Non-ulcer dyspepsia

Functional or non-ulcer dyspepsia is defined as at least three
months of dyspepsia in which no definite biochemical or
structural cause can be found to explain symptoms. There
is no confirmatory test and the diagnosis can only be made
after exclusion of the aforementioned structural causes.
A diagnosis of non-NSAID, non-H pylori ulcer should
only be entertained after:
■ exclusion of surreptitious NSAID use
■ careful exclusion of H pylori infection by several
biopsies
■ use of more than one H pylori diagnostic test
■ exclusion of confounders that would alter the sensitivity
of these tests, such as concurrent proton pump inhibitor
(PPI) use, recent antibiotic therapy or gastrointestinal
bleed.
Management involves 4-8 weeks of PPI therapy.
Although rare, exclusion of gastric carcinoma and other
upper gastrointestinal malignancies is important in those
with “alarm symptoms”, which the American Gastroenterological
Association guidelines summarise as:
■ age older than 55 years with new-onset dyspepsia
■ family history of upper gastrointestinal cancer
■ unintended weight loss
■ gastrointestinal bleeding
■ progressive dysphagia
■ odynophagia
■ unexplained iron-deficiency anemia
■ persistent vomiting
■ palpable lymphadenopathy
■ jaundice.
However, the presence of alarm symptoms has been
found to have poor predictive value for malignancy – rather
they alert the practitioner to the need for early endoscopy
to avoid the risk of missing a neoplastic process.
Functional dyspepsia can be difficult to manage. There
is evidence showing a small benefit with H pylori eradication
and PPI therapy. Although impaired gastric emptying
is noted in 25-40% of patients with functional dyspepsia,
there is inadequate evidence for the efficacy of
prokinetic therapy.
Despite its similarities to irritable bowel syndrome in
pathophysiology, there is also inadequate evidence to support
routine use of anti-depressants and psychological
therapies, although these should be considered as alternatives
for refractory patients. Counselling and reassurance
is essential.

EPIGASTRIC PAIN

peptic ulcer disease
(5-15%)
■ gastro-oesophageal reflux
disease (5-15%)
■ gastric or oesophageal
cancer (<2%)
■ gallstones/biliary pain
■ chronic pancreatitis/
pancreatic cancer
■ coeliac disease
■ lactose intolerance
■ medications – digoxin,
theophylline, erythromycin,
potassium supplements,
corticosteroids and NSAIDs
■ infiltrative diseases of
the stomach – eosinophillic
gastritis, Crohn’s disease,
sarcoidosis
■ metabolic causes –
hypothyroidism,
hypercalcaemia,
hyperkaelemia, heavy
metals
■ hepatoma and
steatohepatitis
■ intestinal angina
■ abdominal wall pain
■ Zollinger-Ellison syndrome
■ diabetic radiculopathy
Functional dyspepsia
(up to 60%)
■ caffeine, alcohol and
smoking can exacerbate
symptoms

PERINATAL DEPRESIION

■ Women often don’t recognise
themselves as being depressed
– they hide their symptoms or
present as the baby having the
problem.
■ When symptoms (anxiety,
lowered mood, tearfulness,
fears of not being able to cope
or being a bad mother) are
recurrent, severe or continue for
more than two weeks, the diagnosis
of depression or anxiety
disorder must be considered.
■ In PND many anxieties arise
from the lack a balanced
perspective. Cognitive behavioural
therapy is well suited to
address these issues.
■ Maternal depression is associated
with poor developmental
outcomes for children with
implications for the child’s
education and the potential for
mental illness as adults.
■ Mothers’ groups can be
beneficial if they are specifically
for women with PND but general
mothers groups can alienate
women if they feel different to
the other “coping” mothers.
■ Early detection and treatment
of PND may lead to remission
of symptoms and improvement
for mother, child and family
members, but it does not
guarantee a good outcome.
For some women, mother-infant
or long-term therapy is needed

Dermatology

Skin care advice for patients with lymphoedema


■ Keep the skin supple using a non-perfumed moisturising cream such as sorbolene.
■ Avoid drying out your skin and consider using a soap-free alternative.
■ Clean any scratches, grazes or cuts immediately using an antiseptic solution,
use an antibacterial cream and cover the area with a clean, dry plaster.
■ Use an electric razor for shaving instead of a wet razor.
■ Avoid tattoos and body piercing.
■ Consider ways to protect the skin, such as wearing gloves while washing dishes,
gardening or handling pets.

Administration of Anti -D

At the first pregnancy consultation the mother's blood
group should be determined and blood taken for detection/
measurement of blood group antibodies. For
complete and incomplete miscarriages all Rh(D) negative
women who have not actively formed their own
anti-D should be given 250IU of anti-D.
There is insufficient evidence to suggest that a threatened
miscarriage before 12 weeks gestation necessitates
use of anti-D, but meta-analyses indicate that antenatal
administration of anti-D (for all indications
including miscarriage) can result in a 78% reduction
in allo-immunisation.