Dyspepsia Ilan Lenga, former CMR and David Cherney, former CMR MSH AIMGP 2004.
Transcript of Dyspepsia Ilan Lenga, former CMR and David Cherney, former CMR MSH AIMGP 2004.
Dyspepsia
Ilan Lenga, former CMR
and David Cherney, former CMR
MSH AIMGP 2004
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
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
US vs. Canadian Guidelines
• CMAJ guidelines agree with AGA
• AGA slightly easier to follow
What is Dyspepsia?
indigestionindigestion
bloatingbloating early satietyearly satiety
nauseanausea
vomitingvomiting
epigastric discomfortepigastric discomfort
fullnessfullness
upset stomachupset stomach
heartburnheartburn
stomachachestomachache
queasinessqueasiness
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
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
Differential Diagnosis
Organic40%
Functional =“Non-Ulcer Dyspepsia”
60%
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
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)
Management
Step One
History & Physical for Specific Etiologies
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
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
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
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
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.
Step Two
Explicitly Consider: Could this patient have cancer?
Red Flags
• Age > 45
• Weight loss
• Bleeding
• Anemia
• Dysphagia
Dyspepsia
Clinical evaluation
Exclude by History: GERD; biliary; IBS; Meds; aerophagia
From AGA Guidelines
Manageappropriately
45 years and no red flags
>45 or red flags
Endoscopy
+
-
Step 3
Treat for Non-Ulcer Dyspepsia
The Role of H. pylori in Non-Ulcer Dyspepsia
• Association between H. pylori & Non-Ulcer dyspepsia not clear
• Role in pathogenesis disputed
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)
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)
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)
Non-invasive tests for H. pylori
SENS SPEC
14C Urea Breath Test 90-95 90-95
Serology* 85-95 85-90
*cannot discriminate between active & previous infection (therefore, do not use to diagnose recurrence)
Treatment of H. pylori
• Multiple Regimens• UHN/MSH Guidelines...
1st line: Most cost-effective (for the hosp.) Lansoprazole 30mg BID
Clarithromycin 500 BIDAmoxicillin 1000mg BID
Alternate regimens substitute metronidazole for amoxil (but some H.pylori are resistant)
7 daysHP Pack
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."
What if H. pylori is negative?
• Minimal evidence supports:
– H2 blockers
– Proton Pump Inhibitors
– Prokinetic agents
• metoclopramide, domperidone• cisapride no longer available
45 years and no red flags
H. pylori Testing
Treat H.p. Empiric H2, PPI, or prokinetic x 1 month
+ -
From AGA Guidelines
45 years and no red flags
H. pylori Testing
Treat H.p. Empiric H2, PPI, or prokinetic x 1 month
failsfails
EndoscopyFollow-up Follow-up
successsuccess
+ -
From AGA Guidelines
Step 4
Endoscopy if still symptomatic
Step 5
Post-Endoscopy Management
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
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
Summary
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