DYSPEPSIA Dr.Vishal Rathore
Dec 16, 2015
Dyspepsia
• popularly known as indigestion
• meaning hard or difficult digestion, is a medical condition characterized by chronic or recurrent pain in the upper abdomen, upper abdominal fullness and feeling full earlier than expected when eating.
Prevalence 25-40 %, of which • 50% self medicate • 25% consult their G.P.
• 5% of G.P. consultations are for dyspepsia • Prescribed drugs and endoscopies cost £600M in 2000
• OTC indigestion remedies sold for £100M in 2002
Causes
• Reflux oesophagitis 12% • Duodenal ulcer 10% • Gastric ulcer 6%• Gastric carcinoma 1% • Oesophageal carcinoma 0.5%
Non-erosive GORDFunctional (non-ulcer) dyspepsia
Alarm Symptoms/ Signs*
• GI bleeding (same day referral)
• Persistent vomiting
• Weight loss (progressive unintentional)
• Dysphagia
• Epigastric mass
• Anaemia due to possible GI blood loss
Thus all patients with new-onset dyspepsia should have abdominal examination and FBC
First Approach to Dyspepsia
• Consider possible causes outside upper GI tract -Heart, lung, liver, gall bladder, pancreas, bowel
• Consider drugs and stop if possible - Aspirin / NSAIDs, calcium antagonists, nitrates, theophyllines, etidronate, steroids
Refer if dyspepsia in 55+* year old
• Alarm symptoms/signs (2 week referral)
• Unexplained and persistent recent-onset dyspepsia without alarm symptoms – Unexplained means no cause known – Persistent implies present for a length of time (NICE suggest 4-6 weeks) – Recent-onset implies new-not a recurrent episode.
Referral for Endoscopy
• Review medications for possible causes of dyspepsia
(calcium antagonists, nitrates, theophyllines,
bisphosphonates, corticosteroids and non-steroidal
anti-inflammatory drugs [NSAIDs]).
• In patients requiring referral, suspend NSAID use.
Urgent specialist referral
Endoscopic investigation is indicated for patients of anyage with dyspepsia when presenting with any of thefollowing: • chronic gastrointestinal bleeding, • progressive unintentional weight loss, • progressive difficulty swallowing, • persistent vomiting, • Iron deficiency anaemia, • epigastric mass • suspicious barium meal
Routine Endoscopic Investigation
• Patients of any age, presenting with dyspepsia and without alarm signs, is not necessary.
• However, in patients aged 55 years and older with unexplained and persistent recent-onset dyspepsia alone, an urgent referral for endoscopy should be made.
Management of simple dyspepsiain those aged < 55 years
• Stress benign nature of dyspepsia
• Lifestyle advice
– Healthy eating
– Weight reduction
– Stop smoking
– Use of antacids
Interventions for uninvestigated dyspepsia
• Initial therapeutic strategies for dyspepsia are
empirical treatment with a proton pump inhibitor (PPI) or testing for and treating H. pylori.
• There is currently insufficient evidence to guide which should be offered first.
• A 2-week washout period following PPI use is necessary before testing for H. pylori with a breath test or a stool antigen test
Nice Guideline Summary
• Refer if “alarm symptoms” at any stage
• Test and treat
(Test for H. pylori and treat positives)
THEN, IF STILL SYMPTOMATIC
PPI for one month
THEN
Manage recurrent symptoms as functional dyspepsia
Rx of H. Pylori
• One week triple therapy * PPI (full dose) e.g. omeprazole 20mg bd Clarithromycin 500mg bd Amoxycillin 1g bd (or Metronidazole 400mg bd)
• Use a carbon-13 urea breath test, stool antigen test or, when performance has been validated, laboratory based serology.
• If re-testing for H. pylori use a carbon-13 urea breath test.*