Dak Enak Perut

7/26/2019 Dak Enak Perut

1/25

1

Gastritis kronik

erosiva

TREATMENT POST DIAGNOSIS

MAJOR DIAGNOSESIn our original guidelines we recommended treatment of H.pylori

infection only for duodenal and gastric ulcer.The test and treatstrategy now favoured in uncomplicated dyspepsia assumes thatall cases of undiagnosed functional dyspepsia associated withH Pylori will receive eradication therapy and thus it follows thateradication of H Pylori in known cases of functional dyspepsia isan acceptable therapy.

DUODENAL ULCER (DU)

HP+ve !oena" !"#er$95% are associated with H.pyloriand should receive treatmentdirected aainst this oranism! "e advise con#rmation o$H.pylori in$ection e$ore treatment& ut acce't that the'revalence o$ ( )*lori in$ection is so hih in D+ that this ma* econsidered unnecessar*! We recognise that there is no knownsingle best eradication regime but the highest expectederadication results are associated with these regimensrecommended by consensus !"#. $xperience with the second

line regimen below is relatively limited% A


2/25

%

One wee, -ri'le -hera'*. /irst 0ine no continued antisecretoryre&uired#PPI standard dose twice daily# or '() ranitidine bismuthcitrate#* plus +moxycillin ,"" - g twice daily or /etronida0ole

1""2,""mg twice daily*plus )larithromycin ,""mg twice daily. &

It is sensible to avoid metronida0ole if the patient has had aprevious course of treatment with this agent.

3uadruple Therapy% 4econd line%PPI standard dose twice daily#* plus (ismuth 4ubcitrate !"mg&ds#* plus metronida0ole 1""2,""mg tds* plus tetracycline,""mg &ds

1om'liance with treatment has een shown to e ver* im'ortantin determinin the success o$ tri'le thera'* reimens!


3/25

'

o""o*!$

As*m'tomatic 'atients. Re'eat endosco'* is not needed! A ureareath test 2ideall* 341 should e 'er$ormed in all 'atients 2one

month or loner a$ter the end o$ ( )*lori eradication treatment i$s*m'toms 'ersist or recur! A urea reath test is also re6uired inan* 'atient whose ulcer had 'resented with com'lications andwho would otherwise e iven lon7term anti7secretor* treatmentto 'revent recurrence! I$ the result o$ the reath test is neativewe recommend no $urther treatment! I$ the result is 'ositive asecond course o$ eradication thera'* should e 'rescried!Assessment o$ antiiotic sensitivit* ma* e considered in those

with 'ersistent ( )*lori! D

S*m'tomatic a$ter initial s*m'tom res'onse. A urea reath testis indicated ! I$ neative clinical re7evaluation is necessar* and i$

'ositive re'eat anti7H.pyloritreatment! D

HP*ve D!oena" U"#er$Antisecretor* thera'*8 1imetidine ::m nocte is chea'est!Gastroenteroloical re$erral is advised i$ ulcers are not associatedwith NSAID! NSAID should e sto''ed i$ 'ossile and i$ s*m'toms'ersist 'atients ma* need astroenteroloical review

0on term antisecretor* drus. 5ow dose PPI 6maintenance isre&uired only in patients with persistent H Pylori infection orthose at risk of serious complications while receiving 74+I84.7I)$ guidance on )9:! speci;c antagonists should be

considered in these instances. !!# D

%, EROSI-E DUODENITIS$In the asence o$ other evidence we consider erosive duodenitisto e 'art o$ the s'ectrum o$ duodenal ulcer and advisetreatment as in this condition!


4/25

.

