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
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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