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									Dyspepsia
     Sam Dent
    Kizzy Dyas
   Ed Forsythe
   Dan Stringer
Introduction

What is dyspepsia
Important causes and differentials
10 minute consultation
Testing for H. Pylori
NICE Guidelines
              Question 1




When testing for H. Pylori after PPI therapy,
   how long a washout period is required?

A : 1 week                       C : 3 weeks

B : 2 weeks                      D : 1 month
Question 2

 Which of the following drugs is not associated
    with dyspepsia ?
   a)   Calcium antagonists
   b)   Nitrates
   c)   Theophylline
   d)   Bisphosphonates
   e)   Corticosteroids
   f)   NSAID’s
Question 3
 For H pylori positive patients what is the
     recommended course of treatment?
    a) Omeprazole 40mg bd
       Metronidazole 400mg tds
       Clarithromycin 250mg bd
    b) Omeprazole 20 mg bd
       Amoxicillin 1g bd
       Clarithromycin 500mg bd
    c) Omeprazole 20mg bd
       Metronidazole 400mg bd
       Clarithromycin 250mg bd
Question 4

 Patients undergoing an endoscopy should be
     free from PPI therapy for how long?
   a)   1 week
   b)   2 weeks
   c)   4 weeks
   d)   6 weeks
Question 5
 Uninvestigated Dyspepsia
                            Fill in the gaps:
           (a)
                            a)   Test and treat H. Pylori
   Review Medications       b)   H2RA - 1 month
                            c)   Lifestyle advice
 Full Dose PPI - 1 month
                            d)   Refer to gastroenterology
           (b)              e)   Re-test for H. Pylori
           (c)

         Review
Question 6
 Which of the following cases would not qualify
    for the 2 week rule referral criteria ?
   a) A 45 year old with back pain, taking NSAIDs,
      presenting with new onset dyspepsia.
   b) A 55 year old female with iron deficiency anemia
      and dyspeptic symptoms.
   c) A 45 year old 20 per day smoker with dysphagia
      to solids.
   d) A 35 year old man with longstanding indigestion
      presenting with persistent vomiting.
   e) A 30 year old with dyspeptic symptoms and
      unintentional weight loss.
Question 7

 Dyspepsia is a group of symptoms and not a
  diagnosis
     True or False
Question 8

 Which of the following does not occur in patients
    with dyspepsia?
   a)   Haemorrhage
   b)   Perforation
   c)   Strictures
   d)   Aphthous ulcers
   e)   Anaemia
Question 9

 PPI’s are more effective than antacids or
   alginates at reducing dyspeptic symptoms in
   people with uninvestigated dyspepsia.
 In trials the average response rate with an
   antacid or alginate was 37%. PPI therapy
   increased this to 55%
   What is the Number Needed to Treat (NNT) for one
    person to respond to a PPI?
Question 10

 In uninvestigated dyspepsia early endoscopy
     has not been shown to produce better
     outcomes than empirical acid suppression.
   a)   Strongly agree
   b)   Agree
   c)   Neutral
   d)   Disagree
   e)   Strongly disagree
Question 11

 In patients successfully treated for GORD, how
     many are likely to relapse within 1 year if
     they do not continue on maintenance
     therapy?
   a)   0-20%
   b)   20-40%
   c)   40-60%
   d)   60-80%
   e)   80-100%
 Dyspepsia
Common causes
Dyspepsia - What is it?
 Epigastric pain
 Indigestion
 Fullness
 Early satiety
 Bloating
 Belching
 Nausea
 Retching
 Heartburn
Dyspepsia - Why is it important?

