common gastric problems for interns: dyspepsia and PU

1. COMMON GASTRIC
PROBLEMS FOR
INTERNS
FACEBOOK: HAPPY FRIDAY KNIGHT

2. An approach to epigastric pain
Alarm features of dyspeptic patients
GI evaluation of IDA
Common disease: Peptic Ulcer
OUTLINIES

3. An Approach to Epigastric Pain
Anatomical approach
Pathophysiological approach
LORDCAFT

4. Mayumi T et al. The Practice Guide
lines for Primary Care of Acute Ab
domen 2015. Journal of General a
nd Family Medicine 2016;7:(1);5–52

5. Longo DL, Fauci AS. Harrison’s g
astroenterology and hepatology.
2nd ed. McGraw-Hill education,
2013.

6. Longo DL, Fauci AS. Harrison’s gastroenterology and hepatology. 2nd ed. McGraw-Hill education, 2013.

7. How to approach epigastric pain
by HAPPY FRIDAY KNIGHT:
1. R/O life-threatening chest pain: MI >>> EKG
2. R/O surgical condition that require emergency
operation: PU perforation >>> AXR
3. R/O surgical condition that require urgency operation:
acute cholecystitis, cholangitis >>> US bedside
4. R/O condition that require hospitalization: acute
pancreatitis >>> serum + urine amylase
5. Treatment as appropriate: gastritis

8. Epigastric Pain from GI Diseases
= dyspepsia
S/S:
Rome IV criteria
Excluding heartburn and regurgitation***
Epigastric pain
Epigastric fullness
Indigestion
Upper abdominal discomfort AFTER eating

9. Dyspepsia: Alarm features
AKA alert features, red flag, warning signs
GI malignancies are uncommon but must be ruled
out!!!
Indicate endoscopy
New onset at age > 50 years
Fail medication
Signs of malignancy:
GI bleeding
Weight loss
Dysphagia
Leea SW, Changa CS, Yeha HJ, Liena H
C, Leea TY, Penga YC. The Diagnostic V
alue of Alarm Features for Identifying T
ypes and Stages of Upper Gastrointesti
nal Malignancies. Gastroenterol Res. 20
17;10(2):120-125
แนวทางเวชปฏิบัติในการดูแลรักษาผู้ป่วย Dyspepsia
ในประเทศไทย ปี พ.ศ. 2561

10. Investigation: Upper GI endoscopy
Esophagogastroduodenoscopy (EGD)
Gastroscopy
Flexible esophagoscopy
https://www.mountsinai.org/health-library/discharge-instruction
s/egd-discharge

11. https://www.viralpatelmd.com/upper-endoscopy-egd-best-doctor-to-do-egd-in-dallas-rockwall-rowlett-tx/

12. Gastric Cancer
https://assets.cureus.com/uploads/figure/file/133674/lightbo
x_70f91ac0cd5111ea8da6c175d5a684ee-insert-gastric-conve
rted-edited.png
https://www.endoscopy-campus.com/wp-content/uploads
/Paris-Klassifikationen-oberflaechlicher-Tumoren-im-Mage
n-Abb-01.jpg

13. Gastritis and Gastric Ulcer
https://muschealth.org/-/sm/health/ddc/i/gastritis.ashx?
h=212&w=270&la=en&hash=58F8940E8526805A04A12
A755DF2CD2FBF20CD30
https://glutenfreeworks.com/health/gastric-ulcer/

14. GI Evaluation of IDA
Ko CW, Siddique SM, Patel A, Harris A, Sultan S, Altayar O, Falck-Ytter Y. AGA clinical practice guidelines on gastrointestinal ev
aluation of iron deficiency anemia. Gastroenterol. 2020;159:1085-1094.

15. AGA recommend BIDIRECTIONAL ENDOSCOPY in
asymptomatic patients with IDA
Postmenopausal women
Men
GI Evaluation of IDA

16. Peptic Ulcer Disease (PU)

17. Peptic Ulcer Disease
focal defects in the gastric or duodenal mucosa
that extend into the submucosa or deeper
Acute or chronic

18. Peptic Ulcer Disease: Balance
Brunicardi FC et al. Schwartz’s Principle of surgery, 10th ed. McGraw-Hill, 2015.

19. Peptic Ulcer Disease: Causes
Brunicardi FC et al. Schwartz’s Principle of surgery, 10th ed. McGraw-Hill, 2015.

20. Peptic Ulcer Disease: HP infection
Helicobacter pylori
Specialized flagella
Urease rich supply
50% of world population has infected H.pylori
Should we empirical treat???

