Transcript Dyspepsia - Derby GP Specialty Training Programme

Dyspepsia
What is dyspepsia?
‘pain or discomfort related to eating or drinking that
can be attributed to the upper gastro-intestinal tract’
The problem of dyspepsia
•
•
•
•
•
•
25 - 40 % prevalence, and increasing
25% of these seek help from GP
2 % population have endoscopies p.a.
0.45 % on long term PPIs
£500 million pa (E&W)
£ 2-3 billion Europe
Drugs that cause dyspepsia
• NSAIDS
• Bisphosphonates
• Steroids
• Metformin
• Calcium antagonists
• Theophyllines
• Nitrates
Endoscopic diagnoses in dyspepsia
60
50
40
%
30
20
GERD
PUD
Functional
Benign stricture
Cancer
10
0
Westbrook at al, 2001
What all patients worry about
GORD
Gastro-oesophageal junction
Causes of GORD
Diagnosis of GORD
Complications of GORD
•
•
•
•
Stricture
Barrett’s Oesophagus
Oesophageal adenocarcinoma
Extra-oesophageal
– Asthma
– Cough
– Pharyngitis
Barrett’s Oesophagus
Barrett’s Oesophagus
Barrett’s Adenocarcinoma
European age-standardised mortality rates for
oesophageal cancer in UK, 1979-1999
©Cancer Research UK
Anti-reflux surgery (ARS)
•
•
•
•
•
Helps 90%
Lasts about 10 years
50% still need PPI
Morbidity in 10% (dysphagia, bloating)
Laparoscopic probably better – but no evidence
Gastric Ulcer
Gastric ulcer - causes
H. pylori
60%
NSAIDs
30%
Carcinoma
5%
Others
5%
- neoplasia
- Crohn’s
- stress
- ZE syndrome
Duodenal Ulcer
Duodenal ulcer - causes
H. pylori
85%
NSAIDs
10-14%
Rare causes 1%
- Zollinger Ellison
- Crohn’s
- Stress
Giving NSAIDs in patients with or at risk of
peptic ulcer
• Avoid NSAID if possible
• Consider COX2 inhibitors
– Beware cardiovascular risks
• Hypertension
• MI
• CVA
• Add PPI to COX2 inhibitor
• Add PPI to ‘low-risk NSAID’ (ibuprofen)
Functional Dyspepsia
Gastric cancer
Age standardised (European) incidence and
mortality by sex, stomach cancer, UK, 1979-2001
© Cancer Research UK
Five year relative survival rates by sex,
stomach cancer
© Cancer Research UK
ALARM symptoms
•
•
•
•
•
•
Abdominal swelling (Anaemia)
Loss of weight
Anorexia
Recurrent symptoms*
Melaena/Haematemesis
Swallowing problems
*Only if age >55 years
Audit characteristics
• 1170 practices
– 14% of practices
– 71% of cancer networks
• April 2009 – April 2010
• Represents 8% of cancers registered that year
Delays for gastric cancer
100
90
80
70
60
Patient
GP
Hospital
50
40
30
20
10
0
0
14
31
62
182
Stage of gastric cancer
No spread
Local
Distant
No data
Number of consultations
40
35
30
25
20
15
10
5
0
0
1
2
3
4
5 or more
Route of referral
Emergency
2WW
Routine
Private
Other
Upper GI 2 week cancer referral cancers
Others
Unknown
primary
Oesophagus
NHL
Lung
Colon
Biliary
Gastric
Pancreas
Cancer risk in 2WW referrals
30
% cancer
25
Male
Female
20
15
10
5
0
25
35
45
55
65
75
85
2 week UGI cancer referrals
1200
1000
800
Referred
Cancers
600
400
200
0
2001
2002
2003
2004
2005
2006
Community Care & Pharmacy
General Advice
General Advice
GP management of Dyspepsia
Irritable Bowel Syndrome
Diagnosis
•
•
•
•
Pain associated with bowels
Longstanding
History of dysenteric illness
Associated conditions
–
–
–
–
Fibromyalgia
Headache
CFS
Non-cardiac chest pain
Warning signs
•
•
•
•
•
•
•
Short history
Weight loss
Nocturnal diarrhoea
Incontinence
Rectal bleeding
Age >50
Abnormal blood tests
Blood tests
• FBC, CRP, UE, LFT (incl Ca), TSH, tTG, B12,
folate
• Rectal examination
Faecal calprotectin
Faecal calprotectin
Faecal calprotectin
• Useful to diagnose IBD
• Not useful to confirm IBS (at present)
• May miss other important diagnoses
– Cancer
– Bile acid malabsorption
– Diverticulosis
Management of DP-IBS
•
•
•
•
•
•
Avoid bran
Reduce non-soluble fibre
Reduce lactose (use soy or rice products)
Loperamide
Anti-spasmodics
Amitriptyline
Management of CP-IBS
•
•
•
•
Increase dietary fibre (20-30g)
Unprocessed wheat bran
Increase fluids
Bulking laxatives
– Ispaghula husk
• Consider citalopram
Pain in IBS
•
•
•
•
Hypnotherapy beneficial
Cognitive Behavioural Therapy beneficial
Acupuncture not proven
Citalopram/amitriptyline may help
FODMAPs
•
•
•
•
•
•
Fermentable
Oligosaccharides
Disaccharides
Monosaccharides
And
Polyols (sorbitol, sweeteners)
Category A (suspected lower GI cancer)
Any patient over the age of 50 with change in bowel
habit/diarrhoea (>6 weeks but <6 months) who has
one or more of the following features:
Weight loss, iron deficiency anaemia, tenesmus, strong
family history of bowel cancer (in first degree relative
aged <60), abdominal mass, mass on PR
Action: Refer as 2WW to Colorectal Dept
Category B (Organic diarrhoea)
Any patient presenting with diarrhoea, not
fulfilling ‘A’, who has any of the following features:
Bloody stools, frequent loose stools ++,
incontinence, nocturnal diarrhoea, strong family
history of IBD, raised CRP, positive TTG
Action: Refer to Dept of Gastroenterology
*Urgent referral or emergency admission is
recommended for patient who may have a severe
colitis, typical patients may have 6 or more bloody
stools per day, fever, tachycardia and anaemia*
Category C (Probable IBS)
Patient below the age of 40 who has altered
bowel habit, abdominal pain or discomfort that is
relieved by defaecation, bloating but in the absence
of category A and B features.
Action: Does not require referral for
confirmation of diagnosis. To exclude inflammatory
bowel disease, perform faecal calprotection test.
Only refer if positive. Do not carry out faecal
calprotectin within 1 week of gastrointestinal
infection (will be raised).
Manage as per IBS guidelines