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An Evidence-based Approach      to the Management of Uninvestigated Dyspepsia  in the Primary Care Settings:             a...
Dyspepsia:       the size of the problem15–25% of the general population experiencedyspepsia within a 12-month periodMuch ...
Dyspepsia covers a range of symptoms                      DYSPEPSIA  GERD          PAIN OR DISCOMFORT                     ...
Definition of dyspepsia (Rome II) Pain or discomfort occurringcentred in the upper abdomen                                ...
Gastritis                  Peptic ulcer disease                       (Includes NSAID-induced ulcers)                  Aci...
Reflux esophagitis          Normal                                23.9%                       33.6%                       ...
Functional Dyspepsia (Rome I)                                      Dysmotility-like                           21      11  ...
Definition of Functional Dyspepsia (Rome II)    Twelve weeks or more (within the last 12   months) of persistent or recurr...
Definition of Functional Dyspepsia               (Rome III)At least 3 months, with onset at least 6 monthspreviously, of 1...
Functional dyspepsia:an exclusion diagnosis
Uninvestigated DyspepsiaPatient with new onset or recurrent dyspeptic symptoms in whom noinvestigation have been conducted...
Uninvestigated dyspepsia     vs functional dyspepsia  Uninvestigated dyspepsia      ●   All symptomatic patients,         ...
Management ofuninvestigated dyspepsia
Uninvestigated Dyspepsia                          Consider :                                                              ...
RecommendationExclude other possible causes of the dyspeptic symptoms with      thorough history-taking and physical exami...
Uninvestigated Dyspepsia                               Consider :                                                         ...
Older patients and with alarm features                America > 45 years          Canada > 50 years          Indon...
      Diagnostic test: endoscopy or radiography?      Radiography : 70 %      Endoscopy : 96 %             Dooley et a...
Specialist management of uninvestigated dyspepsiaEndoscopy with biopsies           and   treat accordingly!           Tall...
Recommendation   Prompt investigation is recommended for patients over 50 years of age   with uninvestigated dyspepsia and...
Uninvestigated Dyspepsia                               Consider :                                                         ...
   Patients who use NSAIDs    Hp infection is the most common cause of                    peptic ulcers        NSAIDs ...
Recommendation      Patients with uninvestigated dyspepsia         who are regular users of NSAIDS       (including ASA) s...
NSAID and/or       reguler ASA use                               YES  Can NSAID/ASA                                     St...
Recommendation                    If possible, NSAID use should be stopped                    and the patient’s response m...
Uninvestigated Dyspepsia                               Consider :                                                         ...
Patients with dominant symptom of heartburn             or acid regurgitation, or both      Heartburn (89 %) or acid reg...
Recommendation  Patients aged 50 years or less with uninvestigated dyspepsia  and dominant symptoms of heartburn or acid r...
Reflux mini-management schema  Dominant symptom heartburn and/or regurgitation      Treat      a. PPI      b. H2-RA      c...
   Management of patients with GERD           Five treatment possibilities for GERD                   - lifestyle modifi...
RecommendationThe effectiveness of lifestyle modifications and antacids for the treatment of GERD is not proven. Patient w...
Uninvestigated Dyspepsia                           Consider :                                                             ...
Hp test and treat strategy            Hp infection is associated with             - duodenal ulcer 90 – 95 %           ...
RecommendationA test-and-treat strategy for uninvestigated dyspepsia      in younger patient (aged 50 years or less)   who...
   Testing for Hp infection             Infection can be detected by:             - invasive (endoscopy based)       - n...
Recommendation           Noninvasive methods are recommendedfor the detection of H. pylori in patient aged 50 years or les...
Recommendation             No more serology   Stool antigen is the recommended test  Test with stool antigen before pre...
H. Pylori positive mini-management schema             Patient Hp positiveEradicate Hp:a. PPI + AC or MC or   RBC + AC or M...
Hp eradication therapy           (a) First line therapy      PPI + AC or PPI + MC (bid for 7 days)    or ranitidine bismut...