', GASTRIC ULCER (GU)H.pylori is 'resent in aout ;:% and most o$ the remainder areassociated with NSAIDs! 1*toloical smears and io'sies should

e ta,en $or histolo* and a urease test should e 'er$ormed at

endosco'*! D

HP+ve Gastri# !"#er $

Anti H.pylori thera'* as $or duodenal ulcer A $ollowed *antisecretor* thera'* $or two months! -he reason $or this latterrecommendation is the lac, o$ evidence that astric ulcers heal

as 6uic,l* as D+ a$ter H.pylori eradication alone! D 0on termtreatment with a ))I or miso'rostol should e considered in'atients with 'roven ulcer who continue to ta,e NSAIDs! 7I)$guidance on )9:! speci;c antagonists should be considered in

these instances. !!# D

HP*ve Gastri# U"#er.Standard antisecretor* thera'* $or two months! NSAIDs should e

sto''ed i$ 'ossile! /ull dose ))I is more e


5/25

., OESOPHAGITIS.( )*lori in$ection is no more li,el* to e associated with thiscondition than in the normal 'o'ulation! )atients should e

in$ormed o$ the association o$ oesit* and hearturn! "eiht lossis elieved to e e


6/25

3

anormalit* is 'oor! -he cause o$ s*m'toms in these 'atients&who account $or a lare 'ro'ortion o$ those investiated& isusuall* unclear! It is li,el* that multi'le $actors are involvedincludin acid& de$ective motilit*& ( )*lori in$ection and

de'ression! -reatment is s*m'tomatic ut o$ten ine


7/25

4

d) 'epeat investigations if serious symptoms develop see table

#. D

e) Aeneral reassurance may be su


8/25

5

PIN!" #$

C%%I""INE$"

RESO+R1E RE+IREMEN-S

3! General 'ractitioners and 'atients should have eas* access to341 +rea reath testin! (ih 6ualit* seroloical assa*s $or ()*lori antiodies should e availale until 341 urea reathtestin is universall* availale!

=! Eas* and ra'id access to endosco'* is a re6uirement $or ood'ractice and endosco'* units should e ale to 'rovide histolo*&urease testin and 341 reath tests!

Resources $or the 'rovision o$ this level o$ service should eavailale nationwide!

4! In some laoratories the $acilities needed $or $ull

acterioloical assessment o$ H.pylorisensitivit* and resistanceshould e 'rovided! One in each maor cit* could 'rovide anationwide service!

1ON-ROFERS. -(E NEED /OR /+R-(ERRESEAR1(!

-hese uidelines attem't to 'romote 'ramatic manaementsased on e>istin evidence or consensus when evidence islac,in! Man* clinical 'ractices which are elieved to eene#cial 2#nanciall* and clinicall* are at 'resentl em'irical andnot ased on sound evidence!

-hese include.

A! Screenin and treatment o$ as*m'tomatic 'atients $or ( )*lori

in an attem't to 'revent astric cancer!


9/25

6

@! Selective screenin and treatment $or H.pylori in 'atients onlon7term anti7secretor* aents or those contem'latin lonterm NSAIDs

-here is a elie$ that such 'ractices will reduce costs and 'rovideclinical ene#t! -he $re6uenc* o$ sini#cant side7e


10/25

17

RE/EREN1ES.

3 Mendall MA& Goin )M& Marrero JM& Molineau>& 0ev* J& @adveS& et al (elicoacter Screenin 'rior to endosco'*! Euro'ean

Journal o$ Gastroenterolo* and (e'atolo* 399=8 ?. ;347;

= (unin A)S& -homas )R& @ramle MG& 1orett "A& Idle N&1ontractor @R& @erride D1& 1ann G! "hat ha''ens to 'atients$ollowin o'en access astrosco'*H An outcome stud* $romeneral 'ractice! @rit J Gen )rac 399?8??.53975=3

4 Jones R! "hat ha''ens to 'atients with non7ulcer d*s'e'siaa$ter endosco'*H )ractitioner 398=4=.;57;

?! @*ter )& (ansen J M& de Muc,adell O@S! Em'irical (= loc,erthera'* or 'rom't endosco'* in manaement o$ d*s'e'sia!0ancet 399?84?4.3373

5! )atel )& Khulusi S& Mendall MA& 0lo*d R& Ma>well JD& North#eld-1! )ros'ective screenin o$ d*s'e'tic 'atients * (elicoacter)*lori serolo*! 0ancet 399584?.343573

! -he Manaement o$ D*s'e'sia 7 A 1onsensus Develo'ment1on$erence Re'ort to the National Advisor* 1ommittee on 1ore(ealth and Disailit* Su''ort Services! IS@N :7?;;7:3;:97

;! (elicoacter )*lori in )e'tic +lcer Disease! NI( 1onsensusStatement 399?8 3=.3

! @ritish National /ormular* !"""B 1".

