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Practice Guidelines & clinical pathway on management of Dyspepsia. Clinical Scenario. 30 year old, male Call center representative Epigastric pain Denies any alarm features Smoker; alcohol and coffee drinker Unremarkable past medical & family history Direct epigastric tenderness. - PowerPoint PPT Presentation
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Clinical Scenario
30 year old, male Call center representative Epigastric pain Denies any alarm features Smoker; alcohol and coffee
drinker Unremarkable past medical &
family history Direct epigastric tenderness
Dyspepsia
Presence of 1 or more of the following symptoms (Rome III Committee):
Postprandial fullness Early satiety Epigastric pain or burning
Assessment & Diagnosis
Based on history and physical and exam
Consider or rule out: Dietary indiscretion Medication induced Cardiac disease Gastroparesis Hepatobiliary disorders Other systemic disease
4 Major Causes:
Chronic peptic ulcer disease Gastroesophageal reflux (+/-
esophagitis) Functional dyspepsia (NUD) Malignancy
Stratify Patients
Age (55 or less/ above 55) Presence of alarm features
Family history of upper GI cancer Unintended weight loss GI bleeding, unexplained anemia Progressive dyspepsia, odynophagia Persistent vomiting Palpable mass or lymphadenopathy Jaundice
Review of Current Literatures
Peptic ulcer is found in ~5-15% of patients
Gastric or esophageal Adenocarcinoma is identified in <2% of all patients who undergo endoscopy for dyspepsia
Upper gastrointestinal malignancy becomes more common after age 55 years
Review of Current Literatures
Absence of alarm features has a negative predictive value of >97%
Chronic infection with H. pylori is associated with >80% of peptic ulcers and >1/2 of gastric cancers
Patient Profile
30 year old, male Burning epigastric pain No alarm symptoms
Empiric PPI Therapy
Empiric therapy with proton pump inhibitors for 4- 6weeks
Reassurance No further investigations if
symptoms improve Out patient clinic follow-up
Failed Empirical Therapy
No response to therapy after 7-10 days
Symptoms has not resolved after 6-8 weeks
EGD with biopsy for H. pylori Organic disease (PUD, GERD, CA) Treat accordingly
Normal EGD (Functional Dyspepsia)
Reassurance Lifestyle changes Treat H. pylori if present
H. pylori regimen: PPI 40 mg 2x a day Amoxicillin 1G 2x a
day Clarithromycin 500mg 2x a day
(10-14 days)
<55 y/o and below, no alarm
features
Empiric PPI therapy
Response Failed empirical therapy
EGD with biopsy for H.
pylori
Functional dyspepsia
ReassuranceLifestyle modificationsTreat H. pylori if (+)
Organic disease
(PUD, GERD, CA)
>55 y/o or<55 y/o w/ alarm features
Treat accordingly
H. Pylori Follow -up
Patients who remain symptomatic after initial course of treatment should be retested 4 weeks after completion of the course
Urea breath test or stool antigen test
Some success in using previous triple therapy
Switch to another regimen: PPI+metronidazole+bismuth+tetracycline
Unresponsive Functional Dyspepsia
Persistent dyspeptic symptoms Not infected with H. pylori or have
been rendered free of H. pylori Do not respond to short course of PPI
therapy (-) negative findings on endoscopy
Unresponsive Functional Dyspepsia
Reevaluate diagnosis Consider: gastroparesis, biliary or
pancreatic diseases, IBS, anxiety disorder
Limited data on use of antidepressants, prokinetic agents
References
Talley NJ, Vakil NB, Moayyedi P: American Gastroenterological Association Technical Review: Evaluation of Dyspepsia. Gasteroenterology 2005, 129:1756-1780.
American Gastroenterological Association Medical Position Statement: Evaluation of Dyspepsia Gastroenterology 2005, 129:1753-1755.
Lam SK, Talley NJ: Report for the 1997 Asia Pacific. Consensus Guidelines on the management of H. pylori. Journal Gasteroenterology & Hepatology 1998, 13:1-2.
American Society for Gastrointestinal Endoscopy’s The role of endoscopy in dyspepsia. Gastrointestinal Endoscopy 2007, 6:1071-1075
Sleisenger and Fordtran’s Gastrointestinal and Liver Disease 8th Edition
Test-and-Treat Approach
Test for H. pylori (Urea Breath Test or Stool Antigen Test)
Treat if (+) Trial of PPI therapy if (-)
Do endoscopy if no symptom improvement
Need for in-patient work-up and care
Severity of dyspepsia Alarm symptoms present Need for additional lab tests and
imaging studies
Possible Scenario
50 year old with CAD on ASA Severe epigastric pain, weakness, melena Pale
Will need: Hospital admission for medical
management Early endosocopy, CBC Blood transfusion