Transcript Dyspepsia - Medicine is an art

OBJECTIVES OF THE SESSION:
• At the end of this session, students will be able to:
• Identify differential diagnosis of a case presented with the
symptoms of dyspepsia.
• Differentiate between different causes of dyspepsia.
• Discuss briefly about non-ulcer dyspepsia.
• Discuss briefly about peptic ulcer diseases.
• Discuss briefly about Gastro-esophageal reflux disease (GERD).
• Enumerate and discuss the importance of ALARM signs &
symptoms in patients with dyspepsia.
• Investigate appropriately a patient with dyspepsia.
• Advice initial management plan for a patient with dyspepsia.
• Discuss non-drug management of GERD.
• Identify long term complications of dyspepsia.
Case:
• A 43 y/o man, a taxi driver for long time, presented to the
clinic today with the complaint of indigestion and upper
abdominal pain.
• These complaints initiated for last 3 months. Pain and
indigestion are usually felt after heavy meals. Bowel
movements are normal. He does not use NSAID, but he is
smoker, 10-20 cigarettes per day. No history of
hematemesis or melena. No history recent weight loss or
generalized weakness. He is not known to have any other
chronic illness.
• Initially, he could manage this problem taking antacid
brought over the counter, but during the last week he
could not get relief by the antacid and has vomited 2-3
times.
On examination:
• Look well, not in pain, not pale or jaundiced.
• Systematic examination revealed normal, apart from
tenderness in the upper abdomen in the gastric region.
Dyspepsia?
Indigestion?
dyspepsia
dyspepsia
• It is defined as having one or more symptoms of epigastric
pain, burning, postprandial fullness, or early satiation [Tack et
al. 2006].
• Bloating and nausea often coexist.
• Heartburn is excluded from diagnostic criteria for dyspepsia
since it is thought to primarily arise from the esophagus and it
is suggestive of (GERD).
• Approximately 25 % of patients with dyspepsia have
an underlying organic cause.
• However, up to 75 % of patients have functional
(idiopathic or nonulcer) dyspepsia with no
underlying cause on diagnostic evaluation.
"When you have
excluded all
possibilities, then
what remains --however
improbable --must be the
truth"..Sherlock
Holmes.
Differential diagnosis
DDX
WHAT IS CAUSING HIS DYSPEPSIA?
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Chronic peptic ulcer disease (PUD)?
Gastritis?
MEDICATIONS?
gastroesophageal reflux?
• malignancy ?
• functional dyspepsia?
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irritable bowel syndrome (IBS)
pancreatic or hepatobiliary.
motility disorders
small intestine bacterial overgrowth (SIBO)
metabolic disturbances (e.g., hypercalcemia, heavy metal), diabetic
radiculopathy, hernia.
Indigestion vs. Heart attack!
• People expect the Hollywood heart attack!
• Heavy smoker
• stress
What medications?
• Acarbose (Precose),
Metformin
(Glucophage)
• Alcohol
• Codeine
• Iron
• NSAID’s
• Oral antibiotics (e.g.,
erythromycin)
• Ca Antagonist
• Orlistat (Xenical)
• Potassium
• Corticosteroids (e.g.,
prednisone)
• Theophylline
• Quinidine
• Colchicine
• Gemfibrozil
• Alendronate
Herbs?!
• Dietary supplements and herbal products can be
harmful.
• Patients may not care to tell you.
• Most, are not regulated by the FDA.
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Garlic
Gingko (memory loss)
Saw palmetto (prostate)
Feverfew (migraine)
Chaste tree berry (chastity)
White willow (pain)
A detailed history is key!
• Directed questioning for the presence of alarm symptoms is
important.
• Pain pattern & Radiation.
• Thorough medication review.
• Diet, alcohol consumption.
• Ask about Typical reflux symptoms.(overlap)
• Family history.
• Admissions, surgery, previous diagnosis.
• Previous investigation & endoscopy.
Alarm signs & symptoms!
