- Chronic or recurrent upper gastrointestinal symptoms affect 25-40% of adults and account for a substantial economic burden. Appropriate management is essential to reduce costs. - The document discusses controversies in the management of uninvestigated dyspepsia, including the choice of empirical treatment strategy and the benefits of early endoscopy in older patients. - Empirical treatment with a proton pump inhibitor or a test-and-treat approach for Helicobacter pylori are discussed as first-line strategies, with test-and-treat having additional long-term benefits like reducing gastric cancer risk.

1. Prepared by: Dr.Mohammad Sheikhani. Assistant professor. Sulaimaneyah Univ College of Medicine. Department of Medicine . Kurdistan Center for GIT/Hepatology. Sulaimaneyah-Iraqi Kurdistan.

2. Introduction: Chronic/recurrent UGIT sympts. Cardinal symptoms: epigastric pain/ discomfort; postprandial fullness/early satiety, which may overlap with heartburn/regurgitation. 25-40% of adults have dyspepsia , 2-5% of all PC consultations with a substantial economic impact,so appropriate management is essential to reduce costs. In spite of several guidelines, the management of uninvestigated dyspepsia is still controversial specially: 1. The choice of the most appropriate empirical strategy. 2.The benefit of early endoscopy in older patients without alarm symptoms.

4. DD: Extragastrointestinal; hepatobiliary/ pancreatic diseases, are infrequent but important & should always be considered. Most cases 1 of 4 causes: GERD with or without oesophagitis PUD Malignancy Functional dyspepsia. 2/3. FD essentially a diagnosis of exclusion& its causes are uncertain. Symptoms are often associated with gastroduodenal motor / sensitivity disorders, but causes unknown. FD is the most common cause of dyspeptic symptoms, 50%. Of the remaining 20% have NERD, 20% oesophagitis, 10% PUD, 2% Barrett’s oesophagus, 1% malignancy.

6. Dyspeptic symptoms predictive value: Individual dyspeptic symptoms or subgroups of symptoms, as predominant epigastric pain(ulcer-like) or discomfort (dysmotility-like), poorly predict underlying organic lesions. Neither PCPs nor GEists can distinguish patients with organic lesions from functional dyspepsia on basis of symptom evaluation. The presence of predominant heartburn/regurgitation may predict underlying GERD& are good predictors of pathological GERD. International guidelines support the view that uninvestigated patients with dyspeptic symptoms& predominant heartburn or regurgitation can be considered to have GERD. Patients with predominant epigastric pain or discomfort are more likely to have peptic ulcer or functional dyspepsia.

7. Dyspeptic symptoms predictive value: A Canadian study: univestigated dyspepsia with predominant heartburn were as likely as those with predominant epigastric pain or discomfort to have underlying PUD. In investigated patients without structural lesions, predominant heartburn or regurgitation can reliably identify those with NERD, whereas those with predominant epigastric pain or discomfort should be considered as having functional dyspepsia.

8. Investigations:history/PE A careful history & physical exam will help to exclude non-Gl causes of dyspeptic symptoms such as the use of drugs. Lifestyle/dietary factors may also be identified. Obesity,smoking, alcohol, fatty foods may be associated with GERD& may exacerbate dyspeptic symptoms.

9. Investigations: OGD Endoscopy is the “gold standard” for the investigation of UGIT. Its accuracy in detecting organic lesions is > 95%& biopsies can be taken to diagnose HP, precancerous conditions& malignancy. Antisecretory drugs should be stopped at least two weeks before endoscopy because this treatment may heal early malignant ulcers masking early gastric cancer. Endoscopy cannot be used to investigate all patients with dyspepsia being invasive, expensive& has limited availability. Ba meal may be more readily available than endoscopy, but less sensitive/specific & may miss early malignancy.

10. Investigations: HP test A non-invasive test for H pylori, as the 13C-urea breath test, can be used as an indirect “PUD test.” A positive H pylori test is a good predictor of PUD in patients with uninvestigated dyspepsia.

11. Investigations or empirical trt: International guidelines recommend prompt endoscopy for patients with dyspepsia& alarm features& all older patients with new onset dyspepsia. Patients with alarm features, as GIB, dysphagia, or weight loss, should be promptly investigated to exclude ulcer complications & malignancy, although only a minority will have structural lesions. Older patients(45 in Asia& 55 USA) have an increased risk of malignancy&early endoscopy is recommended even in the absence of alarm features. The advantage of above strategy is now unclear because gastric ca now not common, in UK only 0.3% > 55 with uncomplicated dyspepsia had malignancy& a Scottish study showed that routine endoscopy for older people with new onset dyspepsia may have minimal effect on mortality for UGI cancer. UK guidelines suggest that patients>55 with uncomplicated dyspepsia should receive empirical treatment first & endoscopy is recommended only if symptoms persist after 1-2 months.

