone pancreatitis

2 Attempt to differentiate, by history and physical examination, between conditions presenting with dyspepsia (e.g., gastroesophageal reflux disease, gastritis, ulcer, cancer), as plans for investigation and management may be very different.

GERD:
  • heartburn, regurgitation, dysphagia,
PUD/GASTRITIS:
  • postprandial dyspepsia (immediate with gastric ulcer / gastritis), worse at night (duodenal ulcer)
  • Relief with acid suppression medications
CANCER BADNESS
  • >50, early satiety, weight loss, UGIB

3 In a patient presenting with dyspepsia, ask about and examine the patient for worrisome signs/symptoms (e.g., gastrointestinal bleeding, weight loss, dysphagia).

Despepsia Alarming symptoms – VW BAAAD
  • Vomiting
  • Wt loss – unexplained, night sweat, fever, chills (constitutional symptoms)
  • Blood – Hematemesis or melena
  • Age > 50
  • Anemia
  • Abdominal mass
  • Dysphagia, odynophagia

Lifestyle Modifications:

PUD
  1. Avoidance of foods that aggravate dyspepsia: alcohol, caffeine, irritating food
  2. Smaller meals,
  3. smoking cessation,
  4. d/c NSAIDs if possible
GERD
  1. weight control
  2. reduce alcohol/tobacco/caffeine
  3. avoid lying down within 2 hrs of eating and elevate head of bed
  4. avoid food triggers such as spices, peppermint, chocolate, citrus juice
  5. over the counter antacid or H2 receptor blocker, e.g. ranitidine, if not already tried.
Risk Factors – GUD
  • H Pylori infection (GUD, but not GERD)
  • NSAID, bisphosphonate, or steroid use
  • Smoking, EtOH (gastritis)
  • Radiation damage
  • Crohn’s dz
Risk Factors – GERD
  • Increased intraabdominal pressure, pregnancy, obesity
  • Medications decrease LES pressure: CCB, anticholingergics, theophylline, nitrate, sildenafil

PUD – Empiric versus Test-and-Treat strategy
  1. Empiric tx strategy:
    1. PPI OD or H2RA BID, x 4-8 wk
    2. reassess, if still symptomatic switch PPI, or BID PPI
    3. if still symptomatic, breath test for H Pylori (Must be off PPi for min of 2 weeks), or prompt endoscopy
  2. Test-and-treat strategy:
    1. test for H pylori,
    2. tx with triple therapy if positive
  3. Endoscopy if
    1.  >50 with new symptoms
    2. Alarm features (see above)
    3. Failed repeated trial of therapy (see empiric tx strategy)

(however 10% of DU and 30% of GU may be H pylori negative)


Triple therapy regimes:
  1. PPI BID, Clarithro 500mg BID, Amoxil 1 g BID, x 7 days
    • (Hp-PACLosec 1-2-3 A) –less resistance to this regime
  2. PPI BID, Clarithro 250mg BID, Metronidazole 500mg BID, x 7 days
    • (Losec 1-2-3 M)
  3. Urea breath test for test of cure 30d after Tx
  • If ulcer not related to H pylori (H pylori negative) or NSAIDs, tx ulcer with OD PPI x 2-4 wk, consider maintenance tx.
  • GU will need f/u endoscope to prove healing, in case cancer.
    No clinically significant differences between PPI’s (other than cost).

GERD – Reassess after one month of lifestyle modifications

  1. if no response with above – full dose H2 receptor blocker x 1 month OR PPI trial x 1 month and reassess
  2. if still no response double dose of PPI x 1 month and reassess
  3. if failure reassess for alarm symptoms
    1. dysphagia,
    2. odynophagia,
    3. bleeding, anemia,
    4. weight loss
  4. failure to respond to 4 months of PPI therapy warrants endoscopy and/or specialist referral

Complications:

Chronic GERD may be complicated by chronic laryngitis and Barrett‘s esophagus in 10% of individuals, leading to esophageal adenocarcinoma

risk factors:
  1. male
  2. smoker
  3. Caucasian
  4. >50yrs
  5. >10yrs of GERD sx.
  6. >3x/week
GUD Complications
  • Bleeding, penetration, perforation (duodenal ulcer)
  • Gastric outlet obstruction

References

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Posted in 31 Dyspepsia, 99 Priority Topics, FM 99 priority topics, GI

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