>.# 9fman C. The e=ectiveness of endoscopy in the managementof dyspepsia% a &ualitative systematic review. +m C /ed>>>B"D%EE,21D

"# )hristie C* 4hepherd 7+* )odling (W* Falori '/. Aastriccancer below the age of ,,% implocations for screening patientswith uncomplicated dyspepsia Aut >>GB1%,E2G*

# Aillen 8* /c)oll $5. 8oes concern about missing malignancyustify endoscopy in uncomplicated dyspepsia in patients lessthan ,,. +m C Aastroenterol >>>B >1% G,2G>


11/25

11

!# Heaney +* )ollins C4* Tham T) et al + prospective study ofthe management of the young helicobacter negative dyspeptic

patient - can gastroscopies be saved in clinical practiceJ $ur CAastroenterol >>KB"%>,E2>,D#

E# The management of 8yspepsia% + systematic 'eview. HT+!"""B1%E>

1# 8elaney () Innes /+ et al Initial /anagement 4trategies for8yspepsia. The )ochrane 5ibrary* Issue E* !"" 9xford.

,# Heaney +* )ollins C4+* Watson 'AP et al. + prospectiverandomised trial of a 6test and treat policy versus endoscopy

based management in young Helicobacter Pylori positivepatients with ulcer2like dyspepsia referred to a hospital clinic. Aut>>>B1,%KD2>"

D# 5assen +T* Pedersen L/* (yt0er P* 4cha=alit0ky 9(.Helicobacter Pylori test2and2eradicate versus prompt endoscopyfor management of dyspeptic patients% a randomised trial.5ancet !"""BE,D%1,,2D"

G# Cones '* Tait )* 4laden A* Weston2(aker C. + trial of a test2and2treat strategy for Helicobacter Pylori positive dyspepticpatients in general practice. IC)P* >>>B,E%1E2D

K# Weinen )L* 7umans /$* deWit 7C* et al. Testing forHelicobacter Pylori in dyspeptic patients suspected of pepticulcer disease in primary care% cross sectional study. (/C !""BE!E%G2G,

># 8etection of upper gastrointestinal cancer in patientstaking antisecretory therapy prior to gastroscopy.Aut. !""" +prB1D1#%1D12G

!"# $uropean Helicobacter pylori 4tudy Aroup. )urrent)oncepts in the /anagement of Helicobacter pylori Infection.The /aastricht ! 2!""" )onsensus 'eport.

!# 7ice Technology +ppraisal Auidance 7o G* Auidance on theuse of Proton Pump Inhibitors in the treatment of dyspepsia.I4(7% 2K1!,G2"K2K Culy !"""


12/25

1%

!!# 7ice Technology +ppraisal Auidance 7o !G* Auidance on theuse of cyclo2oxygenase )ox#II selective inhibitors* celecoxib*rofecoxib* meloxicam and etodolac for osteoarthritis andrheumatoid arthritis. I4(7 2K1!,G212


13/25

1'


14/25

1.

MANAGEMEN- G+IDE0INESMANAGEMEN- G+IDE0INES

-hese uidelines were oriinall* 'roduced * a wor,in

rou' o$ the @ritish Societ* o$ Gastroenterolo*! -he

'ortions in red are u'dated sections revised in A'ril =::=!

A dra$t o$ these u'dated uidelines was sent $or

comments to the clinical e


15/25

1

PREACE

8yspepsia is a common complaint.Treatments may often be very e=ectiveand investigations can be costly andinvasive. /ore is spent on drugs fordyspepsia than on any other treatment

for a symptom group. 'ationalmanagement poses a challenge to thoseresponsible for purchasing* promotingand providing health care.

