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Family Medicine Seminar




Dyspepsia
Let’s GO


   Case    Approach                 Knowledge
   Study




              If you Don’t know it, you will Not see it
Case Study



             As a family physician
Family Physician
Family Medicine


                  • Consultation in family
                    medicine practice
                  • To establish rapport
                    with the patient
                  • To find out risk factors
                  • To find out possible
                    cause
                  •
Hello
Hi Doc !
                                                           Ahmed !




            Prepare the setting
Establish
            Introduce yourself, call by name , smile , hand shaking
Rapport
            Verbal / non-verbal
Hello
Hi Doc !
                                                      Ahmed !




           Empathy
           Respect
Show as
           Confidentiality
possible
           Eye contact
           Silence and understanding of the patient
Mr. Ahmed
• 40 yrs old
• Saudi
• From Abha
• Father of 4 children
• Teacher
What's
  I don’t
                                    Wrong
feel good
                                   with you
  doctor
                                   Ahmed ?




Presenting   What do you mean ??
complaint    Tell me more
pain
•   Intermittent
•   6 months
•    epigastric
•   Retrosternal burning
    sensation

Regurgitation

Nausea
Let me ask
  OK                           you few
 doctor                       questions
                                Ahmed




Analysis   Bio-Psych-Social
Bio-Psych-Social



Bio      6-month history of intermittent upper gastrointestinal symptoms. He describes
         an epigastric and retrosternal burning sensation but finds it difficult to decide
         in which of these areas symptoms are predominant. He occasionally notices
         regurgitation and feels nauseated. Eating, swallowing, postural change, or
         exercise do not influence her symptoms. Antacids provide some relief.
         Unremarkable past history and family history.
Psycho   He feels unwell but the pain does not affect his life or his sleeping frequently
Social   He is smoker for >15 years , school teacher and a father of 4 children
Acute GI bleeding
       Progressive weight loss
Persistent vomiting
IDA
Epigastric mass
Progressive dysphagia
I don’t                                 What do
think it is                              you think
   bad                                  you have ?




ICEE          Idea/Concern/Expectation/Effect
OK Ahmed,
              May I examine
Sure doctor
               you please
On Examination :
Was vitally stable
Obese: BMI= 32
No signs of anemia
No jaundice
Abdomen is soft and lax and
not distended
No abdominal mass
No abdominal tenderness
Let’s GO


   Case    Approach                 Knowledge
   Study




              If you Don’t know it, you will Not see it
Approach



           What Do you Think Ahmed Has ???
History:

   • Complaint:
      – Epigastric pain.


   • Analysis of complaint:
      –    Onset.
      –    Duration.
      –    Nature, quality.
      –    Radiation.
      –    Course.
      –    Aggravating & relieving factors.
Risk factor and History




  • Past medical Hx:
     – Previous ulcer, GI bleed
     – DM, hypo/hyperthyroidism, parathyroid dis.
     – Colitis, diverticulosis, liver disease
     – Previous Upper GI series, OGD, Abdo U/S
     – Anxiety, stress, depression.
Risk factor and History
 Drug Hx:
- iron, NSAIDs, bisphosphonates, antibiotics, etc.

Life style Hx:
•   Diet (fatty, big meals)
•   Smoking
•   Alcohol use
•   Exercise
• Family Hx:
Analysis                    Bio-Psych-Social

• Psychosocial:
• Ideas      - Ideas and beliefs of the patient towards his illness
• Concern - Patient might think that this complaint is due to cancer, ulcer
  or other serious disease, he might also feel concern that he could not
  work because of this problem.
• Expectations:
• Patient may expect any of the following:
• Reassurance
• Investigation, endoscopy - Barium meal
• Peferral
• Sick leave
Risk factor and History
• Effect on life:
   – You need to explore the effect of this problem on his
     family, work, etc.


• Depression, anxiety and stress:
   – Screen your patient for depression, anxiety and stress
     and go in details when needed.


