DYSPEPSIA Enhanced Primary Care Pathway [July 2016]

Click here to load reader

  • date post

    13-Jan-2017
  • Category

    Documents

  • view

    234
  • download

    4

Embed Size (px)

Transcript of DYSPEPSIA Enhanced Primary Care Pathway [July 2016]

  • Name:

    DOB:

    PHN/ULI:

    RHRN:

    RefMD: Dr.

    RefMDFax:

    RefDate:

    DateToday: CONFIRMATION: ReferralReceived

    DYSPEPSIATRIAGECATEGORY: EnhancedPrimaryCarePathwayREFERRALSTATUS: CLOSEDDearDr.,Theclinicalanddiagnosticinformationyouhaveprovidedfortheabove-namedpatientisconsistentwithdyspepsia. Based on full review of your referral, it has been determined thatmanagement of thispatientwithin the Enhanced Primary Care Pathway is appropriate, without need for specialistconsultationatthistime.ThisclinicalpathwayhasbeendevelopedbytheCalgaryZonePrimaryCareNetworkinpartnershipwiththe Section of Gastroenterology andAlbertaHealth Services. These local guidelines are based on bestavailableclinicalevidence,andarepracticalintheprimarycaresetting.Thispackageincludes:

    1. Focusedsummaryofdyspepsiarelevanttoprimarycare2. Checklisttoguideyourin-clinicpatientreview3. Linkstoadditionalresourcesforthisspecificcondition4. Clinicalflowdiagramwithexpandeddetail

    ThisreferralisCLOSED.IfyouwouldliketodiscussthisreferralwithaGastroenterologist,callSpecialistLINK,adedicatedGIphoneconsultationservice,available08:00-17:00weekdaysat403-910-2551ortoll-free1-855-387-3151.If your patient completes the Enhanced Primary Care Pathway and remains symptomatic or ifyourpatientsstatusorsymptomschange,anewreferralindicatingcompletedcarepathwayornewinformationshouldbefaxedtoGICentralAccessandTriageat403-944-6540.Thankyou.

    KevinRioux,MDPhDFRCPCMedicalLead,GICentralAccessandTriageSectionofGastroenterology

  • Enhanced Primary Care Pathway: DYSPEPSIA July 2016 - Page 2/6

    EnhancedPrimaryCarePathway:DYSPEPSIA

    1.Focusedsummaryofdyspepsiarelevanttoprimarycare

    Dyspepsia refers to a symptom complex of gastroduodenal origin, characterized by epigastric pain ordiscomfortthatmaybetriggeredbyeatingandmaybeaccompaniedbyasenseofabdominaldistentionorbloatingandlossofappetite.TheRomeIIIcommitteeonfunctionalGIdisordersdefinesdyspepsiaasoneormoreofthefollowingsymptoms:

    Postprandialfullness(postprandialdistresssyndrome) Epigastricpainorburning(epigastricpainsyndrome) Earlysatiety

    Othersymptomssuchasbelchingandnauseamayoccur.There is frequentoverlapbetweendyspepsiaandheartburn,which typifiesgastroesophageal reflux (GERD). Irritablebowel syndromealsooverlapswith functionaldyspepsia,where thepredominantsymptomcomplex includesbloatingandreliefafterdefecation. Biliary tract pain should also be considered, the classic symptom description being post-prandial(worsewithfattymeals)deep-seatedrightupperquadrantpainthatbuildsoverseveralhoursandthendissipates.Dyspeptic symptoms in the general population are common: estimates as high as 30% of individualsexperience dyspeptic symptoms, while few seek medical care. Although the causes of dyspepsiaincludeesophagitis,pepticulcerdisease,Helicobacterpylori infection, celiacdisease,andrarelyneoplasia, most patients with dyspepsia have no organic disease, with a normal battery ofinvestigations including endoscopy. The mechanism of this symptom complex is incompletelyunderstood, but likely involves visceral hypersensitivity, alterations in gastric accommodation andemptyingandalteredcentralpainprocessing.2.Checklisttoguideyourin-clinicreviewofthispatientwithdyspepsiasymptoms