RecommendationEradication therapies recommended for patientswith uninvestigated dyspepsia who are foundto be H. pylori pos...
A meta-analysis of short versus long therapy         with a PPI, clarithromycin  and either metronidazole or amoxicillin  ...
Meta-analysis:duration of first-line PPI-based triple therapy     for Helicobacter pylori eradication    Extending triple ...
Pantoprazole based therapies in HP eradication:     a systematic review and meta-analysis  Pantoprazole achieves similar c...
Uninvestigated Dyspepsia                             Consider :                                                           ...
H. Pylori negative mini-management schema       Patient Hp negative     Treat x 4 weeks     a. PPI     b. H2-RA     c. Pro...
Recommendation    There is good evidence that antacids are ineffectivefor functional dyspepsia, and they are not recommend...
RecommendationTreatment recommendation for patients who presentwith uninvestigated dyspepsia and who subsequentlyhave nega...
Summaries    Clinical management tool consists of 5 key steps in     the evaluation of patients with uninvestigated     d...
PRIMARY MANAGEMENT OF NEW ONSET               UNINVESTIGATED DYSPEPSIA IN INDONESIA  EXCLUDE BY HISTORY :                 ...
Dispepsia
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Dispepsia

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Kuliah Dyspepsia UPH

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  • Dyspepsia – whatever the cause – is common in the general population, and is more common than peptic ulcers. Dyspepsia affects up to a quarter of the population in a 12-month period. Up to 5% of primary care consultations are due to dyspepsia.
  • The pain of dyspepsia overlaps with that of GORD and irritable bowel syndrome (IBS). Functional dyspepsia is a diagnosis that can only be made after investigation to exclude an organic cause. It is not necessary to investigate all patients with dyspepsia. Use of the term ‘non-ulcer’ dyspepsia is now discouraged.
  • According to Rome II criteria, dyspepsia is any pain or discomfort occurring in the upper abdomen. Dyspepsia is further divided into subgroups on the basis of the predominant symptom (ulcer-like, dysmotility-like and non-specific) rather than symptom clusters. While proposed for research purposes, these dyspepsia subgroups are not particularly useful in clinical practice in providing clues to the underlying disease, and therefore, remain contentious.
  • All of the diseases on this slide are related to inappropriate amounts of acid/levels of acid secretion in the various regions of the upper gastrointestinal (GI) tract. These are the primary areas dealt with in this slide kit.
  • Patients with dyspepsia may have underlying organic lesions Among patients diagnosed as having dyspepsia, 60–80% may have underlying organic lesions. Reflux esophagitis is frequently the most common such lesion, occurring in up to 1 in 4 dyspeptic patients. 23-25 In a group of 3667 primary care patients in the UK with a clinical diagnosis of dyspepsia, over 60% were subsequently diagnosed endoscopically as having an organic lesion, and over 20% of the dyspeptic patients had reflux esophagitis 25 . However, given the prevalence of dyspepsia, it is not feasible to refer all patients for endoscopy, and the physician has to make a decision on who should be treated empirically and who should receive further investigation.
  • Dyspepsia has been classified into subgroups based on medical history Dyspeptic patients have been divided into clinical subgroups based on their medical history to try to match symptoms with pathophysiological disturbances and thus enable rational prescribing. The subgroups include those with ulcer-like (typical ulcer symptoms), reflux-like (retrosternal and concomitant upper abdominal symptoms), dysmotility-like (symptoms suggestive of gastric stasis) and unspecified (those whose symptoms cannot be classified) dyspepsia 5 . For any individual patient, however, the symptom pattern may change over time 21 . In addition, considerable overlap exists between the subgroups and few patients exhibit symptoms exclusive to one particular group 3, 22 . For example, in an endoscopy-based study of patients diagnosed with dyspepsia, the prevalence of peptic ulcer disease was found to be similar among patients regardless of whether they had reflux-like (11%), ulcer-like (9%) or dysmotility-like dyspepsia (7%) 22 .