• Supporting system:
   – Sources of support at home, work, friends, community.
• Vital signs:                 • Signs anemia
  Weight                          – Brittle nails
  Height.                         – Cheilosis
  Blood Pressure.                 – Pallor palpebral mucosa or
  Pulse.                            nail beds
  Respiratory rate,
  Temperature .                • Other
                                  – Teeth (loss enamel)
                                  – Lymphadenopathy -
                                    Virchow’s node
Respiratory & Cardiovascular      – Acanthosis nigrans
  Examination.                    – Hypo/Hyperthyroid
• Abdominal Examination:
   – Epigastric tenderness
   – Palpable mass
   – Distention
   – Colon tenderness
   – Jaundice
   – Murphy’s sign
   – Stool for OB
   – Hernia
Let’s GO


   Case    Approach                 Knowledge
   Study




              If you Don’t know it, you will Not see it
Knowledge
Dyspepsia...
It is a group of
        symptoms
    characterized by
   upper abdominal
       discomfort,
   retrosternal pain,
 vomiting, heartburn,
   upper abdominal
  fullness and feeling
    full earlier than
expected when eating.
Prevalence:


  Surveys carried out in western countries
  reported that:
  between 23-41%. Only 25% of dyspeptic
  populations visit their own doctors (About 4%
  of G.P.)
  Only 10% of the patients with dyspepsia are
  referred to hospital .
Differential Diagnosis:




           Functional     Organic
            50 – 70%      30 – 40%
•Medications (ASA/NSAIDS, Abx)
                                     •Gastroparesis
               Peptic                •Cholelithiasis, Choledocholithiasis
              Ulcer 5-
                21%                  •Pancreatitis (acute or chronic)
                          Gastric    •Carbohydrate malabsorption
Esophagitis
                         cancer 1-
  0-18%                              •Ischemic bowel
                            3%
                                     •Other GI malignancy (ep. Pancreatic
              Organic                cancer)
                                     •Systemic disease
                                     (DM, Thyroid, Parathyroid, CTD)
                                     •Intestinal parasite
Risk Factors:


  Obesity.

  Smoking.

  Anxiety, depression.

  Fatty meal.

  Junk food.
functional Dyspepsia...
Functional 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).
Pathophysiology


• The pathophysiology of dyspepsia is not well
  understood.

• Researchers have focused on several key
  factors:
  – (Motility Disorders) vs .( Nonmotility Disorders).
  – Psychosocial factors.
Abnormal Fundic Relaxation in Response
      to Meal in Functional Dyspepsia




       Normal                              Fundic
                                           accommodation
                                           or receptive
                                           relaxation

Meal


                                     Impaired fundic
                                     accommodation
Functional                           with a redistribution of
dyspepsia                            food to antrum
Stress
 Behavioural
 Factors




Local Factors:
Gastritis
H. pylori infection


                      Abnormal Motility
                 • Decreased antral motility
                 • Impaired fundal relaxation
NONMOTILITY DISORDERS


• with motility disorders, there is little correlation
  between symptoms and severity of duodenitis, and
  no relationship between treatment and
  improvement of mucosal appearance on endoscopy.

• One of the most prevalent theories currently being
  evaluated is the possible involvement of H. pylori
  infection in non-ulcer dyspepsia (as in ulcer disease).
PSYCHOSOCIAL FACTORS


  • Patients with nonulcer dyspepsia are more likely to have symptoms of
    anxiety and depression than are healthy persons or patients with
    ulcers.


  •   Multiple somatic complaints also are more common in patients who
      have nonulcer dyspepsia.


  • A history of child abuse has been linked to the symptoms of nonulcer
    dyspepsia.


  •   Stress from life events also has been correlated with these symptoms
      and has been linked to exacerbations of nonulcer dyspepsia.
Investigations
Specific investigations
- Depend on expected cause:
• Usually we use the invasive procedure (endoscopy)
   to exclude the serious causes epically with patents
   have alarm symptoms:

• Alarm symptoms:
   –    Age > 45
   –   Weight loss
   –   Bleeding
   –   Palpable mass
   –   Dysphagia
Specific investigations


• Peptic ulcer disease :
  – Hx : Past history of ulcers, NSAIDs, Smoking.
  – Dx: Endoscopy (0.99 specificity)

• Gastric ulcer or Duodenal ulcer :
• Dx : Endoscopy (0.98 specificity)
Specific Investigations:

• Gastroesophygeal reflux ( GERD):
  – Hx : Heartburn or regurgitation symptoms, aggravated
    when supine, chronic cough
  Dx:
  – Omeprazole Test (0.89 specificity)
  – Endoscopy.
  – 24 Hrs PH – monitoring

  ,
Specific investigations

  Gastric Cancer:
      – Hx .Older (>50),unexplained wt. loss, dysphagia,
        smoker
       Dx : Endoscopy

  Helicobacter pylori infection :
  -   Urea breath test.
  -   Stool antigen test.
  -   Serum IGg antibody test.
  -   Whole- blood antibody test .
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
MANGEMENT




management
Management:


• Clarification; Explanation:

  – Nature of the problem.

