Transcript Dyspepsia - University of Toronto

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, evidencebased 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?
indigestion
bloating
nausea
early satiety
stomachache
fullness
vomiting
upset stomach
queasiness
epigastric discomfort
heartburn
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
• bloating
• early satiety
• 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
Organic
40%
Functional
=“Non-Ulcer
Dyspepsia”
60%
Organic Causes
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Peptic Ulcer Disease
Most common organic causes,
GERD
according to AGA
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
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
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Age > 45
Weight loss
Bleeding
Anemia
Dysphagia
From AGA Guidelines
Dyspepsia
Clinical evaluation
Exclude by History:
GERD; biliary; IBS;
Meds; aerophagia
-
 45 years
and no red
flags
+
Manage
appropriately
>45 or red flags
Endoscopy
Step 3
Treat for Non-Ulcer Dyspepsia
The Role of H. pylori in NonUlcer 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
14
90-95
90-95
Serology*
85-95
85-90
C Urea Breath Test
*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 BID
HP Pack
7 days
Amoxicillin 1000mg BID
Alternate regimens substitute metronidazole for amoxil
(but some H.pylori are resistant)
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
From AGA Guidelines
 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.
success
Follow-up
Empiric H2, PPI, or
prokinetic x 1 month
fails
fails
Endoscopy
success
Follow-up
Step 4
Endoscopy if still symptomatic
Step 5
Post-Endoscopy Management
From AGA Guidelines
Endoscopy
Organic Disease H. pylori detected
Functional
Rx & Follow-up
H2/PPI or prokinetic
success
4 weeks
fails
Switch to other agent
success
Re-evaluate
fails
? Behavioral/ Psychotherapy/
Antidepressant
Non-pharmacologic
Tx
Quit smoking
• Therapy for
•
• 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
– 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