Skenario English Blok 9

6th Scenario of 9th Block's tutorial

Author : Fauzan Kurniawan

What is dyspepsia?

Dyspepsia is a term which includes a group of symptoms that come from a problem in your

upper gut. The gut (gastrointestinal tract) is the tube that starts at the mouth and ends at

the anus. The upper gut includes the oesophagus, stomach and duodenum.

Various conditions cause dyspepsia. The main symptom is usually pain or discomfort in the upper

tummy (abdomen). In addition, other symptoms that may develop include :

- Bloating.

- Belching.

- Quickly feeling full after eating.

- Feeling sick (nausea).

- Being sick (vomiting).

Symptoms are often related to eating. It also include heartburn (a burning sensation

felt in the lower chest area) and bitter-tasting liquid coming up into the back of the throat

(sometimes called 'water brash') as symptoms of dyspepsia. However, these are now considered to

be features of a condition called gastro-oesophageal reflux disease (GORD).

Symptoms tend to occur in bouts which come and go, rather than being present all the time.

Most people have a bout of dyspepsia, often called indigestion, from time to time. For example,

after a large spicy meal. In most cases it soon goes away and is of little concern. However,

some people have frequent bouts of dyspepsia, which affects their quality of life.

What causes dyspepsia?

Common causes

Most cases of repeated (recurring) dyspepsia are due to one of the following:

1. Non-ulcer dyspepsia.

This is sometimes called functional dyspepsia. It means that no known cause

can be found for the symptoms. That is, other causes for dyspepsia, such as duodenal or stomach

ulcer, acid reflux, inflamed oesophagus (oesophagitis), gastritis, etc, are not the cause. The inside

of your gut looks normal (if you have a test called an gastroscopy (endoscopy). It is

the most common cause of dyspepsia. About 6 in 10 people who have recurring bouts of dyspepsia

have non-ulcer dyspepsia. The cause is not clear, although infection with a germ (bacterium) called

Helicobacter pylori (commonly just called H. pylori) may account for some cases.

2. Duodenal and stomach (gastric) ulcers.

An ulcer occurs when the lining of the gut is damaged and

the underlying tissue is exposed. If you could see inside your gut, an ulcer looks like a small, red

crater on the inside lining of the gut. These are sometimes called peptic ulcers.

Duodenitis and gastritis (inflammation of the duodenum and/or stomach) - which may be mild, or

more severe and may lead to an ulcer.

3. Acid reflux, oesophagitis and GORD.

Acid reflux occurs when some acid leaks up (refluxes) into

the oesophagus from the stomach. Acid reflux may cause oesophagitis (inflammation of the lining

of the oesophagus). The general term gastro-oesophageal reflux disease (GORD) means acid

reflux, with or without oesophagitis.

4. Hiatus hernia.

This occurs when the top part of the stomach pushes up into the lower chest

through a defect in the diaphragm. The diaphragm is a large flat muscle that separates the lungs

from the tummy (abdomen). It helps us to breathe. A hiatus hernia commonly cause GORD.

5. Medication.

Some medicines may cause dyspepsia as a side-effect.

Anti-inflammatory medicines are the most common culprits. These are medicines that

many people take for arthritis, muscular pains, sprains, period pains, etc.

For example:

• aspirin,
• ibuprofen, and
• diclofenac - but there are others.

Anti-inflammatory medicines

sometimes affect the lining of the stomach and allow acid to cause inflammation and

ulcers.

Various other medicines sometimes cause dyspepsia, or make dyspepsia worse. They

include:

• digoxin
• antibiotics
• steroids
• iron
• calcium antagonists
• nitrates
• theophyllines
• bisphosphonates.

H. pylori and dyspepsia

The germ (bacterium) H. pylori can infect the lining of the stomach and duodenum. It is one

of the most common infections in the UK. More than a quarter of people in the UK become

infected with H. pylori at some stage in their lives. Once you are infected, unless treated, the

infection usually stays for the rest of your life.