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Anemia (unexplained iron deficiency)
Black , Bloody stools
Dysphagia
Jaundice
Weight loss (unexplained)
GI bleeding
persistent continuous vomiting
• Epigastric pain (severe ,sudden & persistant)
You must know it
To differentiate it
Non-ulcer dyspepsia
• Functional dyspepsia
• Most common cause in young age.
• No evidence of any organic disease that is likely to explain the
occurring symptoms.
• episodic, recurrent, or persistent symptoms of abdominal pain
or discomfort with or without symptoms indigestion.
• GI motility affected
• Gastric secretion usually normal
• H-Pylori
Rome III
• Diagnostic criteria Must
include One or more of
the following:
• a. Bothersome
postprandial fullness
• b. Early satiation
• c. Epigastric pain
• d. Epigastric burning
• PLUS
• No evidence of structural
disease (including at
upper endoscopy) that is
likely
• Criteria fulfilled for the
last 3 months with
symptom onset at least 6
months prior to diagnosis
Initial treatment :
• Diet & life style
• Antisecretory drug (H2RAs, PPI)
• Prokinetic drug (domperidone) if antisecretory treatment fails
• Promotility agents used include metoclopramide and
erythromycin.
• Psychologic factors
• Antidepressant drugs.
Resistant?
• H pylori eradication
• No treatment is proved to be fully beneficial
in these patients
Gastroesophageal Reflux Disease (GERD)
• Gastroesophageal reflux is a normal
physiologic phenomenon.
• Gastroesophageal reflux disease (GERD)
Exceeds the normal limit, causing symptoms
with or without esophageal mucosal injury.
• Physiologic GERD
– Postprandial
– Short lived
– Asymptomatic
– No nocturnal
symptomes
• Pathologic GERD
– Symptoms
– Mucosal injury
– Nocturnal
symptomes
Causes
1. impaired lower esophageal sphincter
2. hypersecretion.
3. decreased acid clearance.
4. delayed gastric emptying.
Clinical presentation
Heartburn—retrosternal burning discomfort.
Regurgitation—effortless return of gastric
contents into the pharynx.
Atypical symptoms
 coughing,
 chest pain
 wheezing.
Diagnosis
• The most useful tool is Good clinical history.
• Empiric therapy and look for improvement
(Omeprazole)
Treatment
• 3 phases in treatment:
• Phase I: Lifestyle changes.
• Phase II: Pharmacologic interventions
H 2 receptor Blockers (Cimetidine )
Proton pump inhibitors ( Omeprazole)
• phase III: Surgical intervention
• Patients who fail or have severe complications of
GERD
24-hour pH monitoring:
• patients who continue to have symptoms.
• patients who present with atypical symptoms.
Endoscopy:
• Do not respond to therapy
• present with alarm symptoms
Peptic ulcer disease (PUD)
• Less common
• A breach in the mucosa of the stomach as a
result of caustive effects of acid and pepsin in
the lumen.
Classification of peptic ulcers By Region:
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Duodenal ulcer
Gastric ulcer
Esophageal ulcer GERD
Meckel's diverticulum ulcer
Causes of PUD
• Helicobacter pylori (HP).
• (NSAID)
suppressing prostaglandin synthesis
• stress-related mucosal damage
Symptoms
• Abdominal pain, classically
epigastric.
• Bloating
• water brash
• Nausea
• vomiting
• loss of appetite
• weight loss
• Hematemesis
• melena.
• The timing of the
symptoms in relation to
the meal may
differentiate between
gastric and duodenal
ulcer.
Diagnosis
• Exclude the most common (Hp)
• Upper endoscopy if there are any alarming
symptoms .
How to treat?!
• NSAIDs immediately discontinued with positive H pylori +
Eradication
• For patients who must continue with NSAIDs, PPI
maintenance or changing to a COX-2 selective inhibitor is an
option.
• Use acetaminophen or nonacetylated salicylates when
possible.
• Consider prophylactic or preventive therapy.