  • Functional dyspepsia is a diagnosis that can only be made after investigation. Patients with functional dyspepsia (non-organic dyspepsia) have undergone investigation, such as upper GI barium series or upper GI endoscopy, at which time an ulcer (an organic cause of the pain/discomfort) has not been observed. It is not necessary to investigate all patients with dyspepsia, but it is important to take a careful history to rule out the more obvious serious differential diagnoses.
  • Specialist investigation usually takes place after one or more therapeutic trials with antisecretory agents have been carried out in general practice. Endoscopy and biopsy is used to rule out possible organic causes for the pain.
  • Transcript of "Dispepsia"

    1. 1. An Evidence-based Approach to the Management of Uninvestigated Dyspepsia in the Primary Care Settings: an update
    2. 2. Dyspepsia: the size of the problem15–25% of the general population experiencedyspepsia within a 12-month periodMuch more common than peptic ulcerUp to 5% of primary care visits are due to dyspepsiaMost patients have no detectable abnormality onradiological upper GI series or endoscopyEndoscopy findings and symptoms do not correlate Talley, J Clin Gastroenterol 2001; 32: 286–93. Locke, Ballieres Clin Gastroenterol 1998; 12: 435–42. Paré, Can J Gastroenterol 1999; 13: 647–54. van Bommel et al., Postgrad Med J 2001; 77: 514–18. Talley et al., BMJ 2001; 323: 1294–7.
    3. 3. Dyspepsia covers a range of symptoms DYSPEPSIA GERD PAIN OR DISCOMFORT IBS centred in upper abdomen UNINVESTIGATED INVESTIGATED FUNCTIONAL ORGANIC (or idiopathic) (use of the term ‘non-ulcer’ is discouraged) Talley et al., Gut 1999; 45(Suppl II): II37–42.
    4. 4. Definition of dyspepsia (Rome II) Pain or discomfort occurringcentred in the upper abdomen Talley et al., Gut 1999; 45(Suppl II): II37–42. Malfertheiner, Eur J Gastroenterol Hepatol 1999; 11(Suppl 1): S25–9.
    5. 5. Gastritis Peptic ulcer disease (Includes NSAID-induced ulcers) Acid reflux Oesophagitis Strictures Barrett’s oesophagus Oesophageal adenocarcinoma DuodenitisDuodenal ulcer
    6. 6. Reflux esophagitis Normal 23.9% 33.6% 2% Cancer 19.9% 20.8% Peptic ulcer diseaseGastritis/duodenitis Richter 1991
    7. 7. Functional Dyspepsia (Rome I) Dysmotility-like 21 11 dyspepsia Ulcer-like (10%) (5%) dyspepsia 27 51 (13%) 7 (3%) (24%) 36 (17%) 10 (5%)Unspecified dyspepsia Reflux-like dyspepsian=50 (23%) Talley et al 1992
    8. 8. Definition of Functional Dyspepsia (Rome II) Twelve weeks or more (within the last 12 months) of persistent or recurrent dyspepsia and evidence that organic disease likely to explain the symptoms is absent (including at upper endoscopy) Dyspepsia subgroups ● Ulcer-like (predominantly pain) ● Dysmotility-like (predominantly discomfort) ● Unspecified (non-specific, no predominant symptom) Talley et al., Gut 1999; 45(Suppl II): II37–42. Malfertheiner, Eur J Gastroenterol Hepatol 1999; 11(Suppl 1): S25–9.