21. Peptic Ulcer Disease: NSAIDS
Brunicardi FC et al. Schwartz’s Principle of surgery, 10th ed. McGraw-Hill, 2015.

22. Peptic Ulcer Disease:
Modified Johnson
Classification
Brunicardi FC et al. Schwartz’s Principle of surgery, 10th ed. McGraw-Hill, 2015.
I: lesser curve, incisura
II: body, incisura + DU
III: prepyloric
IV: high lesser curve, near
EGJ
V: medication (NSAIDS) –
induced >>> anywhere

23. Peptic Ulcer Disease: Complications
Bleeding
Perforation
Obstruction

24. Bleeding Peptic Ulcer
Most common cause of UGIB
Abdominal pain: uncommon
Melena/hematemesis
Shock
Mortality rate 14%
Management: ABCDE

25. Bleeding Peptic Ulcer: ABCDE
Airway: consider ETT when massive bleeding
Breathing: oxygen supplement
Circulation: resuscitation, blood transfusion when Hb
< 7 (Hb < 10 when VB, HM unstable, CVD)
Drugs: PPI
endoscope

26. Bleeding Peptic Ulcer:
Risk Stratification
Evaluate for
management
Admit or OPD
Timing for
endoscope
Re-bleeding risk
Clinical (pre-endoscopic):
Glasgow-Blatchford
Clinical Rockall score
AIM65
Clinical and endoscopic:
Rockall
Endoscopic
Forrest

27. Ramaekers R, Mukarra
m M, Smith CA, et al. T
he predictive value of
preendoscopic risk scor
es to predict adverse o
utcomes in emergency
department patients wi
th upper gastrointestin
al bleeding: a systemat
ic review. Acad Emerg
Med 2016;23:1218-27.

28. Bleeding Peptic Ulcer:
Timing for Endoscopy
High risk
hemodynamic unstable
NG fresh blood
urgent endoscopy within 12 hours
Hemodynamic stable:
within 24 hours
Kumar NL, Travis AC, Saltzman JR. Initial management and timing of endoscopy in nonvariceal upper GI bleeding. Gastrointest
Endosc. 2016;84:10-7.

29. https://www.grepmed.
com/images/11423/bl
eeding-peptic-gastroe
nterology-classificatio
n-grading

30. Bleeding Peptic Ulcer:
Endoscopic Treatment Modalities
Injection therapy
Thermal therapy
Mechanical hemostasis devices

31. Bleeding Peptic Ulcer:
Time to Surgery
High rebleeding risk:
Hemodynamic instability
Active bleeding at endoscopy
Large ulcer size > 2 cm
Ulcer location
Posterior duodenum
Lesser curvature
Severe comorbidity
Bleeding ulcer refractory to endoscopic treatment
Uncontrolled bleeding by endoscopy
Rebleeding after repeated endoscopic treatment

32. Brunicardi FC et al. S
chwartz’s Principle of
surgery, 10th ed. McG
raw-Hill, 2015

33. Peptic Ulcer Perforation
Generalized peritonitis
Epigastric pain
Board-like rigidity: low sensitivity

34. PU Perforation: Plain Radiograph
Bowel-related signs: double bowel wall, triangle
Peritoneal ligament-related signs: football, falciform
ligatment, inverted V, urachus
RUQ signs: cupula, fissure for ligamentum teres,
hepatic edge, lucent liver, Morrison pouch, periportal
free gas
https://radiopaedia.or
g/articles/pneumoperi
toneum

35. Brunicardi FC et al. Sc
hwartz’s Principle of s
urgery, 10th ed. McGr
aw-Hill, 2015

36. Obstructing Peptic Ulcer
Acute ulcer: edema
Response to PPI
Chronic ulcer
More common
Treatment: balloon dilatation and surgery

37. Intractable or Non-healing PU
Brunicardi FC et al. Sc
hwartz’s Principle of s
urgery, 10th ed. McGr
aw-Hill, 2015

38. Conclusion
Other causes of epigastric pain other than dyspepsia
MUST be ruled out
Do not forget to look for alarm features in dyspepsia
patients
Look for risk factors of PU and treat: H.pylori, NSAIDS,
smoking
Look for indication to EGD
Look for complications: UGIB, PUP, obstructing PU

39. References
Longo DL, Fauci AS. Harrison’s gastroenterology and hepatology. 2nd ed. McGraw-
Hill education, 2013.
Brunicardi FC et al. Schwartz’s Principle of surgery, 10th ed. McGraw-Hill, 2015.
Mayumi T et al. The Practice Guidelines for Primary Care of Acute Abdomen 2015.
Journal of General and Family Medicine 2016;7:(1);5–52
Leea SW, Changa CS, Yeha HJ, Liena HC, Leea TY, Penga YC. The Diagnostic Value
of Alarm Features for Identifying Types and Stages of Upper Gastrointestinal Malig
nancies. Gastroenterol Res. 2017;10(2):120-125
ศัลยศาสตร์ทั่วไป เล่มที่ 20, 27, 29. สมาคมศัลยแพทย์ทั่วไปแห่งประเทศไทย
แนวทางเวชปฏิบัติในการดูแลรักษาผู้ป่วย Dyspepsia ในประเทศไทย ปี พ.ศ. 2561
Ko CW, Siddique SM, Patel A, Harris A, Sultan S, Altayar O, Falck-Ytter Y. AGA clini
cal practice guidelines on gastrointestinal evaluation of iron deficiency anemia. Ga
stroenterol. 2020;159:1085-1094.

40. Ramaekers R, Mukarram M, Smith CA, et al. The predictive value of preend
oscopic risk scores to predict adverse outcomes in emergency department
patients with upper gastrointestinal bleeding: a systematic review. Acad Em
erg Med 2016;23:1218-27.
Kumar NL, Travis AC, Saltzman JR. Initial management and timing of
endoscopy in nonvariceal upper GI bleeding. Gastrointest Endosc.
2016;84:10-7.
References