dyspepsia ilan lenga, former cmr and david cherney, former cmr msh aimgp 2004
TRANSCRIPT
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