Transcript Salmonella Megacolon - Private Gastroenterologist UK

BSG Guidelines
Management of Dyspepsia
By
Matt Johnson
Recommendation Grading
• A >1 meta-analysis, systematic review or body
of evidence from RCTs
• B high quality case control or cohort studies, or
extrapolated from a meta-analysis,
systematic review or RCTs
• C lesser case control or cohort studies
• D expert opinion or case series / reports
Dyspepsia Introduction
• Dyspepsia is not a diagnosis but a collection of
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symptoms including; upper abdo discomfort,
heartburn, retrosternal pain, anorexia, nausea,
vomiting, bloating, fullness and early satiety
Prevalence in the Western societies is quoted at
being between 23 – 41%
4% of GP consultations are for dyspepsia
10% of these are referred to hospital
2% of entire adult population receive either an
OGD or a barium meal each year
Causes of Dyspepsia
• Normal
• Gastritis, Duodenitis, HH
• GORD
• DU
• GU
• Oesophageal, Gastric Ca
30%
30%
10-17%
10-15%
5-10%
2%
Rationalisation of Endoscopy
• Patients with dyspepsia in whom endoscopy is inappropriate
– Those < 55y with uncomplicated dyspepsia
– Patients with known DU who have responded appropriately to
medication
– Those who have recently had an OGD for the same symptoms
• “Test and treat” has replaced the “test and scope” strategy in
patients <55y
– Pros =
– Cons =
A
approporiate for PU, reduction of relapse, may benefit
H.pylori associated non-ulcer dyspepsia, potential
reduction in Cancer risk
increases antibiotic exposure, may miss significant GORD and
Barretts oesophagus (although therapy here should be
directed at symptom control as treatment directed at healing
does not prevent the known complications)
H.Pylori Ix
• Serology
A
– Simple, useful, less specific than other methods
– Instant / near tests are less accurate and not
recommended
• 13C Urea Breath Test
B
– 13C or 14C cleaved by the H.pylori urease and then
monitored in the exhaled breath
– Best test for identification
– Best test to ensure eradication
• Endoscopic Clo Test
B
– Cheap, accurate but endoscopy not always necessary
– Recommended in all patients with newly found PU
• Faecal Ag Tests
–?
Rationing of Endoscopy
• Death from diagnostic OGD = 1 in 2-10,000
• The incidence of gastric Ca is age related
• OGD is recommended in all patients >55y
D
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C
– with new onset uncomplicated dyspepsia
– for > 1/12 duration
Most patients with gastric cancer have “alarm symptoms”
OGD is recommended in all patients with “alarm symptoms”
– National Cancer Guidelines request Ix within 2/52
• These include dyspeptic patients with:
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Unintentional weight loss
GI Bleeding
Previous gastric surgery
Epigastric mass
Previous gastric ulcer
Unexplained Fe deficiency
Dysphagia or Odynophagia
Persistent continous vomiting
Suspicious barium meal
Treatments
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Pre – Endoscopy
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<55y =
>55y =
Test and treat
Pre-treatment with anti-secretory drugs may mask significant diagnosis
D
therefore BSG recommend witholding or stopping pre-treatment 4/52 before OGD
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Oesophagitis
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Lifestyle advice
– weight loss, propping up head end of bed
Medication
– Symptom relief
– 4/52 course of PPIs recommended by NICE
Follow-up
– ? Long term management of Barretts
– Repeat OGD only recommended to review
• Healing of oesophageal ulcers
• Dilatation of strictures
• Anaemia secondary to GORD
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D
Treatments
• Functional Dyspepsia
• Lifestyle advice
– little benefit (stop smoking)
• Medication
D
– Recommends H.pylori eradication
D
– Cochrane review May 2000 showed resolution of symptoms in
9% after H.pylori eradication therapy
– Symptomatic control with anti-secretory agents is recommended
especially in ulcer like or reflux like symptoms
B
– Stop NSAIDS
D
– Reassurance may be sufficient
D
Treatments
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Duodenal Ulcers / Erosive Duodenitis
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95% associated with H.pylori
Advise confirmation, although this may be unneccssary
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HP +ive DU
A
1st Line
B
– PPI bd
or Ranitidine bismuth citrate
– Amoxicillin 500mg-1g bd
Metronidazole 400-500mg bd
– Clarithromycin 500mg bd
2nd Line
– PPI bd
– Bismuth Subcitrate 120mg qds
– Metronidazole 400-500mg tds
– Tetracycline 500mg qds
Follow Up
– Urease breath test in all >1/12 after finishing HP eradication therapy
– In asymptomatic patients further OGD + follow up is then unneccessary unless symptoms recur or persist
– In those where symptoms recur after an initial response = repeat urease breath test and treated if
necessary with an alternative regime. If HP persists biopsy for C+Sensitivity
D
– Low dose PPI maintainance only necessary in persistent HP infections or those at risk of NSAID
complications
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HP -ive DU
Medication
– Antisecretory therapy = Cimetidine 800mg is cheapest
– Stop NSAIDS + consider COX 2
Follow Up
– OPA nesseccary only if DUs not associated with NSAIDS
D
Treatments
• Gastric Ulcer
• 70% are associated with H.pylori, most of the rest are assoc with NSAIDS
• HP +ive GU
– Eradication therapy
A
– Antisecretory agents for 2/12 (as GUs take longer to heal)
D
– If ongoing NSAIDS are necessary consider prophylactic PPI or misoprostol
• NICE guidance on COX 2 antagonists
• HP –ive GU
D
– 2/12 of antisecretory therapy
– NICE guidance re COX 2 antagonists
• Follow Up
– Repeat OGD in all untiil ulcer healing
– Surgery if GU has not healed by 6/12
D
Resource Requirements
• Easy access for GPs to organise urease breath
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tests
Aim to provide rapid access to endoscopy for all
those meeting criteria
Aim to provide endoscopy access within 2 weeks
for those with alarm symptoms
1 laboratory in each major city must be able to
provide facilities for full bacteriological
assessment of HP sensitivity and resistance
AGA Guidelines
• Age cut off is <45
• Management options
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1)
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Empirical treatment
Immediate OGD
Test and scope *
Test and treat
• * may be preferential in areas with a high background
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incidence of gastric Ca
Scope <45y HP-ive who fail 2/12 of treatment using an
antisecretory preparation and then a prokinetic agent
(cisapride)