Costs of management outstrip all other
 conditions in NHS
Very common – every 6 months 40% of
 general population suffer dyspepsia + ¼
 consult their GP!
3% of UK population are on medication for
 dyspepsia
Dyspepsia – Aetiology

Common Causes Found on Endoscopy:
Functional / Non ulcer dyspepsia (30-50%)
Gastritis / Duodenitis (20%)
Peptic ulcer disease (15-25%)
GORD / Oesophagitis (15-25%)
Gastric cancer (2%)
Dyspepsia - Important differentials

Cardiac pain
Gallstone pain
Pancreatitis
Mesenteric ischaemia
Dyspepsia - Functional Dyspepsia

Chronic, persistent recurrent dyspepsia
No organic disease found
Common in patients with IBS -BUT not
 relieved by defaecation/ associated with
 change in stool form/ frequency
Dyspepsia - Functional Dyspepsia
 Endoscopically normal

 GI dysmotility / Autonomic dysfunction – causing
  delayed gastric emptying
 Augmented visceral perception / irritable
  stomach (1/3 have IBS)
 H pylori infection – improved by eradication if
  present
 Psychological factors – anxiety/ depression/
  concerns – something serious
Dyspepsia - H. Pylori
 Strongly associated with gastritis/ gastric/
  duodenal ulcers/ gastric cancer
 Acquired in childhood
 20-40% - developed world, 80-90% -
  developing world
 More common in low socioeconomic
  groups
 Causes hypergastrinaemia + increased
  acid output
 Damage to surface epithelium of stomach
 Dyspepsia - Peptic Ulcer Disease
                      Gastric                 Duodenal
Age           Older                   Younger (Males)
Pain          Post-meals              Pre-meals / nocturnal
Weight Loss   Yes                     No
Vomiting      Yes                     No
Cause         60% - H. Pylori         95% - H. pylori
              Drug induced (NSAIDS)   NSAIDS
              Smoking                 Genetic susceptibility
              Duodenogastric bile     Zollinger Ellison syndrome
              reflux                  (H.Pylori negative / not of
                                      NSAIDS)– gastrin secreting
                                      neuroendocrine tumours
Dyspepsia - Gastritis
 Non immune (more common) or immune
 Acute
  Caused by drugs (aspirin)/ alcohol/ physiological stress
   (ITU)
 Chronic
  Almost always H Pylori (95%)
 Autoimmune
  Affects body of stomach – autoantibodies to parietal
   cells + intrinsic factor causing pernicious anaemia –
   check B12 + Rx with hydroxycobalamine
Dyspepsia - Gastric Carcinoma

Dyspepsia poorly related to meals
Anorexia + weight loss
Nausea + frequent vomiting
Ca of cardia may cause dysphagia
Signs - ie. Epigastric mass, Virchow’s
 node, jaundice – late + represent incurable
 disease.
Poor prognosis often presents late
Dyspepsia - Gastric Carcinoma
 Adenocarcinoma
 4th commonest cancer in europe
 3X more common in men
 80% of people over 65 yrs
 H. Pylori - metaplasia (3% of people) = 2.5X
  increased risk of cancer
 Diet - higher in Japan + decreases in migrants
  (N-nitrosamines)
 Genetic predisposition
 Pernicious anaemia
 Previous gastric surgery (due to H. Pylori)
Dyspepsia - GORD
 Reflux of acid into lower oesophagus
 Heartburn, regurgitation, water brash, nocturnal
  asthma. Not typically epigastric pain
 Dysphagia - Oesphageal dysmotility due to
  chronic irritation of oesophagus
 Very common
 Normally due to dysfunction of lower
  oesophageal sphincter
 Prolonged exposure of oesophageal mucosa to
  low pH – oesophagitis          Metaplasia /
  Barretts oesophagus (squamous epithelium
  replaced by columnar/ glandular)
 Increased risk of oesophageal adenocarcinoma
Dyspepsia - GORD

Increased by pregnancy/ obesity
Fatty foods / alcohol / smoking / over
 eating
Hiatus hernia
Drugs – nitrates / antimuscarinics/ Ca
 channel blockers
Dyspepsia - Oesophageal Carcinoma

Present with dysphagia/ weight loss
Assoc with GORD/ Barrett’s
Alcohol / smoking
Squamous – upper 2/3
Adenocarcinoma – lower 1/3
Dyspepsia - Summary

