Peptic Ulcer Disease and Dyspepsia - UCSF Ulcer Disease and Dyspepsia ... Duodenal ulcer, 1...

download Peptic Ulcer Disease and Dyspepsia - UCSF   Ulcer Disease and Dyspepsia ... Duodenal ulcer, 1 central pathologist ... Gastro 2005. Functional Dyspepsia

of 45

  • date post

    06-Feb-2018
  • Category

    Documents

  • view

    226
  • download

    4

Embed Size (px)

Transcript of Peptic Ulcer Disease and Dyspepsia - UCSF Ulcer Disease and Dyspepsia ... Duodenal ulcer, 1...

  • Peptic Ulcer Disease and Peptic Ulcer Disease and DyspepsiaDyspepsia

    John M. Inadomi, MDJohn M. Inadomi, MDProfessor of MedicineProfessor of Medicine

    UCSFUCSFChief, Clinical GastroenterologyChief, Clinical GastroenterologySan Francisco General HospitalSan Francisco General Hospital

  • Case HistoryCase History

    49 y/o woman complains of several 49 y/o woman complains of several months of intermittent epigastric months of intermittent epigastric discomfort made worse with mealsdiscomfort made worse with meals She has associated nausea, bloating and early She has associated nausea, bloating and early

    satiety but denies weight losssatiety but denies weight lossQuestions:Questions: What is the difference between dyspepsia and What is the difference between dyspepsia and

    functional dyspepsia?functional dyspepsia? Where is Rome and what does it have to do Where is Rome and what does it have to do

    this this case?this this case?

  • Rome Consensus GroupRome Consensus Group

    Description of group processDescription of group process Meeting since 1988 to address functional GI Meeting since 1988 to address functional GI

    disorders disorders Chair, coordinating committee, working Chair, coordinating committee, working

    committeescommittees Functional esophageal, gastroduodenal, Functional esophageal, gastroduodenal,

    bowel, bowel, pancreaticobiliarypancreaticobiliary, , anorectalanorectal, and , and childhood disorderschildhood disorders

    Design of treatment trials; basic science; Design of treatment trials; basic science; physiology:motility/sensation; psychosocialphysiology:motility/sensation; psychosocial

  • Rome Dyspepsia Definition:Rome Dyspepsia Definition:Rome II: Rome II: Dyspepsia refers to pain or Dyspepsia refers to pain or

    discomfort centered in the upper discomfort centered in the upper abdomen.abdomen.

    Rome III: Rome III: Dyspepsia refers to postprandial Dyspepsia refers to postprandial fullness, early satiation, or epigastric pain or fullness, early satiation, or epigastric pain or burningburning

    Note: patients with primarily heartburn or acid Note: patients with primarily heartburn or acid regurgitation are excludedregurgitation are excluded

  • More DefinitionsMore Definitions

    Pain: subjective, unpleasant sensationPain: subjective, unpleasant sensation Discomfort: subjective, unpleasant sensation Discomfort: subjective, unpleasant sensation

    that is not interpreted as pain by patientthat is not interpreted as pain by patient Early satiety: feeling that stomach is overfilled Early satiety: feeling that stomach is overfilled

    soon after starting to eat so that meal cannot soon after starting to eat so that meal cannot be finishedbe finished

    Bloating: tightness located in upper abdomenBloating: tightness located in upper abdomen Nausea: queasiness or sick sensationNausea: queasiness or sick sensation Retching: heaving as if to vomit but no gastric Retching: heaving as if to vomit but no gastric

    contents are forced upcontents are forced up

  • DyspepsiaDyspepsiaEpidemiologyEpidemiology

    Prevalence Prevalence 25%25% U.S. and Western countriesU.S. and Western countries

    Incidence Incidence 1%1% Resolution of symptoms in similar number Resolution of symptoms in similar number

    therefore prevalence constanttherefore prevalence constant

    BurdenBurden 22--5% of all family practice consultations are 5% of all family practice consultations are

    for dyspepsiafor dyspepsia

  • What Comprises the Differential What Comprises the Differential Diagnosis of Dyspepsia?Diagnosis of Dyspepsia?

  • Differential Diagnosis of DyspepsiaDifferential Diagnosis of Dyspepsia

    50%

    10%

    20%

    1%

    19%

    Functional Dyspepsia Peptic Ulcer GERD Cancer Other

  • Dyspepsia: Dyspepsia: OtherOther

    Medications Medications BiliaryBiliaryPancreaticPancreaticCeliac diseaseCeliac diseaseLactose intoleranceLactose intoleranceGastroparesisGastroparesisIBSIBSChronic mesenteric ischemiaChronic mesenteric ischemiaOther Other othersothers EosinophilicEosinophilic gastritis, Crohngastritis, Crohns disease, s disease, sarcoidosissarcoidosis, ,

    metabolic (metabolic (hypercalcemiahypercalcemia, heavy metals), , heavy metals), hepatomahepatoma, , steatohepatitis steatohepatitis

  • What would increase your What would increase your suspicion of cancer?suspicion of cancer?