12. Investigations or empirical trt:

13. Investigations or empirical trt: Patients with dyspepsia < 55 with no alarm features can be managed empirically,as UGI cancer is rare in these patients& when found, is often incurable. In the UK, a retrospective study found that, of the 3293 patients with dyspepsia diagnosed with malignancy over two years in Scotland, 21 (0.6%) were < 55& without alarm features, only two (0.1%) had curative surgery. Studies from the US have found similar results.

14. What empirical trt: 2 strategies: 1. Non-invasive test for HP &treatment of positive patients with eradication therapy (test/ treat) 2. Empirical antisecretory PPI, being the most effective antisecretory drug for treating uninvestigated dyspepsia. International guidelines recommend test/treat for patients with predominant epigastric pain or discomfort &PPI for those with predominant heartburn or regurgitation. PPI recommended as a second line strategy in patients with persistent symptoms after HP eradication& in those HP negative. The main benefit of test/ treat over PPI:it definitively cures most patients with underlying PUD& a small group of those with FD. H pylori &PUD has decreased & it is not clear whether test/treat is still the best first line strategy. In Denmark / UK, prevalence of H pylori is 20- 30%, Test/ treat &PPI were similarly effective, but that test/treat resulted in fewer endoscopies&more cost effective. UK RCT reported similar results but no difference in cost.

15. What empirical trt: These results suggest that, even in areas with a relatively low prevalence of H pylori, test/treat has a persistent, albeit modest, benefit over treatment with PPIs. Taking into account the potential long term benefits of HP eradication in reducing the risk of gastric cancer & preventing future PUD, test/treat remains a valuable first line strategy. Test /treat is not recommended for heartburn predominant dyspepsia, because these patients are thought to be most likely to have underlying GERD,but evidence now suggests that this strategy may also be beneficial for these patients. Danish/UK trials found that test/treat also reduces symptoms in heartburn-predominant dyspepsia,suggest that a subgroup has an underlying PUD,recently reported by a Canadian study. A recent RCT reported that a sequential strategy PPI followed by test/treat if symptoms recur, more cost effective than early OGD.

16. What HP test: The 13C-urea breath test is the most accurate noninvasive test & is the preferred test for the initial diagnosis of H pylori. The stool antigen test maybe a valid alternative because it has a similarly high sensitivity/specificity. PPIs should be stopped at least two weeks before&antibiotics at least four weeks before performing these tests as they can lead to false negative results. Serology is widely available,inexpensive, but its sensitivity/ specificity are too poor for it to be recommended in patients with uninvestigated dyspepsia.

18. HP: HP is one of the most common human infections, 50% world’s population carries this organism,major cause of several UGI dis. 80% of adults in Japan/South America,40% UK, 20% Scandinav. Many acquire the infection in childhood—social deprivation, household crowding, number of siblings are important RFs. The prevalence increases with age. Being chronic, several antibiotics must be given simultaneously sometimes repeated courses of different combinations to eradicate H pylori. Eradicating H pylori is still a challenge, because of the rapidly increasing MDR strains worldwide.

27. Treatment after investigation: When a patient is referred for endoscopy, biopsy should be taken from the antrum &body of the stomach for the diagnosis of HP. Endoscopy may show oesophagitis or PUD, which should be treated with PPI or H pylori eradication. Most patients will have no structural lesions. Patients with NERD should be treated with PPI &HP radication does not usually provide symptom relief in these patients, but it maybe considered because it does not worsen symptoms&may have other long term benefits. HP erradication should, be the 1st line trt in patients with FD. A Cochrane review: 10% with FD benefit from HP eradication Although this benefit is small, eradication is the most cost effective approach for these patients as it is given once&have long term benefit. PPI should be given to HP -ve patients&if fail to respond to HPE. Reassurance/explanation of the benign nature of symptoms may be the best treatment for FD& may be sufficient for many Prokinetics,antideps,spasmolytics reserved for refractory disease.

28. Summary: A combination of HP test/treat &PPI is still a valuable strategy for the empirical management of most patients. In Western countries, an initial empirical treatment may also be considered in older patients with uncomplicated dyspepsia.

29. Summary: