August 2001

Pakistan

Jounal of Family Medicine

An overview of Acid Peptic Disease

Expert

Dr Arif M.Siddiqui

MBBS,MD,MRCP,FRCP(London,Edin,Glasg)

Associate Professor of Medicine

Allama Iqbal Medical College Lahore

Clinic:Hameed Latif Hospital

14- Abu Baker Block,

Garden Town,Ferozpur Road,Lahore.

Tel Office:5168660,Clinic:5862623,5862718,5837014,5837019,Fax = 5166501

Email :amsidiqi@brain.net.pk

National Academy of Family Medicine

Pakistan Society of Family Physicians

www.pakjfm.com

  Contents

Panel Interviews

Panel Interviews

Dr Arif Mehmood Sidiqi Page 2

Dr Ghias-un-Nabi Tayyab Page 8

Practical tips on Upper GIT Symptoms Page 10

Internet Corner

Helicobacter Pylori Page 15

Drug therapy of H Pylori Page 16

Dr Arif M.Siddiqui

MBBS,MD,MRCP,FRCP(London,Edin,Glasg)

Associate Professor of Medicine

Allama Iqbal Medical College

(Panel consisted of Dr Saleem A Rana,Dr Mehboob Ashraf,Dr Arshad Javaid Sh,Dr Liaqat Ali Ch.Choice of questions lied with the panel)

How do family physicians manage Acid Peptic Disease?

Job of primary care physicians is always more difficult than other physicians in one aspect.Illness does not manifest fully during initial days.Investigations are yet not there.Lot of diagnostic tools are missing or yet to be used.This is the setting where primary care physicians are working.Taking all these difficulties in account ,one has to say that job is being done pritty nicely.On the whole there are no major complaints about primary care level.

On the Use of H2 Antagonists and PPIs.Are these being overused?

Where ever these are being prescribed ,there is usually some indication.These are not being overused.

Definition of Acid Peptic Disease.

This term is not of technical nature.Upper G.I symptoms,or upper abdominal pain are more descriptive.All complaints in epigastrium or upper abdomen can be grouped together and then analysed.

Main causes of these symptoms can be described as under.

1 Peptic ulceration consisting of

• Duedenal Ulcer

• Gastric Ulcer

• GERD (Gasteroesophageal reflux disease.)

1.Non Ulcer Dysphagia

2. IBS

3. Somatic Complaints of Psychological Diseases.

4. Acute Pancreatitis

5. Chronic Pancreatitis

6. Acute or Chronic Cholecystitis

7. Malignancy in stomach,liver,biliary tract or pancreas or G I T .

There are many other rare causes.AMI or Acute Pancreatitis are severe emergencies and differential diagnosis should not be difficult when investigations like ECG are taken into account.Dr Arshad Javaid Sh pointed out that many young female patients present with epigastric pain rather than UTI symptoms while investigations reveal UTI as diagnosis.Dr Saleem Rana also supported this experience.PID could be causing lot of confusion if it is there according to Prof Arif Siddiqi.Dr Liaqat proposed that use of NSAIDS and other similar drugs might cause these problems when used for symptoms of UTI.

Diagnostic tools are ,as anywhere else,thorough history and proper examination.Pay special attention to

• Duration of Illness.Does the duration fit any particular disease.For example a patient having CA stomach can not have severe pain for two years.Normal weight or healthy appearance will contradict the diagnosis of any serious somatic disorder.

• General appearance and behaviour of Patient.Does he look like realy underweight,weak,suffering from pain,or anyother noticeable apparent feature which is either in support of or is against certain diseases.Thin lean underweight and anaemic patients propose a chance of serious disease.

• Any positive sign like fever,anaemia or anyother readily discernable feature.

• Age of patient is very important.When combined with duration of illness it should lead to possibility of specific diseases.A patient more than 50 years old with recent loss of weight or intractable pain should lead one to think of malignancy.

Alarming Symptoms.