    9. 9. Definition of Functional Dyspepsia (Rome III)At least 3 months, with onset at least 6 monthspreviously, of 1 or more of the following:• Bothersome postprandial fullness• Early satiation• Epigastric pain• Epigastric burning And• No evidence of structural disease (including at upperendoscopy) that is likely to explain the symptoms
    10. 10. Functional dyspepsia:an exclusion diagnosis
    11. 11. Uninvestigated DyspepsiaPatient with new onset or recurrent dyspeptic symptoms in whom noinvestigation have been conductedand no specific diagnosis for the current symptoms exist Sander et al., CMAJ 2000; 162 (Suppl): S1–23
    12. 12. Uninvestigated dyspepsia vs functional dyspepsia Uninvestigated dyspepsia ● All symptomatic patients, regardless of whether a cause has been sought Functional dyspepsia ● Symptomatic patients in whom an organic cause has been sought and excludedTalley et al., Gut 1999; 45(Suppl II): II37–42.
    13. 13. Management ofuninvestigated dyspepsia
    14. 14. Uninvestigated Dyspepsia Consider : - Cardiac - Hepatobiliary (A) YES - Medication-induced Other possible causes ? - Dietary indiscretion - Other Treat as appropriateFirst Visit Sander et al., CMAJ 2000; 162 (Suppl): S1–23
    15. 15. RecommendationExclude other possible causes of the dyspeptic symptoms with thorough history-taking and physical examination Consider: cardiac and hepatobiliary sources  medication-induced symptoms  possible dietary indiscretion  lifestyle or other causes (grade C recommendation, consensus)
    16. 16. Uninvestigated Dyspepsia Consider : - Cardiac - Hepatobiliary (A) YES - Medication-induced Other possible causes ? - Dietary indiscretion No - Other (B) Age >50 or alarm features? Treat as appropriate - Vomiting - Bleeding anemia YES - Abdominal mass/ Investigate unexplained weight loss - Dysphagia (endoscopy recommended)First Visit Sander et al., CMAJ 2000; 162 (Suppl): S1–23
    17. 17. Older patients and with alarm features       America > 45 years Canada > 50 years Indonesia > 55 years Cancer is a rare cause of dyspeptic symptoms <2%
    18. 18.    Diagnostic test: endoscopy or radiography? Radiography : 70 % Endoscopy : 96 % Dooley et al., Ann Intern Med 1984; 101: 538-45
    19. 19. Specialist management of uninvestigated dyspepsiaEndoscopy with biopsies and treat accordingly! Talley et al., BMJ 2001; 323: 1294–7
    20. 20. Recommendation Prompt investigation is recommended for patients over 50 years of age with uninvestigated dyspepsia and for any patient presenting with alarm features Alarm features: persistent vomiting evidence of gastrointestinal bleeding or anemia  presence of an abdominal mass unexplained weight loss dysphagia (grade B recommendation, level III evidence) Endoscopy is the recommended method of investigation for patientswith uninvestigated dyspepsia who are over 50 years of age or who have alarm features (grade A recommendation, level II evidence)
    21. 21. Uninvestigated Dyspepsia Consider : - Cardiac - Hepatobiliary (A) YES - Medication-induced Other possible causes ? - Dietary indiscretion No - Other (B) Age >50 or alarm features? Treat as appropriate - Vomiting - Bleeding anemia YES - Abdominal mass/ Investigate unexplained weight loss - Dysphagia (endoscopy recommended)First Visit NO (C) YES NSAID and/or Regular ASA NSAID Management Use? Sander et al., CMAJ 2000; 162 (Suppl): S1–23
    22. 22.  Patients who use NSAIDs Hp infection is the most common cause of peptic ulcers NSAIDs are responsible for most Hp-negative ulcers
    23. 23. Recommendation Patients with uninvestigated dyspepsia who are regular users of NSAIDS (including ASA) should be identified, and if there are no alarm features,they can be managed without initial endoscopy (grade C recommendation, consensus)
