Dyspepsia

1. Dyspepsia

2. OBJECTIVES OF THE SESSION: • At the end of this session, students will be able to: • Identify differential diagnosis of a case presented with the symptoms of dyspepsia. • Differentiate between different causes of dyspepsia. • Discuss briefly about non-ulcer dyspepsia. • Discuss briefly about peptic ulcer diseases. • Discuss briefly about Gastro-esophageal reflux disease (GERD). • Enumerate and discuss the importance of ALARM signs & symptoms in patients with dyspepsia. • Investigate appropriately a patient with dyspepsia. • Advice initial management plan for a patient with dyspepsia. • Discuss non-drug management of GERD. • Identify long term complications of dyspepsia.

3. Case: • A 43 y/o man, a taxi driver for long time, presented to the clinic today with the complaint of indigestion and upper abdominal pain. • These complaints initiated for last 3 months. Pain and indigestion are usually felt after heavy meals. Bowel movements are normal. He does not use NSAID, but he is smoker, 10-20 cigarettes per day. No history of hematemesis or melena. No history recent weight loss or generalized weakness. He is not known to have any other chronic illness. • Initially, he could manage this problem taking antacid brought over the counter, but during the last week he could not get relief by the antacid and has vomited 2-3 times.

4. On examination: • Look well, not in pain, not pale or jaundiced. • Systematic examination revealed normal, apart from tenderness in the upper abdomen in the gastric region.

5. Dyspepsia? Indigestion?

6. dyspepsia

7. dyspepsia • It is defined as having one or more symptoms of epigastricpain, burning, postprandial fullness, or early satiation [Tack et al. 2006]. • Bloating and nausea often coexist. • Heartburn is excluded from diagnostic criteria for dyspepsia since it is thought to primarily arise from the esophagus and it is suggestive of (GERD).

8. Approximately 25 % of patients with dyspepsia have an underlying organic cause. • However, up to 75 % of patients have functional (idiopathic or nonulcer) dyspepsia with no underlying cause on diagnostic evaluation.

9. "When you have excluded all possibilities, then what remains ---however improbable --- must be the truth"..Sherlock Holmes.

10. Differential diagnosis DDX

11. WHAT IS CAUSING HIS DYSPEPSIA? • Chronic peptic ulcer disease (PUD)? • Gastritis? • MEDICATIONS? • gastroesophageal reflux? • malignancy ? • functional dyspepsia? • irritable bowel syndrome (IBS) • pancreatic or hepatobiliary. • motility disorders • small intestine bacterial overgrowth (SIBO) • metabolic disturbances (e.g., hypercalcemia, heavy metal), diabetic radiculopathy, hernia.

12. Indigestion vs. Heart attack! • People expect the Hollywood heart attack! • Heavy smoker • stress

13. What medications? • Acarbose (Precose), Metformin (Glucophage) • Alcohol • Codeine • Iron • NSAID’s • Oral antibiotics (e.g., erythromycin) • Ca Antagonist • Orlistat (Xenical) • Potassium • Corticosteroids (e.g., prednisone) • Theophylline • Quinidine • Colchicine • Gemfibrozil • Alendronate

14. Herbs?! • Dietary supplements and herbal products can be harmful. • Patients may not care to tell you. • Most, are not regulated by the FDA. • Garlic • Gingko (memory loss) • Saw palmetto (prostate) • Feverfew (migraine) • Chaste tree berry (chastity) • White willow (pain)

16. A detailed history is key! • Directed questioning for the presence of alarm symptoms is important. • Pain pattern & Radiation. • Thorough medication review. • Diet, alcohol consumption. • Ask about Typical reflux symptoms.(overlap) • Family history. • Admissions, surgery, previous diagnosis. • Previous investigation & endoscopy.

17. Alarm signs & symptoms! • Anemia (unexplained iron deficiency) • Black , Bloody stools • Dysphagia • Jaundice • Weight loss (unexplained) • GI bleeding • persistent continuous vomiting • Epigastric pain (severe ,sudden & persistant)

18. You must know it To differentiate it

19. Non-ulcer dyspepsia • Functional dyspepsia • Most common cause in young age. • No evidence of any organic disease that is likely to explain the occurring symptoms. • episodic, recurrent, or persistent symptoms of abdominal pain or discomfort with or without symptoms indigestion. • GI motility affected • Gastric secretion usually normal • H-Pylori

20. Rome III • Diagnostic criteria Must include One or more of the following: • a. Bothersome postprandial fullness • b. Early satiation • c. Epigastric pain • d. Epigastric burning • PLUS • No evidence of structural disease (including at upper endoscopy) that is likely • Criteria fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis

21. Initial treatment : • Diet & life style • Antisecretory drug (H2RAs, PPI) • Prokinetic drug (domperidone) if antisecretory treatment fails • Promotility agents used include metoclopramide and erythromycin. • Psychologic factors • Antidepressant drugs.

22. Resistant? • H pylori eradication • No treatment is proved to be fully beneficial in these patients

25. Gastroesophageal Reflux Disease (GERD) • Gastroesophageal reflux is a normal physiologic phenomenon. • Gastroesophageal reflux disease (GERD) Exceeds the normal limit, causing symptoms with or without esophageal mucosal injury.

