Dispepsia - Mini Lecture

8/11/2019 Dispepsia - Mini Lecture

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An Evidence An Evidence- -based Approachbased Approachto the Diagnostic of to the Diagnostic of

Uninvestigated DyspepsiaUninvestigated Dyspepsiain the Primary Care Settingsin the Primary Care Settings

MUHAMMAD BEGAWAN BESTARIMUHAMMAD BEGAWAN BESTARI

Division ofDivision of GastroenterohepatologyGastroenterohepatologyDepartment of Internal MedicineDepartment of Internal Medicine

Medical SchoolMedical School PadjadjaranPadjadjaran UniversityUniversityHasanHasan SadikinSadikin General HospitalGeneral Hospital

BANDUNGBANDUNG


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Talley, J Clin Gastroenterol 2001; 32 : 28693.Locke, Ballieres Clin Gastroenterol 1998; 12 : 43542.

Par, Can J Gastroenterol 1999; 13 : 64754.van Bommel et al ., Postgrad Med J 2001; 77 : 51418.

Talley et al ., BMJ 2001; 323 : 12947.

1525% of the general population experiencedyspepsia within a 12-month period

Much more common than peptic ulcerUp to 5% of primary care visits are due todyspepsia

Most patients have no detectable abnormality on

radiological upper GI series or endoscopyEndoscopy findings and symptoms do not correlate

Dyspepsia:Dyspepsia:the size of the problemthe size of the problem

Dyspepsia:Dyspepsia:the size of the problemthe size of the problem


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ORGANIC

UNINVESTIGATED

FUNCTIONAL(or idiopathic)

(use of the term non-ulceris discouraged)

INVESTIGATED

Talley et al., Gut 1999; 45 (Suppl II): II3742.

Dyspepsia covers a range of symptomsDyspepsia covers a range of symptomsDyspepsia covers a range of symptomsDyspepsia covers a range of symptoms

DYSPEPSIA

PAIN OR DISCOMFORTcentred in upper abdomen IBSGERD


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Pain or discomfort occurringPain or discomfort occurringcentred in the upper abdomencentred in the upper abdomen

Talley et al., Gut 1999; 45 (Suppl II): II3742.Malfertheiner, Eur J Gastroenterol Hepatol 1999; 11 (Suppl 1): S259.

Definition of dyspepsia (Rome II)Definition of dyspepsia (Rome II)Definition of dyspepsia (Rome II)Definition of dyspepsia (Rome II)


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GastritisGastritis

Peptic ulcerPeptic ulcerdiseasedisease

(Includes(IncludesNSAIDNSAID--inducedinducedulcers)ulcers)

DuodenitisDuodenitis

Duodenal ulcer Duodenal ulcer

Acid reflux Acid reflux

OesophagitisOesophagitis

StricturesStrictures

BarrettsBarrettsoesophagusoesophagus

OesophagealOesophagealadenocarcinomaadenocarcinoma


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NormalNormal

Gastritis/duodenitisGastritis/duodenitis

Reflux esophagitisReflux esophagitis

Cancer Cancer

Peptic ulcer diseasePeptic ulcer disease

33.6%33.6%23.9%23.9%

2%2%

19.9%19.9%20.8%20.8%

Richter 1991Richter 1991


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51(24%)

36(17%)

27(13%)

21(10%)

11(5%)

7 (3%)

10(5%)

Ulcer Ulcer--likelikedyspepsiadyspepsia

DysmotilityDysmotility--likelikedyspepsiadyspepsia

RefluxReflux--likelikedyspepsiadyspepsia

UnspecifiedUnspecifieddyspepsiadyspepsian=50 (23%)n=50 (23%)

Talley et al 1992

Functional Dyspepsia (Rome I)Functional Dyspepsia (Rome I)Functional Dyspepsia (Rome I)Functional Dyspepsia (Rome I)


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Twelve weeks or more (within the last 12Twelve weeks or more (within the last 12months) of persistent or recurrent dyspepsiamonths) of persistent or recurrent dyspepsia

and evidence that organic disease likely toand evidence that organic disease likely toexplain the symptoms is absentexplain the symptoms is absent(including at upper endoscopy)(including at upper endoscopy)

Definition of Functional DyspepsiaDefinition of Functional Dyspepsia

(Rome II)(Rome II)

Definition of Functional DyspepsiaDefinition of Functional Dyspepsia

(Rome II)(Rome II)

Talley et al., Gut 1999; 45 (Suppl II): II3742.

