BSG Guidelines BSG Guidelines Management of DyspepsiaManagement of Dyspepsia

ByBy

Matt JohnsonMatt Johnson

Recommendation GradingRecommendation Grading

• AA >1 meta-analysis, systematic review or >1 meta-analysis, systematic review or body body of evidence from RCTsof evidence from RCTs

• BB high quality case control or cohort high quality case control or cohort studies, or studies, or extrapolated from a meta-extrapolated from a meta-analysis, analysis, systematic systematic review or RCTsreview or RCTs

• CC lesser case control or cohort studieslesser case control or cohort studies

• DD expert opinion or case series / reportsexpert opinion or case series / reports

Dyspepsia IntroductionDyspepsia Introduction

• Dyspepsia is not a diagnosis but a collection of Dyspepsia is not a diagnosis but a collection of symptoms including; upper abdo discomfort, symptoms including; upper abdo discomfort, heartburn, retrosternal pain, anorexia, nausea, heartburn, retrosternal pain, anorexia, nausea, vomiting, bloating, fullness and early satietyvomiting, bloating, fullness and early satiety

• Prevalence in the Western societies is quoted at being Prevalence in the Western societies is quoted at being between 23 – 41%between 23 – 41%

• 4% of GP consultations are for dyspepsia4% of GP consultations are for dyspepsia• 10% of these are referred to hospital10% of these are referred to hospital• 2% of entire adult population receive either an OGD or 2% of entire adult population receive either an OGD or

a barium meal each yeara barium meal each year

Causes of DyspepsiaCauses of Dyspepsia

• NormalNormal 30%30%

• Gastritis, Duodenitis, HHGastritis, Duodenitis, HH 30%30%

• GORDGORD 10-17%10-17%

• DUDU 10-15%10-15%

• GUGU 5-10%5-10%

• Oesophageal, Gastric CaOesophageal, Gastric Ca 2%2%

Rationalisation of Rationalisation of EndoscopyEndoscopy• Patients with dyspepsia in whom endoscopy is Patients with dyspepsia in whom endoscopy is

inappropriateinappropriate– Those < 55y with uncomplicated dyspepsiaThose < 55y with uncomplicated dyspepsia– Patients with known DU who have responded appropriately to Patients with known DU who have responded appropriately to

medicationmedication– Those who have recently had an OGD for the same symptomsThose who have recently had an OGD for the same symptoms

• ““Test and treat” has replaced the “test and scope” strategy Test and treat” has replaced the “test and scope” strategy in patients <55yin patients <55y AA– Pros = Pros = approporiate for PU, reduction of relapse, may benefit approporiate for PU, reduction of relapse, may benefit

H.pylori associated non-ulcer H.pylori associated non-ulcer dyspepsia, potential dyspepsia, potential reduction in Cancer reduction in Cancer risk risk

– Cons = Cons = increases antibiotic exposure, may miss significant increases antibiotic exposure, may miss significant GORD and GORD and Barretts oesophagus (although therapy Barretts oesophagus (although therapy here should be here should be directed at symptom control as directed at symptom control as treatment directed at healing treatment directed at healing does not prevent the does not prevent the known complications) known complications)

H.Pylori IxH.Pylori Ix

• SerologySerology AA– Simple, useful, less specific than other methodsSimple, useful, less specific than other methods– Instant / near tests are less accurate and not Instant / near tests are less accurate and not

recommendedrecommended• 13C Urea Breath Test13C Urea Breath Test BB

– 13C or 14C cleaved by the H.pylori urease and then 13C or 14C cleaved by the H.pylori urease and then monitored in the exhaled breathmonitored in the exhaled breath

– Best test for identificationBest test for identification– Best test to ensure eradicationBest test to ensure eradication

• Endoscopic Clo TestEndoscopic Clo Test BB– Cheap, accurate but endoscopy not always necessaryCheap, accurate but endoscopy not always necessary– Recommended in all patients with newly found PURecommended in all patients with newly found PU

• Faecal Ag TestsFaecal Ag Tests– ??