There are certain alarming symptoms which should make all physicians alert to the possibility of some serious situation.These are followings.

• Anorexia of recent origin coupled with weight loss.

• Dysphagia of recent onset

• Odinophagia (feeling of discomfort or pain at specific point in retrosternal area after the food has passed down from this point)

• Hemetemisis

• Bleeding per rectum or black tarry stools.

• Severe epigastric pain.

• A man older than 50 years presenting with epigastric pain,recent weight loss and recent change in bowel habits.

Incidence of Psycho-Somatic Illness

More than 50 % of patients in the practice of Prof Arif Siddiqi belong to this group.These patients need very careful handling.They need help certainly.Physicians usually pick up the diagnosis quite early during the history taking.We do know that these patients need reassurance more than anything.But real reassurance comes after only and it is effective only when physician

• Examines thoroughly (spends more time than needed to ).For his satisfaction and for the satisfaction of patient.

• Orders minimal investigations and medicines.

• Explains things to the satisfaction of the patient.

If reassurance is attempted without these 3 basic steps than it may not succeed.

Relation to Meals of pain from upper G I T.

Pain from stomach,duedenum,oesophagus,pancreas,liver and biliary tract is most of the times related to food.So this aspect in the history should not be given much weight.It shall only be interpreted in the light of general impression.

Peptic Ulcerations

GERD/ Heart Burn

Here patient does not use words meaning pain.Rather some word which depicts feeling of burning is used.This is very important.Than it is mostly in the retrosternal area.Patient points to a wide and vague area above epigastrium.This is worsened after meals.Very small percentage of GERD patients have hiatus hernia.Majority has no such thing.Etiology lies in the transient lower oesophageal valve relaxation.During the relaxation of the valve lower oesophagus is exposed to acid,for which it is not made.So this exposure to acidic pH is the main cause.

Duedenal and Gastric Ulcers

Here words depicting pain are used.Burning is not prominent.Feelings of pain and multiple descriptions for painful feelings rather than burning are presenting symptoms.Patient points to (pointing sign) a small area in epigastrium with the finger rather than moving his fist on chest.

Precipitating factors: Careful and detailed history can identify use of NSAIDS,smoking or use of alcohal as contributing or precipitating factors.

Diagnosis

History and examination can make a good provisional diagnosis.Physician can commit his diagnosis on the basis of history and examination.Confirmation can come only with endoscopy.Even endoscopy will pick up cases if H2 Antagonists and PPIs have not been uses for healing.H2 antagonists can heal in 7 days and PPIs can heal in 3-4 days to the degree where endoscopy can not make diagnosis.Barium Meal studies are no more prefered for this purpose.Even under best circumstances where double contrast medias and techniques of follow through have been undertaken with flouroscopy ,sensitivity is only upto 15-20 %.

Indications for Endoscopy

• Where diagnosis of ulcer or GERD is contemplated.

• One of the alarming symptoms are present

• Confirmation of Helicobacter Pylori by biospy of gastric tissue.

Acute Pancreatitis/Peptic Ulcer

Diagnosis can be difficult in between these two conditions.Patient with Ac pancreatitis is usually sitting up in the bed,doubling on his epigastrium with the fist pressed against epigastrium.Response to drugs and progress over next 24-48 hours usually decide the diagnosis.Serum amylase and Serum Lipase help in the diagnosis.

Hiatus Hernia and GERD are not Synonimous.

Hiatus hernia can produce GERD.But most of the times it is asymptomatic.Very small percentage of patients of hiatus hernia have GERD and similary very few cases of GERD have hiatus hernia as the cause.Most of the patients of GERD have no hiatus hernia.Barium meal is here as ineffective to pick up the diagnosis as in peptic ulcer.

Enodscopy can diagnose Hiatus Hernia.These are rarely symptomatic.These can be managed with acid inhibitors.As long as patient remains symptom free no surgical option is justified because it requires major surgery.In situations where herniation is quite large and occupies large space in the chest cavity, surgery is mandatory.