Malfertheiner, Eur J Gastroenterol Hepatol 1999; 11 (Suppl 1): S259.

Dyspepsia subgroupsDyspepsia subgroupsUlcer Ulcer--like (predominantly pain)like (predominantly pain)DysmotilityDysmotility--like (predominantly discomfort)like (predominantly discomfort)Unspecified (nonUnspecified (non- -specific, no predominant symptom)specific, no predominant symptom)


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Functional dyspepsia:Functional dyspepsia:an exclusion diagnosisan exclusion diagnosis


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Patient with new onset or recurrentPatient with new onset or recurrentdyspeptic symptoms in whom nodyspeptic symptoms in whom no

investigation have been conductedinvestigation have been conductedand no specific diagnosis forand no specific diagnosis forthe current symptoms existthe current symptoms exist

Uninvestigated DyspepsiaUninvestigated DyspepsiaUninvestigated DyspepsiaUninvestigated Dyspepsia

Sander et al., CMAJ 2000; 162 (Suppl): S123


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Uninvestigated dyspepsiaAll symptomatic patients,

regardless of whether a causehas been sought

Functional dyspepsiaSymptomatic patients in whoman organic cause has beensought and excluded

TalleyTalley et alet al .,., GutGut 1999;1999; 45(45( Suppl II): II37Suppl II): II37 42.42.

Uninvestigated dyspepsiaUninvestigated dyspepsiavsvs functional dyspepsiafunctional dyspepsia

Uninvestigated dyspepsiaUninvestigated dyspepsiavsvs functional dyspepsiafunctional dyspepsia


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Management ofManagement ofuninvestigated dyspepsiauninvestigated dyspepsia


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YES

First Visit

(A)

Other possible causes ?

Consider :Consider :-- CardiacCardiac-- HepatobiliaryHepatobiliary-- MedicationMedication- -inducedinduced-- Dietary indiscretionDietary indiscretion-- Other Other Treat as appropriateTreat as appropriate

Uninvestigated DyspepsiaUninvestigated Dyspepsia



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Consider:Consider:

RecommendationRecommendation

Exclude other possible causes of the dyspeptic symptomsExclude other possible causes of the dyspeptic symptomswith thorough historywith thorough history- -taking and physical examinationtaking and physical examination

(grade C recommendation, consensus)(grade C recommendation, consensus)

cardiac andcardiac and hepatobiliaryhepatobiliary sourcessourcesmedicationmedication- -induced symptomsinduced symptomspossible dietary indiscretionpossible dietary indiscretionlifestyle or other causeslifestyle or other causes


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No

YES

YES

First Visit

(A)




InvestigateInvestigate(endoscopy recommended)(endoscopy recommended)

(B) Age >50 o r alar m f eatur es?

- Vomiting- Bleeding anemia- Abdominal mass/

unexplained weight loss- Dysphagia



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Prompt investigation is recommended for patientsPrompt investigation is recommended for patients over 50 years of ageover 50 years of agewith uninvestigated dyspepsia and for any patient presenting withwith uninvestigated dyspepsia and for any patient presenting with alarmalarmfeaturesfeatures

Endoscopy is the recommended method of investigation for patientsEndoscopy is the recommended method of investigation for patientswith uninvestigated dyspepsia who are over 50 years of age or who havewith uninvestigated dyspepsia who are over 50 years of age or who havealarm featuresalarm features


Alarm features:

(grade B recommendation, level III evidence)(grade B recommendation, level III evidence)

(grade A recommendation, level II evidence)(grade A recommendation, level II evidence)

persistent vomiting

evidence of gastrointestinal bleeding or anemiapresence of an abdominal massunexplained weight lossdysphagia


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Older patients and with alarm featuresOlder patients and with alarm features

America America

> 50 years> 50 years



CanadaCanada

IndonesiaIndonesia Cancer is a rare cause of dyspeptic symptomsCancer is a rare cause of dyspeptic symptoms

< 2 %< 2 %


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Diagnostic test: endoscopy or radiography?Diagnostic test: endoscopy or radiography?

Radiography :

96 %

70 %

Endoscopy :

DooleyDooley et al.et al. ,, Ann Intern Med Ann Intern Med 1984; 101: 5381984; 101: 538- -4545


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(C)NSAID and/orRegular ASA

Use?

NSAID Management

No

NO

YES

YES

YES

First Visit

(A)










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Patients with uninvestigated dyspepsiaPatients with uninvestigated dyspepsiawho are regular users of NSAIDSwho are regular users of NSAIDS

(including ASA) should be identified,(including ASA) should be identified,and if there are no alarm features,and if there are no alarm features,they can be managed without initial endoscopythey can be managed without initial endoscopy




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Patients who use NSAIDsPatients who use NSAIDs

Hp infection is the most common cause of peptic ulcers

NSAIDs are responsible for mostHp-negative ulcers


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Use?

(D)

Is dominant symptomheartburn and/or regurgitation ?

NSAID Management

Treat as reflux

No

NO

NO

YES

YES

YES

YES

First Visit

(A)










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Patients with dominant symptom of heartburnPatients with dominant symptom of heartburnor acid regurgitation, or bothor acid regurgitation, or both

Heartburn (89 %) or acid regurgitation (95 %) haveHeartburn (89 %) or acid regurgitation (95 %) havehigh specificity for GERDhigh specificity for GERD

Most GERD patients do not have macroscopicMost GERD patients do not have macroscopicesophagitisesophagitis

Initial treatment can be started based onInitial treatment can be started based onsymptoms of reflux in primary caresymptoms of reflux in primary care

Endoscopy is not a useful diagnosticEndoscopy is not a useful diagnostic gold standardgold standard for for GERD, nor 24GERD, nor 24- -hour pH monitoringhour pH monitoring

A reliable interpretation of the term heartburn is A reliable interpretation of the term heartburn iskey for the diagnosis of GERDkey for the diagnosis of GERD


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The effectiveness of lifestyle modifications and antacids for the treatmentThe effectiveness of lifestyle modifications and antacids for the treatmentof GERD is not proven. Patient with mild GERD symptoms may deriveof GERD is not proven. Patient with mild GERD symptoms may derivebenefit from these treatmentbenefit from these treatment

Treatment recommendations for patients with a dominant symptom ofheartburn or acid regurgitation, or both, are as follows :(a) PPI(b) H 2 RA

(c) Prokinetic agent



Patients should be reassessed after 4 weeks of therapy

(grade A recommendation, level I evidence)(grade A recommendation, level I evidence)



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Use?

(D)

Is dominant symptomheartburn and/or Regurgitation ?

NSAID Management

Treat as reflux

Treat as Hp positive

No

NO

NO

NO

YES

YES

YES

YES

YES

First Visit

(A)








(E)Hp test positive?1. UBT

2. Serology


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HpHp test and treat strategytest and treat strategy

Hp infection is associated with- duodenal ulcer 90 95 %- gastric ulcer 60 80 %- gastric cancer

Option for the treatment of younger patients w/o alarm features:Option for the treatment of younger patients w/o alarm features:

Uncertainty as to whether Hp plays a role indyspepsia in the absence of ulcers

-- trial of empiric (trial of empiric (antisecretoryantisecretory oror prokineticprokinetic) )-- diagnostic evaluationdiagnostic evaluation-- non invasive testing fornon invasive testing for HpHp

followed by eradication therapy for patients w/ (+)followed by eradication therapy for patients w/ (+)ve ve resultsresults-- non invasive testing fornon invasive testing for HpHp

followed by endoscopy for patients w/ (+)followed by endoscopy for patients w/ (+)ve ve resultsresults


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A test A test--andand--treat strategy for uninvestigated dyspepsiatreat strategy for uninvestigated dyspepsiain younger patient (aged 50 years or less)in younger patient (aged 50 years or less)who have no alarm features is recommendedwho have no alarm features is recommended


(grade B recommendation, level I evidence)(grade B recommendation, level I evidence)


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Testing forTesting for HpHp infectioninfection

Infection can be detected by:Infection can be detected by:-- invasive (endoscopy based)invasive (endoscopy based)-- non invasive (UBTnon invasive (UBT, HPSA, HPSA or serologicor serologic

testing)testing)

Serologic testing cannot be used to determine cureSerologic testing cannot be used to determine cureas theas the IgGIgG antibodies remain detected for a longantibodies remain detected for a longtime after eradicationtime after eradication

UBTUBT has a high (+)has a high (+)veve and (and (--))veve predictive valuepredictive value(both > 90 %)(both > 90 %)


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Noninvasive methods are recommendedNoninvasive methods are recommendedfor the detection offor the detection of H. pyloriH. pylori in patient aged 50 years or lessin patient aged 50 years or less

with uninvestigated dyspepsia who have no alarm featureswith uninvestigated dyspepsia who have no alarm features


(grade B recommendation, level II(grade B recommendation, level II- -2 evidence)2 evidence)

Hp stool antigenHp stool antigen is the preferred testis the preferred test


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No more serologyNo more serology


((AGA guidelines from 2005 AGA guidelines from 2005) )

StoolStool aantigenntigen iiss tthehe rrecommendedecommended t testestTTest withest with stoolstool antigenantigen beforebefore prescribingprescribing PPPIPIss

do not have alarm symptomsdo not have alarm symptomshave not been using NSAIDShave not been using NSAIDS

who are not > 55who are not > 55 yrsyrs


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Use?

(D)Is dominant symptom

heartburn and/or Regurgitation ?

NSAID Management

Treat as reflux

Treat as Hp positiveTreat as Hp Negative

No

NO

NO

NO

NO

YES

YES

YES

YES

YES

First Visit

(A)


Consider :Consider :-- CardiacCardiac-- HepatobiliaryHepatobiliary-- MedicationMedication- -inducedinduced-- Dietary indiscretionDietary indiscretion

-- Other Other Treat as appropriateTreat as appropriate






(E)Hp test positive?1. UBT

2. Serology Sander et al., CMAJ 2000; 162 (Suppl): S123


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There is good evidence that antacids are ineffectiveThere is good evidence that antacids are ineffectivefor functional dyspepsia, and they are not recommendedfor functional dyspepsia, and they are not recommended

for the treatment of uninvestigated dyspepsiafor the treatment of uninvestigated dyspepsiain patients subsequently found to bein patients subsequently found to be H. PyloriH. Pylori negativenegative


(grade B recommendation, level I evidence)(grade B recommendation, level I evidence)


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SS PECIALISTPECIALIST RREFFERALEFFERAL ::

PP RIMARYRIMARY MM ANAGEMENT ANAGEMENT OFOF NNEWEW OONSETNSETUUNINVESTIGATEDNINVESTIGATED DDYSPEPSIAYSPEPSIA ININ IINDONESIANDONESIA

IIFF < 2< 2 4 W4 W KSKS ..DDIETARYIETARY A ADVICEDVICE , O, O BSERVEBSERVERREVIEWEVIEW CCURRENTURRENT MMEDSEDS ..