Rationing of EndoscopyRationing of Endoscopy

• Death from diagnostic OGD = 1 in 2-10,000Death from diagnostic OGD = 1 in 2-10,000• The incidence of gastric Ca is age relatedThe incidence of gastric Ca is age related• OGD is recommended in all patients >55y OGD is recommended in all patients >55y DD

– with new onset uncomplicated dyspepsiawith new onset uncomplicated dyspepsia– for > 1/12 durationfor > 1/12 duration

• Most patients with gastric cancer have “alarm symptoms”Most patients with gastric cancer have “alarm symptoms”• OGD is recommended in all patients with “alarm symptoms” OGD is recommended in all patients with “alarm symptoms” CC

– National Cancer Guidelines request Ix within 2/52National Cancer Guidelines request Ix within 2/52• These include dyspeptic patients with:These include dyspeptic patients with:

– Unintentional weight lossUnintentional weight loss– GI BleedingGI Bleeding– Previous gastric surgeryPrevious gastric surgery– Epigastric massEpigastric mass– Previous gastric ulcerPrevious gastric ulcer– Unexplained Fe deficiencyUnexplained Fe deficiency– Dysphagia or OdynophagiaDysphagia or Odynophagia– Persistent continous vomitingPersistent continous vomiting– Suspicious barium mealSuspicious barium meal

TreatmentsTreatments

• Pre – EndoscopyPre – Endoscopy

– <55y = <55y = Test and treatTest and treat– >55y = >55y = Pre-treatment with anti-secretory drugs may mask significant diagnosis Pre-treatment with anti-secretory drugs may mask significant diagnosis

DD therefore BSG recommend witholding or stopping pre-therefore BSG recommend witholding or stopping pre-treatment 4/52 before OGDtreatment 4/52 before OGD

• OesophagitisOesophagitis

• Lifestyle advice Lifestyle advice – weight loss, propping up head end of bedweight loss, propping up head end of bed

• MedicationMedication– Symptom relief Symptom relief – 4/52 course of PPIs recommended by NICE 4/52 course of PPIs recommended by NICE DD

• Follow-upFollow-up– ? Long term management of Barretts? Long term management of Barretts– Repeat OGD only recommended to reviewRepeat OGD only recommended to review

• Healing of oesophageal ulcersHealing of oesophageal ulcers• Dilatation of stricturesDilatation of strictures• Anaemia secondary to GORDAnaemia secondary to GORD

TreatmentsTreatments

• Functional DyspepsiaFunctional Dyspepsia

• Lifestyle advice Lifestyle advice – little benefit (stop smoking)little benefit (stop smoking) DD

• MedicationMedication– Recommends H.pylori eradicationRecommends H.pylori eradication DD– Cochrane review May 2000 showed resolution of Cochrane review May 2000 showed resolution of

symptoms in 9% after H.pylori eradication therapysymptoms in 9% after H.pylori eradication therapy– Symptomatic control with anti-secretory agents is Symptomatic control with anti-secretory agents is

recommended especially in ulcer like or reflux like recommended especially in ulcer like or reflux like symptoms symptoms BB

– Stop NSAIDSStop NSAIDS DD– Reassurance may be sufficientReassurance may be sufficient DD

TreatmentsTreatments• Duodenal Ulcers / Erosive DuodenitisDuodenal Ulcers / Erosive Duodenitis

• 95% associated with H.pylori95% associated with H.pylori• Advise confirmation, although this may be unneccssaryAdvise confirmation, although this may be unneccssary

• HP +ive DUHP +ive DU AA• 11stst Line Line BB

– PPI bd PPI bd or Ranitidine bismuth citrateor Ranitidine bismuth citrate– Amoxicillin 500mg-1g bdAmoxicillin 500mg-1g bd Metronidazole 400-500mg bdMetronidazole 400-500mg bd– Clarithromycin 500mg bdClarithromycin 500mg bd