Most people with H. pylori have no symptoms and do not know that they are infected. However,

H. pylori is the most common cause of duodenal and stomach ulcers. About 3 in 20 people who

are infected with H. pylori develop an ulcer. It is also thought to cause some cases of non-

ulcer dyspepsia, duodenitis and gastritis. The exact way H. pylori causes problems in some

infected people is not totally clear. In some people this bacterium causes inflammation in the

lining of the stomach or duodenum. This causes the defence mucous barrier to be disrupted in

some way (and in some cases the amount of acid to be increased) which seems to allow the

acid to cause inflammation and ulcers.

Other uncommon causes of dyspepsia

Other problems of the upper gut such as stomach cancer and oesophageal cancer can cause

dyspepsia when they first develop.

Test for H. pylori infection and treat if it is present

A test to detect H. pylori is commonly done if you have frequent bouts of dyspepsia. As

mentioned, it is the underlying cause of most duodenal and stomach ulcers and some cases of

gastritis, duodenitis and non-ulcer dyspepsia. One of supporting tests that can detect H. pylori is :

A breath test can confirm that you have a current H. pylori infection. A sample of your breath

is analysed after you have taken a special drink. Note: prior to this test you should not have

taken any antibiotics for at least four weeks. Also, you should not have taken a proton pump

inhibitor (PPI) or H2-receptor antagonist (also known as an H2 blocker medicine) for at least two

weeks. (These are acid-suppressing medicines - discussed further below.) Also, you should not eat

anything for six hours before the test. The reason for these rules is because they can affect the

test result.

Treatment

Offer eradication therapy to all patients with positive tests for H. pylori.

There are several regimes. There is probably no difference between the various PPIs available,

provided that they are used at the equivalent dose and this is a matter of personal choice.

The following is based on the recommendations of NICE :

1. Recommended first-line regimes

These are optimum regimes on current evidence:

- A seven-day course of PPI plus either amoxicillin 1 g and either clarithromycin 500 mg or

metronidazole 400 mg - all three given twice a day.

- Choose the treatment regime with the lowest acquisition cost and take into account previous

exposure to clarithromycin or metronidazole.

- For people allergic to amoxicillin use a PPI, clarithromycin and metronidazole - all twice a day

for seven days.

- For people allergic to amoxicillin who have previously been exposed to clarithromycin, use a

PPI, metronidazole, tetracycline and bismuth.

2. Second-line H. pylori eradication regimes

- For people who do not respond to first-line therapy, offer a PPI, amoxicillin and either

clarithromycin or metronidazole (whichever was not used first-line).

- For people who have had previous exposure to clarithromycin and metronidazole, offer a

seven‑day, twice-daily course of treatment with a quinolone or tetracycline (whichever has the

lowest acquisition cost).

- For people who are allergic to penicillin and who have not had previous exposure to a

quinolone), offer a seven‑day, twice-daily course of a PPI, amoxicillin and either metronidazole

or levofloxacin.

- For people who are allergic to penicillin and who have had previous exposure to a quinolone,

offer a PPI, amoxicillin, bismuth, metronidazole and tetracycline.

Prevention

- Studies suggest that probiotics and lactobacilli reduce the activity of H. pylori.

- It is generally advocated that H. pylori testing should be driven purely to confirm an infection as

the cause of disease and then to eradicate it.

- The risk : benefit ratio of H. pylori eradication in asymptomatic patients requires further evaluation.

- A large trial of Asian patients provided moderate evidence that eradication reduced the risk of

gastric carcinoma but studies of patients from other ethnic communities are required.

- H. pylori infection has been implicated in the etiology of coronary heart disease but this has

recently been refuted. Likewise, evidence linking cirrhosis , gastroduodenal ulcers and H. pylori

is lacking.

Sources 

- www.patient.co.uk/health/dyspepsia-indigestion

- www.patient.co.uk/doctor/helicobacter-pylori-pro