Transcript Dyspepsia
Dyspepsia Resident Teaching Rounds Steve Radke August 11, 2003 References: Ontario Program for Optimal Therapeutics, Ontario Guidelines for PUD and GERD Guidelines 2000 Sander et al, “Evidence based approach to the management of uninvestigated dyspepsia in the era of H. pylori. CMAJ, June 13, 2000;162 (12 Suppl) Dyspepsia Introduction PUD/GERD - overview Investigations Approach to dyspepsia NSAID induced PUD Recurrent PUD Take home messages Dyspepsia - pain or discomfort in upper abdomen • • • • heartburn acid regurgitation excessive burping/belching abdominal bloating, nausea overall prevalence 29% – DU or GU - 15-25% – Reflux esophagitis - 5-15% – Esophageal or gastric CA - < 2% PUD Lifetime incidence: men 10%, women 4% classic sxs: – localized epigastric pain – usually intermittent – often relieved with food poor correlation b/n sxs and ulcers PUD Etiology: – H. pylori • associated with 90-95% DU, 60-80% GU – NSAIDs • including ASA – smoking, ETOH – benign or malignant tumors GERD Retrosternal burning and regurgitation – 89-95% specificity for GERD – worse after meals – exacerbated by position – transiently relieved by antacids atypical presentations: – hoarseness, cough, asthma, dysphagia poor correlation b/n sxs and grade of esophagitis • most patients have no findings on endoscopy GERD Complications: – esophagitis – stricture – Barrett’s esophagus – esophageal adenocarcinoma – occurs in 2.5-24% of pts Drug-Induced GERD • anticholinergics (e.g.. TCA), CCB, nitrates, benzos, opioids, OCP, bisphosphinates Investigations endoscopic tests – histology, culture, rapid urease test non-endoscopic – urea breath test, serology H. Pylori Serology NPV - 90% PPV - decr. as prevalence decr. – results in increased risk of false positive – < 50 yo, PPV 52-72% Remains positive >6-12 months post Rx – not recommended to confirm eradication Urea Breath Test PPV - 90% NPV - 90% - irrespective of incidence C13, C14 preferred test – C13 - not covered by OHIP – C14 - only available in few major centres can be used to confirm eradication • NB: pt must be > 4 wks post Rx, and > 1 week off of PPI or H2RA Approach to Dyspepsia See handout Red Flags: “ABCDV” A - age >50, anemia, abdo mass B - bleeding (GIB) C - constitutional sxs D - dysphagia V - vomiting NSAID induced PUD Prevention: – PPI – cytoprotective agent - mesoprostol 200ug tid – High dose H2RA - ranitidine 300mg bid – COX-2? 2 or more of: – Previous GIB – Previous peptic ulcer – Age >75 yo – Hx of cardiovascular dz PUD recurrence If H. pylori +ve – recurrence rate <5% / yr – confirm with UBT or endo. (not serology) – treat with alternate regime that does NOT have the same 2 ABx as initial Rx - x 14d If H. pylori -ve – review NSAID use, smoking, etoh – refer for endoscopy Take home messages: Red flags - “ABCDV” Retrosternal burning and regurgitation – 89-95% specificity for GERD H. pylori serology - limitations Consider prevention in high risk pts taking NSAIDS (including ASA) Always consider scope