Oesphageal – present with reflux/
 heartburn / dysphagia
Gastric/ duodenal – epigastric pain /
 indigestion
Important not to miss malignancies / other
 serious differentials including MI
 The 10 Minute Consultation…

45 y old man presents with
 recurrent epigastric pain
  On and off for years
  Tried PPIs in the past
  Uses gaviscon ++
  “Tell me what is wrong Doctor…”
 The 10 Minute Consultation…
History
Is this dyspepsia? - SOCRATES
   Epigastric pain
   Heartburn
   Acid regurgitation
   Meals
   Lying flat
   Reponse to antacids / previous PPI

Cardiac pain
Biliary colic
IBS
 The 10 Minute Consultation…
Alarm symptoms
Drug history
  NSAIDS, aspirin, theophylline, calcium antagonists,
   nitrates, bisphosphonates, corticosteroids
SHx – smoker, alcohol
Previous investigations
Effect on lifestyle / QOL
Ideas, concerns, expectations
  What has been tried / failed previously
The 10 Minute Consultation…
Examination
General appearance
  Weight, anaemia etc….
Abdominal examination
The 10 Minute Consultation…
So What’s The Plan?
 If possible stop any medication likely to cause
  dyspepsia
 Lifestyle advice
   Weight reduction
   Smoking cessation
   Healthy eating
   Alcohol / coffee reduction
The 10 Minute Consultation…
Investigations & Treatment
Clear NICE guidelines available


        Vs                 Vs
Testing for H. Pylori
Why?
 Motile Gram negative, curved or spiral bacillus
 Prevalence of 30-40% in UK
 Peptic ulcer rare without H pylori or NSAIDs
 Its present in almost all cases of DU and most
  cases of GU
 Associated with adenocarcinoma and
  lymphoma of the stomach
 No association between H. Pylori infection and
  GORD (note NICE guidelines)
Testing for H. Pylori
How?
 C urea breath test.
  Preference for eradication
  therapy.
  Based on the detection of
  the enzyme urease
  produced by H. pylori.
  In the presence of
  urease, orally
  administered C-14 urea
  will be hydrolyzed into
  ammonia and 14 C O2 -
  -> detected in exhaled
  air.
Testing for H. Pylori
How?
 Stool antigen test.

 H pylori serology. IgG- not for re testing as
     antibodies persist for a while
Testing for H. Pylori
                     Endoscopy with
                      biopsy / rapid urease
                      test / CLO test
                        A biopsy of mucosa is taken
                        from the antrum of the
                        stomach, and is placed into a
                        medium containing urea and
                        an indicator such as phenol
                        red. The urease produced by
                        H. Pylori hydrolyzes urea to
                        ammonia, which raises the pH
                        of the medium, and changes
                        the color of the specimen
Testing for H. Pylori

It’s Positive - Now what?
Optimum regimen:
Double dose PPI + amoxicillin 1g and
 clarithromycin 500mg all given bd 7/7
Double dose PPI + metronidazole 400mg
 and clarithromycin 250mg all given bd 7/7
NICE Guidelines 2004
                Assessing need for
                 referral

                Guide to uninvestigated
                 dyspepsia

                Treating investigated
                 dyspepsia
NICE Guidelines 2004
            New Episode of Dyspepsia

               Referral Criteria Met?
                                        ** Stop PPI & H2RA for 2 weeks

 Treat Uninvestigated       Urgent Specialist Referral:
 Dyspepsia                   GI bleeding
                             Weight loss
                             Dysphagia
                             Persistent vomiting
                             Iron deficiency anaemia
                             Epigastric Mass

                             > 55 years with unexplained
                            and persistent (> 4 weeks) recent
                            onset dyspepsia
NICE Guidelines 2004
Uninvestigated Dyspepsia             • Avoid precipitants – alcohol,
                                     smoking, coffee, chocolate,
     Lifestyle Advice                fatty foods
                                     • Lose weight
                                     • Avoid meals before bedtime
  Review Medications                 • Raise head of bed
                                     • Use antacids