26. Physiologic GERD • Postprandial • Short lived • Asymptomatic • No nocturnal symptomes • Pathologic GERD • Symptoms • Mucosal injury • Nocturnal symptomes

27. Causes  1. impaired lower esophageal sphincter 2. hypersecretion. 3. decreased acid clearance. 4. delayed gastric emptying.

28. Clinical presentation • Heartburn—retrosternal burning discomfort. • Regurgitation—effortless return of gastric contents into the pharynx. • Atypical symptoms • coughing, • chest pain • wheezing.

29. Diagnosis • The most useful tool is Good clinical history. • Empiric therapy and look for improvement  (Omeprazole)

30. Treatment • 3 phases in treatment: • Phase I: Lifestyle changes. • Phase II: Pharmacologic interventionsH 2 receptor Blockers  (Cimetidine )Proton pump inhibitors  ( Omeprazole) • phase III: Surgical intervention• Patients who fail or have severe complications of GERD 

31. 24-hour pH monitoring: • patients who continue to have symptoms. • patients who present with atypical symptoms. Endoscopy: • Do not respond to therapy • present with alarm symptoms

32. Peptic ulcer disease (PUD) • Less common • A breach in the mucosa of the stomach as a result of caustive effects of acid and pepsin in the lumen.

33. Classification of peptic ulcers By Region: • Duodenal ulcer • Gastric ulcer • Esophageal ulcer GERD  • Meckel'sdiverticulum ulcer

34. Causes of PUD • Helicobacter pylori (HP). • (NSAID)suppressing prostaglandin synthesis • stress-related mucosal damage 

35. Symptoms • Abdominal pain, classically epigastric. • Bloating • water brash • Nausea • vomiting • loss of appetite • weight loss • Hematemesis • melena. • The timing of the symptoms in relation to the meal may differentiate between gastric and duodenal ulcer.

36. Diagnosis •  Exclude the most common  (Hp) • Upper endoscopy if there are any alarming symptoms .

37. How to treat?! • NSAIDs immediately discontinued with positive H pylori + Eradication • For patients who must continue with NSAIDs, PPI maintenance or changing to a COX-2 selective inhibitor is an option. • Use acetaminophen or nonacetylatedsalicylates when possible. • Consider prophylactic or preventive therapy. (Omeprazole20-40 mg PO every day)

38. HPbacteria • H. pylori is a spiral-shaped. • commonly found in the stomach. • Weakens the lining and make the stomach more susceptible to damage from gastric acids. • The bacteria can also attach to cells of the stomach, causing stomach inflammation >> gastritis, Production of excess stomach acid.

39. Diagnosis of HP • Serologic tests detect circulating IgG • The UBT • stool antigen test • Endoscopy

40. Importance of eradication • Studies have shown that HP eradication effect on symptoms improved quality of life of primary care patients. • H. pylori-positive adult patients with FD, were randomly assigned to receive omeprazole, amoxicillin trihydrate, and clarithromycin for 10 days. • Endoscopy and H. pylori tests were performed at screening and at 12 months. Outcome measures were at least 50% symptomatic improvement at 12 months.

41. Eradication • Triple Regimn (PPI, 2 antibiotics) usually clarithromycinand amoxicillin. • Quadruple therapy using a PPI (with bismuth, metronidazole, and tetracycline) gives similar results as triple therapy but permits a shorter treatment duration (7 days). • Used as second line if Triple fails.

42. Investigations for dyspepsia Who to Investigate? • Over 50 years of age • Failed therapy • Symptoms that are severe

44. Endoscopy ??

45. Endoscopy • ALARMsigns • Failure of therapy • Symptoms persist 6-8 wks • Recurrence • Persistant GERD • diagnostic uncertainty • Patients wish

46. Urgent endoscopy! • Chronic GI bleeding • Progressive unexplained weight loss • Progressive dysphagia • Persistent vomiting • Iron deficiency anaemia • Epigastric mass

47. Management of dyspepsia • Simple lifestyle modification: eat healthy, reduce weight, smoking cessation • Stop alcohol • Sleep well, avoid stress • Reassurance and explanation This is often helpful.

48. Managing dyspepsia • Antacid, sucralfate • H2A • or PPI therapy for one month to patients with dyspepsia. • Use lowest effective dose. • Prokinetic agents

49. Recommendations • Dyspepsia, older than 50 years of age or with alarm features should undergo endoscopic evaluation. • Patients with dyspepsia who are younger than 50 years of age and without alarm features may undergo an initial test-and-treat approach for H. pylori • Patients who are younger than 50 years of age and are H. pylori negative can be offered an initial endoscopy or a short trial of PPI acid suppression • Patients with dyspepsia who do not respond to empiric PPI therapy or have recurrent symptoms after an adequate trial should undergo endoscopy

50. Complications of dyspepsia Esophageal stricture Treatment is usually surgery to widen the esophagus. Symptoms of it: • Difficulty swallowing • Food becoming lodged in the throat • Chest pain Pyloric stenosis Treatment is surgery to return the pylorus to its proper width.