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In this lecture, I talked about everything concerning dyspepsia and its management from medical aspect.
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Dyspepsia
By
Jaber Manasia5th year medical student
Mutah University-Jordan
Presented to:
Dr. mai hadidi
Objectives
• By the end of this seminar you will:
– have a working definition of dyspepsia
– know the main causes of dyspepsia
– have a rational, cost-effective, evidence-based approach to dyspepsia
Differential Diagnosis
Organic40%
Functional =“Non-Ulcer Dyspepsia”
60%
Differential Diagnosis and PathophysiologyDiagnosis Typical Features Frequency %
Functional dyspepsia Epigastric pain or burning, postprandial fullness, early satiety
60%
Peptic ulcer disease Postprandial epigastric burning pain 15%–25%
Reflux esophagitis Heartburn, sour taste in the mouth 5%–15%
Gastric or esophageal cancer
Abdominal pain or heartburn, dysphagia ,weight loss
2%
Rare causes*
*Rare causes include carbohydrate malabsorption, small intestinal mucosal disorders (e.g., sprue, intestinal parasites, chronicpancreatitis), infiltrative diseases of the stomach (e.g., Crohndisease), ischemic bowel disease, metabolic disorders (hypothyroidism, hyperkalemia), medications (e.g., erythromycin), cardiac conditions (e.g., inferior myocardial ischemia), and pulmonaryconditions (e.g., lower lobe pneumonia).
Frequency of diagnosis on endoscopy. The diagnosis of functional dyspepsia is made if there are no findings on endoscopy.
Functional dyspepsia :
• It refers to the dyspepsia that occurs without identifiable abnormality in the digestive system (most common).
Usually affecting young adults .Women affected twice as men .
Morning symptoms (pain and nausea are characterstics).
But No diagnostic signs .= diagnosis of exclusion .
Rome III Diagnostic Criteria For Functional Dyspepsia:
Presence of at least one of the following symptoms with no evidence of structural disease (including at upper endoscopy) that is likely to explain the symptoms:
•Bothersome postprandial fullness•Early satiation •Epigastric pain •Epigastric burning
•Note: criteria must be fulfilled for the past three months, with symptom onset at least six months before the diagnosis.
• Three major potential pathophysiologic mechanisms of functional dyspepsia have been identified
• 1.delayed gastric emptying
• about 30% of patient
• associated with postprandial fullness, nausea and vomiting
• 2.impaired gastric accommodation
• about 40% of patients
• associated with early satiety
• 3.hypersensitivity to gastric distention
• 37% of patients
• associated with postprandial pain, belching and weight loss
Peptic Ulcer Disease (PUD)
• The primary causes of PUD are Helicobacter pylori infection and nonsteroidal anti-inflammatory drug (NSAID) use.
• Cigarette smoking is an additional risk factor that may impair the healing of an ulcer and increase the likelihood of recurrence after successful treatment .
• Zollinger-Ellison syndrome is an uncommon cause of PUD that results from tumors of the small intestine or pancreas that secrete excessive amounts of gastrin hormone which leads to an overproduction of stomach acid.
Gastroesophageal Reflux Disease
• is a condition in which the reflux of gastric contents into the It may also cause evidence of inflammation (esophagitis) and erosions in the esophageal mucosa.
• One important causative factor is esophago-gastric junction (EGJ) incompetence.
• After the reflux occurs, another key factor is ineffective esophageal clearance of acid and reflux material that may result from impaired esophageal emptying, esophageal peristalsis dysfunction.
Management
History & Physical for Specific Etiologies
History
1- patiant profile.
2-present complaint :
-what do you mean by dyspepsia?
-then try to analyze the pain (SOCRATES)
-what other symptoms ?
ALSO DON’T FORGET TO ASK ABOUT RISK FACTORS ????
Risk Factors and Past Hx• Risk Factors
– Smoker, NSAID use, FHx ulcer• Personal Hx
– Previous ulcer, GI bleed– DM, hypo/hyperthyroidism, parathyroid dis.– Colitis, diverticulosis, liver disease– Anxiety, stress, depression– Previous Upper GI series, Abdo U/S
History
• PUD – Past history of ulcers, NSAIDs, Smoking
• GERD – Heartburn or regurg symptoms,
aggravated when supine, chronic cough• Gastric Cancer
– Older (>50), wt. loss, dysphagia, smoker, long-standing GERD
History
• Biliary Tract disease – Episodic RUQ pain > 1 hr, associated with
meals, post-prandial
• Meds– iron, NSAIDs, bisphosphonates, antibiotics, etc.
• Metabolic disorder/Gastroparesis– DM, Hyper or Hypo -Thyroidism,
Hyperparathyroidism
History
• IBS
– Rome criteria
• Pain relieved with defectation
• more freq stools at onset of pain
• abdominal distention
• passage of mucus
• sense of incomplete evacuation
Examination• Fever, weight loss,
hypotension, tachycardia
• Abdo
– Epigastric tenderness
– Palpable mass
– Distention
– Colon tenderness
– Jaundice
– Murphy’s sign
– Stool for OB
• Signs anemia
– Brittle nails
– Cheilosis
– Pallor palpebral mucosa or nail beds
• Other
– Teeth (loss enamel)
– Lymphadenopathy - Virchow’s node
– Acanthosis nigrans
– Hypo/Hyperthyroid.
Explicitly Consider: Could this patient have cancer?