Full Dose PPI - 1 month              • Ca Antagonists
                            either
                            first
                                     • Nitrates
 Test and Treat H. Pylori            • Theophyllines
                                     • Bisphosphonates
    H2RA - 1 month                   • Steroids
                                     • NSAIDS
         Review
NICE Guidelines 2004
NICE Guidelines 2004
Gastro-oesophageal Reflux
 Do not test and treat for H. Pylori (NNT 17).
 Treat with PPI or H2RA

Peptic Ulcer (Gastric or Duodenal)
 Test and treat for H. Pylori (NNT 2).
 Treat with PPI
 Require repeat endoscopy +/- H.Pylori re-test (C-13 urea
  breath test)
Non-Ulcer Dyspepsia
 Test and treat for H. Pylori
 PPI or H2RA.
  Question 1 - Answers




When testing for H. Pylori after PPI therapy,
   how long a washout period is required?

A : 1 week                       C : 3 weeks

B : 2 weeks                      D : 1 month
Question 2 - Answers

 Which of the following drugs is not associated
    with dyspepsia ?
   a)   Calcium antagonists
   b)   Nitrates
   c)   Theophylline          All Are
   d)   Bisphosphonates
   e)   Corticosteroids
   f)   NSAID’s
Question 3 - Answers
 For H pylori positive patients what is the
     recommended course of treatment?
    a) Omeprazole 40mg bd
       Metronidazole 400mg tds
       Clarithromycin 250mg bd
    b) Omeprazole 20 mg bd
       Amoxicillin 1g bd
       Clarithromycin 500mg bd
    c) Omeprazole 20mg bd
       Metronidazole 400mg bd
       Clarithromycin 250mg bd
Question 4 - Answers

 Patients undergoing an endoscopy should be
     free from PPI therapy for how long?
   a)   1 week
   b)   2 weeks
   c)   4 weeks
   d)   6 weeks
Question 5 - Answers
 Uninvestigated Dyspepsia
                            Fill in the gaps:
           (a)
                            a)   Test and treat H. Pylori
   Review Medications       b)   H2RA - 1 month
                            c)   Lifestyle advice
 Full Dose PPI - 1 month
                            d)   Refer to
           (b)                   gastroenterology
                            e)   Re-test for H. Pylori
           (c)

         Review
Question 6 - Answers
 Which of the following cases would not qualify
    for the 2 week rule referral criteria ?
   a) A 45 year old with back pain, taking NSAIDs,
      presenting with new onset dyspepsia.
   b) A 55 year old female with iron deficiency anemia
      and dyspeptic symptoms.
   c) A 45 year old 20 per day smoker with dysphagia
      to solids.
   d) A 35 year old man with longstanding indigestion
      presenting with persistent vomiting.
   e) A 30 year old with dyspeptic symptoms and
      unintentional weight loss.
Question 7 - Answers

 Dyspepsia is a group of symptoms and not a
  diagnosis
     True or False
Question 8 - Answers

 Which of the following do not occur in patients
    with dyspepsia?
   a)   Haemorrhage
   b)   Perforation
   c)   Strictures
   d)   Aphthous ulcers
   e)   Anaemia
Question 9 - Answers

 PPI’s are more effective than antacids or
   alginates at reducing dyspeptic symptoms in
   people with uninvestigated dyspepsia.
 In trials the average response rate with an
   antacid or alginate was 37%. PPI therapy
   increased this to 55%
                 1           = 6
  NNT =is the Number Needed to Treat (NNT) for one
   What
     person the respond to a PPI?
            0.55 – 0.37
Question 10 - Answers

 In uninvestigated dyspepsia early endoscopy
     has not been shown to produce better
     outcomes than empirical acid suppression.
   a)   Strongly agree
   b)   Agree
   c)   Neutral
   d)   Disagree
   e)   Strongly disagree
Question 11 - Answers

 In patients successfully treated for GORD, how
     many are likely to relapse within 1 year if
     they do not continue on maintenance
     therapy?
   a)   0-20%
   b)   20-40%
   c)   40-60%
   d)   60-80%
   e)   80-100%

								
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