-hese uidelines have een com'iled on ehal$ o$ the @ritishSociet* o$ Gastroenterolo* $ollowin consultation with the

)rimar* 1are Societ* o$ Gastroenterolo*! -he 'rinci'al oectiveis to descrie ood clinical 'ractice $or clinicians in 'rimar* andsecondar* care drawin on evidence where it e>ists andreconisin the need to use limited resources e


16/25

13

C 7 Recommendation ased on lesser 6ualit* case control orcohort studies with overall consistenc* or e>tra'olated $rom hih6ualit* studies!

D Recommendation $rom case series or re'orts and e>'erto'inion includin consensus!


17/25

14

S+MMAR O/ MAIN REFISIONS=::=

3 AGE /OR ENDOS1O)-he ae at which endosco'* is recommended $or new d*s'e'siahas een increased $rom ?5* to 55* in line with national cancerre$erral uidance! 0ocal adustments in areas with a hih'revalence o$ astric cancer are a''ro'riate!

= -ES- AND -REA--he recommendation to treat 'atients under 55 withuncom'licated d*s'e'sia on the asis o$ a 'ositive ( )*lori testsu'ercedes the 'revious recommendation to Ltest and sco'e!

4 341 +REA @REA-( -ES-S-he est test $or identi#cation o$ ( )*lori and $or con#rmation o$eradication is the 341 urea reath test

? +se o$ ))Is"e acce't that the uidance issued * NI1E on ))Is should e$ollowed


18/25

15

INTRODUCTION$What is 8yspepsiaJD*s'e'sia is a rou' o$ s*m'toms which alerts doctors toconsider disease o$ the u''er GI tract! It is not a dianosis& utincludes s*m'toms o$ u''er adominal discom$ort& retrosternal'ain& anore>ia& nausea& vomitin& loatin& $ullness& earl* satiet*and hearturn amonst others! A #rm clinical dianosis can edicult on the asis o$ these s*m'toms as $ew s*m'toms arediscriminator*! Man* diseases cause d*s'e'sia and these include'e'tic ulcers& oeso'haitis& cancer o$ the stomach or 'ancreas&and allstones! In a lare 'ro'ortion o$ cases no clear'atholoical cause $or a 'atients s*m'toms can e determined!

PrevalenceD*s'e'sia is common! Surve*s in "estern societies haverecorded 'revalences o$ etween =4 and ?3%! /or man* 'eo'led*s'e'tic s*m'toms are an unavoidale 'art o$ livin! "h*some su


19/25

16

Oeso'haoGastric 1ancerQ =Oeso'haitis 3:73;GastritisQ& DuodenitisQ or (iatus (ernia 4:Normal 4:

Q-hese conditions are stronl* associated with H.pyloriIn$ection!HELICO&ACTER P2LORI

-his oranism lives on the astric mucosa and is associated witha numer o$ diseases! It is unclear whether it actuall* causesallthe diseases ut some are est treated * eradicatin thisin$ection!

-estin $or H.pyloriH.pyloriin$ection can e dianosed * demonstratin antiodies

to the oranism in serum& * showin urease activit* in thestomach usin reath tests or * e>amination o$ io'sies!Antien derived $rom the oranism can also e identi#ed in stoolsam'les!

Serolo*Seroloical methods are sim'le& non7invasive& and widel*availale ut are not use$ul in demonstratin success$uleradication! Some ,its 'rovide a ra'id result while the 'atient

waits 2Lnear 'atient test! 0aorator* ased tests with a highsensitivity are useful but much less accurate speci;c# than othermethods. Near patient blood tests are less accurate still

and are not recommended. A

@reath tests1aron taed reath tests& which de'end on ureasederadation o$ urea to 'roduce taed caron dio>ide which thena''ears in e>haled reath are o$ intermediate cost& ut are non7invasive! -wo methods have een used with either 3?1 2a tin*radioactive dose& ut chea' or 341 2a stale& non7radioactivedose ut more e>'ensive laelled urea! E) urea breath testsare available as kits on prescription. -hese tests can con#rmsuccess$ul eradication ut the* must e 'er$ormed when 'atientsare not ta,in 'roton 'um' inhiitors& ismuth nor within ?wee,s o$ antiiotic use! !he most accurate test for H Pylori

is the urea breath test. &


20/25

%7

Endosco'ic testsMethods o$ identi$*in H.pylor iwhich involve endosco'* andio's* are e>'ensive! Sim'le io's* urease tests are a ver* smalladditional cost to that o$ endosco'*! (istolo*& or culture o$ the

oranism add sini#cantl* to costs! $outine use of endoscopyfor diagnosis of H. pylori is not recommended. &

/aecal antien tests-hese have ecome availale in the last three *ears ut theire>act role remains to e determined!

