Zero to GP - GP Revision Podcast
The Zero to GP podcast helps you learn and revise the key facts that you need for your GP exams. It is for educational purposes only. The information is not medical advice and should not be used to guide patient management. There may be errors - always check with the appropriate policies, guidelines and colleagues.
Zero to GP - GP Revision Podcast
Dyspepsia and GORD - Essential GP Revision
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Hi, this is Tom and welcome to the Zero to GP podcast. In this episode, we're going to be going through dyspepsia, which basically means indigestion. The format of these episodes, as always, is I'm going to present you with cases and ask you questions. I want you to come up with your answer. Ideally, write it down or say it out loud to really commit to the answer, and then we'll go through explanations. So let's jump straight into this episode. The first case is a 46-year-old man and he presents to his GP with two months of upper abdominal discomfort. He also has heartburn after eating. So he feels like acid is refluxing. He just has the indigestion symptoms. He hasn't got any vomiting. My question to you is, my first question, what symptom would you specifically ask about which would prompt an immediate two-week weight referral in this patient? The key symptom here is dysphagia, and that means difficulty swallowing. So if you said here's a sandwich, he tried to eat it, he would feel as though that got stuck halfway down on the way to the stomach. If someone has dysphagia at any age, they need an immediate two-week rate referral for upper gastrointestinal cancer, for example, esophageal cancer or stomach cancer. They need an endoscopy. My next question to you is this patient has dyspepsia or indigestion. What are the key trigger foods that can worsen indigestion or dyspepsia, acid reflux, heartburn, and so on? The common key foods for worsening dyspepsia are fatty or spicy meals, so think about greasy, sort of spicy takeaways. Coffee can particularly exacerbate reflux, chocolate and finally tomatoes. The next question is what psychosocial kind of social triggers or psychological triggers can worsen dyspepsia and reflux?
SPEAKER_00One is stress.
SPEAKER_01So often stress can bring on episodes of reflux and dyspepsia. Anxiety and depression can also cause it. And key triggers in the social history are alcohol consumption, alcohol worsens dyspepsia and reflux, and it can irritate the lining of the stomach, causing upper causing gastritis and upper abdominal pain. And smoking is also a contributing trigger. My next question to you is what blood test would you consider in patients with dyspepsia and indigestion, reflux, upper abdominal pain?
SPEAKER_00What key blood test to consider? The key blood test is a full blood count.
SPEAKER_01The reason being is that in patients with uh, say, upper gastrointestinal cancers, if they have some bleeding from the cancer in the stomach or the esophagus, they could become anemic. And another red flag is raised platelets. If there's raised platelets on the full blood count, that can also indicate malignancy and is a red flag. Okay, so we've got a 26-year-old man, he's got two months of dyspepsia. You take a full history and examine him, there's no red flags, so you're not worried about cancer in this patient. And he's also addressed lifestyle factors. So he's done what he can to reduce alcohol, smoking, stress, and avoid trigger foods. What's going to be your initial medical or your initial management as a GP in this scenario. So you can pick which option you want to choose from these two. The first option is to give him a month-long course of a proton pump inhibitor at the full dose, for example, ameprozole or lanzozole. So you give a month-long trial of a proton pump inhibitor that reduces the amount of acid in the stomach, and that the aim is to reduce the acid and reduce his symptoms, get his symptoms under control, and then he may not need any further treatment after that. So a month of treatment may be enough to settle things down. The other option, the alternative option, is to test him for H. pylori infection. Helicobacter pylori is a bug that can infect the stomach and cause gastritis, inflammation of the stomach, and irritation there, and symptoms of dyspepsia. So you choose one of these two and give them a try. Let's say you try one of them and he comes back after a month or two and the symptoms are persisting or reoccurring. So let's try he's tried a proton hum inhibitor for a month, symptoms persist or they settle but reoccur, or he's had a H. pylori test, it's negative, or it's positive and he's treated.
SPEAKER_00What do you do at that point? The answer's fairly simple.
SPEAKER_01You try the other strategy. So let's say he had a proton pump inhibitor, instead you test him for H. pylori. Let's say he had the H. pylori test, instead you give him the proton pump inhibitor. So you try one, if it doesn't work, you try the other. Quite simple. The next question is what is the test for H. pylori?
SPEAKER_00How are you going to test for Helicobacter pylori infection?