    24. 24. NSAID and/or reguler ASA use YES Can NSAID/ASA Stop therapy be stopped? YES NO Patient improved? EndTreat or investigate NOa. PPIb. Cytoprotective agentc. High-dose H2-RAd. Switch to COX-2 inhibitor Sander et al., CMAJ 2000; 162 (Suppl): S1–23
    25. 25. Recommendation If possible, NSAID use should be stopped and the patient’s response monitored (grade C recommendation, level III evidence) If NSAIDs cannot be stopped the choice is to treat or investigateTreatment recommendations for patients aged 50 years or less whopresent with uninvestigated dyspepsia, who no alarm features andwho need to use NSAIDs (including ASA) are as follows:• PPI• Cytoprotective agent• High-dose H2–RA therapy(d) Consider switch to COX-2 inhibitor (grade C recommendation, consensus)
    26. 26. Uninvestigated Dyspepsia Consider : - Cardiac - Hepatobiliary (A) YES - Medication-induced Other possible causes ? - Dietary indiscretion No - Other (B) Age >50 or alarm features? Treat as appropriate - Vomiting - Bleeding anemia YES - Abdominal mass/ Investigate unexplained weight loss - Dysphagia (endoscopy recommended)First Visit NO (C) YES NSAID and/or Regular ASA NSAID Management Use? NO (D) YES Is dominant symptom heartburn and/or Treat as reflux regurgitation ? Sander et al., CMAJ 2000; 162 (Suppl): S1–23
    27. 27. Patients with dominant symptom of heartburn or acid regurgitation, or both Heartburn (89 %) or acid regurgitation (95 %) have high specificity for GERD Initial treatment can be started based on symptoms of reflux in primary care Most GERD patients do not have macroscopic esophagitis Endoscopy is not a useful diagnostic gold standard for GERD, nor 24-hour pH monitoring A reliable interpretation of the term heartburn is key for the diagnosis of GERD
    28. 28. Recommendation Patients aged 50 years or less with uninvestigated dyspepsia and dominant symptoms of heartburn or acid regurgitation, or both should be diagnosed as having GERD and be treated accordingly Rather than using the term “heartburn”, describing thesensation of “a burning feeling rising from your stomach or lower chest toward your neck” increases the diagnostic accuracy for GERD (grade B recommendation, level II-2 evidence)
    29. 29. Reflux mini-management schema Dominant symptom heartburn and/or regurgitation Treat a. PPI b. H2-RA c. Prokinetic Reassess at 4 weeks Symptoms YES Resolved? NOTreat- If not on PPI, switch to PPI x 4-8 weeks- If on PPI, double dose x 4-8 weeks or consider investigation Symptoms YES Stop therapy (if symptoms recur, resolved? repeat original therapy) NO Investigate Sander et al., CMAJ 2000; 162 (Suppl): S1–23
    30. 30.  Management of patients with GERD Five treatment possibilities for GERD - lifestyle modification - antacids - H2RAs - prokinetic - PPIs Review of lifestyle modification and antacids concluded that definitive evidence of efficacy is unavailable Milder symptoms of GERD may derive benefit from lifestyle modification
    31. 31. RecommendationThe effectiveness of lifestyle modifications and antacids for the treatment of GERD is not proven. Patient with mild GERD symptoms may derive benefit from these treatment (grade C recommendation, consensus)Treatment recommendations for patients with a dominant symptom of heartburn or acid regurgitation, or both, are as follows : • PPI (a) H2 – RA (b) Prokinetic agent (grade A recommendation, level I evidence)Patients should be reassessed after 4 weeks of therapy (grade C recommendation, consensus)
