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.)
2 Non Ulcer Dysphagia
3 IBS
4 Somatic Complaints of Psychological Diseases.
5 Acute Pancreatitis
6 Chronic Pancreatitis
7 Acute or Chronic Cholecystitis
8 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.