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Dyspepsia

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Show Notes

Slide 1 :

Dyspepsia Ilan Lenga, former CMR and David Cherney, former CMR MSH AIMGP 2004

Slide 2 :

Objectives By the end of this seminar you will: have a working definition of dyspepsia know the main causes of dyspepsia have a rational, cost-effective, evidence-based approach to dyspepsia

Slide 3 :

References AGA Guidelines for Management of Dyspepsia NEJM Review Article “Management of Non-Ulcer Dyspepsia” 339(19); 1376-81 Clinical Evidence Dec 2001 CMAJ 2000;162 (12 Suppl) OPOT Guidelines for PUD & GERD

Slide 4 :

US vs. Canadian Guidelines CMAJ guidelines agree with AGA AGA slightly easier to follow

Slide 5 :

What is Dyspepsia? indigestion bloating early satiety nausea vomiting epigastric discomfort fullness upset stomach heartburn stomachache queasiness

Slide 6 :

What is Dyspepsia? Everyone knows what it is, but no one knows what to call it! Multiple definitions in the literature Rome Criteria II (def’n for research purposes) pain or discomfort in midline upper abdomen “Discomfort” = negative feeling which can be characterized by: fullness • early satiety bloating • nausea

Slide 7 :

Incidence Occurs in 25% of the population per year Of these 20-25% seek medical attention Accounts for 2-5% of primary care physicians’ workload

Slide 8 :

Differential Diagnosis Organic 40% Functional =“Non-Ulcer Dyspepsia” 60%

Slide 9 :

Organic Causes Peptic Ulcer Disease GERD Gastric cancer Medications (ASA/NSAIDS, Abx) Gastroparesis Cholelithiasis, Choledocholithiasis Pancreatitis (acute or chronic) Carbohydrate malabsorption Ischemic bowel Other GI malignancy (ep. Pancreatic cancer) Systemic disease (DM, Thyroid, Parathyroid, CTD) Intestinal parasite Most common organic causes, according to AGA

Slide 10 :

Non-Ulcer Dyspepsia The most common cause overall Defined as: at least 12 weeks (need not be consecutive) within the last 12 months of: Dyspepsia No evidence of organic disease Dyspepsia not exclusively relieved by defecation or associated with change in stool frequency or form (i.e. not IBS)

Slide 11 :

Management

Slide 12 :

Step One History & Physical for Specific Etiologies

Slide 13 :

Risk Factors and Past Hx Risk Factors Smoker, NSAID use, Heavy EtOH, FHx ulcer Personal Hx Previous ulcer, GI bleed DM, hypo/hyperthyroidism, parathyroid dis. Colitis, diverticulosis, liver disease Anxiety, stress, depression Previous Upper GI series, OGD, Abdo U/S

Slide 14 :

History & Physical PUD Past history of ulcers, NSAIDs, Smoking GERD Heartburn or regurg symptoms, aggravated when supine, chronic cough Gastric Cancer Older (>50), wt. loss, dysphagia, smoker, long-standing GERD

Slide 15 :

History & Physical Biliary Tract disease Episodic RUQ pain > 1 hr, associated with meals, post-prandial Meds iron, NSAIDs, bisphosphonates, antibiotics, etc. Metabolic disorder/Gastroparesis DM, Hyper or Hypo -Thyroidism, Hyperparathyroidism

Slide 16 :

History & Physical IBS Rome criteria Pain relieved with defectation more freq stools at onset of pain abdominal distention passage of mucus sense of incomplete evacuation

Slide 17 :

Examination Fever, weight loss, hypotension, tachycardia Abdo Epigastric tenderness Palpable mass Distention Colon tenderness Jaundice Murphy’s sign Stool for OB Signs anemia Brittle nails Cheilosis Pallor palpebral mucosa or nail beds Other Teeth (loss enamel) Lymphadenopathy - Virchow’s node Acanthosis nigrans Hypo/Hyperthyroid.

Slide 18 :

Step Two Explicitly Consider: Could this patient have cancer?

