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Page 1: Dyspepsia Kamela

Dyspepsia

Kamela Ali abu-shalha5th year medical student

Hashemite university

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Dyspepsia is defined as “episodic or persistent symptoms that include abdominal pain or discomfort and which are ”referable to the upper gastrointestinal tract

Other symptoms

upper abdominal bloating

fullness

early satiety

nausea The formal definition excludes

patients whose only symptom is heartburn

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How common is it

Stomach pain, cramps, and spasms” was the 11th most frequent reason for patients to present to their physicians, estimated to account for more

than 13.5 million visits per year

About 25% of persons in the United States or other western countries experience recurrent

upper abdominal pain during a typical year

If one adds heartburn, then the prevalence is closer to 40%

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Causes of dyspepsia Upper gastrointestinal disorders

'Functional' Peptic ulcer disease Acute gastritis Gallstones Motility disorders, e.g. oesophageal

spasm

Other gastrointestinal disorders Pancreatic disease (cancer, chronic

pancreatitis) Hepatic disease (hepatitis,

metastases) Colonic carcinoma

Systemic disease Renal failure Hypercalcaemia

Drugs Non-steroidal anti-inflammatory

drugs (NSAIDs) Iron and potassium supplements Corticosteroids Digoxin

Others Alcohol Psychological, e.g. anxiety,

depression

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Frequency Diagnosis

60 % Functional dyspepsia

15-25 % Peptic ulcer disease

5-15% Reflux esophagitis

<2% Gastric or esophageal cancer

Rare causes

Differential Diagnosis of the Patient with Dyspepsia Based on Endoscopic Results from

36 Studies

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Rare causes of dyspepsia : Carbohydrate malabsorptionSmall intestinal mucosal disorders (e.g., sprue)Intestinal parasitesChronic pancreatitisInfiltrative diseases of the stomach (e.g., Crohn's disease)Metabolic disorders (e.g., hypothyroidism, hypercalcemia)Cardiac conditions (e.g., inferior myocardial ischemia)Pulmonary conditions (e.g., lower lobe pneumonia)

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Peptic Ulcer Disease (PUD)

• The primary causes of PUD are Helicobacter pylori infection and nonsteroidal anti-inflammatory drug (NSAID) use.

• While either of these alone is a significant cause, these two factors can act synergistically to further increase the risk of PUD .

Cigarette smoking is an additional risk factor that may impair the healing of an ulcer and increase the likelihood of recurrence after successful treatment

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Gastroesophageal Reflux DiseaseGERD

• Gastroesophageal reflux disease (GERD) is a condition in which the reflux of gastric contents into the esophagus results in symptoms such as heartburn or a bitter taste in the back of the mouth.

• Reflux events occur more often in the lying position as opposed to the upright position.

• It may also cause evidence of inflammation (esophagitis) and erosions in the esophageal mucosa

• There is a poor correlation between endoscopic findings and symptoms

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KEY FACTORS IN GERD • transient lower esophageal

sphincter relaxations• lower esophageal sphincter

hypotension• or anatomic deformities of

the EGJ such as a hiatal hernia

esophago-gastric junction (EGJ) incompetence

• impaired esophageal emptying

• esophageal peristalsis dysfunction

• decreased salivary neutralizing capacity .

ineffective esophageal clearance of acid and

reflux material

GERD

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risk factors for GERD

Family hx.

Increased BMI

Smoking alcohol

Certain food

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Functional dyspepsia

• In up to 60% of patients with dyspepsia, there is no identifiable cause on endoscopy. In this case, the patient is diagnosed as having functional dyspepsia.

• Three major potential pathophysiologic mechanisms of functional dyspepsia have been identified.

1. The first is delayed gastric emptying that occurs in about 30% of patient with functional dyspepsia and is associated with postprandial fullness, nausea and vomiting.

2. Another is impaired gastric accommodation that occurs in about 40% of patients with functional dyspepsia and is associated with early satiety.

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Functional dyspepsia

3. Finally, hypersensitivity to gastric distention is noted in approximately 37% of patients with functional dyspepsia, and is associated with postprandial pain, belching and weight loss .

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Clinical Evaluation

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Alarm Symptomsanorexia,unexplained recent weight loss dysphagiaOdynophagiapersistent vomitingHematemesislongstanding gastroesophageal

reflux symptoms melenablood in the stoolanemia, previous gastric surgery a palpable abdominal mass gastrointestinal perforation or jaundice

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• Age is another important factor; current guidelines recommend that all patients who are above 55 years of age with the new onset of dyspepsia should receive an endoscopy to evaluate for more serious disease

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History

SOCRATES

Medication Smoking Any red

flag

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Physical examination

The patient's

vital signs and

appearance

Abdominal

examinationRSS & CVS

any alarm symptoms

or concern about GI

bleeding… rectal exam

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Gastroesophageal Reflux Disease

Patients with GERD commonly present with ………

Symptoms may be aggravated by ….Symptoms may be alleviated by ….Findings on physical examination…. Extra-esophageal symptoms are ……

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Peptic Ulcer Disease The classic presentation of PUD is epigastric

abdominal pain that is burning in character. A variety of other symptoms, including vomiting,

loss of appetite, and flatulence may also be present Epigastric tenderness may or may not be present on

physical examination. The patient's stool may be heme-positive if bleeding

has occurred

GU DU

Gastric ulcers may occur sooner after eating and are less frequently relieved by

food or antacids

occur on an empty stomach or at least 2 hours after eating

and are relieved by eating food or taking antacids.

