2) Cohen

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  • in clinical practice, there is considerable overlap among reflux and dyspeptic symptoms; based on expert opinion, where symptoms of reflux are prominent, GERD should be the diagnosis until proven otherwise in gastroenterology practice. Bloating is difficult to localize to a specific abdominal site and is more typically a symptom of irritable bowel syndrome (IBS), 26 so it may be best not to consider this a characteristic feature of dyspepsia. It has been suggested that if the upper abdominal pain or discomfort is relieved by defecation or associated with altered stool symptoms, the diagnosis of IBS should be strongly entertained, Nausea can be due to gastric, intestinal, or extraintestinal causes; alone it is not sufficient to identify dyspepsia, although it may cluster with these symptoms. 27 Recurrent belching is common but is most often attributable to air swallowing 28 and alone is not considered to constitute dyspepsia in the absence of upper abdominal discomfort.
  • To avoid false negative UBT and stool AG assy, advise pt to stop taking antibiotics for at least 4 weeks prior to testing, PPI’s at least 2 weeks prior to testing and H2RA at least one day prior to testing. No need to stop PPI prior to serology testing Serology will remain positive for many months after treatment. F/u testing (if performed) should be done with either UBT or stool antigen assay
  • 3 randomized control trials comparing hpylori eradication to placebo abx ( all received acid suppression) Combined 1106 pts with dypepsia in primary care setting. Relative Risk .82 with NNT 9.
  • Figure 6. Forest plot of randomized trial of H pylori eradication versus endoscopy in patients with dyspepsia. Proportion of patients with cure of dyspepsia.
  • Pts with mild non progressive dysphagia may benefit from empiric ppi to see if “alarm” sxs disappear. Age Cutoff chosen b/c rsk of malignancy in most US populatins is < 10 per 100,00 in pts < 55 y/o An age of 45 or 50 may be considered for US pts of Asian, hispanic or Afro-carribean extraction. This rec is based on Expert opinion only. PPi rx should be discontinued after 1 month if pts respond. If sxs recur, longer term acid suppression should be considered but need for acid suppression should be reviewed every 6-12 months If standard dose PPI fails, double dose PPI should be considered based on Expert opinion.
  • Can substitute Metronidazole for Amox in pcn allergic pts or for clarithro in macrolide allergic pt
  • If PPI rx fails, consider EGD but realize that the yield of EGD in this setting is poor. It may serve to relieve anxiety about a serious underlying disorder. The theoretical concern that a long delay in seeking endoscopy will lead to a curable cancer becoming incurable has not been borne out- early endoscpy has not been shown to improve the poor outcome of pts with gastric cancer.
  • Figure 3. Forest plot of randomized controlled trials comparing PPI with H2RA therapy in uninvestigated dyspepsia.
  • Figure 1. Summary of randomized controlled trials of H pylori eradication versus placebo on the risk of more than mild chronic gastritis persisting. Heterogeneity chi-squared = 1.58 (d.f. = 2) P = .45.
  • Figure 9. Forest plot of randomized controlled trials of H pylori eradication therapy versus placebo antibiotics in H pylori –positive patients with nonulcer dyspepsia
  • Figure 7. Forest plot of randomized trial of H pylori eradication versus endoscopy in patients with dyspepsia. Proportion of patients who underwent endoscopy.
  • Figure 8. Forest plot of randomized controlled trials of PPI therapy versus placebo in patients with nonulcer dyspepsia.
  • Figure 5. Forest plot of randomized controlled trials of endoscopy versus empirical acid suppression in patients with dyspepsia.
  • Figure 1. Summary of randomized controlled trials of H pylori eradication versus placebo on the risk of more than mild chronic gastritis persisting. Heterogeneity chi-squared = 1.58 (d.f. = 2) P = .45.
