Functional Dyspepsia ppt

1. DYSPEPSIA
DR. TIN KYU
SENIOR CONSULTANT SURGEON
SAO SAN HTUN HOSPITAL, TAUNGGYI
17-8-2014
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2. DYSPEPSIA
• Popularly known as indigestion
• Means hard or difficult digestion
• Is a medical condition characterized by
chronic or recurrent pain in the upper
abdomen, upper abdominal fullness and
feeling full earlier than expected when
eating
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3. DYSPEPSIA
Functional
Dyspepsia
Non-GI
Causes
(cardiac disease,
muscular pain, etc)
Structural
Dyspepsia
(GERD, PUD,
Cancers, etc)
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4. Endoscopy findings
• 15% >> Duodenal or Gastric ulcer
• 15% >> Esophagitis = GERD
• 30% >> Gastritis, duodenitis or hiatus hernia
• 30% >> Normal (functional dyspepsia)
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5. Structural Dyspepsia
(GERD, PUD, Barrett’s Esophagus,
Cancers etc.)
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6. GERD
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7. Gastro-Esophageal junction
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8. Causes of GERD
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9. Diagnosis of GERD
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10. Complications of GERD
• Stricture
• Barrett’s esophagus
• esophageal adenocarcinoma
• Extra-esophageal
–Asthma
–Cough
–Pharyngitis
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11. Barrett’s Esophagus
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12. Barrett’s Oesophagus
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13. Barrett’s Adenocarcinoma
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14. Gastric Ulcer
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15. Gastric ulcer - causes
• H. pylori 60%
• NSAIDs 30%
• Carcinoma 5%
• Others 5%
- Neoplasia
- Crohn’s
- Stress
- ZE syndrome
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16. Duodenal Ulcer
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17. Duodenal ulcer - causes
• H. pylori 85%
• NSAIDs 10-14%
• Rare causes 1%
- ZE syndrome
- Crohn’s Disease
- Stress
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18. Gastric acid secretion
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19. Helicobacter Pylori
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20. Helicobacter Pylori
• 95% Duodenal ulcers
• 70% Gastric ulcers
• 10% Non-ulcer dyspepsia
• Treatment benefits gastritis more than
reflux symptoms
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21. Diagnosing H. pylori
• Urea breath test - 95% sensitive & specific
• Stool antigen test - 92% sensitive & specific
• Serology - 80% sensitive & specific
• Endoscopy (CLO test) - 98% sensitive & specific
(urea and phenol red, a dye that turns pink in a pH of 6.0
or greater)
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22. Gastric cancer
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23. ALARM symptoms
• Abdominal swelling (Anaemia)
• Loss of weight
• Anorexia
• Recurrent symptoms*
• Melaena/Haematemesis
• Swallowing problems
*Only if age >55 years
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24. Stage of gastric cancer
No spread
Local
Distant
No data
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25. Drugs that cause dyspepsia
• NSAIDS
• Bisphosphonates
• Steroids
• Metformin
• Calcium antagonists
• Theophyllines
• Nitrates
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26. Functional Dyspepsia
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27. Clinical Definition
One or more of :
- Bothersome postprandial fullness
- Early satiation
- Epigastric pain
- Epigastric burning
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28. • No evidence of structural disease
(including at upper endoscopy) that is likely
to explain the symptoms
• These criteria should be fulfilled for the last
three months with symptom onset at least
six months before diagnosis
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29. Symptoms of Functional Dyspepsia
- Nocturnal
pain
- Localized
epigastric
burning
- Better with
food
Heartburn
Retrosternal
burning
- Nausea
- Bloating
- Early satiety
- Worse with
food
Ulcer-like Dominant Dysmotility-like Dominant
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30. Pathophysiology
• The pathophysiology of functional dyspepsia
is unclear. Research has focused upon the
following factors:
 Gastric motor function
 Visceral sensitivity
 Helicobacter pylori infection
 Psychosocial factors
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31. Practical Management of
Dyspepsia
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32. Who needs endoscopy?