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Functional Dyspepsia• Functional dyspepsia is defined as having at least 12 weeks (not

necessarily consecutive) of the following symptoms within the previous 12 months:

1) “persistent or recurrent dyspepsia” (upper abdominal pain or discomfort);

2) “no evidence of organic disease” (on endoscopy or other tests) that probably accounts for the symptoms;

3) It is not “exclusively relieved by defecation or associated with the onset of a change in stool frequency or stool form” and therefore, unlikely to be irritable bowel syndrome

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-Heartburn and/or regurgitation- often postprandial

- aggravated by recumbency or bending over- and are relieved by antacids .

Offer empirical therapy for GERD

- Alarm symptoms (dysphagia, odynophagia, bleeding, weight loss, or

anemia) -Sufficient duration of symptoms (risk for

Barrett's esophagus)

No response

Further diagnostic modalities

GERD / diagnostic approach

EndoscopyPh-monitoring

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• ENDOSCOPY

• Ph-monitoring

direct visualization of the esophageal mucosa and documentation and biopsy

• in documenting persistent acid reflux events in patients with symptoms that have not responded to usual treatment and have no endoscopic findings. • in patients with atypical symptoms (such as a cough) •to followup reflux symptoms in patients after a trial of medication or surgery.

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PUD / diagnosis

• Both generalist physicians and gastroenterologists have difficulty in making the diagnosis of peptic ulcer disease based on history and physical alone. Therefore, other diagnostic studies are needed to confirm the diagnosis .

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PUD diagnosis • very sensitive and specific

• direct observation of the esophageal, gastric, and duodenal mucosa

• the ability to perform biopsies • The risk of complications from an upper endoscopy is extremely

low (<0.3%)

Upper endoscopy

• less sensitive and specific • and results in radiation exposure for the patient

• may still have a role in the diagnosis if the patient is not able to tolerate endoscopy or if a trained endoscopist is not available in

the community

upper gastrointestinal series (UGI)

• Because H. pylori infection is the most common cause of peptic ulcer disease, the presence or absence of an H. pylori infection should guide the management of a patient with dyspepsia and

suspected PUD • 13C and 14C urea breath tests, serologic tests, and stool antigen

tests

Tests for diagnosing an H. pylori infection

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Tests for diagnosing an H. pylori infection

• Breath tests highly sensitive and specific PPIs may increase the likelihood of false-

negative results on breath tests for up to 2–4 weeks after stopping the PPI

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• Serologic tests include both serum antibody tests performed in a

reference laboratory and whole blood tests performed at the point of care.

The most commonly used serum antibody tests are enzyme-linked immunosorbent assays (ELISAs).

Although whole blood tests used in the ambulatory setting may be more convenient for the physician and patient, they are less sensitive than serum antibody tests performed in a reference laboratory

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• Stool antigen tests detect H. pylori antigen in the stool are more accurate than whole blood or serologic

tests, although somewhat less convenient . They can also be used to confirm eradication

because they are an antigen and not an antibody test.

However, concurrent use of PPIs can cause false negative stool antigen results

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• Current guidelines recommend breath tests or stool antigen tests as the preferred initial test to detect H. pylori infection .

• Serologic tests at a reference laboratory are an alternative if : breath tests or stool antigen tests are not

available or if the patient has recently taken a PPI

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Functional dyspepsia

• It’s a diagnosis of exclusion

History and physical findings alone are not sensitive or specific A diagnostic evaluation should be performed to exclude other conditions such as peptic ulcer disease, GERD and cancer Extensive diagnostic testing is not recommended in patients with functional dyspepsia, unless the patient's symptoms and signs suggest an alternate diagnosis.

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Recommended Diagnostic Strategy

• The recommended strategy outlined here is based on evidence-based guidelines published in 2005 on the management of dyspepsia from the American Gastroenterological Association (AGA) and management of GERD from the American College of Gastroenterology

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TEST AND TREAT

STRATEGYgive acid suppression treatment with a PPI to control symptoms.

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Management

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H.Pylori eradication therapy• The eradication rate after triple therapy is 79% and after quadruple therapy is 80%

with no significant difference in side-effects between triple and quadruple therapy .

• Although one guideline recommends that patients should have a repeat H. pylori test at least 4 weeks after completing eradication therapy, this is not standard practice in the United States.

• If a patient remains symptomatic, the urea breath test or a stool antigen test (provided the patient is not taking a PPI) is best for evaluating whether the H. pylori infection has been eradicated .

• For the patient whose H. pylori infection is not eradicated after two courses of treatment, it is appropriate for family physicians to refer the patient for an endoscopy at that point so that tissue culture and sensitivity can be obtained to guide further treatment.

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THANK YOU

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Resources

• Essentials of Family Medicine (Sloane)• Davidson’s principles and practice of medicine