SPEAKER_01So there are two possible tests you can use, depending on your local setup and the local lab. Where I work or where I've always worked, uh, you test for the you do the stool antigen test. So you give them a sample pot, tell them to bring a sample of poo or stool back to the surgery, um, and send it off for the stool antigen. So you're looking for part of the Helicobacter bug in the stool. The other option is the carbon-13 urea breath test. So they pick up a kit, they drink a drink that contains a carbon-13 labeled urea, and then that gets digested, it gets metabolized by the Helicobacter, and they breathe out, they then uh breathe into a machine that tries to detect carbon dioxide with this carbon-13 on it. And if that's positive, it suggests Helicobacter pylori infection. That's a little bit more involved, but you have the choice of those two tests. One or two very important points regarding testing for Helicobacter pylori. Firstly, they should have no proton pump inhibitors for at least two weeks before the test. If they're taking proton pump inhibitors, this can give a false negative H. pylori test. Also, they need to have no antibiotics for at least four weeks before the test. If they take antibiotics before the test or during the test, it could also give a false negative. The next question I have is, let's say H. pylori, the H. pylori test is positive. What is the treatment for H.
SPEAKER_00pylori? The standard treatment for H.
SPEAKER_01pylori is triple therapy. This involves a full-dose proton pump inhibitor, for example ameprazole or lasoprazole, plus two antibiotics. And you could kind of pick two from amoxicillin, chlorithromycin, and metronidazole. So a combination of two of those, so it could be amoxillin plus chlorithromycin or amoxicillin plus metronidazole. If they're allergic to penicillin, you could use chlorithromycin plus metronidazole. So you need two of those antibiotics. So three drugs, and it's for a total of seven days, and that should treat and clear the H. pylori infection. Okay, onto a new case. We've got a 52-year-old woman, and she presents with six months of acid reflux and dyspepsia. She's already made lifestyle changes. She's had a H. pylori test, which was negative. She had a full dose proton pump inhibitor for one month, but her symptoms remain. She's still having these symptoms of acid reflux and dyspepsia. So she's been through our full kind of initial treatment. She also has no red flag, so no weight loss, no dysphagia. She's otherwise well.
SPEAKER_00What is the next step?
SPEAKER_01The next step is to try a histamine H2 receptor antagonist. We used to use renitidine, but we no longer use that, it's no longer available. So the typical choices are fermotiden or nizatidine. Let's say you try a histamine H2 receptor antagonist, like fermotive, and that doesn't work.
SPEAKER_00What's the next step after that? This would be very treatment-resistant dyspepsia.
SPEAKER_01They need a referral for an endoscopy. Okay, next case is a 60-year-old man, and he's had lanzoprazole for four years. So let's say Lanzoprazole worked really well, uh, treated his dyspepsia, he stopped the Lanzoprazole and it kind of came back, so you agree to carry on with it, and he's now been on it for four years. What is the key electrolyte disturbance that can happen with long-term proton pump inhibitors? The answer is hypomagnesemia, so a low magnesium level in the blood. If you see a patient with a low magnesium, check whether they're on a proton pump inhibitor, as that's quite commonly the cause. The next question I have is in patients on long-term proton pump inhibitors, what nutrient deficiencies do you need to think about. Proton pump inhibitors can inhibit the absorption of certain nutrients, and those key ones are B12, so you can have B12 deficiency, and the other one is iron, so they can develop iron deficiency. So if you have a patient with low B12 or low iron, check about pro whether they're on a proton pump inhibitor, as that can be the cause as well. Okay, on to the next case, which is a 48-year-old man, and he has a history of dyspepsia. It's a bit treatment resistant, he gets referred for an endoscopy, and the endoscopy shows esophagitis. So the the part of the esophagus at the bottom is inflamed. And he's diagnosed this is endoscopy proven gastroesophageal reflux disease, or gourd. Next question is what change would you advise to hit for um advise for him about his evening meal? So you can recommend he eats at least three to four hours before he goes to bed. If he's got proven gastroesophageal reflux disease and he eats 30 minutes before he goes to bed, all that food and stomach acid and everything in the stomach is gonna reflux during the night and cause problems. The next question is what change would you advise to his sleeping environment if it's practical and possible? You can advise him to raise the head of the bed by 10 to 20 centimeters, so he could put bricks or blocks of wood under the back of the one end of the bed to raise it up, and this will make him slightly more vertical during sleep, and this will help gravity to pull uh the food and the acid and so on down into the stomach as opposed to refluxing up into the esophagus. Importantly, don't recommend extra pillows. So someone might you might think, okay, he needs to keep his head up and more vertical so he could put pillows under his head to keep it up and prevent reflux. The problem with that is it squashes the stomach and that will just worsen reflux. You want to raise the whole bed up so the whole bed is tilted slightly up, as opposed to just raising up the head. Okay, next question is what would be the initial treatment in this patient who has proven esophagitis on his endoscopy. So if proven esophagitis, he needs a full dose proton pump inhibitor for four to eight weeks to help that settle down, depending on the severity. And then if it's severe esophagitis, he can continue that proton pump inhibitor long term to help reduce the esophagitis and then maintain it and prevent it reoccurring. My next question is would you test this patient in this scenario for H. pylori? It's got a history of dyspepsia and endoscopy shows esophagitis and proven gastrosophageal reflux disease. Does he need H.
