DYSPEPSIA

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DYSPEPSIA

• Dr.Vishal
  Rathore

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Dyspepsia

• popularly known as indigestion
• meaning 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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Prevalence

• 25-40 , of which
• 50 self medicate
• 25 consult their G.P.
• 5 of G.P. consultations are for dyspepsia
• Prescribed drugs and endoscopies cost 600M in
  2000
• OTC indigestion remedies sold for 100M in 2002

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Causes

• Reflux oesophagitis 12
• Duodenal ulcer 10
• Gastric ulcer 6
• Gastric carcinoma 1
• Oesophageal carcinoma 0.5
• Non-erosive GORD
• Functional (non-ulcer) dyspepsia

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Alarm Symptoms/ Signs

• GI bleeding (same day referral)
• Persistent vomiting
• Weight loss (progressive unintentional)
• Dysphagia
• Epigastric mass
• Anaemia due to possible GI blood loss
• Thus all patients with new-onset dyspepsia should
  have abdominal examination and FBC

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First Approach to Dyspepsia

• Consider possible causes outside upper GI tract
• -Heart, lung, liver, gall bladder, pancreas,
  bowel
• Consider drugs and stop if possible
• - Aspirin / NSAIDs, calcium antagonists,
  nitrates,
• theophyllines, etidronate, steroids

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Refer if dyspepsia in 55 year old

• Alarm symptoms/signs (2 week referral)
• Unexplained and persistent recent-onset
• dyspepsia without alarm symptoms
• Unexplained means no cause known
• Persistent implies present for a length of
• time (NICE suggest 4-6 weeks)
• Recent-onset implies new-not a recurrent
  episode.

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Referral for Endoscopy

• Review medications for possible causes of
  dyspepsia
• (calcium antagonists, nitrates,
  theophyllines,
• bisphosphonates, corticosteroids and
  non-steroidal
• anti-inflammatory drugs NSAIDs).
• In patients requiring referral, suspend NSAID
  use.

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Urgent specialist referral

• Endoscopic investigation is indicated for
  patients of any
• age with dyspepsia when presenting with any of
  the
• following
• chronic gastrointestinal bleeding,
• progressive unintentional weight loss,
• progressive difficulty swallowing,
• persistent vomiting,
• Iron deficiency anaemia,
• epigastric mass
• suspicious barium meal

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Routine Endoscopic Investigation

• Patients of any age, presenting with dyspepsia
  and
• without alarm signs, is not necessary.
• However, in patients aged 55 years and older with
  unexplained and persistent recent-onset dyspepsia
  alone, an urgent referral for endoscopy should be
  made.

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Management of simple dyspepsiain those aged lt 55
years

• Stress benign nature of dyspepsia
• Lifestyle advice
• Healthy eating
• Weight reduction
• Stop smoking
• Use of antacids

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Interventions for uninvestigated dyspepsia

• Initial therapeutic strategies for dyspepsia are
• empirical treatment with a proton pump
  inhibitor (PPI) or testing for and treating H.
  pylori.
• There is currently insufficient evidence to guide
  which should be offered first.
• A 2-week washout period following PPI use is
  necessary before testing for H. pylori with a
  breath test or a stool antigen test

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Nice Guideline Summary

• Refer if alarm symptoms at any stage
• Test and treat
• (Test for H. pylori and treat positives)
• THEN, IF STILL SYMPTOMATIC
• PPI for one month
• THEN
• Manage recurrent symptoms as functional dyspepsia

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Rx of H. Pylori

• One week triple therapy
• PPI (full dose) e.g. omeprazole 20mg bd
• Clarithromycin 500mg bd
• Amoxycillin 1g bd
• (or Metronidazole 400mg bd)
• Use a carbon-13 urea breath test, stool antigen
  test or, when performance has been validated,
  laboratory based serology.
• If re-testing for H. pylori use a carbon-13 urea
  breath test.

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• THANK YOU !!!!!