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