    AlarmAlarm features: warrant immediate features: warrant immediate evaluationevaluation Age Age >> 4545--50 w/new onset50 w/new onset DysphagiaDysphagia Weight lossWeight loss Symptoms of GI bleeding, overt or occultSymptoms of GI bleeding, overt or occult Iron deficiency anemiaIron deficiency anemia Family history of gastric cancerFamily history of gastric cancer

  • Value of Alarm SymptomsValue of Alarm Symptoms

    Prevalence of alarm symptoms among dyspeptic Prevalence of alarm symptoms among dyspeptic patients referred for EGDpatients referred for EGD 3333--61%61%

    Sensitivity Sensitivity 00--100%100% Negative predictive value Negative predictive value >97%>97%

    SpecificitySpecificity 1616--98%98% Positive predictive valuePositive predictive value

  • Rome III Functional DyspepsiaRome III Functional Dyspepsia

    One or more ofOne or more of:: Bothersome postprandial fullnessBothersome postprandial fullness Early satiationEarly satiation Epigastric painEpigastric pain Epigastric burningEpigastric burningANDAND

    No evidence of structural disease (including at No evidence of structural disease (including at upper endoscopy) that is likely to explain the upper endoscopy) that is likely to explain the symptomssymptoms

  • Functional Dyspepsia SubgroupsFunctional Dyspepsia Subgroups

    Postprandial Distress Syndrome (PDS)Postprandial Distress Syndrome (PDS)Either symptomEither symptom Bothersome postprandial fullness, occurring after Bothersome postprandial fullness, occurring after

    ordinary sized meals at least several times per weekordinary sized meals at least several times per week Early satiation that prevents finishing a regular meal Early satiation that prevents finishing a regular meal

    at least several times per weekat least several times per week

    Symptoms for the last 3 months with onset at least 6 Symptoms for the last 3 months with onset at least 6 months before diagnosismonths before diagnosis

  • Functional Dyspepsia SubgroupsFunctional Dyspepsia Subgroups

    Epigastric Pain Syndrome (EPS)Epigastric Pain Syndrome (EPS) Pain or burning localized to the Pain or burning localized to the epigastriumepigastrium of at least of at least

    moderate severity at least once per weekmoderate severity at least once per week The pain is intermittentThe pain is intermittent Not generalized or localized to other abdominal or Not generalized or localized to other abdominal or

    chest regionschest regions Not relieved by defecation of passage of flatusNot relieved by defecation of passage of flatus Not fulfilling criteria for gallbladder and sphincter of Not fulfilling criteria for gallbladder and sphincter of

    Oddi disordersOddi disorders

    Symptoms for the last 3 months with onset at least 6 Symptoms for the last 3 months with onset at least 6 months before diagnosismonths before diagnosis

  • This patient has no warning symptoms or This patient has no warning symptoms or signs. What do you want to do next?signs. What do you want to do next?

    Upper endoscopyUpper endoscopyTest for Test for H. pyloriH. pylori If positive, eradicateIf positive, eradicate

    Empirical antiEmpirical anti--secretory trial (4secretory trial (4--8 weeks)8 weeks)Other testsOther tests Ultrasound, CT scan, Gastric emptying, ERCP, Ultrasound, CT scan, Gastric emptying, ERCP,

    EGG, functional MR imagingEGG, functional MR imaging

  • Yield of Other TestsYield of Other Tests

    Gastric emptyingGastric emptying 2525--40% positive40% positive Usually fails to alter managementUsually fails to alter management

    UltrasonographyUltrasonography 11--3% yield3% yield Gallstones are usually incidentalGallstones are usually incidental

  • Management Trials (1)Management Trials (1)

    Test forTest for H. pyloriH. pylori, EGD for positives, EGD for positives 3 RCTs3 RCTs No benefit over empirical acid suppressionNo benefit over empirical acid suppression More expensiveMore expensive

    Empiric Empiric H. pyloriH. pylori eradicationeradication Not tested in U.S.Not tested in U.S. Needs high prevalence to be feasibleNeeds high prevalence to be feasible

    Neither strategy reasonable in U.S.Neither strategy reasonable in U.S.

  • Management Trials (2)Management Trials (2)

    Early EGD vs. empiric acid suppressionEarly EGD vs. empiric acid suppression 5 prospective trials5 prospective trials No clear benefit from EGD despite greater costsNo clear benefit from EGD despite greater costs

    Early EGDEarly EGD vs. vs. H. pyloriH. pylori test & treat test & treat EGD cured 4% (95% C.I. 1EGD cured 4% (95% C.I. 1--8%) more 8%) more

    dyspepsia, but at substantial cost increase dyspepsia, but at substantial cost increase ($7000 per dyspepsia cure)($7000 per dyspepsia cure)

  • Management Trials (3)Management Trials (3)

    Empiric acid suppression vs. placeboEmpiric acid suppression vs. placebo PPI therapy more effective in symptom reliefPPI therapy more effective in symptom relief Symptom odds 0.65 (95% CI .55Symptom odds 0.65 (95% CI .55--.78).78) PPI more effective against heartburn than PPI more effective against heartburn than

    epigastric painepigastric painH. pyloriH. pylori T&T vs. empiric acid suppress