    32. 32. Uninvestigated Dyspepsia Consider : - Cardiac - Hepatobiliary (A) YES - Medication-induced Other possible causes ? - Dietary indiscretion No - Other (B) Age >50 or alarm features? Treat as appropriate - Vomiting - Bleeding anemia YES - Abdominal mass/ Investigate unexplained weight loss - Dysphagia (endoscopy recommended)First Visit NO (C) YES NSAID and/or Regular ASA NSAID Management Use? NO (D) YES Is dominant symptom heartburn and/or Treat as reflux Regurgitation ? NO (E) YES Hp test positive? 1. UBT Treat as Hp positive 2. Serology
    33. 33. Hp test and treat strategy Hp infection is associated with - duodenal ulcer 90 – 95 % - gastric ulcer 60 – 80 % - gastric cancer Uncertainty as to whether Hp plays a role in dyspepsia in the absence of ulcers Option for the treatment of younger patients w/o alarm features: - trial of empiric (antisecretory or prokinetic) - diagnostic evaluation - non invasive testing for Hp followed by eradication therapy for patients w/ (+)ve results - non invasive testing for Hp followed by endoscopy for patients w/ (+)ve results
    34. 34. RecommendationA test-and-treat strategy for uninvestigated dyspepsia in younger patient (aged 50 years or less) who have no alarm features is recommended (grade B recommendation, level I evidence)
    35. 35.  Testing for Hp infection Infection can be detected by: - invasive (endoscopy based) - non invasive (UBT, HPSA or serologic testing) Serologic testing cannot be used to determine cure as the IgG antibodies remain detected for a long time after eradication UBT has a high (+)ve and (-)ve predictive value (both > 95 %) Gisbert et al. Aliment Pharmacol Ther 2004;20:1001–17
    36. 36. Recommendation Noninvasive methods are recommendedfor the detection of H. pylori in patient aged 50 years or less with uninvestigated dyspepsia who have no alarm features Hp stool antigen is the preferred test (grade B recommendation, level II-2 evidence)
    37. 37. Recommendation  No more serology  Stool antigen is the recommended test  Test with stool antigen before prescribing PPIs do not have alarm symptoms have not been using NSAIDS who are not > 55 yrs (AGA guidelines from 2005)
    38. 38. H. Pylori positive mini-management schema Patient Hp positiveEradicate Hp:a. PPI + AC or MC or RBC + AC or MC (bid x 7 days)b. Alternative first line therapyc. PPI + BMT (bid x 14 days)(advise patient to return 4 weeks aftertreatment if symptoms recur or persist) YES Symptoms No further therapy resolved at follow up? or investigation NO Confirm Hp eradication by UBT or histology (not serology) YES Hp eradicated? Treat as Hp negative NO Switch regimen and retreat or refer for investigation Sander et al., CMAJ 2000; 162 (Suppl): S1–23
    39. 39. Hp eradication therapy (a) First line therapy PPI + AC or PPI + MC (bid for 7 days) or ranitidine bismuth citrate + AC or MC • Alternative first-line therapy• PPI + BMT (14-day quadruple regimen) PPI (bid) B (4x2 tablets/day) M (4x250 mg/day) T (4x500 mg/day) PPI = Lansoprazole 30 mg; Omeprazole 20 mg; Pantoprazole 40 mg A = Amoxicillin 1000 mg B = Bismuth subsalicylate (2 tablets) C = Clarithromycin 250 (or 500 mg if treatment failure) M = Metronidazole 500 mg (250 mg in BMT combination therapy) T = Tetracyclin 500 mg Sander et al., CMAJ 2000; 162 (Suppl): S1–23
    40. 40. RecommendationEradication therapies recommended for patientswith uninvestigated dyspepsia who are foundto be H. pylori positive are as follow:• PPI + AC or MC, or ranitidine bismuth citrate + AC or MC• Alternative first-line therapy(c) PPI + BMT PPI = Lansoprazole 30 mg; Omeprazole 20 mg; Pantoprazole 40 mg A = Amoxicillin 1000 mg B = Bismuth subsalicylate (2 tablets) C = Clarithromycin 250 (or 500 mg if treatment failure) M = Metronidazole 500 mg (250 mg in BMT combination therapy) T = Tetracyclin 500 mg (grade A recommendation, level I evidence)
