1. Mr. Al-Momtan, a 56-year-old male, presented with epigastric abdominal pain for 2 weeks which was worse after eating. Clinical exams and tests diagnosed him with a peptic ulcer disease. 2. He was prescribed a triple therapy of antibiotics and a PPI for 3 weeks to treat his condition. 3. Dyspepsia is a common gastrointestinal condition with many potential causes including non-ulcer dyspepsia, GERD, peptic ulcers, and H. pylori infection. Guidelines recommend lifestyle changes, antacids, and empirical PPI therapy as first-line treatment options.

1. An approach to Dyspepsia Al-Momtan, Ahmed Tahir C-2

2. Case Presentation

3. P/P and HPI Mr. Al-Momtan, Tahir Abdullah is a 56 year old male who presented to our clinic with epigastric abdominal pain x 2 weeks. He describes it as a burning pain which is non-radiating and is worse after he eats. He has frequent belching with bloating sensation but denies nausea, vomiting, diarrhea, constipation, or weight loss. He has tried epicogel ® found to be composed of ( Each 5 ml contains Dried aluminium hydroxide gel 405 mg, Magnesium hydroxide 100 mg, Dimethicone 125 mg) in which he claimed, “helps a little”.

4. Mr Al-Momtan History PMH: HTN stable diagnosed 4 years ago, Osteoarthritis in knees, treated for an ulcer 3 years ago Meds: Hydrochlorothiazide 25 mg twice daily, ibuprofen 400 mg X 4 times daily Soc HX: Married, worked in his local municipal a civil engineer and now a Manager of a private business, drinks 2-4 cups coffee per day, no Hx of alcohol intake or smoking.

5. Mr. Al-Momtan Physical Exam VS: BP 137/82, HR 85, afeb, RR 14 HEENT: conjunctiva pink, clear OP MMM Heart: RRR no M/R/G ABD: Soft, NABS, mild-moderate epigastric TTP, no HSM or masses, no acute abd signs Skin: no pallor Rectal: stool brown, heme (-), no masses

6. Mr. Tahir Prior Ulcer History On further questioning Mr. Al-Momtan states he had similar abdominal pain three years ago and was told by his physician at that time that it was most likely due to an “ulcer”. He took “the purple pill” for a month and his symptoms resolved. He had no definitive diagnostic tests done at that time.

7. Diagnosed From his clinical Hx and PE plus CBC, Urea breath test were done for him, the patient was diagnosed to have a PUD. Given an appointment for Upper GI endoscopy but he refused.

8. Treatment Sent home, Started on Tripple therapy composed of 2 antibiotics and a PPI: Clarythromycine 500 mg PO bid for 2 weeks Metronidazole 500 mg PO bid for 2 weeks Lansoprazole 30 mg PO bid for 3 weeks Asked to visit the clinic 4 weeks later..

9. Objectives To review some common causes • To review the evidence based management strategies • What to treat & when to to refer safely & effectively ??

10. Definition Group of symptoms consisting mostly upper abdominal or epigastric pain or discomfort, heartburn, or acid regurgitation.Often associated with belching, bloating, nausea or vomiting

11. INTRODUCTION • Dyspepsia • 40% of adult population / year, 2% consult their GPs • Substantial health care cost: - - - Medication Diagnostic evaluation Time cost from work • Out of 100 pts. 90% will be pain free after 2-3 wks without Rx • Definitive established guideline (NICE) • H.pylori & PUD – well accepted & confirmed

12. 5 common causes of dyspepsia 1- NUD. 2- GORD 3- Gastritis 4- Gastric Ulcer. 5- Doudenal Ulcer Rare causes Gastic and oesophageal CA.

13. Less common causes of upper abdominal pain Aerophagy. Biliary colic Abdominal wall pain Malignancy Mesenteric vascular insuffeciency Angina Metabolic disease

14. Drugs associated with dyspepsia NSAIDs Iron. Metformin Codiene Antibiotics Orlistat Corticosteroids theophyllin Digoxin. Colchicine Alendronate. Nitrates Quinidine Gemfibrozil ,,,,

15. 5 common Diagnoses 1- NUD (non-ulcer dyspepsia) most common cause. Younger age group more than later life. Causes? GI motility? Gastric secretion  normal Presence of H-pylori. Incidence decrease with advancing age.

