Dyspepsia

What is dyspepsia?

‘pain or discomfort related to eating or drinking that can be attributed to the upper gastro-intestinal tract’

The problem of dyspepsia

• 25 - 40 % prevalence, and increasing• 25% of these seek help from GP• 2 % population have endoscopies p.a.• 0.45 % on long term PPIs• £500 million pa (E&W)• £ 2-3 billion Europe

Drugs that cause dyspepsia

• NSAIDS• Bisphosphonates• Steroids

• Metformin

• Calcium antagonists• Theophyllines• Nitrates

Endoscopic diagnoses in dyspepsia

0

10

20

30

40

50

60

GERDPUDFunctionalBenign strictureCancer

%

Westbrook at al, 2001

What all patients worry about

GORD

Gastro-oesophageal junction

Causes of GORD

Diagnosis of GORD

Complications of GORD

• Stricture• Barrett’s Oesophagus• Oesophageal adenocarcinoma• Extra-oesophageal

– Asthma– Cough– Pharyngitis

Barrett’s Oesophagus

Barrett’s Oesophagus

Barrett’s Adenocarcinoma

©Cancer Research UK

European age-standardised mortality rates for oesophageal cancer in UK, 1979-1999

Anti-reflux surgery (ARS)

• Helps 90%• Lasts about 10 years• 50% still need PPI• Morbidity in 10% (dysphagia, bloating)• Laparoscopic probably better – but no evidence

Gastric Ulcer

Gastric ulcer - causesGastric ulcer - causes

H. pylori 60%NSAIDs 30%Carcinoma 5%Others 5%

- neoplasia- Crohn’s- stress- ZE syndrome

Duodenal Ulcer

Duodenal ulcer - causesDuodenal ulcer - causes

H. pylori 85%NSAIDs 10-14%Rare causes 1%

- Zollinger Ellison- Crohn’s- Stress

Giving NSAIDs in patients with or at risk of peptic ulcer

• Avoid NSAID if possible• Consider COX2 inhibitors

– Beware cardiovascular risks• Hypertension• MI• CVA

• Add PPI to COX2 inhibitor• Add PPI to ‘low-risk NSAID’ (ibuprofen)

Functional Dyspepsia

Gastric cancer

Age standardised (European) incidence and mortality by sex, stomach cancer, UK, 1979-2001

© Cancer Research UK

Five year relative survival rates by sex, stomach cancer

© Cancer Research UK

ALARM symptoms

• Abdominal swelling (Anaemia)

• Loss of weight

• Anorexia

• Recurrent symptoms*

• Melaena/Haematemesis

• Swallowing problems

*Only if age >55 years

Audit characteristics

• 1170 practices – 14% of practices– 71% of cancer networks

• April 2009 – April 2010• Represents 8% of cancers registered that year

Delays for gastric cancer

0

10

20

30

4050

60

70

80

90

100

0 14 31 62 182

PatientGPHospital

Stage of gastric cancer

No spreadLocalDistantNo data

Number of consultations

0

5

10

15

20

25

30

35

40

0 1 2 3 4 5 or more

Route of referral

Emergency2WWRoutinePrivateOther

Upper GI 2 week cancer referral cancers

Oesophagus

GastricPancreas

Biliary

Colon

NHL

Unknown primary

Others

Lung

Cancer risk in 2WW referralsCancer risk in 2WW referrals

0

5

10

15

20

25

30

25 35 45 55 65 75 85

MaleFemale

% c

ance

r

2 week UGI cancer referrals

0

200

400

600

800

1000

1200

2001 2002 2003 2004 2005 2006

ReferredCancers

Community Care & Pharmacy

General Advice

General Advice

GP management of Dyspepsia

Irritable Bowel Syndrome

Diagnosis

• Pain associated with bowels• Longstanding• History of dysenteric illness• Associated conditions

– Fibromyalgia– Headache– CFS– Non-cardiac chest pain

Warning signs

• Short history• Weight loss• Nocturnal diarrhoea• Incontinence • Rectal bleeding• Age >50• Abnormal blood tests

Blood tests

• FBC, CRP, UE, LFT (incl Ca), TSH, tTG, B12, folate

• Rectal examination

Faecal calprotectin

Faecal calprotectin

Faecal calprotectin

• Useful to diagnose IBD• Not useful to confirm IBS (at present)• May miss other important diagnoses

– Cancer– Bile acid malabsorption– Diverticulosis

Management of DP-IBS

• Avoid bran• Reduce non-soluble fibre• Reduce lactose (use soy or rice products)• Loperamide• Anti-spasmodics• Amitriptyline

Management of CP-IBS

• Increase dietary fibre (20-30g)• Unprocessed wheat bran• Increase fluids• Bulking laxatives

– Ispaghula husk• Consider citalopram

Pain in IBS

• Hypnotherapy beneficial• Cognitive Behavioural Therapy beneficial• Acupuncture not proven• Citalopram/amitriptyline may help

FODMAPs

• Fermentable• Oligosaccharides• Disaccharides• Monosaccharides• And• Polyols (sorbitol, sweeteners)

Category A (suspected lower GI cancer)

Any patient over the age of 50 with change in bowel habit/diarrhoea (>6 weeks but <6 months) who has one or more of the following features:

Weight loss, iron deficiency anaemia, tenesmus, strong family history of bowel cancer (in first degree relative aged <60), abdominal mass, mass on PR

Action: Refer as 2WW to Colorectal Dept

Category B (Organic diarrhoea)

Any patient presenting with diarrhoea, not fulfilling ‘A’, who has any of the following features:

Bloody stools, frequent loose stools ++, incontinence, nocturnal diarrhoea, strong family history of IBD, raised CRP, positive TTG

Action: Refer to Dept of Gastroenterology

*Urgent referral or emergency admission is recommended for patient who may have a severe colitis, typical patients may have 6 or more bloody stools per day, fever, tachycardia and anaemia*

Category C (Probable IBS)

Patient below the age of 40 who has altered bowel habit, abdominal pain or discomfort that is relieved by defaecation, bloating but in the absence of category A and B features.

Action: Does not require referral for confirmation of diagnosis. To exclude inflammatory bowel disease, perform faecal calprotection test. Only refer if positive. Do not carry out faecal calprotectin within 1 week of gastrointestinal infection (will be raised).

Manage as per IBS guidelines