  • 2) Cohen

    1. 1. Dyspepsia Evaluation and Treatment of a Common Ambulatory Topic Stuart Cohen MD Associate Professor of Medicine General Internal Medicine 3-27-07
    2. 2. Road Map <ul><li>Definition </li></ul><ul><li>Epidemiology </li></ul><ul><li>Differential Diagnosis </li></ul><ul><li>Pros and Cons of various Diagnostic Strategies </li></ul><ul><li>Management algorithm </li></ul>
    3. 3. Dyspepsia <ul><li>Definition: Rome II Criteria (2000) </li></ul><ul><ul><li>Chronic or recurrent pain or discomfort centered in the upper abdomen </li></ul></ul><ul><ul><li>Excludes predominant reflux symptoms </li></ul></ul>
    4. 4. Dyspepsia <ul><li>Rome III Criteria (2006) </li></ul><ul><li>One or more of the following symptoms </li></ul><ul><ul><li>Postprandial fullness </li></ul></ul><ul><ul><ul><li>(postprandial distress syndrome) </li></ul></ul></ul><ul><ul><li>Early satiation </li></ul></ul><ul><ul><ul><li>(inability to finish normal sized meal or postprandial fullness) </li></ul></ul></ul><ul><ul><li>Epigastric pain or burning </li></ul></ul><ul><ul><ul><li>(epigastric pain syndrome) </li></ul></ul></ul>
    5. 5. Epidemiology <ul><li>Annual prevalence as defined by Rome II criteria in Western Countries is ~ 25% </li></ul><ul><li>If heartburn is considered ~40% </li></ul><ul><li>Often the symptoms are of short duration, self limited and self-managed </li></ul><ul><li>2-5% of general practice consultations are for dyspepsia </li></ul>
    6. 6. Differential Diagnosis of Dyspepsia <ul><li>Peptic ulcer disease </li></ul><ul><li>Gastroesophageal reflux </li></ul><ul><li>Gastric malignancy </li></ul><ul><li>Biliary pain </li></ul><ul><li>Irritable bowel syndrome </li></ul><ul><li>Drug induced dyspepsia </li></ul><ul><li>Functional (non-ulcer) dyspepsia </li></ul>
    7. 7. Peptic ulcer disease <ul><li>“ Classic” symptoms of Duodenal Ulcer occur when acid is secreted in absence of food buffer </li></ul><ul><ul><li>2-5 hrs after a meal or on an empty stomach </li></ul></ul><ul><ul><li>At night (11 pm-2 am) when circadian stimulation of acid secretion is maximal </li></ul></ul><ul><li>Discomfort is in epigastrium but may radiate to right and left upper quadrant or back </li></ul><ul><li>Usually burning, gnawing or hunger-like but may be vague or cramping </li></ul><ul><li>Symptomatic periods lasting days or weeks followed by symptom free periods for weeks or months is characteristic </li></ul>
    8. 8. Peptic ulcer disease <ul><li>Individual symptoms have NOT been useful in identifying organic from functional dyspepsia </li></ul><ul><li>PUD found in 5-15% of pts with dyspepsia </li></ul><ul><ul><li>May be missed in pts receiving antisecretory therapy (PPI or H2RA) </li></ul></ul><ul><ul><li>Duodenal ulcer  H pylori 90% </li></ul></ul><ul><ul><li>Gastric Ulcer  H pylori 70% </li></ul></ul>
    9. 9. GERD <ul><li>Most common symptoms are heartburn and regurgitation </li></ul><ul><li>Clinical diagnosis </li></ul><ul><ul><li>heartburn correlates poorly with 24-hr ph monitoring and EGD findings </li></ul></ul><ul><li>Reflux esophagitis found in 5-15% of pts with dyspepsia at endoscopy </li></ul>
    10. 10. Gastric Malignancy <ul><li>Gastroesophageal malignancy is an uncommon cause of chronic dyspepsia </li></ul><ul><li>Identified in < 2% of all patients referred for endoscopy to evaluate dyspepsia </li></ul><ul><li>Yet concern for malignancy drives the evaluative process </li></ul><ul><li>H-pylori has been associated with a 6-fold increase in gastric adenocarcinoma distal to the cardia, both diffuse and intestinal type </li></ul>