    o Absenceofredflagfeatures(weightloss,anemia,irondeficiency,dysphagia,vomiting,age>50ywithnewsymptoms)

    o Negativeureabreathtest(mustbedoneoffPPI,H2-receptorantagonists,antacidsforminimumof3days,andoffallantibioticsforminimumof4weeks)

    o Lifestylemodificationshavebeendiscussedandpatienthasincorporatedtheseintotheirinitialtreatmentplan(smallermeals,avoidanceofidentifiedfoodtriggers,appropriateweightloss,elevationofheadofbed,smokingcessation)

    o PatientadherenttotrialofPPI(canstartoncedailythenescalatetotwicedaily,30minutesbeforebreakfastandsupperforminimumof8weeks)

  • Enhanced Primary Care Pathway: DYSPEPSIA July 2016 - Page 3/6

    EnhancedPrimaryCarePathway:DYSPEPSIA3.Linkstoadditionalresourcesforphysiciansandpatients

    CalgaryGIDivisionhttp://www.calgarygi.com

    MyHealth.Alberta.cahttps://myhealth.alberta.ca/health/pages/conditions.aspx?Hwid=tm6322

    CanadianDigestiveHealthFoundationhttp://www.cdhf.ca/en/disorders/details/id/20

    UpToDateBeyondtheBasicsPatientInformation(freelyaccessible)http://www.uptodate.com/contents/upset-stomach-functional-dyspepsia-in-adults-beyond-the-basics?source=search_result&search=dyspepsia+patient+info&selectedTitle=2~1504.Clinicalflowdiagramwithexpandeddetail

    This AHS Calgary Zone pathway incorporates the most current evidence-based clinical guidelines fordiagnosisandmanagementofdyspepsia,frombothGastroenterologyandPrimaryCareliterature:

    Miwaetal.Evidence-basedclinicalpracticeguidelinesforfunctionaldyspepsia.JGastroenterol.50:125-39,2015

    Ansari etal. Initialmanagement of dyspepsia in primary care: an evidence-based approach. Br J GenPract.63:498-9,2013

    Diagnosis and treatment of chronic undiagnosed dyspepsia in adults. Toward Optimized Practicehttp://www.topalbertadoctors.org/cpgs/3294128

    AmericanSocietyofGastrointestinalEndoscopyStandardsofPracticeCommittee.Theroleofendoscopyindyspepsia.GastrointestEndosc66:1071-5,2007

    Thefollowingisabest-practiceclinicalpathwayformanagementofdyspepsiaintheprimarycaremedicalhome,whichincludesaflowdiagramandexpandedexplanationoftreatmentoptions:

  • Enhanced Primary Care Pathway: DYSPEPSIA July 2016 - Page 4/6

  • Enhanced Primary Care Pathway: DYSPEPSIA July 2016 - Page 5/6

    FlowDiagram:DYSPEPSIADiagnosisandManagement-ExpandedDetail1. Establishthediagnosisofdyspepsiaasdefinedabovethroughhistoryandphysicalexamination,

    excludingworrisomefeaturesorredflags.Inthepresenceofanyredflags,referraltoGastroenterologyforconsiderationofurgentendoscopicinvestigationisrecommended,eventhoughthepredictivevalueofthesefeaturesissomewhatlimited.

    2. Reviewofthepatientsmedicationprofileshouldbeundertakentotrytoidentifyobviousculprits

    suchasASA/NSAIDs/COX-2inhibitors,steroids,bisphosphonates,calciumchannelblockers,antibiotics,ironormagnesiumsupplements.Anyneworrecentlyprescribedmedication,overthecounterorherbal/naturalproductmaybeimplicatedasvirtuallyallmedicationscancauseGIupsetinsomepatients.