Red Flags
• Age > 45
• Weight loss
• Bleeding
• Anemia
• Dysphagia
Red Flag Symptoms Red Flag Symptoms There are certain red flags to look for which may There are certain red flags to look for which may indicate the possibility for serious disease :indicate the possibility for serious disease :
Age > 55 yanorexia,unexplained recent weight loss,dysphagia,odynophagia,persistent vomiting,hematemesis,longstanding gastroesophageal reflux
symptoms,
blood in the stool, anemia, previous gastric surgery, a palpable abdominal mass, gastrointestinal perforation, jaundice melena
Dyspepsia
Clinical evaluation
Exclude by History: GERD; biliary; IBS; Meds; aerophagia
From AGA Guidelines
Manageappropriately
45 years and no red flags
>45 or red flags
Endoscopy
+
-
Treat for Non-Ulcer Dyspepsia
The Role of H. pylori in Non-Ulcer Dyspepsia
• Association between H. pylori & Non-Ulcer dyspepsia not clear
• Role in pathogenesis disputed
Non-invasive tests for H. pylori
SENS SPEC
14C Urea Breath Test 90-95 90-95
Serology* 85-95 85-90
*cannot discriminate between active & previous infection (therefore, do not use to diagnose recurrence)
Treatment of H. pylori
• Multiple Regimens• UHN/MSH Guidelines...
1st line: Most cost-effective (for the hosp.) Lansoprazole 30mg BID
Clarithromycin 500 BIDAmoxicillin 1000mg BID
Alternate regimens substitute metronidazole for amoxil (but some H.pylori are resistant)
7 daysHP Pack
NICE guidance – Indigestion
‘eradication therapy’ for H.pylori
• a PPI to take for 7 days, and
• two types of antibiotics, which are either:
metronidazole and clarithromycin, or
amoxicillin and clarithromycin.
American College of Gastroenterology Position
• "There is no conclusive evidence that eradication of H. pylori infection will reverse the symptoms of nonulcer dyspepsia. Patients may be tested for H. pylori on a case-by-case basis, and treatment offered to those with a positive result."
What if H. pylori is negative?
• Minimal evidence supports:
– H2 blockers
– Antiacid
– Proton Pump Inhibitors
– Prokinetic agents
• metoclopramide, domperidone• cisapride no longer available
Antacids:
Usually the first drugs recommended to relieve symptoms of indigestion.
Side effects: Magnesium salt → diarrhea aluminum salt → constipation.
Calcium carbonate antacids, can also be a supplemental source of calcium, though
they may → constipation.
H2 receptor antagonists (H2RAs)
include ranitidine, cimetidine, famotidine, and nizatidine
reduce stomach acid.
Side effects: headache, nausea, vomiting, constipation, diarrhea, and unusual bleeding
or bruising.
Proton pump inhibitors (PPIs)
Include omeprazole, lansoprazole, pantoprazole and esomeprazole
Most effective in people who also have GERD
Side effects: back pain, aching, cough, headache, dizziness, vomiting, constipation,
and diarrhea.
Prokinetics
As metoclopramide, may be helpful for people who have a problem with the stomach
emptying
Improves muscle action in the digestive tract
Side effects: limit their use, as sleepiness, depression and involuntary muscle spasms or
movements.
45 years and no red flags
H. pylori Testing
Treat H.p. Empiric H2, PPI, or prokinetic x 1 month
failsfails
EndoscopyFollow-up Follow-up
successsuccess
+ -
From AGA Guidelines
Investigations if still symptomatic
Upper GI series
The upper GI series is noninvasive and relatively
inexpensive.
It is sensitive in detecting gastric and duodenal ulcers (80%–90%). Its accuracy improves with disease severity.
The double-contrast technique including spot views during
vigorous compression with the barium-filled bulb improves detection of duodenal ulcers.
In patients with GERD, only severe esophagitis may be detected, although reflux and motility disorders of the esophagus can be seen.
The presence of a hiatal hernia does not correlate with GERD.
Upper GI Endoscopy
Upper GI endoscopy is the gold standard for identifying esophagogastroduodenal pathology and is the investigation of choice for patients older than 55 with uninvestigated dyspepsia or in the presence of alarm features.
Upper endoscopy is preferred to upper GI barium study, because lesions can be directly visualized and biopsy can be performed. In addition, testing for H pylori can be performed.
Intraesophageal pH monitoring
Most physicians consider this procedure to be the
single best test for diagnosis for GERD.
Coupled with a symptom diary, 24-hour monitoring has a sensitivity between 87% - 93% and a specificity of 92% - 97% for GERD.
Scintigraphy
Scintigraphy is best used to detect
delayed gastric emptying. GERD and delayed gastric emptying can be detected using [99mTc] sulfur colloid, although intraesophageal pH monitoring is a better test for reflux.
Management
Endoscopy
Organic Disease H. pylori detected Functional
Rx & Follow-up H2/PPI or prokinetic
4 weeks
Switch to other agent
Re-evaluate
? Behavioral/ Psychotherapy/ Antidepressant
From AGA Guidelines
fails
fails
success
success
Non-pharmacologic Tx• Quit smoking
• Stop / reduce caffeine
• Stop / reduce EtOH
• Hold medications associated w/ dyspepsia
– NSAIDS, ASA
• Avoid foods and other factors precipitate symptoms
– Better eating habits
• Don’t eat late
Antidepressants.
Tricyclic antidepressants and selective serotonin reuptake inhibitors (SSRIs).
• Therapy for
– Stress– Anxiety– Depression
• Elevate head of bed?
• Stress-reducing activities
– Exercise – Relaxation