Upper GI potpourri

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Upper GI potpourri

• Anthony Worsham, MD
• Division of Hospital Medicine
• Department of Internal Medicine
• University of New Mexico Health Sciences Center
• Thursday, October 9, 2014

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Outline

• dyspepsia
• gastroesophageal reflux disease (GERD)
• peptic ulcer disease
• Barretts esophagus
• Helicobacter pylori

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What is dyspepsia?
Picture credithttp//blog.givelify.com/wp-content/
uploads/2014/07/Princess_Bride_That_Word.jpg
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Functional dyspepsia

• presence of symptoms thought to originate in the
  gastroduodenal region, in the absence of any
  organic, systemic, or metabolic disease
• Rome III diagnostic criteria (at least 1 of)
• Bothersome postprandial fullness
• Early satiation
• Epigastric pain
• Epigastric burning
• No evidence of structural disease

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Functional dyspepsiaDifferential diagnosis

• Functional (nonulcer) dyspepsia Up to 70
  percent
• Peptic ulcer disease 15 to 25 percent
• Reflux esophagitis 5 to 15 percent
• Gastric or esophageal cancer lt 2 percent
• Abdominal cancer, especially pancreatic
  cancer Rare
• Biliary tract disease Rare
• Carbohydrate malabsorption (lactose, sorbitol,
  fructose, mannitol) Rare
• Gastroparesis Rare
• Hepatoma Rare
• Infiltrative diseases of the stomach (Crohn
  disease, sarcoidosis) Rare
• Intestinal parasites (Giardia species,
  Strongyloides species) Rare
• Ischemic bowel disease Rare
• Medication effects (Table 3) Rare
• Metabolic disturbances (hypercalcemia,
  hyperkalemia) Rare
• Pancreatitis Rare
• Systemic disorders (diabetes mellitus, thyroid
  and
• parathyroid disorders, connective tissue
  disease) Rare

Loyd RA and McClellan DA. Update on the
evaluation and management of functional
dyspepsia. Am Fam Physician 2011 83(5) 547-552
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Upper gastrointestinal alarm symptoms

• Age 55 years with new onset dyspepsia
• Chronic gastrointestinal bleeding
• Dysphagia
• Progressive unintentional weight loss
• Persistent vomiting
• Iron deficiency anaemia
• Epigastric mass
• Suspicious barium meal result

taken from National Institute for Health and Care
(formerly Clinical) Excellence referral
guidelines for suspected cancer
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Functional dyspepsia treatment

• Diet and lifestyle
• weight loss
• smoking and alcohol cessation
• Avoid certain foods (e.g., fatty foods)
• Medication
• acid suppression therapy (e.g., PPIs)
• H. pylori eradication therapy
• prokinetic drugs (e.g., metoclopramide,
  cisapride, domperidone)
• antidepressants and psychologic therapies
• Alternative therapies (e.g., accupuncture)

Ford AC. Dyspepsia. BMJ 2013347f5059
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What is GERD?
Picture credithttp//blog.givelify.com/wp-content/
uploads/2014/07/Princess_Bride_That_Word.jpg
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Definition

• GERD should be defined as symptoms or
  complications resulting from the reflux of
  gastric contents into the esophagus or beyond,
  into the oral cavity (including larynx) or lung.
  GERD can be further classified as the presence of
  symptoms without erosions on endoscopic
  examination (nonerosive disease or NERD) or GERD
  symptoms with erosions present (ERD).

Katz et al, Guidelines for the diagnosis and
management of gastroesophageal reflux disease. Am
J Gastroenterol 2013 108308 328.
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Kahrilas PJ, Boeckxstaens G. Failure of reflux
inhibitors in clinical trials bad drugs or wrong
patients? Gut 20126115011509.
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Kahrilas PJ, Boeckxstaens G. Failure of reflux
inhibitors in clinical trials bad drugs or wrong
patients? Gut 20126115011509.
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GERD treatments

• lifestyle modification
• medication
• surgery

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Kahrilas PJ, Boeckxstaens G. Failure of reflux
inhibitors in clinical trials bad drugs or wrong
patients? Gut 20126115011509.
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Top 100 Most Prescribed, Top Selling
Drugs. http//www.medscape.com/viewarticle/825053
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PPI Complications

• community-acquired pneumonia
• hip fracture
• infectious gastroenteritis
• C difficile
• Vitamin B12 deficiency/malabsorption
• secondary hypergastrinemia
• hypochlorhydria

Kahrilas PJ, Gastroesophageal reflux disease,
NEJM 20083591700-7.
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Katz et al, Guidelines for the diagnosis and
management of gastroesophageal reflux disease. Am
J Gastroenterol 2013 108308 328.
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Peptic ulcers can be deadly

• Rudyard Kipling J. R. R. Tolkien James Joyce

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Ulcer complications

• bleeding
• perforation
• penetration

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Management of acute bleeding from a peptic ulcer

• Clinical status
• At presentation
• Assess hemodynamic status (pulse and blood
  pressure, including orthostatic changes).
• Obtain complete blood count, levels of
  electrolytes (including blood urea nitrogen and
  creatinine), international normalized ratio,
  blood type, and cross-match.
• Initiate resuscitation (crystalloids and blood
  products, if indicated) and use of supplemental
  oxygen.
• Consider nasogastric-tube placement and
  aspiration no role for occult-blood testing of
  aspirate.
• Consider initiating treatment with an intravenous
  proton-pump inhibitor (80-mg bolus dose plus
  continuous infusion at 8 mg per hour) while
  awaiting early endoscopy no role for H2
  blocker.
• Perform early endoscopy (within 24 hours after
  presentation).
• Consider giving a single 250-mg intravenous dose
  of erythromycin 30 to 60 minutes before
  endoscopy.
• Perform risk stratification consider the use of
  a scoring tool (e.g., Blatchford score16 or
  clinical Rockall score17) before endoscopy.
• At early endoscopy
• Perform risk stratification consider the use of
  a validated scoring tool (e.g., complete Rockall
  score17) after endoscopy.

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Low-risk lesions
Gralnek IM, et al. Management of acute bleeding
from a peptic ulcer. NEJM 2008359928-37
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Recommended treatment to prevent ulcer rebleeding
Laine L and Jensen DM. Management of patients
with ulcer bleeding. Am J Gastroenterol 2012
107345360
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Peptic ulcer treatment
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All NSAIDs are associated with GI bleed
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Barretts esophagus
Spechler SJ and Souza RF. Barretts esophagus. N
Engl J Med 2014371836-45.
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Helicobacter pylori
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H. pylori treatment regimens

• Triple therapy (7-14 days)
• PPI, healing dose bid
• amoxicillin 1 gm bid
• clarithromycin 500 mg bid
• Sequential therapy
• Days 1-5
• PPI, healing dose bid
• amoxicillin 1 gm bid
• Days 6-10
• PPI, healing dose bid
• clarithromycin 500 mg bid
• tinidazole 500 mg bid

• Quadruple therapy
• PPI, healing dose bid
• tripotassium dicitrato-bismuthate, 120 mg qid
• tetracycline 500 mg qid
• metronidazole 250 mg qid
• Healing dose PPI (all bid)
• omeprazole 20 mg
• pantoprazole 40 mg
• lansoprazole 30 mg
• esomeprazole 20 mg

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H. pylori testing

• Testing criteria
• Active gastric or duodenal ulcer
• history of active gastric or duodenal ulcer not
  previously treated for H. pylori infection
• gastric MALT lymphoma
• history of endoscopic resection of early gastric
  cancer
• uninvestigated dyspepsia
• Test-and-treat criteria
• age lt55 yr and no alarm symptoms