Dyspepsia - Jaber Manasia

Dyspepsia

By

Jaber Manasia5th year medical student

Mutah University-Jordan

Jaber.manasia@gmail.com

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