1. 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

2. Outline ● dyspepsia ● gastroesophageal reflux disease (GERD) ● peptic ulcer disease ● Barrett’s esophagus ● Helicobacter pylori

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

4. 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

5. Functional dyspepsia Differential diagnosis Functional (nonulcer) dyspepsiaUp to 70 percent Peptic ulcer disease15 to 25 percent Reflux esophagitis5 to 15 percent Gastric or esophageal cancer< 2 percent Abdominal cancer, especially pancreatic cancerRare Biliary tract diseaseRare Carbohydrate malabsorption (lactose, sorbitol, fructose, mannitol)Rare Gastroparesis Rare HepatomaRare Infiltrative diseases of the stomach (Crohn disease, sarcoidosis)Rare Intestinal parasites (Giardia species, Strongyloides species)Rare Ischemic bowel diseaseRare Medication effects (Table 3)Rare Metabolic disturbances (hypercalcemia, hyperkalemia)Rare PancreatitisRare 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

6. 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

9. 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 2013;347:f5059

10. What is GERD? Picture credithttp://blog.givelify.com/wp-content/uploads/2014/07/Princess_Bride_That_Word.jpg

11. 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; 108:308 – 328.

12. Kahrilas PJ, Boeckxstaens G. Failure of reflux inhibitors in clinical trials: bad drugs or wrong patients? Gut 2012;61:1501–1509.

15. GERD treatments ● lifestyle modification ● medication ● surgery

21. Kahrilas PJ, Boeckxstaens G. Failure of reflux inhibitors in clinical trials: bad drugs or wrong patients? Gut 2012;61:1501–1509.

23. Top 100 Most Prescribed, Top Selling Drugs. http://www.medscape.com/viewarticle/825053

24. PPI Complications ● community-acquired pneumonia ● hip fracture ● infectious gastroenteritis ● C difficile ● Vitamin B12 deficiency/malabsorption ● secondary hypergastrinemia ● hypochlorhydria Kahrilas PJ, Gastroesophageal reflux disease, NEJM 2008;359:1700-7.

25. Katz et al, Guidelines for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroenterol 2013; 108:308 – 328.

26. Peptic ulcers can be deadly Rudyard Kipling J. R. R. Tolkien James Joyce

27. Ulcer complications ● bleeding ● perforation ● penetration

28. 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.

31. Low-risk lesions Gralnek IM, et al. Management of acute bleeding from a peptic ulcer. NEJM 2008;359:928-37

35. Recommended treatment to prevent ulcer rebleeding Laine L and Jensen DM. Management of patients with ulcer bleeding. Am J Gastroenterol 2012; 107:345–360;

36. Peptic ulcer treatment

38. All NSAIDs are associated with GI bleed

40. Barrett’s esophagus Spechler SJ and Souza RF. Barrett’s esophagus. N Engl J Med 2014;371:836-45.

43. Helicobacter pylori

44. 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

45. 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 <55 yr and no alarm symptoms