DYSPEPSIA

Dr.Vishal Rathore

Dyspepsia

• popularly known as indigestion

• meaning hard or difficult digestion, is a medical condition characterized by chronic or recurrent pain in the upper abdomen, upper abdominal fullness and feeling full earlier than expected when eating.

Prevalence 25-40 %, of which • 50% self medicate • 25% consult their G.P.

• 5% of G.P. consultations are for dyspepsia • Prescribed drugs and endoscopies cost £600M in 2000

• OTC indigestion remedies sold for £100M in 2002

Causes

• Reflux oesophagitis 12% • Duodenal ulcer 10% • Gastric ulcer 6%• Gastric carcinoma 1% • Oesophageal carcinoma 0.5%

Non-erosive GORDFunctional (non-ulcer) dyspepsia

Alarm Symptoms/ Signs*

• GI bleeding (same day referral)

• Persistent vomiting

• Weight loss (progressive unintentional)

• Dysphagia

• Epigastric mass

• Anaemia due to possible GI blood loss

Thus all patients with new-onset dyspepsia should have abdominal examination and FBC

First Approach to Dyspepsia

• Consider possible causes outside upper GI tract -Heart, lung, liver, gall bladder, pancreas, bowel

• Consider drugs and stop if possible - Aspirin / NSAIDs, calcium antagonists, nitrates, theophyllines, etidronate, steroids

Refer if dyspepsia in 55+* year old

• Alarm symptoms/signs (2 week referral)

• Unexplained and persistent recent-onset dyspepsia without alarm symptoms – Unexplained means no cause known – Persistent implies present for a length of time (NICE suggest 4-6 weeks) – Recent-onset implies new-not a recurrent episode.

Referral for Endoscopy

• Review medications for possible causes of dyspepsia

(calcium antagonists, nitrates, theophyllines,

bisphosphonates, corticosteroids and non-steroidal

anti-inflammatory drugs [NSAIDs]).

• In patients requiring referral, suspend NSAID use.

Urgent specialist referral

Endoscopic investigation is indicated for patients of anyage with dyspepsia when presenting with any of thefollowing: • chronic gastrointestinal bleeding, • progressive unintentional weight loss, • progressive difficulty swallowing, • persistent vomiting, • Iron deficiency anaemia, • epigastric mass • suspicious barium meal

Routine Endoscopic Investigation

• Patients of any age, presenting with dyspepsia and without alarm signs, is not necessary.

• However, in patients aged 55 years and older with unexplained and persistent recent-onset dyspepsia alone, an urgent referral for endoscopy should be made.

Management of simple dyspepsiain those aged < 55 years

• Stress benign nature of dyspepsia

• Lifestyle advice

– Healthy eating

– Weight reduction

– Stop smoking

– Use of antacids

Interventions for uninvestigated dyspepsia

• Initial therapeutic strategies for dyspepsia are

empirical treatment with a proton pump inhibitor (PPI) or testing for and treating H. pylori.

• There is currently insufficient evidence to guide which should be offered first.

• A 2-week washout period following PPI use is necessary before testing for H. pylori with a breath test or a stool antigen test

Nice Guideline Summary

• Refer if “alarm symptoms” at any stage

• Test and treat

(Test for H. pylori and treat positives)

THEN, IF STILL SYMPTOMATIC

PPI for one month

THEN

Manage recurrent symptoms as functional dyspepsia

Rx of H. Pylori

• One week triple therapy * PPI (full dose) e.g. omeprazole 20mg bd Clarithromycin 500mg bd Amoxycillin 1g bd (or Metronidazole 400mg bd)

• Use a carbon-13 urea breath test, stool antigen test or, when performance has been validated, laboratory based serology.

• If re-testing for H. pylori use a carbon-13 urea breath test.*

THANK YOU !!!!!