Dyspepsia
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DYSPEPSIA. Leena Patel 1/2/12. OVERVIEW. Statistics Red flags Management H-pylori testing and treatment. STATISTICS. 5% of adults/year consult their GP for dyspepsia symptoms 1% will go on to have endoscopy Of these: 80% will have non-ulcer dyspepsia or reflux

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DYSPEPSIA

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Dyspepsia

DYSPEPSIA

Leena Patel

1/2/12


Overview

OVERVIEW

  • Statistics

  • Red flags

  • Management

  • H-pylori testing and treatment


Statistics

STATISTICS

  • 5% of adults/year consult their GP for dyspepsia symptoms

  • 1% will go on to have endoscopy

  • Of these:

  • 80% will have non-ulcer dyspepsia or reflux

  • 13% will have a peptic ulcer

  • <3% will have malignancy


Symptoms

SYMPTOMS

  • Nausea

  • Vomiting

  • Bloating

  • Belching

  • Epigastricpain

  • Retrosternal pain

  • Early satiety

  • Chronic cough


Alarm symptoms

ALARM SYMPTOMS

  • Progressive dysphagia

  • Persistent vomiting

  • Progressive unintentional weight loss

  • Iron deficiency anaemia

  • Epigastric mass

  • Chronic GI bleeding

  • Suspicious barium study


Endoscopy

ENDOSCOPY

  • Refer patient of ANY age with ≥1 of the above listed alarm symptoms

  • Refer patients >55 years of age with new onset unexplained dyspepsia which is persistent (4-6 weeks) even without alarm symptoms

    TRY TO AVOID USING PPI/H2RA FOR 2 WEEKS PRIOR TO ENDOSCOPY


Endoscopy results

ENDOSCOPY RESULTS

  • UPPER GI MALIGNANCY

  • PEPTIC ULCER DISEASE (GASTRIC/DUODENAL)

  • NON-ULCER DYSPEPSIA

  • GORD WITH/WITHOUT OESOPHAGITIS


Management

MANAGEMENT

Divided into:

  • Uninvestigated dyspepsia

  • H-pylori eradication

  • GORD, PUD, NUD


Medication induced

MEDICATION INDUCED

  • NSAIDS

  • Steroids

  • Bisphosphonates

  • Calcium channel blockers

  • Nitrates

  • Theophyllines


Lifestyle

LIFESTYLE

  • Healthy balanced diet

  • Avoid/reduce fatty food, caffeine, chocolate

  • Weight reduction

  • Smoking cessation

  • Reduce alcohol intake

  • Avoid late meals

  • Raise end of bed

  • Try antacids/alginate therapy for intermittent symptoms


Uninvestigated dyspepsia

UNINVESTIGATED DYSPEPSIA

  • H-pylori testing and treat with eradication/PPI

    OR

  • Treat with high dose PPI for 1 month and then test for H-Pylori if still symptomatic

    NICE suggests either way is acceptable

  • Both treatments equally effective and cost effective (BMJ 2008)

  • Advises treat and test if still symptomatic


H pylori testing

H-Pylori TESTING

  • Carbon 13 urea breath test, stool antigen and serology

  • Serology is less accurate but can be done whilst on a PPI

  • Breath test and antigen test have similar and high sensitivity and specificity

  • Before either breath/antigen test:

  • Avoid antibiotics for 4 weeks

  • Avoid PPI/H2RA for 2 weeks

  • Patient should fast for 6 HOURS prior to breath test

  • Avoid retesting due to high false positive, breath test if have to


Eradication regimes

ERADICATION REGIMES

  • Standard triple therapy

  • Full dose PPI + amoxicillin (1g BD) + clarithromycin (500mg BD)

  • Full dose PPI + metronidazole (400mg BD) + clarithromycin (250mg BD)

  • 7 day treatment

  • 77% effective at eradication

  • Sequential treatment

  • 10 day treatment

  • Full dose PPI

  • Amoxicillin (1g BD) for the first 5d

  • Metronidazole + clarithromycin (500mg BD) for next 5d

  • 93% effective at H-pylori eradication


Uninvestigated dyspepsia1

UNINVESTIGATED DYSPEPSIA

  • If relapse following successful treatment, consider low dose PPI with regular review

  • If symptoms fail to respond to PPI/eradication treatment, consider a trial of H2 receptor antagonist or prokinetic for 1 month and then review


Gord nud pud

GORD, NUD, PUD

  • If peptic ulcer disease or non-ulcer disease on endoscopy, then test for H-Pylori and eradicate if present

  • If GORD, or H-Pylori negative PUD or NUD, then 1-2 month course of PPI, doubling dose of PPI for 1month if not responding

  • Consider 1 month trial of H2RA/prokinetic if still not responding

  • Repeat endoscopy for H-Pylori positive GU.


Risks of long term ppi treatment

Risks of long term PPI treatment

  • Hip fractures and calcium malabsorption

  • Vitamin B12 malabsorption

  • Iron malabsorption

  • Hypomagnesaemia

  • Atrophic gastritis (esp. if H-pylori +ve)

  • ?pneumonia


Summary

Summary

  • Red flags

  • Don’t forget medication induced dyspepsia, consider alternatives

  • Lifestyle advice

  • Regular review of PPI treatment due to potential risks of long term treatment


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