Dyspepsia. What is dyspepsia? ‘pain or discomfort related to eating or drinking that can be...
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Transcript of Dyspepsia. What is dyspepsia? ‘pain or discomfort related to eating or drinking that can be...
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