IN-ESTIGATION an DIAGNOSIS o/ D2SPEPSIA

-he numer o$ 'atients with d*s'e'sia attendin General)ractitioners is elieved to e>ceed the availailit* o$ dianostic'rocedures! -here are a''ro>imatel* 4: attendances 'er 3::: inGeneral )ractice amountin to aout =3: consultations 'er G)'er annum! Endosco'* is ver* sa$e ut is not totall* ris,7$ree!Death $rom dianostic endosco'* is re'orted in the rane o$ 3 in=&::: 7 3:&:::! In out7'atient 'ractice the rate is li,el* to e evenlower& ut an* death is unacce'tale! 1riteria which identi$* onl*

those 'atients who ma* ene#t $rom the 'rocedure and toe>clude those who would not are worthwhile!

Rationa"isin0 t9e !se o/ enos#o:,

&+E &N( "%P!%"An ae threshold was the traditional 'ractical means o$ limitinendosco'*! -his is ased on the $act that the incidence ofastricmalinanc* is age related. It is also believed that certainassociated symptoms are characteristic and alert clinicians tothis 'ossile dianosis!The evidence base on which these beliefsare founded is not strong. + systematic review found no evidenceto suggest that initial empiric treatment adversely a=ectsoutcome in uncomplicated dyspepsia >#. That review reportedthat curable gastric cancer was a chance ;nding at endoscopy indyspeptics because the incidence was e&ually high in the non2dyspeptic population. Howe,er we recommend endoscopyin patients o,er the age of -- with new onset of

uncomplicated dyspepsia though we accept that in future

this ad,ice may change as e,idence is poor. (


21/25

%1

The ;rst edition of these guidelines >>D# and other similarguidance recommend that endoscopy should be performed in all

patients with dyspepsia associated with so2called 6alarm

symptoms Table #. Indeed most 'atients with astric cancerhave such s*m'toms! -hus i$ endosco'* in 'eo'le M,,y waslimited to those with alarm s*m'toms ver* $ew cancers would emissed "* * !#. In certain ver* hih 'revalence areas thisae ma* need to e lowered ut there is no stron evidence onthis! While there is evidence that alarm symptoms are predictiveof upper gastrointestinal cancer not all studies havedemonstrated this >#. 'ntil this area is claried wecontinue to recommend upper +I endoscopy in all

patients with dyspepsia associated with alarm symptomsC

HE/IC0&C!E$ P/$IIn uncom'licated d*s'e'sia concern aout astric cancer is notthe onl* reason $or investiation! -here is evidence thatsuse6uent thera'eutic decisions and consultin ehaviourchane in those investiated even when maor dianoses areasent!

The ;rst edition of these guidelines commended the practice ofundertaking H.pylori serology before endoscopy in these young

patients and restricting endoscopy to those with H.Pyloriantibodies and providing symptomatic therapy to the remainder.)onsiderable research has subse&uently been carried out in thisarea and we now favour a di=erent strategy 6test and treat#*though the original strategy 6test and scope# remains valid andsafe and itNs rationale is also given below.

A method o$ identi$*in most *oun 'atients at ris, o$ astricneo'lasia and 'e'tic ulcer is * testin $or evidence o$ H.pyloriin$ection! +sin modern seroloical assa*s and restrictinendosco'* in 'atients under ?5 2raised to 55 in this revisionwithuncom'licated troulesome d*s'e'sia to those with evidence o$in$ection has een shown to identi$* most 'e'tic ulcer disease23! -he maorit* o$ *oun 'atients with astric cancer aresero'ositive $or (elicoacter& so these cases too would e

dianosed& even in the rare asence o$ alarm s*m'toms! -hemaor dianoses that would e missed * such a 'rocess areoeso'haitis and @arretts oeso'haus 21olumnar lined