    11. 11. Gastric Malignancy <ul><li>Alarm Features in Dyspepsia </li></ul><ul><ul><li>Age older than 55 with new-onset dyspepsia </li></ul></ul><ul><ul><li>Family history of upper GI malignancy </li></ul></ul><ul><ul><li>Unintended weight loss </li></ul></ul><ul><ul><li>Progressive dysphagia </li></ul></ul><ul><ul><li>Odynophagia </li></ul></ul><ul><ul><li>Unexplained iron-deficiency anemia </li></ul></ul><ul><ul><li>Persistent vomiting </li></ul></ul><ul><ul><li>Palpable mass or lymphadenopathy </li></ul></ul><ul><ul><li>jaundice </li></ul></ul>
    12. 12. Gastric Malignancy <ul><li>Value of alarm features in predicting an underlying malignancy is poor </li></ul><ul><ul><li>Negative predictive value is high 95-99% </li></ul></ul>
    13. 13. Biliary Pain <ul><li>“ Classic” biliary pain characterized by </li></ul><ul><ul><li>episodic acute and severe upper abdominal pain in epigastrium or RUQ </li></ul></ul><ul><ul><li>lasting at least an hour (often several hrs or more) </li></ul></ul><ul><ul><li>Pain may radiate to back or scapula </li></ul></ul><ul><ul><li>Often associated with restlessness, sweating or vomiting </li></ul></ul>
    14. 14. Biliary Pain <ul><li>Careful history is essential as asymptomatic gallstones frequently coexist in pts with dyspepsia </li></ul><ul><li>Meta-analysis including 21 controlled studies investigating association between gallstone and dyspepsia (Kraag,et al. Scand J Gatroenterolgy, 1995) </li></ul><ul><ul><li>In pts with upper abdominal pain, gallstones were somewhat more likely to be identified as cause (odds ratio 2.0) </li></ul></ul><ul><ul><li>Other features of dyspepsia (flatulence, bloating and belching) were not associated with gallstones </li></ul></ul>
    15. 15. Irritable Bowel Syndrome <ul><li>There is considerable overlap between IBS and functional dyspepsia </li></ul><ul><ul><li>Symptom complex of chronic abdominal pain and altered bowel habits remains the nonspecific yet primary characteristic of IBS </li></ul></ul><ul><li>Population based longitudinal survey in Sweden </li></ul><ul><ul><li>Prevalence of dyspepsia 14% </li></ul></ul><ul><ul><li>Prevalence of IBS 12.5% </li></ul></ul><ul><ul><li>Among pts with IBS, 87% fulfilled the dyspepsia criteria </li></ul></ul><ul><ul><li>50% changed there symptom profile over a 1 yr period </li></ul></ul>
    16. 16. Drug Induced Dyspepsia <ul><li>NSAID- related dyspepsia is common </li></ul><ul><ul><li>20% of pts taking NSAIDS </li></ul></ul><ul><ul><li>10-20% may develop PUD detectable by endoscopy </li></ul></ul><ul><li>Other drugs </li></ul><ul><ul><li>Calcium channel blockers </li></ul></ul><ul><ul><li>Methylxanthines </li></ul></ul><ul><ul><li>Bisphosphonates </li></ul></ul><ul><ul><li>Potassium supplements </li></ul></ul><ul><ul><li>Antibiotics (erythromycin, metranidazole) </li></ul></ul><ul><ul><li>Orlistat, acarbose </li></ul></ul>
    17. 17. Functional (non-ulcer) Dyspepsia <ul><li>Definition </li></ul><ul><ul><li>At least 3 month h/o dyspepsia in which there is no obvious structural explanation for the symptoms </li></ul></ul><ul><li>Accounts for up to 60% of all pts presenting with dyspepsia </li></ul>
    18. 18. Functional (non-ulcer) Dyspepsia <ul><li>Pathophysiology is unclear yet overlapping disorders of upper GI motor and sensory function are implicated </li></ul><ul><ul><li>25-40% have delayed gastric emptying </li></ul></ul><ul><ul><li>40% have impaired fundic accommodation to a meal </li></ul></ul><ul><ul><li>30% have altered visceral sensation </li></ul></ul><ul><ul><li>20-60% have H-pylori induced gastritis </li></ul></ul><ul><ul><ul><li>No association between H-pylori and any specific symptom profile </li></ul></ul></ul>