SPEAKER_00pylori testing? The answer is that H.
SPEAKER_01pylori testing is not needed in this scenario because endoscopy has proven that it's gastroesophageal reflux causing his symptoms rather than H. pylori infection causing gastritis and stomach irritation. The next question is what about if he has persistent or recurrent symptoms and he's proven to have gastroesophageal reflux disease?
SPEAKER_00How would you manage that?
SPEAKER_01So you can kind of take a bit of a stepwise approach. If he has recurrent symptoms, let's say he's had his treatment, it's settled, but then symptoms reoccurred, he could have a further dose, a further course of the proton pump inhibitor. So he could go back on it and he could potentially stay on it for a long term if needed. The other option is if he's already on the treatment and he's got recurrence of symptoms, he could have a double proton pump inhibitor dose for a month to help get on top of symptoms and then drop back down to the normal full dose. And another option is to add a histamine-2 receptor antagonist, for example formatidine, and this could be used short term to help control symptoms. This is particularly effective at nighttime if there's you can take it in the evening if there's nocturnal symptoms, so symptoms bothering him at nighttime. Okay, on to the next case. You have a 78-year-old woman, and she comes in with upper abdominal pain and reflux symptoms. She's also had three kilograms of unexplained weight loss. So there's a big red flag there.
SPEAKER_00In this scenario, what is your management?
SPEAKER_01So she has upper abdominal pain and reflux and unexplained weight loss, she needs a two-week weight suspected cancer referral. She's gonna need an endoscopy to see if she has upper gastrointestinal cancer. So the nice guidelines in terms of esophageal or stomach cancer, are that if you have a patient who's aged 55 or above, plus they have unexplained weight loss, plus they have one of upper abdominal pain, reflux, or dyspepsia, they need a two-week weight referral. So those three criteria, aged 55 or above, weight loss and the upper GI symptoms, they get a two-week weight referral for esophageal or stomach cancer. Next, we've got a 63-year-old man. He's got upper abdominal pain and reflux symptoms, but he has no weight loss. So he's over 55, he's got the upper abdo pain and the reflux, but no weight loss. Our next question to you is which blood test would you use to decide on a referral for him? So in this scenario, he needs a full blood count to look for anemia or a low hemoglobin or a raised platelet count. So my next question is what referral are you gonna make if it turns out this man with um with upper abdominal pain and reflux, but no weight loss, what if he also has anemia or a raised platelet count? What referral are you gonna make at that point? So in this scenario, the NICE guidelines say a non-urgent direct access endoscopy referral. So not a two-week rate referral, not a referral to gastroenterology, a non-urgent direct access endoscopy. So you're referring directly from general practice for an endoscopy. Okay, on to our last case in this series, which is a 74-year-old woman, and she has long standing symptoms of reflux. And she has an endoscopy which shows Barrett's esophagus. My first question in this scenario is what histological change occurs in Barrett's esophagus? In Barrett's esophagus, there's a change in the lower esophageal epithelium, so the surface of the esophagus at the lower portion of the esophagus, and there's a change from the normal squamous epithelium, which is what normally lines the esophagus, to columna epithelium. Columna epithelium is the normal lining of the stomach, but not the esophagus. So there's a change from squamous to columna, and this change is called metaplasia. This is a key word. Metaplasia means a change from one type of epithelium to another.
SPEAKER_00My next question is, what's the main risk associated with Barrett's esophagus?
SPEAKER_01The main risk here is esophageal adenocarcinoma, so esophageal cancer. And this can happen as a result of Barrett's esophagus. My next question is what monitoring is going to happen for this patient now that she has Barrett's esophagus? She needs an endoscopy, and this will happen every two to five years depending on her specific changes and the severity and extent of the barrett esophagus. Let's say she has an endoscopy and it shows dysplasia in the barrels esophagus. What's the management if there's dyspl dysplasia of the cells there? So dis depending on the extent and severity of the dysplasia, she's going to need endoscopic treatment of that area, which could mean resection of the section of the esophagus with dysplasia or ablation, for example, with radio frequency ablation. So hopefully that episode on gastrosophageal reflux and dyspepsia was helpful. And remember if you're sitting your AKT exam for your GP exams anytime in the next sort of six or 12 months, there's some really good resources. Link in the description below, which involves the AKT revision book, the zero to GP.com site where there's practice questions to prepare for the exam, and my upcoming course in September, where it's a full day of going through key topics you need for your GP exams. So I hope to see you there. That's all in the description below, and I'll see you in the next episode.