  – What is ulcer & non-ulcer dyspepsia.

  – Prognosis:
     • Ulcer dyspepsia can be treated effectively.
     • Non-ulcer remains recurrent since the cause is unclear.
Management:


• Reassure:

• Advice:
  –   Quit smoking
  –   Stop / reduce caffeine
  –   Stop / reduce EtOH
  –   Hold medications associated w/ dyspepsia
  –   NSAIDS, ASA
  –   Avoid foods and other factors precipitate symptoms
  –   Better eating habits.
Management:



•Prescription:
Gastroesophegeal reflux diseas GERD:



           2- Proton
             pump
           inhibitor (
              PPI)
                              1- Histamine -2
                                  receptor
                             antagonist ( H2RR
                                      )




             Normal dose for 2-4 wks and follow up.
Helicobacter pylori eradication
• Regimen A:

                                   Clarithromyc
              PPI    Amoxicillin
                                         in




 - Duration: 2 weeks and follow up.
 - 50% have mild side effect .
 - 0.1 – 0.5% have pseudomembranous colitis.
In Saudi Arabia:
According to the latest studies :

1- clarithromycin 500mg BID – 10 days                                        clarithromycin   500mg BID – 10 days
2- amoxicillin 1000mg BID – 10 days
3- omeprazole 20mg BID – 6/52




                                        1000mg BID – 10 days   amoxicillin




                                                                              omeprazole      20mg BID – 6/52
Regimen B:


1- Bismuth subsalicylate ( 2 tablets 4 times /day)
2- Metronidazole. ( 250 mg 4 times /day)
3- tetracyclin ( 500 mg 4 times /day)
4- H2RR (normal dose ) or PPI ( high dose ).
- Duration : 2 weeks and follow up.
Peptic ulcer ( H.Pylori negative )


- H2RR or PPI :
For duodenal ulcer : normal dose .
For gastric ulcer : H2RR normal dose or double.

Duration : 4 - 8 weeks and follow up.
Treatment of functional Dyspepsia




• Reassure.
• Modify Life style and avoid risk factor .
• Psycho social Hx ( screen for depression )
• Prescribe non pharmacological and
  pharmacological treatment.
• Observation and follow up .
Functional dyspepsia


  - H2RR or PPI ( normal dose).
  - Duration : 4 weeks and follow up.
Prevention:



 •   Lifestyle modification. (eating habits),
 •   Psychosocial state: screen for depression.
 •   Stop smoking,
 •   Regular exercises.
 •   Avoid irrational use of NSAIDs.
The End…

