Dyspepsia

Ilan Lenga, former CMR and David Cherney, former CMR MSH AIMGP 2004

Objectives

• By the end of this seminar you will: – have a working definition of dyspepsia – know the main causes of dyspepsia – have a rational, cost-effective, evidence based approach to dyspepsia

References

• • • • • AGA Guidelines for Management of Dyspepsia NEJM Review Article “Management of Non-Ulcer Dyspepsia” 339(19); 1376-81 Clinical Evidence Dec 2001 CMAJ 2000;162 (12 Suppl) OPOT Guidelines for PUD & GERD

US vs. Canadian Guidelines

• • CMAJ guidelines agree with AGA AGA slightly easier to follow

What is Dyspepsia?

indigestion nausea bloating stomachache vomiting upset stomach heartburn early satiety fullness queasiness epigastric discomfort

What is Dyspepsia?

• • • Everyone knows what it is, but no one knows what to call it!

Multiple definitions in the literature Rome Criteria II (def’n for research purposes) – pain or discomfort in midline upper abdomen • “Discomfort” = negative feeling which can be characterized by: • fullness • bloating • early satiety • nausea

Incidence

• • • Occurs in 25% of the population per year Of these 20-25% seek medical attention Accounts for 2-5% of primary care physicians’ workload

Differential Diagnosis Organic 40% Functional =“Non-Ulcer Dyspepsia” 60%

Organic Causes

• • • • • • • • • • • • Peptic Ulcer Disease GERD Gastric cancer Medications (ASA/NSAIDS, Abx) Most common organic causes, according to AGA Gastroparesis Cholelithiasis, Choledocholithiasis Pancreatitis (acute or chronic) Carbohydrate malabsorption Ischemic bowel Other GI malignancy (ep. Pancreatic cancer) Systemic disease (DM, Thyroid, Parathyroid, CTD) Intestinal parasite

Non-Ulcer Dyspepsia

• • The most common cause overall Defined as: – at least 12 weeks (need not be consecutive) within the last 12 months of: • Dyspepsia • No evidence of organic disease • Dyspepsia not exclusively relieved by defecation or associated with change in stool frequency or form (i.e. not IBS)

Management

Step One

History & Physical for Specific Etiologies

• •

Risk Factors and Past Hx

Risk Factors – Smoker, NSAID use, Heavy EtOH, FHx ulcer Personal Hx – Previous ulcer, GI bleed – DM, hypo/hyperthyroidism, parathyroid dis.

– Colitis, diverticulosis, liver disease – Anxiety, stress, depression – Previous Upper GI series, OGD, Abdo U/S

History & Physical

• • • PUD – Past history of ulcers, NSAIDs, Smoking GERD – Heartburn or regurg symptoms, aggravated when supine, chronic cough Gastric Cancer – Older (>50), wt. loss, dysphagia, smoker, long-standing GERD

History & Physical

• • • Biliary Tract disease – Episodic RUQ pain > 1 hr, associated with meals, post-prandial Meds – iron, NSAIDs, bisphosphonates, antibiotics, etc.

Metabolic disorder/Gastroparesis – DM, Hyper or Hypo -Thyroidism, Hyperparathyroidism

History & Physical

• IBS – Rome criteria • Pain relieved with defectation • more freq stools at onset of pain • abdominal distention • passage of mucus • sense of incomplete evacuation

Examination

• • Fever, weight loss, hypotension, tachycardia Abdo – Epigastric tenderness – Palpable mass – Distention – Colon tenderness – Jaundice – Murphy’s sign – Stool for OB • • Signs anemia – Brittle nails – Cheilosis – Pallor palpebral mucosa or nail beds Other – Teeth (loss enamel) – Lymphadenopathy Virchow’s node – Acanthosis nigrans – Hypo/Hyperthyroid.

Step Two

Explicitly Consider: Could this patient have cancer?

