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Dyspepsia & Altered Bowel Habit Management

From Mediwikis

Dyspepsia

Causes

  • PUD (DU more common than GU)
  • GORD/Gastritis
  • Gastric cancer
  • Gallstones
  • Chronic pancreatitis
  • MI
  • 60% non-ulcer dyspepsia (NUD)

Symptoms

Typically present for 4 weeks or more:

  • upper abdominal pain/discomfort
  • heartburn/gastric reflux
  • nausea, vomiting
  • bloating
  • red flags: GI bleeding, weight loss, dysphagia, anaemia, epigastric mass

Management

  • <55 years “test and treat” – test for H.pylori – C13 urea breath test or stool antigen test (2 week washout post PPI) if positive, eradication therapy, if negative - 4 weeks full dose PPI
  • >55 years unexplained, persistent symptoms - lifestyle changes and urgent endoscopy biopsy sample - rapid urease test - Don’t prescribe PPI pre-endoscopy as need to be off acid suppression medication for >2 weeks prior other Clo test may give false neg
  • If non-ulcer dyspepsia/functional dyspepsia - lifestyle advice, antacid for immediate relief, eradication therapy if H. pylori positive, 4 weeks low dose PPI if negative or not responding to eradication therapy
  • General advice: Stop smoking, lose weight, increase exercise, avoid precipitants (alcohol, coffee, chocolate, fatty/spicy foods, eat small regular meals

Peptic ulcer disease

Ulceration of mucosa of stomach or duodenum that penetrates the muscularis mucosae

Causes:

  • Helicobacter pylori infection – 80-95% - common childhood infection – inflammation/increased acid production
  • NSAIDs – 5% - reduced mucin/HCO3 production – COX1 inhibitory effect - gastrotoxic
  • Long term steroid use
  • Alcohol – destruction of mucosal barrier protective function
  • Smoking
  • Severe physiological stress – major burns/CNS trauma/surgery, medical illness-ITU
  • Hypersecretory state – zollinger Ellison syndrome – gastrinoma – excess gastrin – excess stimulation of parietal cells

Symptoms

  • asymptomatic
  • epigastric pain: GU – worse with/shortly after meals; DU – relieved during meals, worse 2-3h after meals or at night
  • nausea, vomiting, bloating
  • Weight loss
  • Emergency presentation: UGI bleed - haematemesis, malaena, haemodynamic compromise, severity scoring (Blatchford score, Rockall score); acute abdomen – gastric/duodenal perforation

Treatment

  • If H.pylori positive, not taking NSAIDs - eradication therapy for 1 week (triple therapy, twice daily dosing - two of: amoxicillin/clarithromycin/metronidazole + PPI
  • If H.pylori positive, taking NSAIDs - 8 weeks full dose PPI --> eradication therapy for 1 week (triple therapy, twice daily dosing - two of: amoxicillin/clarithromycin/metronidazole + PPI. Try to stop NSAID, if not, long term treatment with PPI/H2 receptor agonist (tachyphylaxis) or use of COXII selective inhibitors
  • If H.pylori negative - full dose PPI for 1–2 months
  • UGI bleeding - ABC, fluid resuscitation, urgent endoscopy, iv PPI for 3 days --> high dose oral therapy for 2 months, post treatment repeat endoscopy

Side effects of PPIs

  • C. difficile
  • Electrolyte disturbance – hypomagnaesaemia
  • Changes to stool colour – bismuth

Altered Bowel Habit

Note this covers the management of constipation and diarrhoea, not the management of patients presenting with a change in bowel habit suggestive of something else, e.g. IBD, malignancy

Constipation

There are four types of laxatives, each used in slightly different situations. Note that often the best way to treat constipation is with lifestyle changes, e.g. diet and exercise changes, (exercise promotes bowel motility).

Bulk Forming

  • e.g. Methylcellulose
    • These PO medications stimulate peristalsis through ↑ stool volume
    • Used in constipated patients who complain of small hard stools
    • Don't use in patients who are at risk of bowel perforation, e.g. intestinal obstruction patients
    • Side effects include - bloating (rarely obstruction), may take several days to work

Osmotic

  • e.g. Lactulose
    • These PO medications increase the water presence in the bowel as they are poorly absorbed and encourage osmosis
    • Used in constipated patients (and those with hepatic encephalopathy - see Liver Failure)
    • Don't use in patients at risk of bowel perforation, e.g. intestinal obstruction patients
    • Side effects include - cramps, flatulence

Stimulant

  • e.g. Senna
    • These PO medications stimulate peristalsis and secretion of water and electrolytes into the gut lumen, mechanism of action is not clear, thought to act on enteric nervous system
    • Used in constipated patients and those undergoing 'bowel prep' to clear the bowel before a medical intervention
    • Don't use in patients at risk of bowel perforation, e.g. intestinal obstruction patients, don't use long term (see below)
    • Side effects include - cramps short term, atonic colon long term (as there is damage to the enteric nerve plexus)

Softeners

  • e.g. Sodium Docusate
    • These can be given PO/rectally and soften the stool
    • Used in constipated patients and those with impacted faeces, also used in patients with anal pathology (e.g. fissures) to aid the passage of faeces and reduce pain
    • Don't use in small children (<3years)
    • Side effects include - rash with sodium docusate

Diarrhoea

Key in the management of diarrhoea is to ensure that the patient is adequately hydrated, 1st line treatment is Oral Rehydration Therapy (ORT) or if the patient is severely dehydrated they may need to be admitted to hospital for IV fluids.

Acute infectious diarrhoea is often self limiting and does not need antibiotic treatment, but if certain pathogens are suspected then antibiotic therapy should be given. e.g. :

  • Cholera
  • Salmonella
  • Shigella
  • Campylobacter

Salmonella and cholera are treated with a tetracycline antibiotic, shigella with ampicillin and campylobacter with ciprofloxacin. It is important to confirm the presence of suspected pathogens as unnecessary antibiotic treatment of diarrhoea may lead to the development of c.diff. proliferation.

In chronic diarrhoea (and sometimes in acute) it may be deemed appropriate to give an anti-motility drug, e.g. loperimide. These PO medications work by acting on opioid receptors in the enteric plexi to reduce motility (increase tone). Do not give in IBD patients or children. Side effects include nausea and vomiting, cramps.