CCE-CBD-187

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What is your differential diagnosis, and what is the most likely diagnosis?

• Prompt: How would you differentiate between functional dyspepsia, GORD, and peptic ulcer disease?
• Prompt: What features would make you concerned about gastric malignancy?

Q2. What are your initial management steps?

• Prompt: What lifestyle and dietary changes would you recommend?
• Prompt: When would you initiate pharmacological therapy?

Q3. How would you explain the diagnosis and treatment plan to the patient?

• Prompt: How would you address her concerns about gastric cancer?
• Prompt: What reassurance can you provide regarding her symptoms?

Q4. What preventive measures can help reduce recurrence?

• Prompt: What role does H. pylori eradication play in preventing dyspepsia?
• Prompt: How can dietary and behavioural modifications reduce symptoms?

Q5. What are the red flags that would necessitate urgent referral?

• Prompt: What symptoms would indicate the need for urgent gastroscopy?
• Prompt: How would you escalate care if her symptoms persist despite treatment?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What is your differential diagnosis, and what is the most likely diagnosis?

Answer:

A structured approach to dyspepsia includes differentiating between functional, inflammatory, and malignant causes.

Differential Diagnoses:

1. Functional Dyspepsia:
   • Most common cause, linked to stress and dietary triggers.
   • Symptoms: Postprandial fullness, bloating, epigastric discomfort.
   • No alarm symptoms (weight loss, melena, vomiting, dysphagia).
2. Gastro-Oesophageal Reflux Disease (GORD):
   • Epigastric burning pain, regurgitation, worsened by coffee, alcohol, NSAIDs.
   • Relief with antacids.
3. Peptic Ulcer Disease (PUD):
   • Burning epigastric pain, relieved or exacerbated by food.
   • Associated with NSAID use and H. pylori infection.
4. Gastric Malignancy:
   • Alarm features: Unexplained weight loss, progressive symptoms, persistent vomiting, early satiety, FHx of gastric cancer.
   • Needs urgent endoscopy.

Most Likely Diagnosis:

Functional dyspepsia due to stress, dietary factors, and lack of alarm symptoms.

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Q2: What are your initial management steps?

Answer:

Management is stepwise, starting with lifestyle modifications and symptom control.

1. Lifestyle Modifications:

• Reduce trigger foods (caffeine, alcohol, fatty foods).
• Avoid NSAIDs, replace with paracetamol if necessary.
• Stress management techniques (exercise, relaxation).

2. Pharmacological Therapy:

• Trial of a proton pump inhibitor (PPI) (e.g., omeprazole 20mg daily) for 4-8 weeks.
• H. pylori eradication therapy if test is positive.

3. Investigations and Referral:

• No red flags → Trial of therapy and review in 4 weeks.
• Persistent or worsening symptoms → Consider endoscopy.

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Q3: How would you explain the diagnosis and treatment plan to the patient?

Answer:

Diagnosis Explanation:

• “Your symptoms suggest functional dyspepsia, a common condition related to diet and stress.”
• “There is no immediate concern for stomach cancer, but we will monitor your symptoms.”

Treatment Plan:

• “We will start with lifestyle changes and a short course of PPI therapy.”
• “If symptoms persist, we may test for H. pylori or consider endoscopy.”

Safety-Netting:

• “If you develop weight loss, persistent vomiting, or difficulty swallowing, seek urgent review.”
• “We will review in 4 weeks to assess your response.”

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Q4: What preventive measures can help reduce recurrence?

Answer:

• Dietary modifications:
  • Avoid spicy, acidic, and fatty foods.
  • Limit caffeine and alcohol.
• Medication use:
  • Avoid NSAIDs, especially on an empty stomach.
  • Take PPIs only as needed.
• Lifestyle factors:
  • Regular meals, avoid late-night eating.
  • Reduce stress and smoking.
• H. pylori testing:
  • If positive, eradication therapy reduces recurrence risk.

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Q5: What are the red flags that would necessitate urgent referral?

Answer:

Referral for urgent endoscopy is needed if alarm symptoms are present:

• Unintentional weight loss.
• Progressive dysphagia or odynophagia.
• Recurrent vomiting.
• Haematemesis or melena.
• Anaemia or iron deficiency.
• Family history of gastric cancer (especially under age 50).

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SUMMARY OF A COMPETENT ANSWER

• Provides a structured differential diagnosis including functional, inflammatory, and malignant causes.
• Identifies functional dyspepsia as most likely, but considers red flags.
• Suggests a stepwise management approach, starting with lifestyle modifications.
• Explains the diagnosis and treatment clearly to the patient, addressing concerns about cancer.
• Recognises when to refer for urgent endoscopy based on red flags.

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PITFALLS

• Failing to differentiate between dyspepsia, GORD, and PUD.
• Not considering gastric malignancy in the presence of red flags.
• Prescribing a PPI without advising lifestyle modifications.
• Not addressing patient concerns about gastric cancer.
• Delaying endoscopy in a high-risk patient.

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REFERENCES

• RACGP Guidelines – Dyspepsia and GORD Management
• GP Exams – Dyspepsia/indigestion

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MARKING

Each competency area is on the following scale from 0 to 3.

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

1. Communication and Consultation Skills

1.1 Communication is appropriate to the person and the sociocultural context.
1.2 Engages the patient to gather information about their symptoms, ideas, concerns, and expectations.
1.4 Communicates effectively in routine and difficult situations.

2. Clinical Information Gathering and Interpretation

2.1 Obtains a thorough history relevant to upper gastrointestinal symptoms.
2.2 Identifies alarm features requiring further investigation.

3. Diagnosis, Decision-Making and Reasoning

3.1 Differentiates between functional dyspepsia, GORD, and more serious conditions such as peptic ulcer disease and gastric malignancy.

4. Clinical Management and Therapeutic Reasoning

4.1 Provides initial management, including lifestyle modifications and pharmacological treatment.
4.2 Recognises when endoscopy is indicated.

5. Preventive and Population Health

5.1 Educates the patient on dietary and lifestyle modifications to improve symptoms.

Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD