An approach to

Dyspepsia

Al-Momtan, Ahmed TahirC-2

Case Presentation

P/P and HPI

• Mr. Al-Momtan, Tahir Abdullah is a 56 year old male who presented to our clinic with epigastric abdominal pain x 2 weeks. He describes it as a burning pain which is non-radiating and is worse after he eats. He has frequent belching with bloating sensation but denies nausea, vomiting, diarrhea, constipation, or weight loss. He has tried epicogel ® found to be composed of (Each 5 ml contains Dried aluminium hydroxide gel 405 mg, Magnesium hydroxide 100 mg, Dimethicone 125 mg) in which he claimed, “helps a little”.

Mr Al-Momtan HistoryPMH: HTN stable diagnosed 4 years ago, Osteoarthritis in

knees, treated for an ulcer 3 years ago

Meds: Hydrochlorothiazide 25 mg twice daily, ibuprofen 400 mg X 4 times daily

Soc HX: Married, worked in his local municipal a civil engineer and now a Manager of a private business, drinks 2-4 cups coffee per day, no Hx of alcohol intake or smoking.

Mr. Al-Momtan Physical Exam • VS: BP 137/82, HR 85, afeb, RR 14• HEENT: conjunctiva pink, clear OP

MMM • Heart: RRR no M/R/G• ABD: Soft, NABS, mild-moderate

epigastric TTP, no HSM or masses, no acute abd signs

• Skin: no pallor• Rectal: stool brown, heme (-), no

masses

Mr. Tahir Prior Ulcer History

On further questioning Mr. Al-Momtan states he had similar abdominal pain three years ago and was told by his physician at that time that it was most likely due to an “ulcer”. He took “the purple pill” for a month and his symptoms resolved. He had no definitive diagnostic tests done at that time.

Diagnosed

• From his clinical Hx and PE plus • CBC, Urea breath test were done for him, the

patient was diagnosed to have a PUD.• Given an appointment for Upper GI endoscopy

but he refused.

Treatment

• Sent home, Started on Tripple therapy composed of 2 antibiotics and a PPI:- Clarythromycine 500 mg PO bid for 2 weeks- Metronidazole 500 mg PO bid for 2 weeks- Lansoprazole 30 mg PO bid for 3 weeks• Asked to visit the clinic 4 weeks later..

Objectives

• To review some common causes • To review the evidence based

management strategies• What to treat & when to to refer

safely & effectively ??

Definition

• Group of symptoms consisting mostly upper abdominal or epigastric pain or discomfort, heartburn, or acid regurgitation.Often associated with belching, bloating, nausea or vomiting

INTRODUCTION• Dyspepsia• 40% of adult population / year, 2% consult their GPs• Substantial health care cost:

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MedicationDiagnostic evaluationTime cost from work

• Out of 100 pts. 90% will be pain free after 2-3 wks without Rx

• Definitive established guideline (NICE)• H.pylori & PUD – well accepted & confirmed

5 common causes of dyspepsia

1- NUD.2- GORD3- Gastritis4- Gastric Ulcer.5- Doudenal Ulcer

Rare causesGastic and oesophageal CA.

Less common causes of upper abdominal pain

• Aerophagy.• Biliary colic• Abdominal wall pain• Malignancy• Mesenteric vascular insuffeciency• Angina• Metabolic disease

Drugs associated with dyspepsia• NSAIDs• Iron.• Metformin• Codiene• Antibiotics• Orlistat• Corticosteroids• theophyllin

• Digoxin.• Colchicine• Alendronate.• Nitrates• Quinidine• Gemfibrozil,,,,

5 common Diagnoses

1- NUD (non-ulcer dyspepsia)- most common cause.- Younger age group more than later life.- Causes?- GI motility?- Gastric secretion normal- Presence of H-pylori.- Incidence decrease with advancing age.

Pathophysiology

• Functional dyspepsia

T/T of functional dyspepsia

- Initial treatment• Diet , beverages, smoking• Antisecretory drug (H2RAs, PPI) or• Prokinetic drug (domperidone) if antisecretory treatment fails• Switch treatment if first drug type fails

- Stats,, • Systematic review (98 randomised controlled trials) The Cochrane Library, Issue 1, 2005. : • RRR = 48% in the Prokinetics group compared to placebo. •RRR = 22%; in the H2RAs group •RRR = 14%; in PPI group •Antacid & bismuth effects were not statically significant

NICE flowchart (functional dyspepsia)

Cont. T/T of functional dyspepsia

- Resistant cases (failed initial treatment) :• H.pylori eradication • Sucralfate or bismuth • Antispasmodic agent( such as mebeverine) • Antidepressant (such as SSRI or tricyclic drug) • Behavioural therapy or psychotherapy• No treatment is proved tobe fully beneficial in these patients.

- stats:• Systematic review (17 randomised controlled trials) The Cochrane Library, Issue 1, 2005. :• RRR= 8% in the H pylori eradication group (95% CI = 3% to 12%) compared to placebo. NNT to cure one

case of dyspepsia = 18

5 common Diagnoses

2- GORD (Gastroesophageal reflux disease)• Very common • Heartburn , Sharp stabbing sub-sternal pain (probability :89%)• Regurgitation (probability :95%)• At night or after heavy meal• Chronic cough, asthma like wheezing• MI ??

GORD, Cont.

GORD, Cont.• Weakness or incompetence of lower esophageal

sphincter• Esophagitis, esophageal structure• Barret’s esophagus

• Dx: -Hx,PPI test, 24 hours pH manometer!,,Endoscopy??

- Lifestyle modification?? • Medication:

-Antacid-Antisecretory drug: H2 receptor blocker-proton pump inhibitor (2months)

• Prokinetics•Surgery: Laproscopic fundoplication or open?

Dx and Management

5 common Diagnoses

3- PUD (Peptic ulcer disease)• Less than before • P/H ulcer, recurrence more likely• Risk factors include:

-H-pylori-Family Hx -NSAID -Cigarette smoking -Chronic renal failure -Blood group “O”

complications• Weakness or incompetence of lower esophageal

sphincter• Esophagitis, esophageal structure• Barret’s esophagus

Diagnostic Difficulties• Not text book presentation • Early presentation • History:•1.ALARM symptoms ?? •2.Specific symptoms•3.NUD

• MI ??• NSAID• Smoking

ALARM Symptoms!

ALARM!•Anorexia•Loss of weight (progressive & unintentional) •Anaemia due to iron deficiency •Recent onset of persistent symptoms :vomiting •Melaena, haematemesis •Dysphagia (progressive) •Epigastric mass or •Suspicious barium meal.

General Management

1.Management of symptoms in primary care is appropriate for most patients rather than routinely seeking a pathological diagnosis.

2.Alarm signals and signs are the major determinant of the need for endoscopy, not age on its own.

3.Long term care should emphasize patient empowerment with ‘on demand’ use of the lowest effective dose PPI.

Cont. General Management

• Simple lifestyle advice: healthy eating, weight reduction, smoking cessation

• Offer empirical antacid,H2Aor PPI therapy for one month to patients with dyspepsia.

H. Pylori• Gram–ve, flagellated spiral • Casually related to:

- GU - DU - Gastritis- Gastric B – cell lymphoma - Gastric adenoma

• Prevalence-high • More in developing countries• Roughly related to age • • Saudi local study 67-89%

H. Pylori Testing and Eradication

• Serology • Urea Breath test• Fecal antigen test • Endoscopy • Stript test

Benefits:-Cure rate.- Recurrence- Bleeding

**All cases of dyspepsia ??

H-PYLORI ERADICATION - Triple regimen: Proton pump inhibitor + two antibiotics

Flowcharts, DU and GU

Endoscopy• Age < 55 years, presenting with dyspepsia and without alarm S/S, is not necessary.• Age > 55 years presenting with dyspepsia and without alarm S/S do not require routine endoscopy.

Considered if :1.ALARM signals and signs are the major determinant of the need for endoscopy, not age on its own.2. No response to medication7-10days. 3. Symptoms persist after 6-8wks 4. Signs of systemic illness5. Recurrence after treatment6. Long standing G0RD7. Unexplained weight loss, progressive dysphagia, IDA, abdominal mass on plapation

Cont. Endoscopy• Patients undergoing endoscopy should be free

from medication with either a PPI or an H2 receptor antagonist for a minimum of two weeks.

Reasons for referral

• immediate?• If highly suggestive of cardiac or biliary disesases• cancer suspected or proven;• diagnostic uncertainty;• treatments not available• failure of treatment, symptoms persisting;• patients' wishes

Referral flowchart

Take home message!!1. Aggravating factors :tobacco, ASA, NSAIDs,other

medications and alcohol 2. Alarm features –absent OR present. A. Alarm features – abscent:

- Two approaches are acceptable:

1. Test for H. pylori infection 2. Empiric Therapy – A4-week course a histamine-2 receptor – antagonist or PPI

**Failure to respond to treatment justifies further investigation and/or referral

B. Alarm features – present:- Endoscopy ± biopsy,- referral Barium may be as an alternative..- Life style modification ??