• • • • • Age > 45 Weight loss Bleeding Anemia Dysphagia

Red Flags

From AGA Guidelines Dyspepsia Clinical evaluation  45 years and no red flags Exclude by History: GERD; biliary; IBS; Meds; aerophagia + >45 or red flags Manage appropriately Endoscopy

Step 3

Treat for Non-Ulcer Dyspepsia

The Role of H. pylori in Non Ulcer Dyspepsia

• Association between H. pylori & Non-Ulcer dyspepsia not clear • Role in pathogenesis disputed

The Evidence

• • 2 RCT’s comparing “Test All & Eradicate” vs. Endoscopy-guided management for relief of symptoms 1st RCT – 500 patients with >2 weeks symptoms – Results: • no difference in symptom free days • reduced endoscopy rate in “test & eradicate” group (40% required f/u endoscopy)

The Evidence

• 2nd RCT – “test & eradicate” strategy reduced the number of symptomatic patients at 1 year ARR 13% (-6 to 31%) RR 0.82 (0.59-1.1)

The Evidence

• • One systematic review (9 RCT’s, 2541 pt’s) looked at H. pylori eradication in people with proven non-ulcer dyspepsia (after endoscopy) Results: – Small, but statistically significant improvement in symptoms 3-12 months after Rx ARR 7% (3-10%) NNT 15 RR 0.91 (0.86-0.96)

Non-invasive tests for H. pylori

SENS SPEC 14 C Urea Breath Test 90-95 90-95 Serology* 85-95 85-90 *cannot discriminate between active & previous infection (therefore, do not use to diagnose recurrence)

Treatment of H. pylori

• • Multiple Regimens UHN/MSH Guidelines...

1st line: Most cost-effective (for the hosp.) Lansoprazole 30mg BID HP Pack Clarithromycin 500 BID Amoxicillin 1000mg BID Alternate regimens substitute metronidazole for amoxil (but some H.pylori are resistant) 7 days

American College of Gastroenterology Position

• "There is no conclusive evidence that eradication of H. pylori infection will reverse the symptoms of nonulcer dyspepsia. Patients may be tested for H. pylori on a case-by-case basis, and treatment offered to those with a positive result."

What if H. pylori is negative?

• Minimal evidence supports: – H2 blockers – Proton Pump Inhibitors – Prokinetic agents • metoclopramide, domperidone • cisapride no longer available

From AGA Guidelines  45 years and no red flags Treat H.p.

+ H. pylori Testing Empiric H2, PPI, or prokinetic x 1 month

From AGA Guidelines  45 years and no red flags success Treat H.p.

Follow-up + H. pylori Testing fails fails Empiric H2, PPI, or prokinetic x 1 month success Endoscopy Follow-up

Step 4

Endoscopy if still symptomatic

Step 5

Post-Endoscopy Management

From AGA Guidelines Endoscopy Organic Disease H. pylori detected Functional Rx & Follow-up H2/PPI or prokinetic success 4 weeks fails Switch to other agent success Re-evaluate fails ? Behavioral/ Psychotherapy/ Antidepressant

• • • • •

Non-pharmacologic Tx

Quit smoking • Therapy for Stop / reduce caffeine Stop / reduce EtOH – Stress – Anxiety Hold medications associated w/ dyspepsia – NSAIDS, ASA Avoid foods and other factors precipitate symptoms – Better eating habits • Don’t eat late • • – Depression Elevate head of bed?

Stress-reducing activities – Exercise – Relaxation •

Reassurance

Summary

Key Points

• • • • • Step One: Hx & Px – attempt to establish a specific diagnosis Step Two: Consider Cancer – urgent endoscopy if red flags Step Three: Treat for Non-Ulcer Dyspepsia – Test & Eradicate H. pylori – Acid suppression or Prokinetics x 1 month Step Four: Endoscopy – Endoscopy if still symptomatic Step Five: – Post-Endoscopy Management