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Dyspepsia

  • 2. Let’s GO Case Approach Knowledge Study If you Don’t know it, you will Not see it
  • 3. Case Study As a family physician
  • 5. Family Medicine • Consultation in family medicine practice • To establish rapport with the patient • To find out risk factors • To find out possible cause •
  • 6. Hello Hi Doc ! Ahmed ! Prepare the setting Establish Introduce yourself, call by name , smile , hand shaking Rapport Verbal / non-verbal
  • 7. Hello Hi Doc ! Ahmed ! Empathy Respect Show as Confidentiality possible Eye contact Silence and understanding of the patient
  • 8. Mr. Ahmed • 40 yrs old • Saudi • From Abha • Father of 4 children • Teacher
  • 9. What's I don’t Wrong feel good with you doctor Ahmed ? Presenting What do you mean ?? complaint Tell me more
  • 10. pain • Intermittent • 6 months • epigastric • Retrosternal burning sensation Regurgitation Nausea
  • 11. Let me ask OK you few doctor questions Ahmed Analysis Bio-Psych-Social
  • 12. Bio-Psych-Social Bio 6-month history of intermittent upper gastrointestinal symptoms. He describes an epigastric and retrosternal burning sensation but finds it difficult to decide in which of these areas symptoms are predominant. He occasionally notices regurgitation and feels nauseated. Eating, swallowing, postural change, or exercise do not influence her symptoms. Antacids provide some relief. Unremarkable past history and family history. Psycho He feels unwell but the pain does not affect his life or his sleeping frequently Social He is smoker for >15 years , school teacher and a father of 4 children
  • 13. Acute GI bleeding Progressive weight loss Persistent vomiting IDA Epigastric mass Progressive dysphagia
  • 14. I don’t What do think it is you think bad you have ? ICEE Idea/Concern/Expectation/Effect
  • 15. OK Ahmed, May I examine Sure doctor you please
  • 16. On Examination : Was vitally stable Obese: BMI= 32 No signs of anemia No jaundice Abdomen is soft and lax and not distended No abdominal mass No abdominal tenderness
  • 17. Let’s GO Case Approach Knowledge Study If you Don’t know it, you will Not see it
  • 18. Approach What Do you Think Ahmed Has ???
  • 19. History: • Complaint: – Epigastric pain. • Analysis of complaint: – Onset. – Duration. – Nature, quality. – Radiation. – Course. – Aggravating & relieving factors.
  • 20. Risk factor and History • Past medical Hx: – Previous ulcer, GI bleed – DM, hypo/hyperthyroidism, parathyroid dis. – Colitis, diverticulosis, liver disease – Previous Upper GI series, OGD, Abdo U/S – Anxiety, stress, depression.
  • 21. Risk factor and History Drug Hx: - iron, NSAIDs, bisphosphonates, antibiotics, etc. Life style Hx: • Diet (fatty, big meals) • Smoking • Alcohol use • Exercise • Family Hx:
  • 22. Analysis Bio-Psych-Social • Psychosocial: • Ideas - Ideas and beliefs of the patient towards his illness • Concern - Patient might think that this complaint is due to cancer, ulcer or other serious disease, he might also feel concern that he could not work because of this problem. • Expectations: • Patient may expect any of the following: • Reassurance • Investigation, endoscopy - Barium meal • Peferral • Sick leave
  • 23. Risk factor and History • Effect on life: – You need to explore the effect of this problem on his family, work, etc. • Depression, anxiety and stress: – Screen your patient for depression, anxiety and stress and go in details when needed. • Supporting system: – Sources of support at home, work, friends, community.
  • 24. • Vital signs: • Signs anemia Weight – Brittle nails Height. – Cheilosis Blood Pressure. – Pallor palpebral mucosa or Pulse. nail beds Respiratory rate, Temperature . • Other – Teeth (loss enamel) – Lymphadenopathy - Virchow’s node Respiratory & Cardiovascular – Acanthosis nigrans Examination. – Hypo/Hyperthyroid
  • 25. • Abdominal Examination: – Epigastric tenderness – Palpable mass – Distention – Colon tenderness – Jaundice – Murphy’s sign – Stool for OB – Hernia
  • 26. Let’s GO Case Approach Knowledge Study If you Don’t know it, you will Not see it
  • 29. It is a group of symptoms characterized by upper abdominal discomfort, retrosternal pain, vomiting, heartburn, upper abdominal fullness and feeling full earlier than expected when eating.
  • 30.
  • 31. Prevalence: Surveys carried out in western countries reported that: between 23-41%. Only 25% of dyspeptic populations visit their own doctors (About 4% of G.P.) Only 10% of the patients with dyspepsia are referred to hospital .
  • 32. Differential Diagnosis: Functional Organic 50 – 70% 30 – 40%
  • 33. •Medications (ASA/NSAIDS, Abx) •Gastroparesis Peptic •Cholelithiasis, Choledocholithiasis Ulcer 5- 21% •Pancreatitis (acute or chronic) Gastric •Carbohydrate malabsorption Esophagitis cancer 1- 0-18% •Ischemic bowel 3% •Other GI malignancy (ep. Pancreatic Organic cancer) •Systemic disease (DM, Thyroid, Parathyroid, CTD) •Intestinal parasite
