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Dyspepsia

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.

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Dyspepsia

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

  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

  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

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

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

  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

  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

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

  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

  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)

  11. Management

  12. Step One History & Physical for Specific Etiologies

  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

  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

  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

  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

  17. 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. Examination

  18. Step Two Explicitly Consider: Could this patient have cancer?

  19. Red Flags • Age > 45 • Weight loss • Bleeding • Anemia • Dysphagia

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

  21. Step 3 Treat for Non-Ulcer Dyspepsia

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

  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)

  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)

  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)

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

  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) HP Pack 7 days

  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."

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

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

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

  32. Step 4 Endoscopy if still symptomatic

  33. Step 5 Post-Endoscopy Management

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

  35. 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 Non-pharmacologic Tx

  36. Summary

  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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