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Practice Guidelines & clinical pathway on management of Dyspepsia

Practice Guidelines & clinical pathway on management of Dyspepsia. Clinical Scenario. 30 year old, male Call center representative Epigastric pain Denies any alarm features Smoker; alcohol and coffee drinker Unremarkable past medical & family history Direct epigastric tenderness.

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Practice Guidelines & clinical pathway on management of Dyspepsia

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  1. Practice Guidelines & clinical pathway on management of Dyspepsia

  2. Clinical Scenario • 30 year old, male • Call center representative • Epigastric pain • Denies any alarm features • Smoker; alcohol and coffee drinker • Unremarkable past medical & family history • Direct epigastric tenderness

  3. Dyspepsia Presence of 1 or more of the following symptoms (Rome III Committee): • Postprandial fullness • Early satiety • Epigastric pain or burning

  4. Assessment & Diagnosis • Based on history and physical and exam • Consider or rule out: • Dietary indiscretion • Medication induced • Cardiac disease • Gastroparesis • Hepatobiliary disorders • Other systemic disease

  5. 4 Major Causes: • Chronic peptic ulcer disease • Gastroesophageal reflux (+/- esophagitis) • Functional dyspepsia (NUD) • Malignancy

  6. Stratify Patients • Age (55 or less/ above 55) • Presence of alarm features • Family history of upper GI cancer • Unintended weight loss • GI bleeding, unexplained anemia • Progressive dyspepsia, odynophagia • Persistent vomiting • Palpable mass or lymphadenopathy • Jaundice

  7. Review of Current Literatures • Peptic ulcer is found in ~5-15% of patients • Gastric or esophageal Adenocarcinoma is identified in <2% of all patients who undergo endoscopy for dyspepsia • Upper gastrointestinal malignancy becomes more common after age 55 years

  8. Review of Current Literatures • Absence of alarm features has a negative predictive value of >97% • Chronic infection with H. pylori is associated with >80% of peptic ulcers and >1/2 of gastric cancers

  9. Patient Profile • 30 year old, male • Burning epigastric pain • No alarm symptoms

  10. Empiric PPI Therapy • Empiric therapy with proton pump inhibitors for 4- 6weeks • Reassurance • No further investigations if symptoms improve • Out patient clinic follow-up

  11. Failed Empirical Therapy • No response to therapy after 7-10 days • Symptoms has not resolved after 6-8 weeks • EGD with biopsy for H. pylori • Organic disease (PUD, GERD, CA) • Treat accordingly

  12. Normal EGD (Functional Dyspepsia) • Reassurance • Lifestyle changes • Treat H. pylori if present • H. pylori regimen: PPI 40 mg 2x a day Amoxicillin 1G 2x a day Clarithromycin 500mg 2x a day (10-14 days)

  13. <55 y/o and below, no alarm features >55 y/o or <55 y/o w/ alarm features Empiric PPI therapy Response Failed empirical therapy EGD with biopsy for H. pylori Functional dyspepsia Organic disease (PUD, GERD, CA) Reassurance Lifestyle modifications Treat H. pylori if (+) Treat accordingly

  14. H. Pylori Follow -up • Patients who remain symptomatic after initial course of treatment should be retested 4 weeks after completion of the course • Urea breath test or stool antigen test • Some success in using previous triple therapy • Switch to another regimen: PPI+metronidazole+bismuth+tetracycline

  15. Unresponsive Functional Dyspepsia • Persistent dyspeptic symptoms • Not infected with H. pylori or have been rendered free of H. pylori • Do not respond to short course of PPI therapy • (-) negative findings on endoscopy

  16. Unresponsive Functional Dyspepsia • Reevaluate diagnosis • Consider: gastroparesis, biliary or pancreatic diseases, IBS, anxiety disorder • Limited data on use of antidepressants, prokinetic agents

  17. References • Talley NJ, Vakil NB, Moayyedi P: American Gastroenterological Association Technical Review: Evaluation of Dyspepsia. Gasteroenterology 2005, 129:1756-1780.   • American Gastroenterological Association Medical Position Statement: Evaluation of Dyspepsia Gastroenterology 2005, 129:1753-1755.  • Lam SK, Talley NJ: Report for the 1997 Asia Pacific. Consensus Guidelines on the management of H. pylori. Journal Gasteroenterology & Hepatology 1998, 13:1-2.   • American Society for Gastrointestinal Endoscopy’s The role of endoscopy in dyspepsia. Gastrointestinal Endoscopy 2007, 6:1071-1075 • Sleisenger and Fordtran’s Gastrointestinal and Liver Disease 8th Edition

  18. Thank you and good day.

  19. Test-and-Treat Approach • Test for H. pylori (Urea Breath Test or Stool Antigen Test) • Treat if (+) • Trial of PPI therapy if (-) • Do endoscopy if no symptom improvement

  20. Need for in-patient work-up and care • Severity of dyspepsia • Alarm symptoms present • Need for additional lab tests and imaging studies

  21. Possible Scenario • 50 year old with CAD on ASA • Severe epigastric pain, weakness, melena • Pale Will need: • Hospital admission for medical management • Early endosocopy, CBC • Blood transfusion

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