• 22ndnd Line Line– PPI bdPPI bd– Bismuth Subcitrate 120mg qdsBismuth Subcitrate 120mg qds– Metronidazole 400-500mg tdsMetronidazole 400-500mg tds– Tetracycline 500mg qdsTetracycline 500mg qds

• Follow UpFollow Up– Urease breath test in all >1/12 after finishing HP eradication therapyUrease breath test in all >1/12 after finishing HP eradication therapy– In asymptomatic patients further OGD + follow up is then unneccessary unless symptoms recur or persistIn asymptomatic patients further OGD + follow up is then unneccessary unless symptoms recur or persist– In those where symptoms recur after an initial response = repeat urease breath test and treated if necessary In those where symptoms recur after an initial response = repeat urease breath test and treated if necessary

with an alternative regime. If HP persists biopsy for C+Sensitivitywith an alternative regime. If HP persists biopsy for C+Sensitivity DD– Low dose PPI maintainance only necessary in persistent HP infections or those at risk of NSAID complicationsLow dose PPI maintainance only necessary in persistent HP infections or those at risk of NSAID complications

• HP -ive DUHP -ive DU• MedicationMedication

– Antisecretory therapy = Cimetidine 800mg is cheapestAntisecretory therapy = Cimetidine 800mg is cheapest– Stop NSAIDS + consider COX 2 Stop NSAIDS + consider COX 2 DD

• Follow UpFollow Up– OPA nesseccary only if DUs not associated with NSAIDSOPA nesseccary only if DUs not associated with NSAIDS

TreatmentsTreatments

• Gastric UlcerGastric Ulcer

• 70% are associated with H.pylori, most of the rest are assoc with 70% are associated with H.pylori, most of the rest are assoc with NSAIDSNSAIDS

• HP +ive GUHP +ive GU– Eradication therapyEradication therapy AA– Antisecretory agents for 2/12 (as GUs take longer to heal)Antisecretory agents for 2/12 (as GUs take longer to heal) DD– If ongoing NSAIDS are necessary consider prophylactic PPI or If ongoing NSAIDS are necessary consider prophylactic PPI or

misoprostolmisoprostol• NICE guidance on COX 2 antagonistsNICE guidance on COX 2 antagonists DD

• HP –ive GUHP –ive GU– 2/12 of antisecretory therapy2/12 of antisecretory therapy– NICE guidance re COX 2 antagonistsNICE guidance re COX 2 antagonists

• Follow UpFollow Up– Repeat OGD in all untiil ulcer healingRepeat OGD in all untiil ulcer healing– Surgery if GU has not healed by 6/12Surgery if GU has not healed by 6/12 DD

Resource RequirementsResource Requirements

• Easy access for GPs to organise urease Easy access for GPs to organise urease breath testsbreath tests

• Aim to provide rapid access to endoscopy Aim to provide rapid access to endoscopy for all those meeting criteriafor all those meeting criteria

• Aim to provide endoscopy access within 2 Aim to provide endoscopy access within 2 weeks for those with alarm symptomsweeks for those with alarm symptoms

• 1 laboratory in each major city must be 1 laboratory in each major city must be able to provide facilities for full able to provide facilities for full bacteriological assessment of HP bacteriological assessment of HP sensitivity and resistance sensitivity and resistance

AGA GuidelinesAGA Guidelines

• Age cut off is <45Age cut off is <45• Management optionsManagement options

– 1) Empirical treatment1) Empirical treatment– 2) Immediate OGD2) Immediate OGD– 3) Test and scope *3) Test and scope *– 4) Test and treat4) Test and treat

• * may be preferential in areas with a high * may be preferential in areas with a high background incidence of gastric Cabackground incidence of gastric Ca

• Scope <45y HP-ive who fail 2/12 of treatment Scope <45y HP-ive who fail 2/12 of treatment using an antisecretory preparation and then a using an antisecretory preparation and then a prokinetic agent (cisapride)prokinetic agent (cisapride)