16. Pathophysiology Functional dyspepsia

17. T/T of functional dyspepsia Initial treatment • Diet , beverages, smoking • Antisecretory drug (H2RAs, PPI) or • Prokinetic drug (domperidone) if antisecretory treatment fails • Switch treatment if first drug type fails Stats,, • Systematic review (98 randomised controlled trials) The Cochrane Library, Issue 1, 2005. : • RRR = 48% in the Prokinetics group compared to placebo. • RRR = 22%; in the H2RAs group • RRR = 14%; in PPI group • Antacid & bismuth effects were not statically significant

18. NICE flowchart (functional dyspepsia)

19. Cont. T/T of functional dyspepsia Resistant cases (failed initial treatment) : • H.pylori eradication • Sucralfate or bismuth • Antispasmodic agent( such as mebeverine) • Antidepressant (such as SSRI or tricyclic drug) • Behavioural therapy or psychotherapy • No treatment is proved tobe fully beneficial in these patients. stats: • Systematic review (17 randomised controlled trials) The Cochrane Library, Issue 1, 2005. : • RRR= 8% in the H pylori eradication group (95% CI = 3% to 12%) compared to placebo. NNT to cure one case of dyspepsia = 18

20. 5 common Diagnoses 2- GORD (Gastroesophageal reflux disease) • Very common • Heartburn , Sharp stabbing sub-sternal pain (probability :89%) • Regurgitation (probability :95%) • At night or after heavy meal • Chronic cough, asthma like wheezing • MI ??

21. GORD, Cont.

22. GORD, Cont. Weakness or incompetence of lower esophageal sphincter Esophagitis, esophageal structure Barret’s esophagus • Dx: Hx,PPI test, 24 hours pH manometer!,,Endoscopy?? Lifestyle modification?? • Medication: Antacid Antisecretory drug: H2 receptor blocker proton pump inhibitor (2months) • Prokinetics Surgery: Laproscopic fundoplication or open? Dx and Management

23. 5 common Diagnoses 3- PUD (Peptic ulcer disease) • Less than before • P/H ulcer, recurrence more likely • Risk factors include: -H-pylori -Family Hx -NSAID -Cigarette smoking -Chronic renal failure -Blood group “O”

24. complications Weakness or incompetence of lower esophageal sphincter Esophagitis, esophageal structure Barret’s esophagus Diagnostic Difficulties Not text book presentation Early presentation History: 1.ALARM symptoms ?? 2.Specific symptoms 3.NUD MI ?? NSAID Smoking

25. ALARM Symptoms! ALARM! • A norexia • L oss of weight (progressive & unintentional) • A naemia due to iron deficiency • R ecent onset of persistent symptoms :vomiting • M elaena, haematemesis • Dysphagia (progressive) • Epigastric mass or • Suspicious barium meal.

26. General Management 1.Management of symptoms in primary care is appropriate for most patients rather than routinely seeking a pathological diagnosis. 2.Alarm signals and signs are the major determinant of the need for endoscopy, not age on its own. 3.Long term care should emphasize patient empowerment with ‘on demand’ use of the lowest effective dose PPI.

27. Cont. General Management • Simple lifestyle advice: healthy eating, weight reduction, smoking cessation • Offer empirical antacid,H2Aor PPI therapy for one month to patients with dyspepsia.

28. H. Pylori Gram–ve, flagellated spiral Casually related to: GU DU Gastritis Gastric B – cell lymphoma Gastric adenoma Prevalence-high More in developing countries Roughly related to age • Saudi local study 67-89%

29. H. Pylori Testing and Eradication • Serology • Urea Breath test • Fecal antigen test • Endoscopy • Stript test Benefits: Cure rate. Recurrence Bleeding **All cases of dyspepsia ?? H-PYLORI ERADICATION - Triple regimen: Proton pump inhibitor + two antibiotics

30. Flowcharts, DU and GU

31. Endoscopy • Age < 55 years, presenting with dyspepsia and without alarm S/S, is not necessary. • Age > 55 years presenting with dyspepsia and without alarm S/S do not require routine endoscopy. Considered if : 1.ALARM signals and signs are the major determinant of the need for endoscopy, not age on its own. 2. No response to medication7-10days. 3. Symptoms persist after 6-8wks 4. Signs of systemic illness 5. Recurrence after treatment 6. Long standing G0RD 7. Unexplained weight loss, progressive dysphagia, IDA, abdominal mass on plapation

32. Cont. Endoscopy Patients undergoing endoscopy should be free from medication with either a PPI or an H2 receptor antagonist for a minimum of two weeks.

33. Reasons for referral immediate? If highly suggestive of cardiac or biliary disesases • cancer suspected or proven; • diagnostic uncertainty; • treatments not available • failure of treatment, symptoms persisting; • patients' wishes

34. Referral flowchart

35. Take home message!! Aggravating factors :tobacco, ASA, NSAIDs,other medications and alcohol Alarm features –absent OR present. A. Alarm features – abscent: Two approaches are acceptable: 1. Test for H. pylori infection 2. Empiric Therapy – A4-week course a histamine-2 receptor – antagonist or PPI **Failure to respond to treatment justifies further investigation and/or referral B. Alarm features – present: Endoscopy ± biopsy, referral Barium may be as an alternative.. Life style modification ??