22/25

%%

oeso'haus! (owever& these conditions are est treated withthera'* directed at s*m'tom control ecause treatment directedat healin does not 'revent com'lications or decrease thereconised additional ris, o$ oeso'haeal adenocarcinoma! In

man* cases astro7oeso'haeal reu> does not cause erosiveoeso'haitis and a clinical dianosis is o$ten the est indication$or treatment! In man* cases astro7oeso'haeal reu> is a lon7term 'rolem and some arue that endosco'* should e'er$ormed e$ore instiatin lon7term acid su''ressive thera'*!/urther data are re6uired in this area ut endosco'* decreases'rescriin costs& consultation rates and leads to manaementchanes even in 'atients in whom no sini#cant disease is $ound2=&4&?&! -he assum'tion is that the 'rocedure 'rovides

reassurance to 'atients and doctors allowin more rational'rescriin! Similar ene#ts have een re'orted $ollowinneative H.pyloriserolo* without endosco'* in those in whomendosco'* would otherwise have een 'er$ormed 25!

The 6Test and Treat strategy involves testing for H.pylori bybreath test or serology followed by H.pylori eradication in caseswith H.pylori and symptomatic therapy for the remainder. +number of management trials have been published which

demonstrate that the strategy is as e=ective as endoscopy indetermining therapy for dyspepsia. 4uch a strategy shouldprovide appropriate treatment for peptic ulcer includingreduction of relapse* should bene;t a minority of patients withH.pylori associated ulcer negative dyspepsia see later#* shouldlessen concerns about worsening gastritis during treatment ofre@ux with PPIs and potentially could reduce gastric cancer risk.6Test and treat will expose more patients to broad spectrumantibiotics but there are no other known signi;cantdisadvantages of such an approach. The e=ectiveness of thisstrategy wil need to be re2assessed if the prevalence of H Pylorifalls to very much lower levels than at present. However* we arenow convinced by the substantial evidence base that thisapproach is both cost e=ective and safe and therefore we nowfa,our a 1 H.pylori test and treat2 strategy for

uncomplicated dyspepsia in patients under --. !2K#.+


23/25

%'

+'I(E/INE"-he uidelines which $ollow comine the assum'tion o$ are6uirement to 'rotect resources& limit unnecessar* ris, and

'rovide hih 6ualit* care!1, IN-ESTIGATION"aitin times $or investiation should not e>ceed $our wee,s andideall* investiations should e availale within two wee,s!7ational )ancer guidelines have determined that a wait ofgreater than two weeks when cancer is suspected isunacceptable. -he est investiation $or uncom'licatedd*s'e'sia is endosco'*! At endosco'*& io's* urease tests should

e 'er$ormed in all 'atients with ulcer in whom the ( )*loristatus is not alread* ,nown! /urther assessment to identi$* NSAIDand as'irin use& 1rohns& 0*m'homa and other unusual causes o$ulceration is necessar* in such 'atients without evidence o$ ()*lori!

Doule contrast arium radiolo* ma* e e6uall* accurate& utdoes not allow $or io'sies to e ta,en and is thus consideredsecond est! (owever in certain circumstances it 'rovides

valuale com'limentar* in$ormation! -hese circumstancesinclude dianosis o$ minor strictures which ma* e missedendosco'icall*& motilit* disorders& e>trinsic and 'ossil* intra7mural anormalities as well as the dianosis o$ malrotations&herniations and other structural anormalities!

TA&LE 1


24/25

%.

A, Patients it9 :sesia in 9o; ia0nosti#

enos#o: is aroriate, D

3!An: :seti# atient it9 a"ar; s:;to;s or si0ns$+nintentional weiht loss 2T4K& +ne>'lained Iron de#cienc*

anaemia&Gastro7intestinal leedin& D*s'haia and Od*no'haia&)revious astric surer*& )ersistent continuousvomitin&E'iastric mass& Sus'icious arium meal&)revious astric ulcer&

=! An: atient over t9e a0e o/ --it9 re#ent (


25/25

Dak Enak Perut

Documents

Transcript of Dak Enak Perut