Transcript Slide 1
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
Dyspepsia
Presence of 1 or more of the following symptoms
(Rome III Committee):
Postprandial fullness
Early satiety
Epigastric pain or burning
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
4 Major Causes:
Chronic peptic ulcer disease
Gastroesophageal reflux (+/- esophagitis)
Functional dyspepsia (NUD)
Malignancy
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
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
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
Patient Profile
30 year old, male
Burning epigastric pain
No alarm symptoms
Empiric PPI Therapy
Empiric therapy with proton pump inhibitors
for 4- 6weeks
Reassurance
No further investigations if symptoms
improve
Out patient clinic follow-up
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
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)
<55 y/o and below, no
alarm features
>55 y/o or
w/ alarm features
Empiric PPI therapy
Response
Failed empirical therapy
EGD with biopsy
for H. pylori
Functional dyspepsia
Reassurance
Lifestyle modifications
Treat H. pylori if (+)
Organic disease
(PUD, GERD, CA)
Treat accordingly
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
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
Unresponsive Functional
Dyspepsia
Reevaluate diagnosis
Consider: gastroparesis, biliary or pancreatic
diseases, IBS, anxiety disorder
Limited data on use of antidepressants,
prokinetic agents
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
Prepared by:
Dr. Ernesto Olympia
Dr. Benjamin Benitez
Dr. Patricia Prodigalidad
Dr. William Rodriguez
THANK YOU AND GOOD DAY.
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
Need for in-patient work-up
and care
Severity of dyspepsia
Alarm symptoms present
Need for additional lab tests and imaging
studies
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