    3. BaselineInvestigationsaimedatidentifyingconcerningfeaturesorclearetiologies:

    CBCandferritin Anti-tissuetransglutaminasehas>95%sensitivitytoruleoutceliacdisease ALT,ALP,GGT,andlipase,aimedatidentifyingahepatobiliaryorpancreaticsourceof

    pain Ifpainisconsistentwithbiliarycolicorliverenzymesorlipaseareabnormalorthereis

    apalpableabdominalmass,obtainatrans-abdominalultrasound. UpperGIseriesmaybeconsidered,butislowyieldforrelevantfindings,asis

    endoscopy4. TestandtreatHelicobacterpyloribyureabreathtest(UBT).Thisstrategyisbasedonevidencethat

    somedyspepticpatientsarecolonizedbyH.pyloriandwillhaveunderlyingpepticulcerdiseaseorgastritis.

    IftheUBTispositive,2016Canadianconsensusguidelinesnowrecommendquadrupletherapyregimens(seetablebelow).

    Tripletherapy(PPI+clarithromycin+amoxicillinormetronidazole)isnolongerrecommended,asstudiesofHpisolatesinCanadasuggest25-30%areresistanttometronidazoleand15-20%areresistanttoclarithromycin.

    Withtheexceptionoftherifabutin-basedregimen,alltreatmentsforHpshouldbe14daysduration.

    ALWAYSdiscusswithyourpatientthepossibleminororseriousadverseeffectsofantibiotics.SeeEnhancedPrimaryCarePathwayH.Pyloriforadditionaldetails,whichincludesusefulpatientinformationhandouts.

    Iffailsthirdlinetherapy,considerreferraltoGastroenterologyordiscussionviaSpecialistLinkbeforeproceedingtoRifabutin-basedtreatment.

    5. Lifestylemodification.Therearefewstudiestosupportspecificdietaryrecommendations,buta

    trialofvariousdietaryexclusionsundertheguidanceofanutritionistorregistereddieticianmaybehelpful,includingavoidanceoflactoseandfoodshighinfructose(FODMAPs).

    6. Empiricanti-secretorymedicationtrial.IntheabsenceH.pyloriinfectionorcontinuedsymptoms

    despitesuccessfulH.pylorieradication,atrialofstandarddosePPIfor4-8weeksmaybenefitsomepatients.PPIsarefavouredoverH2-receptorantagonists.Initialtherapyshouldbeoncedaily,30minbeforebreakfast.Ifthereisnosignificantsymptomaticimprovementafter4weeks,stepuptoBID

  • Enhanced Primary Care Pathway: DYSPEPSIA July 2016 - Page 6/6

    dosingorswitchtoanotherPPI.Ifsymptomsarethencontrolled,itisadvisabletotitratedowntothelowesteffectivedose.

    7. Trialofmotilityagents.Althoughdelayedgastricemptyingcanbedemonstratedin30-80%of

    patientswithdyspepsia,gastricemptyingstudiesarenotpartofroutineinvestigationofdyspepsia.Prokineticagentsimprovegastricemptying,andsomepatientsmayfindclinicalbenefit.Domperidonecanbeusedinescalatingdoses,suggeststartingat5mgTID-AC,upto10mgPOQIDasa2-4weektrial.

    Thereareinsufficientdatatorecommendtheroutineuseofbismuth,antacids,simethicone,misoprostol,anti-cholinergics,anti-spasmodics,TCAs,SSRIs,herbaltherapies,probioticsorpsychologicaltherapiesinfunctionaldyspepsia.However,thesetherapiesmaybeofbenefitinsomepatients,andthusatrialwithassessmentofresponsemaybereasonableandisunlikelytocauseharm.2016CanadianAssociationofGastroenterologyGuidelinesforTreatmentofH.pylori

    First Round

    CLAMET Quad for 14 days PPI standard dose BID Clarithromycin 500mg BID Amoxicillin 1000mg BID Metronidazole 500mg BID

    OR

    BMT Quad for 14 days PPI standard dose BID Bismuth subsalicylate 524mg QID Metronidazole 375mg QID Tetracycline 500mg BID

    Second Round

    If CLAMET Quad was used as initial treatment, then use BMT Quad for second round If BMT Quad was used as initial treatment, then use CLAMET Quad or consider Levo-Amox

    Third Round Fourth Round

    Levo-Amox for 14 days PPI standard dose BID Amoxicillin 1000mg BID Levofloxacin 250 mg BID

    Rif-Amox for 10 days PPI standard dose