Let me ask OK you few doctor questions AhmedAnalysis Bio-Psych-Social
Bio-Psych-SocialBio 6-month history of intermittent upper gastrointestinal symptoms. He describes an epigastric and retrosternal burning sensation but finds it difficult to decide in which of these areas symptoms are predominant. He occasionally notices regurgitation and feels nauseated. Eating, swallowing, postural change, or exercise do not influence her symptoms. Antacids provide some relief. Unremarkable past history and family history.Psycho He feels unwell but the pain does not affect his life or his sleeping frequentlySocial He is smoker for >15 years , school teacher and a father of 4 children
Acute GI bleeding Progressive weight lossPersistent vomitingIDAEpigastric massProgressive dysphagia
I don’t What dothink it is you think bad you have ?ICEE Idea/Concern/Expectation/Effect
Risk factor and History • Past medical Hx: – Previous ulcer, GI bleed – DM, hypo/hyperthyroidism, parathyroid dis. – Colitis, diverticulosis, liver disease – Previous Upper GI series, OGD, Abdo U/S – Anxiety, stress, depression.
Risk factor and History Drug Hx:- iron, NSAIDs, bisphosphonates, antibiotics, etc.Life style Hx:• Diet (fatty, big meals)• Smoking• Alcohol use• Exercise• Family Hx:
Analysis Bio-Psych-Social• Psychosocial:• Ideas - Ideas and beliefs of the patient towards his illness• Concern - Patient might think that this complaint is due to cancer, ulcer or other serious disease, he might also feel concern that he could not work because of this problem.• Expectations:• Patient may expect any of the following:• Reassurance• Investigation, endoscopy - Barium meal• Peferral• Sick leave
Risk factor and History• Effect on life: – You need to explore the effect of this problem on his family, work, etc.• Depression, anxiety and stress: – Screen your patient for depression, anxiety and stress and go in details when needed.• Supporting system: – Sources of support at home, work, friends, community.
• Vital signs: • Signs anemia Weight – Brittle nails Height. – Cheilosis Blood Pressure. – Pallor palpebral mucosa or Pulse. nail beds Respiratory rate, Temperature . • Other – Teeth (loss enamel) – Lymphadenopathy - Virchow’s nodeRespiratory & Cardiovascular – Acanthosis nigrans Examination. – Hypo/Hyperthyroid
• Abdominal Examination: – Epigastric tenderness – Palpable mass – Distention – Colon tenderness – Jaundice – Murphy’s sign – Stool for OB – Hernia
Let’s GO Case Approach Knowledge Study If you Don’t know it, you will Not see it
It is a group of symptoms characterized by upper abdominal discomfort, retrosternal pain, vomiting, heartburn, upper abdominal fullness and feeling full earlier thanexpected when eating.
Prevalence: Surveys carried out in western countries reported that: between 23-41%. Only 25% of dyspeptic populations visit their own doctors (About 4% of G.P.) Only 10% of the patients with dyspepsia are referred to hospital .
Functional Dyspepsia• The most common cause overall.• Defined as: – at least 12 weeks (need not be consecutive) within the last 12 months of: • Dyspepsia • No evidence of organic disease • Dyspepsia not exclusively relieved by defecation or associated with change in stool frequency or form (i.e. not IBS).
Pathophysiology• The pathophysiology of dyspepsia is not well understood.• Researchers have focused on several key factors: – (Motility Disorders) vs .( Nonmotility Disorders). – Psychosocial factors.
Abnormal Fundic Relaxation in Response to Meal in Functional Dyspepsia Normal Fundic accommodation or receptive relaxationMeal Impaired fundic accommodationFunctional with a redistribution ofdyspepsia food to antrum
NONMOTILITY DISORDERS• with motility disorders, there is little correlation between symptoms and severity of duodenitis, and no relationship between treatment and improvement of mucosal appearance on endoscopy.• One of the most prevalent theories currently being evaluated is the possible involvement of H. pylori infection in non-ulcer dyspepsia (as in ulcer disease).
PSYCHOSOCIAL FACTORS • Patients with nonulcer dyspepsia are more likely to have symptoms of anxiety and depression than are healthy persons or patients with ulcers. • Multiple somatic complaints also are more common in patients who have nonulcer dyspepsia. • A history of child abuse has been linked to the symptoms of nonulcer dyspepsia. • Stress from life events also has been correlated with these symptoms and has been linked to exacerbations of nonulcer dyspepsia.
Specific investigations- Depend on expected cause:• Usually we use the invasive procedure (endoscopy) to exclude the serious causes epically with patents have alarm symptoms:• Alarm symptoms: – Age > 45 – Weight loss – Bleeding – Palpable mass – Dysphagia
Specific investigations• Peptic ulcer disease : – Hx : Past history of ulcers, NSAIDs, Smoking. – Dx: Endoscopy (0.99 specificity)• Gastric ulcer or Duodenal ulcer :• Dx : Endoscopy (0.98 specificity)
Specific Investigations:• Gastroesophygeal reflux ( GERD): – Hx : Heartburn or regurgitation symptoms, aggravated when supine, chronic cough Dx: – Omeprazole Test (0.89 specificity) – Endoscopy. – 24 Hrs PH – monitoring ,
Key Points • Step One: Hx & Px – attempt to establish a specific diagnosis • Step Two: Consider Cancer – urgent endoscopy if red flags • Step Three: Treat for Non-Ulcer Dyspepsia – Test & Eradicate H. pylori – Acid suppression or Prokinetics x 1 month • Step Four: Endoscopy – Endoscopy if still symptomatic • Step Five: – Post-Endoscopy Management
Management:• Clarification; Explanation: – Nature of the problem. – What is ulcer & non-ulcer dyspepsia. – Prognosis: • Ulcer dyspepsia can be treated effectively. • Non-ulcer remains recurrent since the cause is unclear.
Gastroesophegeal reflux diseas GERD: 2- Proton pump inhibitor ( PPI) 1- Histamine -2 receptor antagonist ( H2RR ) Normal dose for 2-4 wks and follow up.
Helicobacter pylori eradication• Regimen A: Clarithromyc PPI Amoxicillin in - Duration: 2 weeks and follow up. - 50% have mild side effect . - 0.1 – 0.5% have pseudomembranous colitis.
In Saudi Arabia:According to the latest studies :1- clarithromycin 500mg BID – 10 days clarithromycin 500mg BID – 10 days2- amoxicillin 1000mg BID – 10 days3- omeprazole 20mg BID – 6/52 1000mg BID – 10 days amoxicillin omeprazole 20mg BID – 6/52
Regimen B:1- Bismuth subsalicylate ( 2 tablets 4 times /day)2- Metronidazole. ( 250 mg 4 times /day)3- tetracyclin ( 500 mg 4 times /day)4- H2RR (normal dose ) or PPI ( high dose ).- Duration : 2 weeks and follow up.
Peptic ulcer ( H.Pylori negative )- H2RR or PPI :For duodenal ulcer : normal dose .For gastric ulcer : H2RR normal dose or double.Duration : 4 - 8 weeks and follow up.
Treatment of functional Dyspepsia• Reassure.• Modify Life style and avoid risk factor .• Psycho social Hx ( screen for depression )• Prescribe non pharmacological and pharmacological treatment.• Observation and follow up .
Functional dyspepsia - H2RR or PPI ( normal dose). - Duration : 4 weeks and follow up.
Prevention: • Lifestyle modification. (eating habits), • Psychosocial state: screen for depression. • Stop smoking, • Regular exercises. • Avoid irrational use of NSAIDs.