    41. 41. A meta-analysis of short versus long therapy with a PPI, clarithromycin and either metronidazole or amoxicillin for treating Hpinfection A meta-analysis of 13 studies: Eradication rate for 14-day therapy vs 10-day therapy was 81% (95% CI, 77%–85%) vs 72% (95% CI, 68%–76%) The eradication rate for 10-day therapy vs 7-day therapy: 83% (95% CI, 75%–89%) vs 80% (95% CI, 71%–86%) Calvet et al. Aliment Pharmacol Ther 2000;14:603–609
    42. 42. Meta-analysis:duration of first-line PPI-based triple therapy for Helicobacter pylori eradication Extending triple therapy beyond 7 days is unlikely to be a clinically useful strategy Fuccio et al. Ann Intern Med. 2007;147(8):553-62
    43. 43. Pantoprazole based therapies in HP eradication: a systematic review and meta-analysis Pantoprazole achieves similar cure rates to those of omeprazole and lansoprazole when co-prescribed with antibiotics Eur J Gastroenterol. 2004;16: 89-99   
    44. 44. Uninvestigated Dyspepsia Consider : - Cardiac - Hepatobiliary (A) YES - Medication-induced Other possible causes ? - Dietary indiscretion No - Other (B) Age >50 or alarm features? Treat as appropriate - Vomiting - Bleeding anemia YES - Abdominal mass/ Investigate unexplained weight loss - Dysphagia (endoscopy recommended) First Visit NO (C) YES NSAID and/or NSAID Management Regular ASA Use? NO (D) YES Is dominant symptom heartburn and/or Treat as reflux Regurgitation ? NO NO (E) YESTreat as Hp Negative Hp test positive? Treat as Hp positive 1. UBT 2. Serology Sander et al., CMAJ 2000; 162 (Suppl): S1–23
    45. 45. H. Pylori negative mini-management schema Patient Hp negative Treat x 4 weeks a. PPI b. H2-RA c. Prokinetic YES Symptoms resolved? NO Modify therapy(increase dose or switch to another therapy) YES Symptoms resolved? Stop NO therapy Reassess or investigate/refer Sander et al., CMAJ 2000; 162 (Suppl): S1–23
    46. 46. Recommendation There is good evidence that antacids are ineffectivefor functional dyspepsia, and they are not recommended for the treatment of uninvestigated dyspepsia in patients subsequently found to be H. Pylori negative (grade B recommendation, level I evidence)
    47. 47. RecommendationTreatment recommendation for patients who presentwith uninvestigated dyspepsia and who subsequentlyhave negative results of testing for H. Pylori are as follows:(a) PPI(b) H2-RA(c) Prokinetic agent (grade B recommendation, level I evidence)
    48. 48. Summaries Clinical management tool consists of 5 key steps in the evaluation of patients with uninvestigated dyspepsia The tool includes 4 mini-management schemata The tool is practical, easy to use, explicit and concise, and it reflects the realities of the primary care setting Adoption of this tool will optimize the treatment of patients with dyspepsia, improve quality of care and be cost-effective
    49. 49. PRIMARY MANAGEMENT OF NEW ONSET UNINVESTIGATED DYSPEPSIA IN INDONESIA EXCLUDE BY HISTORY : IF < 2 – 4 WKS. DYSPEPSIA DIETARY ADVICE, OBSERVE BILLIARY PAIN,IRRITABLE BOWEL, REFLUX REVIEW CURRENT MEDS. AGE > 55 YRS AGE > 55 YRSWITHOUT ALARM FEATURES WITH ALARM FEATURES :  SEVERE VOMITING  FEVER TREATMENT TRIAL : 2 WKS SUCCESS  HEMATEMESIS / MELENA  ANTACIDS  ANTISECRETORY  ICTERUS  ↓ BW  PROKINETICS  NSAIDs FOLLOW UP  STRONG FEAR OF SERIOUS DIS. FAILURE OR EARLY RELAPSE  FAMILY HISTORY : GASTRIC CA. RELAPSE SEROLOGIC Hp TESTING SPECIALIST REFFERAL :  GASTROENTEROLOGIST NEG. POS.  INTERNAL MED./PED. WITH ENDOSCOPIC FACILITIES FINAL EVALUATION AFTER 8 WKS > 3 X RELAPSE
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