EEXCLUDE BYXCLUDE BY HHISTORYISTORY ::BBILLIARYILLIARY PP AIN AIN ,,

IIRRITABLERRITABLE BBOWELOWEL , R, R EFLUXEFLUX

FF AILURE AILURE OROREE ARLY ARLY RRELAPSEELAPSE

FF INALINAL EEVALUATIONVALUATION A AFTERFTER 8 W8 W KSKS> 3 X R> 3 X R ELAPSEELAPSE

RRELAPSEELAPSE

FFOLLOWOLLOW UUPP

SS UCCESSUCCESS

PP OSOS ..

A AGEGE > 55 Y> 55 Y RSRSWITHWITH A ALARMLARM FFEATURESEATURES ::

NNEGEG ..

SS EROLOGICEROLOGIC Hp THp T ESTINGESTING

A ANTACIDSNTACIDS A ANTISECRETORYNTISECRETORYPP ROKINETICSROKINETICS

GG ASTROENTEROLOGIST ASTROENTEROLOGISTIINTERNALNTERNAL MMED.ED. /P/P ED. WITHED. WITHEENDOSCOPICNDOSCOPIC FF ACILITIES ACILITIES

TTREATMENTREATMENT TTRIALRIAL : 2 W: 2 W KSKS

AGE < 55 Y AGE < 55 Y RSRSWW ITHOUTITHOUT A ALARMLARM FFEATURESEATURES

DYSPEPSIADYSPEPSIA

FFEVEREVERHHEMATEMESIS /EMATEMESIS / MMELENAELENAJAUNDICEJAUNDICE

BWBWNSAIDsNSAIDsSS TRONGTRONG FFEAREAR OFOF SS ERIOUSERIOUS DDISIS ..FF AMILY AMILY HHISTORY :ISTORY : GG ASTRIC ASTRIC CC A. A.

SS EVEREEVERE VVOMITINGOMITING


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EERADICATIONRADICATION TTHERAPYHERAPY

RREEVALUATEEEVALUATE : E: E NDOSCNDOSC .,PA, Hp C.,PA, Hp C ULTUREULTURE

RREEVALUATE :EEVALUATE : EENDOSC.,NDOSC., PAPA ,, CLOCLO

CLO (CLO ( ), PA (), PA ( ))

QQUADRUPLEUADRUPLE TTREATMENTREATMENT

MM ANAGEMENT ANAGEMENT OFOF DDYSPEPSIAYSPEPSIA ININ RREFFERALEFFERAL CCENTERENTER

FFROMROM A ALGORHYTMLGORHYTM 11 UGI EUGI E NDOSCOPYNDOSCOPY

CLO (CLO ( ), PA (), PA ( )) CLO (CLO ( ), PA (), PA ( )) CLO (CLO ( ), PA (), PA ( ))

NNOO EERADICATIONRADICATION

EEMPIRICMPIRIC TTREATMENTREATMENTFF INDIND OO THERTHER CC AUSES AUSESSS UCCESSUCCESS FF AILURE AILURE

FF AILURE AILURE

Hp EHp E RADICATIONRADICATION A ACCORDINGCCORDINGTOTO THETHE RRESISTANCYESISTANCY TTESTEST

DYSPEPSIADYSPEPSIA

CLO TCLO T ESTEST , PA, PA

EEVALUATIONVALUATION 4 W4 W KSKS .. A AFTERFTER EERADICATIONRADICATION

Note :Note :CC ASE ASE SS ELECTIONELECTION ::1. Strongly recommended :1. Strongly recommended :

DUDUGUGUPost resection of early gastric CaPost resection of early gastric CaMALT lymphomaMALT lymphoma

2. Recommended :2. Recommended :Ulcer Ulcer--like dyspepsialike dyspepsiaSevere chronic gastritisSevere chronic gastritisNSAIDs gastritisNSAIDs gastritisSevere erosive gastritisSevere erosive gastritisHypertrophic gastritisHypertrophic gastritis

CC ASE ASE SS ELECTIONELECTION


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Dispepsia - Mini Lecture