(Omeprazole 20-40 mg PO every day)
HP bacteria
• H. pylori is a spiral-shaped.
• commonly found in the stomach.
• Weakens the lining and make the stomach
more susceptible to damage from gastric
acids.
• The bacteria can also attach to cells of the
stomach, causing stomach inflammation >>
gastritis, Production of excess stomach acid.
Diagnosis of HP
• Serologic tests detect circulating IgG
• The UBT
• stool antigen test
• Endoscopy
Importance of eradication
• Studies have shown that HP eradication effect on
symptoms improved quality of life of primary
care patients.
• H. pylori-positive adult patients with FD, were
randomly assigned to receive omeprazole,
amoxicillin trihydrate, and clarithromycin for 10
days.
• Endoscopy and H. pylori tests were performed at
screening and at 12 months. Outcome measures
were at least 50% symptomatic improvement at
12 months.
Eradication
• Triple Regimn (PPI, 2 antibiotics) usually
clarithromycin and amoxicillin.
• Quadruple therapy using a PPI (with bismuth,
metronidazole, and tetracycline) gives similar results
as triple therapy but permits a shorter treatment
duration (7 days).
• Used as second line if Triple fails.
Investigations for dyspepsia
Who to Investigate?
1. Over 50 years of age
2. Failed therapy
3. Symptoms that are severe
Are there
alarming
features
No (age)
Under 55(test
for HP
Over55
(endoscopy )
yes
Endoscopy
Endoscopy ??
Endoscopy
1. ALARM signs
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6.
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Failure of therapy
Symptoms persist 6-8 wks
Recurrence
Persistant GERD
diagnostic uncertainty
Patients wish
Urgent endoscopy!
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Chronic GI bleeding
Progressive unexplained weight loss
Progressive dysphagia
Persistent vomiting
Iron deficiency anaemia
Epigastric mass
Management of dyspepsia
• Simple lifestyle modification:
eat healthy, reduce weight, smoking cessation
• Stop alcohol
• Sleep well, avoid stress
• Reassurance and explanation
This is often helpful.
Managing dyspepsia
• Antacid, sucralfate
• H2A
• or PPI therapy for one month to patients with
dyspepsia.
• Use lowest effective dose.
• Prokinetic agents
Recommendations
• Dyspepsia, older than 50 years of age or with alarm
features should undergo endoscopic evaluation.
• Patients with dyspepsia who are younger than 50 years
of age and without alarm features may undergo an
initial test-and-treat approach for H. pylori
• Patients who are younger than 50 years of age and are
H. pylori negative can be offered an initial endoscopy
or a short trial of PPI acid suppression
• Patients with dyspepsia who do not respond to empiric
PPI therapy or have recurrent symptoms after an
adequate trial should undergo endoscopy
Complications of dyspepsia
Esophageal stricture
Treatment is usually surgery to widen the
esophagus.
Symptoms of it:
• Difficulty swallowing
• Food becoming lodged in the throat
• Chest pain
Pyloric stenosis
Treatment is surgery to return the pylorus to its
proper width.
Peritonitis
Treatment is surgery to repair the damage to
the peritoneum, and antibiotics to clear the
infection.
Barrett’s esophagus
Could lead to esophageal cancer.
Summary
• Dyspepsia is common in primary care
practice.
• It’s a blanket for many diseases.
• Most common are FD,GERD,PUD.
• Alarm present or absent?
Summary
• Symptoms of dyspepsia
• What aggrevates it? What
improves it?
• Any specific signs & symptoms.
• Alarm signs?
• Is it organic or functional?
• H.Pylori
Take home massage
 Don’t take it easy , it can be misleading.
 A Good history is always key !
References
• J Clin Gastroenterol. 1997;25 Suppl 1:S1-7.
• Is smoking still important in the pathogenesis of peptic ulcer disease?
Eastwood GL.
• Kumar & Clark's Clinical Medicine (Saunders, 2009)
• Pharmacotherapy: A Pathophysiologic Approach