Differential Diagnosis of Cholecystits,acute and chronic pancreatitis,IHD,

Only investigations like USG,ECG,serum amylase,serum lipase,CT Scan or MRI can make the final diagnosis.History and examination may give some idea but confirmation is required by investigations.CT Scan and MRI can only diagnsose chronic pancreatitis.Clinician must seek the help of investigations.

Helicobacter Pylori and Duedenal /Gastric Ulcers.

H pylori infection is not related or associated to GERD in etiological role.It is strongly associated with duedenal and gastric ulcers.More than 80 % of these ulcers are associated with the infection of H pylori.It is one of the three definite known causes of peptic ulcer.Other two are

• NSAIDS

• Zolinger Ellison Syndrome

• Helicobacter Pylori

Mode of Infection: Orofaecal

Reinfection: Common

Infection in contacts High incidence in family members

Confirmation of Infection: Serological testing for antibodies

Breath test.(not available in Pakistan)

(Ig G testing confirms one time exposure.If infection has not been eradicated in the past then eradication shall be tried.)

If endoscopy shows gasteritis then H.pylori must be demonstrated in the biopsy before it can be incremented in the eitiology.

Diet:

In patients of GERD

Frequent Small and Dry

Meals should be used to avoid reflex.Water can be used inbetween meals.No water shall be taken during meals.Large hotty meal should be avoided.

Therapy of Peptic Ulcerations.

• In severe pain ½ bottle of Mucaine susp taken at one time must give some relief ,may be temporary only.This can be used as diagnostic tool in rare cases where diagnosis is not sure ,as in AMI or Ac Pancreatitis.

• In GERD acid has to be inhibited throughout 24 hours for adequate healing.

• In Duedenal and gastric ulcers only nocturnal inhibition can lead to healing.

• Sucraflate has rating equal to H2 Antagonists.It can stick to ulcers very effectively.On endoscopic examination it may be visible 2-3 days after its use has been stopped.It is especially useful after scelotheray,in stress ulcers and GERD.Pregnancy is another situation where its safety is utilized.In stress ulcers aspiration pneumonia is much less if sucraflate is used.In hepatic insufficiency where drugs ,metabolized through Cytochrome P 450 are preferably avoided,it is again superior to other acid inhibitors.

H2 blockers,Proton Pump Inhibitors

These are remarkabley safe drugs.Occasional headache with H2 inhibitors and severe acute weakness with PPIs have been noticed in practice.Otherwise no important side effects have been observed.PPIs have been licensed to be used continously for one year.

This safety profile is helpful in managing GERD where therapy is almost lifelong with some periodic discontinuations.

H2 Antagonists are metabolized through cytochrome P 450.So these can interact with all drugs which share this pathway.One has to be careful.Pigmentation or fluid retension have been described but are rarely observed.Allergic rash has been seen both with H2 antagonists and PPIs.

Irritable Bowel Syndrome ( IBS).

This is a condition which surfaces in almost all situations.History usually dates back to months or years.Upper G I Symptoms are usually accompanied with some colonic features in IBS.If lower GIT symptoms are lacking then one should not consider IBS in differential diagnosis.Following are the symptoms of lower GIT or Colon.

• Alterations in bowel habits.Either Diarrhea or Constipation

• Change in the consistency of stools.May be very hard or quite liquid.

• Tenesmus,mucous in stools etc.

Management of IBS: Reassurance as described earlier forms more than 50 % of the management.Spasmolytics ,Isabghol Husk,antidepressents from all groups & benzodiazepines in smaller doses are usually helpful.Each individual needs different combinations.

Panel Interview

Dr Ghias-un-Nabi Tayyab.

MBBS,FCPS,MRCP

Associate Proffesor of Medicine

Allama Iqbal Medical College Lahore

(This was conducted ,recorded and published in Feb 99.)

Internet Corner: By Dr Khawar Hameed

(From Feb 99 Issue)

Helicobacter Pylori