DYSPEPSIA

1. DYSPEPSIA Dr.Vishal Rathore

2. Dyspepsia • popularly known as indigestion • meaning hard or difficult digestion, is a medical condition characterized by chronic or recurrent pain in the upper abdomen, upper abdominal fullness and feeling full earlier than expected when eating.

3. Prevalence 25-40 %, of which • 50% self medicate • 25% consult their G.P. • 5% of G.P. consultations are for dyspepsia • Prescribed drugs and endoscopies cost £600M in 2000 • OTC indigestion remedies sold for £100M in 2002

4. Causes • Reflux oesophagitis 12% • Duodenal ulcer 10% • Gastric ulcer 6% • Gastric carcinoma 1% • Oesophageal carcinoma 0.5% Non-erosive GORD Functional (non-ulcer) dyspepsia

5. Alarm Symptoms/ Signs* • GI bleeding (same day referral) • Persistent vomiting • Weight loss (progressive unintentional) • Dysphagia • Epigastric mass • Anaemia due to possible GI blood loss Thus all patients with new-onset dyspepsia should have abdominal examination and FBC

6. First Approach to Dyspepsia • Consider possible causes outside upper GI tract -Heart, lung, liver, gall bladder, pancreas, bowel • Consider drugs and stop if possible - Aspirin / NSAIDs, calcium antagonists, nitrates, theophyllines, etidronate, steroids

7. Refer if dyspepsia in 55+* year old • Alarm symptoms/signs (2 week referral) • Unexplained and persistent recent-onset dyspepsia without alarm symptoms – Unexplained means no cause known – Persistent implies present for a length of time (NICE suggest 4-6 weeks) – Recent-onset implies new-not a recurrent episode.

8. Referral for Endoscopy • Review medications for possible causes of dyspepsia (calcium antagonists, nitrates, theophyllines, bisphosphonates, corticosteroids and non-steroidal anti-inflammatory drugs [NSAIDs]). • In patients requiring referral, suspend NSAID use.

9. Urgent specialist referral Endoscopic investigation is indicated for patients of any age with dyspepsia when presenting with any of the following: • chronic gastrointestinal bleeding, • progressive unintentional weight loss, • progressive difficulty swallowing, • persistent vomiting, • Iron deficiency anaemia, • epigastric mass • suspicious barium meal

10. Routine Endoscopic Investigation • Patients of any age, presenting with dyspepsia and without alarm signs, is not necessary. • However, in patients aged 55 years and older with unexplained and persistent recent-onset dyspepsia alone, an urgent referral for endoscopy should be made.

11. Management of simple dyspepsiain those aged < 55 years • Stress benign nature of dyspepsia • Lifestyle advice – Healthy eating – Weight reduction – Stop smoking – Use of antacids

12. Interventions for uninvestigated dyspepsia • Initial therapeutic strategies for dyspepsia are empirical treatment with a proton pump inhibitor (PPI) or testing for and treating H. pylori. • There is currently insufficient evidence to guide which should be offered first. • A 2-week washout period following PPI use is necessary before testing for H. pyloriwith a breath test or a stool antigen test

13. Nice Guideline Summary • Refer if “alarm symptoms” at any stage • Test and treat (Test for H. pyloriand treat positives) THEN, IF STILL SYMPTOMATIC PPI for one month THEN Manage recurrent symptoms as functional dyspepsia

14. Rx of H. Pylori • One week triple therapy * • PPI (full dose) e.g. omeprazole 20mg bd • Clarithromycin 500mg bd • Amoxycillin 1g bd (or Metronidazole 400mg bd) • Use a carbon-13 urea breath test, stool antigen test or, when performance has been validated, laboratory based serology. • If re-testing for H. pyloriuse a carbon-13 urea breath test.*

16. THANK YOU !!!!!