DYSPEPSIALeena Patel1/2/12

OVERVIEW

Statistics

Red flags

Management

H-pylori testing and treatment

STATISTICS

5% of adults/year consult their GP for dyspepsia symptoms

1% will go on to have endoscopy

Of these:

80% will have non-ulcer dyspepsia or reflux

13% will have a peptic ulcer

<3% will have malignancy

SYMPTOMS

Nausea

Vomiting

Bloating

Belching

Epigastric pain

Retrosternal pain

Early satiety

Chronic cough

ALARM SYMPTOMS

Progressive dysphagia

Persistent vomiting

Progressive unintentional weight loss

Iron deficiency anaemia

Epigastric mass

Chronic GI bleeding

Suspicious barium study

ENDOSCOPY

Refer patient of ANY age with ≥1 of the above listed alarm symptoms

Refer patients >55 years of age with new onset unexplained dyspepsia which is persistent (4-6 weeks) even without alarm symptoms

TRY TO AVOID USING PPI/H2RA FOR 2 WEEKS PRIOR TO ENDOSCOPY

ENDOSCOPY RESULTS

UPPER GI MALIGNANCY

PEPTIC ULCER DISEASE (GASTRIC/DUODENAL)

NON-ULCER DYSPEPSIA

GORD WITH/WITHOUT OESOPHAGITIS

MANAGEMENT

Divided into:

Uninvestigated dyspepsia

H-pylori eradication

GORD, PUD, NUD

MEDICATION INDUCED

NSAIDS

Steroids

Bisphosphonates

Calcium channel blockers

Nitrates

Theophyllines

LIFESTYLE

Healthy balanced diet

Avoid/reduce fatty food, caffeine, chocolate

Weight reduction

Smoking cessation

Reduce alcohol intake

Avoid late meals

Raise end of bed

Try antacids/alginate therapy for intermittent symptoms

UNINVESTIGATED DYSPEPSIA

H-pylori testing and treat with eradication/PPI

OR

Treat with high dose PPI for 1 month and then test for H-Pylori if still symptomatic

NICE suggests either way is acceptable

Both treatments equally effective and cost effective (BMJ 2008)

Advises treat and test if still symptomatic

H-Pylori TESTINGCarbon 13 urea breath test, stool antigen and serology

Serology is less accurate but can be done whilst on a PPI

Breath test and antigen test have similar and high sensitivity and specificity

Before either breath/antigen test:

Avoid antibiotics for 4 weeks

Avoid PPI/H2RA for 2 weeks

Patient should fast for 6 HOURS prior to breath test

Avoid retesting due to high false positive, breath test if have to

ERADICATION REGIMESStandard triple therapy

Full dose PPI + amoxicillin (1g BD) + clarithromycin (500mg BD)

Full dose PPI + metronidazole (400mg BD) + clarithromycin (250mg BD)

7 day treatment

77% effective at eradication

Sequential treatment

10 day treatment

Full dose PPI

Amoxicillin (1g BD) for the first 5d

Metronidazole + clarithromycin (500mg BD) for next 5d

93% effective at H-pylori eradication

UNINVESTIGATED DYSPEPSIA

If relapse following successful treatment, consider low dose PPI with regular review

If symptoms fail to respond to PPI/eradication treatment, consider a trial of H2 receptor antagonist or prokinetic for 1 month and then review

GORD, NUD, PUD

If peptic ulcer disease or non-ulcer disease on endoscopy, then test for H-Pylori and eradicate if present

If GORD, or H-Pylori negative PUD or NUD, then 1-2 month course of PPI, doubling dose of PPI for 1month if not responding

Consider 1 month trial of H2RA/prokinetic if still not responding

Repeat endoscopy for H-Pylori positive GU.

Risks of long term PPI treatment

Hip fractures and calcium malabsorption

Vitamin B12 malabsorption

Iron malabsorption

Hypomagnesaemia

Atrophic gastritis (esp. if H-pylori +ve)

?pneumonia

Summary

Red flags

Don’t forget medication induced dyspepsia, consider alternatives

Lifestyle advice

Regular review of PPI treatment due to potential risks of long term treatment