    19. 19. Diagnostic Strategies for the Evaluation of Dyspepsia <ul><li>Empiric Treatment with acid suppression </li></ul><ul><li>Endoscopy in all patients </li></ul><ul><li>Test for H-pylori and treat if positive </li></ul>
    20. 20. Empiric Treatment with acid suppression <ul><li>Advantages </li></ul><ul><ul><li>Least expensive </li></ul></ul><ul><ul><li>Rapid sx relief </li></ul></ul><ul><ul><li>May reduce the number of EGD’s </li></ul></ul><ul><li>Disadvantages </li></ul><ul><ul><li>Cost advantage lost with sx recurrence </li></ul></ul><ul><ul><li>High rate of sx recurrence may promote inappropriate long term med use </li></ul></ul><ul><ul><li>May delay dx testing </li></ul></ul><ul><ul><li>May mask sxs of PUD or malignancy </li></ul></ul><ul><ul><li>Provides least patient reassurance </li></ul></ul>
    21. 21. Endoscopy in all patients <ul><li>Advantages </li></ul><ul><ul><li>Gold standard test to exclude ulcer, reflux esophagitis and UGI malignancy </li></ul></ul><ul><ul><li>Provides greatest degree of reassurance to patients </li></ul></ul><ul><li>Disadvantages </li></ul><ul><ul><li>Expensive </li></ul></ul><ul><ul><li>Invasive </li></ul></ul><ul><ul><li>Not cost-effective in younger patients without alarm sxs </li></ul></ul>
    22. 22. Test for H-pylori and treat if test is positive (test and treat) <ul><li>Advantages </li></ul><ul><ul><li>More efficacious than empiric PPI strategy if H-pylori prevalence > 10% </li></ul></ul><ul><ul><li>Likely cost-effective compared to endoscopy for all </li></ul></ul><ul><ul><li>May decrease long-term risk for gastric carcinoma </li></ul></ul><ul><li>Disadvantages </li></ul><ul><ul><li>May result in over and under-treatment b/c of false positive and false negative H-pylori results </li></ul></ul><ul><ul><li>Benefits in pts with functional dyspepsia likely small </li></ul></ul><ul><ul><li>Diagnosis of malignancy and ulcer disease may be delayed or missed </li></ul></ul>
    23. 23. Non-invasive H-pylori testing Adapted from: Smoot, DT, Cutler, AF. Heliocobacter pylori: Diagnostic test Gastroenterology and Endoscopy News, Vol 48, No 10, McMahon Publishing Group, October, New York 1997. p.28. 86-95 86-94 Stool antigen assay 88-98 88-95 Urea Breath test 78-95 86-94 Serum ELISA Average Specificity (%) Average Sensitivity (%) Test
    24. 24. Forest plot of randomized trials of H pylori eradication versus placebo antibiotics in H pylori –positive patients with dyspepsia
    25. 25.   Forest plot of randomized trial of H pylori eradication versus endoscopy in patients with dyspepsia. Proportion of patients with cure of dyspepsia
    26. 26. American Gastroenterological Association (AGA) guidelines for the management of Dyspepsia
    27. 27. American Gastroenterological Association (AGA) guidelines for the management of Dyspepsia
    28. 28. H-pylori Treatment Regimens <ul><li>Preferred first line Rx: </li></ul><ul><ul><li>PPI, amoxicillin 1 gm, clarithromycin 500 mg all twice daily for 7-14 days </li></ul></ul><ul><li>Acceptable first line Rx (usually reserved for Rx failure) </li></ul><ul><ul><li>Bismuth 525 mg, metronidazole 500 mg, tetracycline 500 mg all four times daily with a PPI twice daily for 7-14 days </li></ul></ul>
    29. 29. American Gastroenterological Association (AGA) guidelines for the management of Dyspepsia
    30. 30. American Gastroenterological Association (AGA) guidelines for the management of Dyspepsia

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