Clinical Scenario

30 year old, male Call center representative Epigastric pain Denies any alarm features Smoker; alcohol and coffee

drinker Unremarkable past medical &

family history Direct epigastric tenderness

Dyspepsia

Presence of 1 or more of the following symptoms (Rome III Committee):

Postprandial fullness Early satiety Epigastric pain or burning

Assessment & Diagnosis

Based on history and physical and exam

Consider or rule out: Dietary indiscretion Medication induced Cardiac disease Gastroparesis Hepatobiliary disorders Other systemic disease

4 Major Causes:

Chronic peptic ulcer disease Gastroesophageal reflux (+/-

esophagitis) Functional dyspepsia (NUD) Malignancy

Stratify Patients

Age (55 or less/ above 55) Presence of alarm features

Family history of upper GI cancer Unintended weight loss GI bleeding, unexplained anemia Progressive dyspepsia, odynophagia Persistent vomiting Palpable mass or lymphadenopathy Jaundice

Review of Current Literatures

Peptic ulcer is found in ~5-15% of patients

Gastric or esophageal Adenocarcinoma is identified in <2% of all patients who undergo endoscopy for dyspepsia

Upper gastrointestinal malignancy becomes more common after age 55 years

Review of Current Literatures

Absence of alarm features has a negative predictive value of >97%

Chronic infection with H. pylori is associated with >80% of peptic ulcers and >1/2 of gastric cancers

Patient Profile

30 year old, male Burning epigastric pain No alarm symptoms

Empiric PPI Therapy

Empiric therapy with proton pump inhibitors for 4- 6weeks

Reassurance No further investigations if

symptoms improve Out patient clinic follow-up

Failed Empirical Therapy

No response to therapy after 7-10 days

Symptoms has not resolved after 6-8 weeks

EGD with biopsy for H. pylori Organic disease (PUD, GERD, CA) Treat accordingly

Normal EGD (Functional Dyspepsia)

Reassurance Lifestyle changes Treat H. pylori if present

H. pylori regimen: PPI 40 mg 2x a day Amoxicillin 1G 2x a

day Clarithromycin 500mg 2x a day

(10-14 days)

<55 y/o and below, no alarm

features

Empiric PPI therapy

Response Failed empirical therapy

EGD with biopsy for H.

pylori

Functional dyspepsia

ReassuranceLifestyle modificationsTreat H. pylori if (+)

Organic disease

(PUD, GERD, CA)

>55 y/o or<55 y/o w/ alarm features

Treat accordingly

H. Pylori Follow -up

Patients who remain symptomatic after initial course of treatment should be retested 4 weeks after completion of the course

Urea breath test or stool antigen test

Some success in using previous triple therapy

Switch to another regimen: PPI+metronidazole+bismuth+tetracycline

Unresponsive Functional Dyspepsia

Persistent dyspeptic symptoms Not infected with H. pylori or have

been rendered free of H. pylori Do not respond to short course of PPI

therapy (-) negative findings on endoscopy

Unresponsive Functional Dyspepsia

Reevaluate diagnosis Consider: gastroparesis, biliary or

pancreatic diseases, IBS, anxiety disorder

Limited data on use of antidepressants, prokinetic agents

References

Talley NJ, Vakil NB, Moayyedi P: American Gastroenterological Association Technical Review: Evaluation of Dyspepsia. Gasteroenterology 2005, 129:1756-1780.  

American Gastroenterological Association Medical Position Statement: Evaluation of Dyspepsia Gastroenterology 2005, 129:1753-1755. 

Lam SK, Talley NJ: Report for the 1997 Asia Pacific. Consensus Guidelines on the management of H. pylori. Journal Gasteroenterology & Hepatology 1998, 13:1-2.  

American Society for Gastrointestinal Endoscopy’s The role of endoscopy in dyspepsia. Gastrointestinal Endoscopy 2007, 6:1071-1075

Sleisenger and Fordtran’s Gastrointestinal and Liver Disease 8th Edition

Test-and-Treat Approach

Test for H. pylori (Urea Breath Test or Stool Antigen Test)

Treat if (+) Trial of PPI therapy if (-)

Do endoscopy if no symptom improvement

Need for in-patient work-up and care

Severity of dyspepsia Alarm symptoms present Need for additional lab tests and

imaging studies

Possible Scenario

50 year old with CAD on ASA Severe epigastric pain, weakness, melena Pale

Will need: Hospital admission for medical

management Early endosocopy, CBC Blood transfusion