  • 34. Risk Factors: Obesity. Smoking. Anxiety, depression. Fatty meal. Junk food.
  • 36. Functional 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).
  • 37. Pathophysiology • The pathophysiology of dyspepsia is not well understood. • Researchers have focused on several key factors: – (Motility Disorders) vs .( Nonmotility Disorders). – Psychosocial factors.
  • 38. Abnormal Fundic Relaxation in Response to Meal in Functional Dyspepsia Normal Fundic accommodation or receptive relaxation Meal Impaired fundic accommodation Functional with a redistribution of dyspepsia food to antrum
  • 39. Stress Behavioural Factors Local Factors: Gastritis H. pylori infection Abnormal Motility • Decreased antral motility • Impaired fundal relaxation
  • 40. NONMOTILITY DISORDERS • with motility disorders, there is little correlation between symptoms and severity of duodenitis, and no relationship between treatment and improvement of mucosal appearance on endoscopy. • One of the most prevalent theories currently being evaluated is the possible involvement of H. pylori infection in non-ulcer dyspepsia (as in ulcer disease).
  • 41. PSYCHOSOCIAL FACTORS • Patients with nonulcer dyspepsia are more likely to have symptoms of anxiety and depression than are healthy persons or patients with ulcers. • Multiple somatic complaints also are more common in patients who have nonulcer dyspepsia. • A history of child abuse has been linked to the symptoms of nonulcer dyspepsia. • Stress from life events also has been correlated with these symptoms and has been linked to exacerbations of nonulcer dyspepsia.
  • 43. Specific investigations - Depend on expected cause: • Usually we use the invasive procedure (endoscopy) to exclude the serious causes epically with patents have alarm symptoms: • Alarm symptoms: – Age > 45 – Weight loss – Bleeding – Palpable mass – Dysphagia
  • 44. Specific investigations • Peptic ulcer disease : – Hx : Past history of ulcers, NSAIDs, Smoking. – Dx: Endoscopy (0.99 specificity) • Gastric ulcer or Duodenal ulcer : • Dx : Endoscopy (0.98 specificity)
  • 45. Specific Investigations: • Gastroesophygeal reflux ( GERD): – Hx : Heartburn or regurgitation symptoms, aggravated when supine, chronic cough Dx: – Omeprazole Test (0.89 specificity) – Endoscopy. – 24 Hrs PH – monitoring ,
  • 46. Specific investigations Gastric Cancer: – Hx .Older (>50),unexplained wt. loss, dysphagia, smoker Dx : Endoscopy Helicobacter pylori infection : - Urea breath test. - Stool antigen test. - Serum IGg antibody test. - Whole- blood antibody test .
  • 47. 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
  • 49. Management: • Clarification; Explanation: – Nature of the problem. – What is ulcer & non-ulcer dyspepsia. – Prognosis: • Ulcer dyspepsia can be treated effectively. • Non-ulcer remains recurrent since the cause is unclear.
  • 50. Management: • Reassure: • Advice: – Quit smoking – Stop / reduce caffeine – Stop / reduce EtOH – Hold medications associated w/ dyspepsia – NSAIDS, ASA – Avoid foods and other factors precipitate symptoms – Better eating habits.
  • 52. Gastroesophegeal reflux diseas GERD: 2- Proton pump inhibitor ( PPI) 1- Histamine -2 receptor antagonist ( H2RR ) Normal dose for 2-4 wks and follow up.
  • 53. Helicobacter pylori eradication • Regimen A: Clarithromyc PPI Amoxicillin in - Duration: 2 weeks and follow up. - 50% have mild side effect . - 0.1 – 0.5% have pseudomembranous colitis.
  • 54. In Saudi Arabia: According to the latest studies : 1- clarithromycin 500mg BID – 10 days clarithromycin 500mg BID – 10 days 2- amoxicillin 1000mg BID – 10 days 3- omeprazole 20mg BID – 6/52 1000mg BID – 10 days amoxicillin omeprazole 20mg BID – 6/52
  • 55. Regimen B: 1- Bismuth subsalicylate ( 2 tablets 4 times /day) 2- Metronidazole. ( 250 mg 4 times /day) 3- tetracyclin ( 500 mg 4 times /day) 4- H2RR (normal dose ) or PPI ( high dose ). - Duration : 2 weeks and follow up.
  • 56. Peptic ulcer ( H.Pylori negative ) - H2RR or PPI : For duodenal ulcer : normal dose . For gastric ulcer : H2RR normal dose or double. Duration : 4 - 8 weeks and follow up.
  • 57. Treatment of functional Dyspepsia • Reassure. • Modify Life style and avoid risk factor . • Psycho social Hx ( screen for depression ) • Prescribe non pharmacological and pharmacological treatment. • Observation and follow up .
  • 58. Functional dyspepsia - H2RR or PPI ( normal dose). - Duration : 4 weeks and follow up.
  • 59. Prevention: • Lifestyle modification. (eating habits), • Psychosocial state: screen for depression. • Stop smoking, • Regular exercises. • Avoid irrational use of NSAIDs.