• GI bleeding
• Unintentional weight loss
• Dysphagia
• Persistent vomiting
• Iron deficiency anaemia
• Epigastric mass
• >55 with unexplained persistent/recent onset dyspepsia
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33. PUD on endoscopy
• Stop NSAIDs
• Start full dose PPI for 2 months
• Eradication treatment if H Pylori positive
• Repeat endoscopy for gastric ulcer 2%
cancer risk
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34. H.pylori Eradication
• 1st Line
- ‘PO’ PPI
- + ‘PO’ Clarithromycin 500mg BD x 7 Days
- + ‘PO’ Amoxicillin 1G BD
• If penicillin allergic,
- ‘PO’ PPI
- + ‘PO’ Clarithromycin 500mg BD x 7 Days
- + ‘PO’ Metronidazole 400mg BD
(E.g., of PPI = Lansoprazole 30mg BD)
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35. • 2nd line
- ‘PO’ PPI
- + Bismuth 120mg QID x 7 Days
- + Metronidazole 500mg TDS
- + Tetracycline 500mg QID
• Subsequent failures handled on individual basis
with advice from gastroenterologist or
microbiologist
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36. H. Pylori eradication
• 1 week triple-therapy regimens >> eradicate H.
Pylori in >90% cases. Usually no need for
continued antisecretory tx unless ulcer
complicated by bleeding/perforation
• 2 week triple-therapy >> offer higher eradication
rates of 1 week but SE common & poor
compliance
• 2-week dual-therapy (with PPI & antibacterial) >>
produce low rates of H. pylori eradication & not
recommended 36

37. H. pylori eradication
Drug Side effects
Bismuth n&v, unpleasant taste, darkening of tongue &
stools, caution in renal disease
Metronidazol
e
n&v, unpleasant taste, ↓effectiveness OC Pills,
care with lithium/warfarin
Amoxicillin
& tetracycline
GI side effects, ↓ effectiveness OC Pills,
pseudomembranous colitis
Lansoprazole ↓ effectiveness OC Pills
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38. H. Pylori eradication
• Treatment failure may be due to
- Resistance to antibacterial drugs
- Poor compliance
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39. GERD on endoscopy
• Lifestyle advice
• Full dose PPI for 1-2 months
• H Pylori Eradication may not benefit
reflux symptoms
• If recurrence - lowest dose PPI to control
symptoms
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40. • AVOID
- Meals at night, lying down after meals
- Elevate head of bed
- Heavy lifting, tight clothing, bending
- Being overweight
- Smoking (nicotine relaxes lower oesophageal sphincter)
- Aggravating substances (spicy foods, C2H5OH)
- Drugs which encourage reflux (e.g. antimuscarinic,
smooth muscle relaxants, theophylline)
GERD
GERD = Symptoms of “heartburn”
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41. • Drug Treatment
- Antacids
- Pro-kinetic agent e.g., metoclopramide
- H2-antagonist
- PPI
- If severe s/s when treatment stopped, or bleed from
esophagitis or stricture maintenance treatment with PPI
or surgery may be necessary
GERD
GERD = Symptoms of “heartburn”
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42. NSAID Induced Dyspepsia
• 10-20% develop endoscopically visible
PUD
• 1-5% perforation or major bleeding
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43. • Endogenous prostaglandins (PGE2 & I2)
contribute to GI mucosa integrity by
- stimulation of mucus & bicarbonate secretion
- maintenance of blood flow (allows removal of
luminal H-ions)
- prevent luminal H-ions from diffusing into the
mucosa
- ↓ gastric acid secretion
- helping to repair damaged epithelium
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44. NSAID Induced Dyspepsia
• Elderly >65 years
• History PUD
• Other drugs – e.g., bisphosphonates,
Steroids
• PPI or misoprostol protection for at risk
• Consider screening & eradicating H Pylori
infection
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45. Prostaglandin analogues
Misoprostol
- synthetic prostaglandin E1 analogue
- Prevents NSAID induced ulcers & heals
chronic GU & DU
- Side Effects : Abdominal pain, nausea &
vomiting, diarrhoea, abortifacient
(produces uterine contractions)
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46. Non ulcer dyspepsia
• Treat H pylori (no routine retesting)
• Symptomatic treatment
• PPI (proven benefit)
• Prokinetic agent: e.g., metoclopramide
(probable benefit)
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47. Dyspepsia without ALARM
symptoms
• Lifestyle advice
• Antacids and medication review
• Empiric PPI
• Test and treat for H Pylori
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48. THANKS
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