Slide 19 :

Red Flags Age > 45 Weight loss Bleeding Anemia Dysphagia

Slide 20 :

Dyspepsia Clinical evaluation Exclude by History: GERD; biliary; IBS; Meds; aerophagia From AGA Guidelines Manage appropriately ? 45 years and no red flags >45 or red flags Endoscopy + -

Slide 21 :

Step 3 Treat for Non-Ulcer Dyspepsia

Slide 22 :

The Role of H. pylori in Non-Ulcer Dyspepsia Association between H. pylori & Non-Ulcer dyspepsia not clear Role in pathogenesis disputed

Slide 23 :

The Evidence 2 RCT’s comparing “Test All & Eradicate” vs. Endoscopy-guided management for relief of symptoms 1st RCT 500 patients with >2 weeks symptoms Results: no difference in symptom free days reduced endoscopy rate in “test & eradicate” group (40% required f/u endoscopy)

Slide 24 :

The Evidence 2nd RCT “test & eradicate” strategy reduced the number of symptomatic patients at 1 year ARR 13% (-6 to 31%) RR 0.82 (0.59-1.1)

Slide 25 :

The Evidence One systematic review (9 RCT’s, 2541 pt’s) looked at H. pylori eradication in people with proven non-ulcer dyspepsia (after endoscopy) Results: Small, but statistically significant improvement in symptoms 3-12 months after Rx ARR 7% (3-10%) NNT 15 RR 0.91 (0.86-0.96)

Slide 26 :

Non-invasive tests for H. pylori *cannot discriminate between active & previous infection (therefore, do not use to diagnose recurrence)

Slide 27 :

Treatment of H. pylori Multiple Regimens UHN/MSH Guidelines... 1st line: Most cost-effective (for the hosp.) Lansoprazole 30mg BID Clarithromycin 500 BID Amoxicillin 1000mg BID Alternate regimens substitute metronidazole for amoxil (but some H.pylori are resistant) 7 days HP Pack

Slide 28 :

American College of Gastroenterology Position "There is no conclusive evidence that eradication of H. pylori infection will reverse the symptoms of nonulcer dyspepsia. Patients may be tested for H. pylori on a case-by-case basis, and treatment offered to those with a positive result."

Slide 29 :

What if H. pylori is negative? Minimal evidence supports: H2 blockers Proton Pump Inhibitors Prokinetic agents metoclopramide, domperidone cisapride no longer available

Slide 30 :

? 45 years and no red flags H. pylori Testing Treat H.p. Empiric H2, PPI, or prokinetic x 1 month + - From AGA Guidelines

Slide 31 :

? 45 years and no red flags H. pylori Testing Treat H.p. Empiric H2, PPI, or prokinetic x 1 month fails fails Endoscopy Follow-up Follow-up success success + - From AGA Guidelines

Slide 32 :

Step 4 Endoscopy if still symptomatic

Slide 33 :

Step 5 Post-Endoscopy Management

Slide 34 :

Endoscopy Organic Disease H. pylori detected Functional Rx & Follow-up H2/PPI or prokinetic 4 weeks Switch to other agent Re-evaluate ? Behavioral/ Psychotherapy/ Antidepressant From AGA Guidelines fails fails success success

Slide 35 :

Non-pharmacologic Tx Quit smoking Stop / reduce caffeine Stop / reduce EtOH Hold medications associated w/ dyspepsia NSAIDS, ASA Avoid foods and other factors precipitate symptoms Better eating habits Don’t eat late Therapy for Stress Anxiety Depression Elevate head of bed? Stress-reducing activities Exercise Relaxation Reassurance

Slide 36 :

Summary

Slide 37 :

Key Points Step One: Hx & Px attempt to establish a specific diagnosis Step Two: Consider Cancer urgent endoscopy if red flags Step Three: Treat for Non-Ulcer Dyspepsia Test & Eradicate H. pylori Acid suppression or Prokinetics x 1 month Step Four: Endoscopy Endoscopy if still symptomatic Step Five: Post-Endoscopy Management

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Peptic Ulcer Disease; GERD; Gastric cancer; Medications (ASA/NSAIDS, Abx); Gastroparesis; Cholelith more Peptic Ulcer Disease; GERD; Gastric cancer; Medications (ASA/NSAIDS, Abx); Gastroparesis; Cholelithiasis, Choledocholithiasis; Pancreatitis (acute or less