Transcript Clinical case discussion

Case
A 48 year old man presented with post prandial
epigastric pain for 6 months.
Omeprazole 20 mg/D is effective in relieving
pain but pain recurs when the drug is stopped
Heavy smoker
Mild epigastric tenderness
Dyspepsia
Definition
• Group of symptoms consisting mostly
upper abdominal or epigastric pain or
discomfort, heartburn, or acid
regurgitation.Often associated with
belching, bloating, nausea or vomiting
• Dyspepsia is a common symptom with an
extensive differential diagnosis and a
heterogeneous pathophysiology.
• It occurs in approximately 25 percent
(range 13 to 40 percent) of the population
each year, but most affected people do not
seek medical care.
Dyspepsia
Functional
Dyspepsia
Non-GI
Causes of Symptoms
(cardiac disease,
muscular pain, etc.)
Structural Dyspepsia
(GERD, PUD, pancreatic
disease, gallstones, etc.)
common causes of dyspepsia
1- Functional (nonulcer) dyspepsia
2- Peptic ulcer disease
3- GERD
4-Gastric or esophageal cancer
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Up to 70%
15 to 25 %
5 to 15 %
<2%
Less common causes of upper
abdominal pain
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Abdominal cancer, especially pancreatic cancer
Biliary tract disease
Carbohydrate malabsorption (lactose, sorbitol, fructose, mannitol)
Gastroparesis
Hepatoma
Infiltrative diseases of the stomach (Crohn disease, sarcoidosis)
Intestinal parasites (Giardia, Strongyloides)
Ischemic bowel disease
Medication
Metabolic disturbances (hypercalcemia, hyperkalemia)
Pancreatitis
Systemic disorders (diabetes mellitus, thyroid and parathyroid
disorders, connective tissue disease)
Drugs associated with dyspepsia
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NSAIDs including
cox-2 inhibitors
Iron.
Metformin
Codiene
Antibiotics
Orlistat
Corticosteroids
theophyllin
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Digoxin.
Colchicine
Alendronate.
Nitrates
Quinidine
Gemfibrozil
Niacin
Acarbose
Functional dyspepsia
Definition
(Rome III criteria)
One or more of:
 Bothersome postprandial fullness
 Early satiation
 Epigastric pain
 Epigastric burning
AND
 No evidence of structural disease (including at
upper endoscopy) that is likely to explain the
symptoms.
• These criteria should be fulfilled for the
last three months with symptom onset at
least six months before diagnosis.
Alarm features
for MGN
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Age older than 55
Unintended weight loss
Persistent vomiting
Progressive dysphagia
Odynophagia
GIB
Palpable abdominal mass or lymphadenopathy
Unexplained iron deficiency anemia
Family history of upper gastrointestinal cancer
Previous gastric surgery
Jaundice
Diagnostic strategies
• Alarm features
• Age
• Local prevalence of H pylori
Initial managment
• Patients with GERD and NSAID induced
dyspepsia
• PPI for eight weeks and NSAIDs should
be discontinued
Initial managment
• Patient with alarm features or age ≥ 55
• Early upper endoscopy (within two weeks)
& rule out H. pylori.
• further evaluation to exclude other
etiologies. If the upper endoscopy is
normal
• optimal age cut-off for endoscopic evaluation in patients
with dyspepsia (without alarm features) is controversial
yield of upper endoscopy in
patients with dyspepsia
• most prevalent findings in patients with
dyspepsia were erosive esophagitis and
peptic ulcer disease (pooled prevalence 6
and 8 percent
• increases with age
Initial managment
• Patient without alarm features and age
<55 years
• test and treat (efficacy varies based on used in primary or
secondary care settings and the local prevalence)- prevalence of H.
pylori is >20 percent
• empiric antisecretory therapy- prevalence <5
percent
• prevalence of 5 to 20% the strategies may
be equivalent in terms of dyspepsia
resolution, patient satisfaction, and cost
• PPI therapy is more effective in relieving
symptoms of dyspepsia as compared with
H2 antagonists
• Upper endoscopy reserved for patients
with persistent symptoms despite
antisecretory therapy and H. pylori
testing/treatment
EVALUATION OF PERSISTENT SYMPTOMS
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persistent H. pylori infection
patients with an alternate diagnosis
patients with functional dyspepsia
carefully reassessed, paying specific
attention to the type of ongoing symptoms,
the degree to which symptoms have
improved or worsened, and compliance
with medications
• Delayed gastric emptying has been found
in 30 to 50
Pathophysiology
• unclear
• Research has focused upon the following
factors:
• Gastric motor function
• Visceral sensitivity
• Helicobacter pylori infection
• Psychosocial factors
functional dyspepsia
altered gastric motility in up to 80 percent
• Gastroparesis
• gastric dysrhythmias
• abnormal fundus accumulation
• pyloric sphincter dysfunction
• the degree of dysmotility does not correlate with symptoms.
TREATMENT
 — Treatment of patients with functional dyspepsia
is controversial and often disappointing, a sharp
contrast to the therapy of peptic ulcer disease [ 40]
. The goal is to help patients accept, diminish, and
cope with symptoms rather then eliminate them [
40] .
 Similar to patients with irritable bowel syndrome,
the most important aspects of the therapy of
functional dyspepsia include explanation,
validation that the symptoms are not imaginary,
evaluation and management of relevant
psychosocial factors, and dietary advice
• . Medications that might contribute to
symptoms (such as NSAIDs) should be
substituted or discontinued whenever
possible.
• Drug therapy, which is based upon the
putative pathogenetic mechanisms
described above, may help some patients.
Several systematic reviews
 antidepressant -PPI therapy has failed
 Prokinetics